.
.
P144 Post traumatic cerebral thrombophlebitis: prospective study about 15 cases
Chtara Kamilia1, Kais Regaieg2, Olfa Turki1, Najeh Baccouch2, Hedi Chelly1, Mabrouk
Bahloul1, Mounir Bouaziz1
1Réanimation polyvalente, Faculté de médecine de Sfax, Sfax, Tunisia; 2Réanimation
polyvalente, CHU Habib Bourguiba, Sfax, Tunisia
Correspondence: Chtara Kamilia - kamilia.chtaraelaoud@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P144
Introduction Head injury is a rare but possible etiology of cerebral thrombophlebitis.
The diagnosis should be considered especially in front of open head injuries extended
to venous sinuses. The MR angiography is the gold standard for early diagnosis.
Patients and methods This is a descriptive prospective study of all trauma patients
hospitalized in the intensive care unit of the University Hospital Habib Bourguiba
Sfax over a period of 6 years between January 2010 and June 2016 and in whom the diagnosis
of cerebral venous thrombophlebitis has been confirmed by angiography CT or MR angiography.
Results During the period study, 15 patients were included. The median age of patients
was 29 [17–49] years. All patients were male, victims of poly trauma following an
accident of traffic. In admission, SAPSII was 31 [24–52] and SOFA was 4 [2–8]. We
have noted the presence of a serious head injury in 15 patients, extended open skull
fractures of the venous sinus in 9 patients. A related chest trauma was present in
12 patients and abdominal trauma in 4 patients, trauma of the pelvis and/or members
were present in 7 patients. All patients underwent mechanical ventilation. The diagnosis
of cerebral venous thrombosis was confirmed by cerebral angiography CT in 9 patients
and cerebral MR angiography in 6 patients. 7 patients have presented secondary pulmonary
embolism. All patients did not show a contraindication against anticoagulation at
diagnosis of thrombophlebitis. The thrombophilia (antithrombin III, protein C and
S, homocysteine, and antiphospholipid, gene mutation factors II and V) as well as
for anti-neutrophil cytoplasmic antibodies were negative in all patients. The outcome
was favorable in 13 patients. Two patients were died due to a state of refractory
septic shock.
Discussion Post traumatic cerebral thrombophlebitis is a rare thrombotic vascular
disease. It must be mentioned especially with presence of extensive skull fractures
in open sinuses. Venous MR angiography is the gold standard. The treatment is based
on anticoagulation curative dose. Its prescription can be complicated in these cases
associated with traumatic intracranial hemorrhage.
Conclusion Head injury is a rare but possible etiology of cerebral thrombophlebitis.
Other prospective studies are needed to better understand the path physiology and
the prognosis of these thromboses.
Competing interests None.
P145 Pain measurement in mechanically ventilated patients with traumatic brain injury:
behavioral pain tools versus analgesia/nociception index—preliminary results
Ali Jendoubi1, Ahmed Abbes,1, Houda Belhaouane,1, Oussama Nasri,1, Layla Jenzri,1,
Salma Ghedira2, Mohamed Houissa2
1Anesthesia and Intensive Care, Charles Nicolle Teaching Hospital, Tunis, Tunisia;
2 Intensive care, Charles Nicolle Hospital, Tunis, Tunisia
Correspondence: Ali Jendoubi - jendoubi_ali@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P145
Introduction Pain is highly prevalent in critically ill trauma patients especially
those with a traumatic brain injury (TBI). Behavioral pain tools such as the Behavioral
pain scale (BPS), and critical care pain observation tool (CPOT) are recommended for
sedated non-communicative patients. The analgesia nociception index (ANI) assesses
the relative parasympathetic tone as a surrogate for antinociception/nociception balance
in sedated patients. The primary aim is to evaluate the effectiveness of ANI in detecting
pain in TBI patients. The secondary aim was to evaluate the impact of Norepinephrine
use on ANI effectiveness, and to determine the correlation between ANI and BPS.
Patients and methods We performed a prospective observational study in 21 deeply sedated
TBI patients. Exclusion criteria were non-sinus cardiac rhythm; presence of pacemaker;
atropine or isoprenaline treatment; neuromuscular blocking agents and major cognitive
impairment. HR, blood pressure and ANI were continuously recorded using the Physiodoloris®
device at rest (T1), during (T2) and after the end (T3) of the painful stimulus (tracheal
suctioning).
Results In total, 100 observations were scored. Patients’ characteristics were resumed
in Fig. 1. ANI was significantly lower at T2 (Med (min–max) 54.5 (22–100)) compared
with T1 (90.5 (50–100), p < 0.0001) and T3 (82 (36–100), p < 0.0001). Similar results
were found in the subgroups of patients with (65 measurements) or without (35) Norepinephrine.
During procedure, A negative linear relationship was observed between ANI and BPS
(r2 = −0.469, p < 0.001). At the threshold of 50, the sensitivity and specificity
of ANI to detect patients with BPS ≥ 5 were 73 and 62%, respectively with a negative
predictive value of 86%.
Fig. 1
Baseline demographic and clinical characteristics. Values are expressed as mean ± standard
deviation (SD); n (%) or median [interquartile range]. EDH extradural haemorrhage
SDH subdural haemorrhage, SAH subarachnoid hemorrhage
Discussion
Conclusion ANI is effective in detecting pain in deeply sedated critically ill TBI
patients, including those patients treated with Norepinephrine.
Competing interests None.
P146 The prognosis of cervical spine trauma in elderly subjects in surgical intensive
care
Kamal Belkadi1, Ma Bouhouri2, Youness Harti3, Afak Nsiri2, Khalid Khaleq4, Driss Hamoudi2,
Rachid Harrar2
1Anesthesie reanimation, chu ibn rochd, Casablanca, Morocco; 2Reanimation des urgences
chirurgicale, chu ibn rochd, Casablanca, Morocco; 3Anesthésie réanimation, CHU Ibn
Rochd Casa, Casablanca, Morocco; 4Service d’accueil des urgences, Chu Ibn Rochd, Casablanca,
Morocco
Correspondence: Kamal Belkadi - kamal.belkadi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P146
Introduction The aim of our study was to assess the prognostic factors of cervical
spine trauma in elderly subjects admitted in the surgical intensive care unit.
Patients and methods We conducted a retrospective, and single-center study over 16 years
(January 2000–January 2016) in Ibn Rochd hospital, we included all patients aged over
65 years with isolated cervical spine trauma, operated and non-operated, admitted
in surgical intensive care, the death risk factors were searched by uni and multivariate
analysis.
Results 198 patients were collected, the average age was 69.4 ± 3.9 years, with a
male predominance 70.2%, the main causes were road accidents (50.5%) and fall (34.3%),
68.2% had a complete form (Frankel A), 75.7% were operated. The death rate in our
study was 55%. The prognostic factors in univariate analysis were: hypertension, heart
disease, fall injury, surgical delay >10 h; independent factors of death in multivariate
analysis: heart disease and fall injury.
Conclusion The cervical spine trauma in elderly patients hospitalized in intensive
care unit is poor prognosis.
Competing interests None.
P147 Interest of the urine antigen testing for Legionella pneumophila in the management
of severe acute pneumonia: practice survey and analysis of performance in intensive
care unit
Camille Thieffry1, Frédéric Wallet2, Erika Parmentier-Decrucq1, Raphaël Favory1, Daniel
Mathieu1, Julien Poissy1
1Pôle de réanimation, hôpital salengro, C.H.R.U. - Lille, Avenue Oscar Lambret, Lille,
France, Lille, France; 2 Centre de biologie pathologie génétique, Centre Hospitalier
Régional Universitaire de Lille, Lille, France
Correspondence: Julien Poissy - julien_poissy@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):P147
Introduction Legionnaire’s disease is a rare but severe acute pneumonia with a difficult
definitive diagnosis. Legionella’s urine antigen testing is a quick, sensitive and
specific test, widely prescribed in the case of an acute and severe community-acquired
pneumonia. However, its overall contribution to the diagnosis of atypical pneumonia
remains unknown in daily practice. The aims of this study were to evaluate the usefulness
of this test in a “real life” utilization and to identify potential clinical markers
of legionnaire’s disease in order to optimize its prescription. Legionnaire’s disease
is a rare but severe acute pneumonia with a difficult definitive diagnosis. Legionella’s
urine antigen testing is a quick, sensitive and specific test, widely prescribed in
the case of an acute and severe community-acquired pneumonia. However, its overall
contribution to the diagnosis of atypical pneumonia remains unknown in daily practice.
The aims of this study were to evaluate the usefulness of this test in a “real life”
utilization and to identify potential clinical markers of legionnaire’s disease in
order to optimize its prescription.
Patients and methods We conducted a retrospective, monocentric and observational study.
All the prescriptions of the urine antigen testing where monitored in the intensive
care department and the emergency room admitting severe patients, in our University
Teaching Hospital, from January 1st 2013 to December 31st 2015. Qualitative variables
were compared by a Fischer’s exact test, and quantitative variables by a Mann–Whitney
test. All tests were bilateral, and p ≤ 0.05 was considered as significant. ROC curves
were determined for the variables of interest.
Results During the period of the survey, 1142 urinary tests were performed in 1002
patients. Three tests were positive for 0.26% of patients. Only 569 patients suffered
from an actual pneumonia. Other patients suffered mostly from acute bronchitis (137
cases), and exacerbation of chronic obstructive pulmonary disease (123 cases). The
characteristics of the 3 patients suffering from legionnaire’s disease differed significantly
compared to the other kinds of acute pneumonia for: the need for invasive mechanical
ventilation (100 vs 34.96% of patients; p = 0.043), PaO2/FiO2 ratio (107.5 vs 274.5;
p = 0.0107), duration of mechanical ventilation (27.5 vs 2.5 days; p = 0.0062), natremia
(129.5 vs 138 mmol/l; p = 0.0125), Creatine Phospho-Kinase level (16,125 vs 106UI;
p = 0.0225) and Serum Glutamat Oxalacetat Transaminase (251 vs 35UI; p = 0.0157).
We determined ROC curves for these last biological variables. Natremia: better threshold = 131,
Se/Sp = 100/84.2%, AUC = 0.92. SGOT: better threshold = 191, Se/Sp = 100/89.6%, AUC = 0.9.
CPK: better threshold 195, Se/Sp = 100/66.5, AUC = 0.88.
Discussion Urine antigen testing for Legionnaire’s disease appears to be over-prescribed
in many cases with a very poor level of positivity in our cohort. However, it could
be limited to patients exhibiting a pneumonia, and among them to patients with the
classical biological perturbations described in this disease, which have excellent
diagnostic performance. This targeted strategy would present an important benefit
in term of costs.
Conclusion Our results show that a better selection in the patients who could benefit
of this test is mandatory. Simples markers in routine testings could help the clinician
to adapt his prescription, optimizing this test’s efficiency.
Competing interests None.
P148 Staphylococcal community-acquired urinary tract infection in the emergency department:
a sign for acute infective endocarditis?
Thomas Lafon1, Philippe Vignon2, Emmanuelle Begot2, Alexandra Appert3, Mathilde Hadj3,
Paul Claverie3, Morgan Matt4, Olivier Barraud5, Bruno François6
1Inserm cic 1435/urgences/samu, Centre Hospitalier Universitaire de Limoges, Limoges,
France; 2Service de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges,
Limoges, France; 3Urgences/samu, Centre Hospitalier Universitaire de Limoges, Limoges,
France; 4Service de maladies infectieuses, Centre Hospitalier Universitaire de Limoges,
Limoges, France; 5Bactériologie-virologie-hygiène/umr-s 1092, Centre Hospitalier Universitaire
de Limoges, Limoges, France; 6Inserm cic1435/service de réanimation polyvalente, Centre
Hospitalier Universitaire de Limoges, Limoges, France
Correspondence: Thomas Lafon - thomas.lafon@chu-limoges.fr
Annals of Intensive Care 2017, 7(Suppl 1):P148
Introduction Urinary tract infection is a frequent cause of admission at the Emergency
Department (ED). Most prevalent bacteria are usually gram-negative bacilli and Staphylococcus
aureus (Sa) is rarely evidenced (2.5%) except in hospital-acquired infections due
to urinary catheter [1]. Bacteriuria can be observed in Sa infective endocarditis
(IE) because of the metastatic properties of Sa. We hypothesized that presence of
Sa in the urine could be related to Staphylococcal bacteremia associated with unsuspected
IE and not only the expression of a “usual” urinary tract infection.
Patients and methods This is a descriptive single-center study conducted over a 10 year-period
in the Teaching Hospital of Limoges. All patients admitted to the ED with Sa (both
MSSA and MRSA) isolated from their urine cultures were retrospectively analyzed. Data
were collected from the database of the microbiology department and the patient medical
charts. We secondarily searched if a Sa IE had been documented in patients with Sa
isolated from their blood cultures in order to establish a link between IE and presence
of Sa in the urine. We used modified Dukes criteria as diagnostic criteria of IE [2].
Results Between 2005 and 2015, 420,000 patients were admitted in the ED. Out of the
204 records analyzed, 174 patients whose urine culture grew Sa were excluded because
they had a urinary catheter (n = 75) or sterile blood cultures (n = 99). Finally,
30 patients were studied (17 men; median age: 73 years; diabetes: n = 7; mitral valvular
disease: n = 2, aortic valvular disease: n = 2) (Table 1). Reasons for admission were
markedly heterogeneous and fever accounted for 14 cases. Echocardiography was performed
in 25 patients with a median delay of 6.5 days (range: 0–23 days) and IE was confirmed
in 21 of them. Only three cases of IE have been diagnosed in the ED because of a fever
and valvular murmur (n = 2) but no patient was admitted to the ED for IE suspicion.
Other initially suspected diagnoses were prostatitis, pneumonia or appendicitis and
not related to any type of infection in 26% of the cases. The origin of Sa bacteremia
was cutaneous in 67% of the cases. During the hospital stay, 70% of the patients presented
secondary sites of Sa infection in addition to the urinary tract (arthritis, splenic
abcess, cerebral hematoma). Among 21 patients presenting with an IE, 8 died within
7 days, and total hospital mortality reached 50%.
Table 1
Patients characteristics
Characteristics
n (%)
Median age (year)
63
Heart murmur
5 (24)
Congenital heart valve defect
19 (90)
Mitral localization
19 (90)
Abuse (drug, alcohol…)
4 (19)
Microbiology
MSSA
20 (95)
MRSA
1 (5)
Origin
Skin
14 (67)
Unknown
7 (33)
Complications
Central nervous system
9 (43)
Visceral abscesses
2 (9.5)
Septic arthritis
9 (43)
Skin and eye petechiae
9 (43)
Death
8 (38)
Conclusion This case series suggests that IE should be ruled out when Sa bacteriuria
is evidenced, irrespective of the clinical presentation. This could question the reality
of isolated community-acquired urinary tract infections due to Sa.
Competing interests None.
References
Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T, et al. Proposed modifications
to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis
Off Publ Infect Dis Soc Am. 2000;30(4):633–8.
Ekkelenkamp MB, Verhoef J, Bonten MJ. Quantifying the relationship between Staphylococcus
aureus bacteremia and S. aureus bacteriuria: a retrospective analysis in a tertiary
care hospital. Clin Infect Dis Off Publ Infect Dis Soc Am. 2007;44(11):1457–9.
P149 The infectious tricuspid endocarditis in ICU: clinical features, management and
outcome
Amira Jamoussi1, Amira Ben Jazia1, Takoua Marhbène1, Dhouha Lakhdhar1, Jalila Ben
Khelil1, Mohamed Besbes1
1Medical icu, Hospital Abderrahmen Mami De Pneumo-Phtisiologie, Ariana, Tunisia
Correspondence: Amira Jamoussi - dr.amira.jamoussi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P149
Introduction Since the outbreak scourge of intravenous drug addiction in Tunisia,
we are witnessing the emergence of cases of infectious tricuspid endocarditis (ITE).
This pathology should be studied because it requires specific medical and surgical
management. The aim of the study was to describe the clinical features, management
and outcome of ITE in intensive care unit.
Patients and methods This was a retrospective study from January 2009 to December
2014. We enrolled patients who were hospitalized in intensive care unit and had ITE.
We recorded baseline characteristics, management and outcome.
Results During the study period, we collected 10 cases of ITE making an incidence
rate of 3 cases for 1000 patient admissions. They were divided into 8 men and 2 women.
The median age was of 37.5 years. The main reasons of ICU admission was acute respiratory
failure (80%), among them 5 required mechanical ventilation. Hemodynamic failure was
present in 3 cases.
The median SAPS II was of 33 [19–90]. The median APACHE II was of 17 [7–53]. Different
contributing factors were identified: intravenous drug abuse (6 patients), a central
venous catheter (1 patient) and a pacemaker (1 patient).
All patients underwent transesophageal echocardiography showing one or several vegetations
on native tricuspid valve. No associated left endocarditis was found.
Blood cultures were positive in 8 cases of which 5 contained 2 different micro-organisms.
The identified micro-organisms were: Meticillin Resistant Staphylococcus aureus (n = 6),
Meticillin Sensitive Staphylococcus aureus (n = 3), coagulase-negative staphylococcus
(n = 2), Enterobacter cloacae (n = 1), and candida famata (n = 1). Occurring complications
were hospital-acquired infections (n = 5), septic pulmonary embolism (n = 4), withdrawal
syndrome (5 cases), acute renal failure (n = 2) and atrioventricular block (n = 2).
Medical treatment consisted of a double antibiotic treatment. Surgical treatment was
required in 7 patients: tricuspid valve replacement by bioprosthesis (6 cases) and
valvuloplasty (1 case).
The average length of stay was of 31.3 days [2–56]. ITE had recurred on bioprotheses
in two patients after intravenous drug resumption; they underwent surgery again and
one of them died.
In hospital mortality was of 30%. The outcome was favorable in 7 patients.
Conclusion The ITE in ICU is a severe disease with frequent complications and in hospital
mortality reaches 30%. The most frequent incriminated micro-organism is Meticillin
Resistant Staphylococcus aureus. It often requires medical and surgical treatment.
Intravenous drug addiction remains the most common cause and worsens the prognosis
by the risk of recurrence.
Competing interests None.
P150 Microbiological mapping of community-acquired intra-abdominal infections (IAI)
and indicator of local antibiotherapy appropriateness with French national guidelines
Julien Goutay1, Caroline Blazejewski2, Isabelle Joly-Durand3, Isabelle Pirlet4, Marie
Pierre Weillaert5, Sebastien Beague2
1Interne en anesthésie réanimation, C.H. Régional Universitaire de Lille (CHRU de
Lille), Lille, France; 2Réanimation polyvalente, Hospital Center De Dunkerque, Dunkerque,
France; 3Equipe opérationnelle d’hygiene, Hospital Center De Dunkerque, Dunkerque,
France; 4Service de chirurgie digestive, Hospital Center De Dunkerque, Dunkerque,
France; 5Laboratoire, Hospital Center De Dunkerque, Dunkerque, France
Correspondence: Julien Goutay - julien.goutay@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P150
Introduction French guidelines for community-acquired IAI underline the importance
of establishing antibiotherapy protocols based on regular analysis of microbiological
data; and of systematic site infection cultures to determine microbial sensitivity
to antibiotics. Our study describes microbial population involved in our community-acquired
IAI and defines an annual follow-up indicator of probabilistic antibiotherapy inadequacy
to microbial sensitivity.
Materials and methods We conducted a retrospective, monocentric, observational study
from January the 1st 2014 to December the 31st 2015. All community-acquired IAI in
adults were included. Exclusion criteria were: cirrhosis and peritoneal dialysis.
Initial probabilistic antibiotherapy and total antibiotherapy duration were left to
the discretion of the physician in charge. Results of intra-abdominal cultures (IAC)
were analyzed. Three microbial groups were defined: (A) A-group: wild-type bacteria
strains treated with adequat antibiotherapy; (B) B-group: antibiotic resistant bacteria
treated with adequat antibiotherapy; (C) C-group: multi-drug resistant bacteria treated
with inadequat antibiotherapy. A Chi square analysis was performed on SPSS software
(IBM).
Results 98 community-acquired IAI were included: 54 (55%) had positive IAC with 133
bacteria; 34 (35%) didn’t have intra-abdominal swab; 10 (10%) had sterile cultures.
Predominant strains were Gram-negative bacteria (76/133 (57%)). More represented bacteria
were Escherichia Coli (50/133 (38%)) and Bacteroïdes fragilis (16/133 (12%)). 127/133
(95%) bacteria belong to A- and B-groups. B-group importance increased significantly
between 2015 and 2016. C-group characteristics were comparable over the 2 years. Initial
antibiotherapy was inadequate with French guidelines in 38/98 (39%) cases and with
microbial antibiotic susceptibility in 6/133 (4.5%) cases (C-group). Average antibiotherapy
duration was 11.3 days. Antibiotic treatment duration was too long according to French
guidelines for 65/98 (67%) patients.
Discussion Our microbial population in community-acquired IAI is similar to national
studies with a lowest resistance rate (C-group under 10%). Probabilistic antibiotherapy
proposed by French guidelines is appropriated to our microbial ecology. Antibiotherapy
duration is unconformed with guidelines in 67% cases. Peroperative swabs are frequently
missing (35%). Non-compliance with French guidelines highlights the importance to
formalize our local procedure. This formalization at any stage (surgical, medical
and biological cares) seems essential to improve our standard of care. C-group rate
could be used as a real-time feedback to adapt our protocol continuously.
Conclusion The goal of our study is to improve local standard of care by offering
a formalization of community-acquired IAI management procedure. C-group rate seems
to be a good follow-up indicator of probabilistic antibiotherapy inadequacy to microbial
sensitivity, allowing an optimization of our protocol in real-time.
Competing interests None.
Reference
Montravers et al. Recommandations Formalisées d’Experts «Prise en charge des infections
intra-abdominales», Octobre 2015.
P151 The resumption of peritonitis in surgical intensive care unit
Ma Bouhouri1, Kamal Belkadi2, Soufi Aziz1, Khalid Khaleq3, Afak Nsiri1, Driss Hamoudi1,
Rachid Harrar1
1Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco; 2Anesthesie
reanimation, chu ibn rochd, Casablanca, Morocco; 3Service d’accueil des urgences,
Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Kamal Belkadi - kamal.belkadi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P151
Introduction The resumption of peritonitis is a serious complication of abdominal
and pelvic surgery. It’s a medical and surgical emergency, the prognosis depends on
the speed, the quality of the care, and the underlying terrain and etiology.
Patients and methods We conducted a descriptive analytic retrospective study over
a period of 5 years (January 2011–June 2016) 60 cases of peritonitis hospitalized
in surgical intensive care unit.
Results The average age of our patients was 44.36 years with a sex ratio of 1.5 (36H/24F).
The most frequent risk factors were: factors relating to the ground, and factors related
to the initial peritonitis.
Clinical signs were dominated by fever (75%), abdominal pain (52%). The period of
the average recovery was 8.2 days. The decision of the surgical revision was based
on a clinical, biological and radiological criteria.
40 patients in our series, 67% of cases were taken on clinical and biological criteria
while 15 patients 25% were taken on radiological criteria. In 8% of the remaining
cases, the potential severity of the clinical and biological state in association
with an inconclusive ultrasound, led to reoperation.
The therapeutic treatment was based on a perioperative resuscitation, treatment of
organ failure, empirical antibiotic therapy and by midline laparotomy surgery. Bacteriological
samples performed intraoperatively allowed to have the following bacteriological profile:
predominance of BGN (79%) dominated by E. coli (28%) followed by Klebsiella pneumoniae
(21%), Acinetobacter and Enterococcus baumanii (12%). The multimicrobien character
was found in 55%. The E. coli–Klebsiella pneumoniae association was the most frequent
(37%).
The anastomotic dehiscence was the direct cause of the most common surgical revision
found intraoperative (62%). The average hospital stay was 8 days. The mortality rate
was 61%. The main prognostic factors in our study emerged in the univariate analysis
were: kidney failure, the number of organ failure, a TP <50% the needs of ventilation
and the use of catecholamines.
Discussion Mortality is variable depending on the studies, between 25 and 60%.
Conclusion The diagnosis often difficult. Only effective and early therapeutic management
reduces mortality remains high in recent years despite the various advances in the
field of surgery and reanimation.
Competing interests None.
P152 Prognostic factors in intra abdominal sepsis: a prospective study
Reda Hafiane1, Khalid Khaleq1, Khalid Hattabi2, Mohamed Aziz Bouhouri1, Afak Nsiri1,
Driss Hammoudi1, Abdelaziz Fadil2, Rachid Al Harrar1
1Service de réanimation des urgences chirurgicales, CHU IBN ROCHD de Casablanca, casablanca,
Morocco; 2Service des urgences viscérales, CHU Ibn Rochd de casablanca, Casablanca,
Morocco
Correspondence: Reda Hafiane - hafiane.reda89@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P152
Introduction Intra- abdominal sepsis represents a life threatening condition. Its
manifestations are non specific and can quickly lead to multi organ failure if not
treated correctly. Patient’s assessment is essential in order to adjust the therapy.
The aim of our study is to highlight the prognostic factors in this situation.
Patients and methods It’s a prospective observational study performed during 6 months
(02/2016–08/2016) in visceral emergency operating rooms.
Inclusion criteria: adults admitted with intra-abdominal infectious disease diagnosed
with biological and radiological means.
Studied parameters: demographic data, co morbidities, number of organ failure, type
of anesthesia, intraoperative incidents and evolution. Results were analyzed using
SPSS software, prognostic factors were extracted with univariate then multivariate
analysis. Significant results were noted.
Results During this period, we admitted 302 patients, the mean age: 41.14 ± 17 years.
Male predominance was noticed in our population: 69.9%. The mortality rate was: 13.2%.
The main prognostic factors were reported in the attached Table 2.
Table 2
Main prognostic factors in intra abdominal sepsis
Variable
Hazard ratio unadjusted
p
Hazard ratio adjusted
p
Age
1.047
0.001
1.032
0.009
Sex
3.25
0.001
0.068
0.47
High hemoglobin
0.68
0.01
0.33
0.52
creatinine
1.11
0.001
1.16
0.001
Pesence of clammy skin
14.74
0.001
77
0.05
Urea
37.34
0.01
37
0.25
Hemodynamic instability
26
0.001
1.27
0.834
Use of vasoactive drugs
29
0.001
34
0.001
Operating time
1.018
0.0001
1.014
0.001
Discussion Many significant prognostic factors were identified: Age, existence of
hemodynamic failure with renal involvement, long operative time and the use of vasoactive
drugs.
A high hemoglobin level at the admission was a protective factor.
The presence of respiratory distress, the sex and the presence of yeasts were not
significant factors in our study.
Conclusion Intra abdominal sepsis is causing quickly a multi organ dysfunction syndrome
leading to death. Therefore, our priority is to stop this sepsis with the help of
the surgeon and the efficient use of antibiotics.
Competing interests None.
P153 Community acquired intra abdominal sepsis: concerning 302 cases
Reda Hafiane1, Khalid Khaleq1, Khalid Hattabi2, Mohamed Aziz Bouhouri1, Afak Nsiri1,
Driss Hammoudi1, Khalid Zerouali3, Abdelaziz Fadil2, Rachid Al Harrar1
1Service de réanimation des urgences chirurgicales, CHU IBN ROCHD de Casablanca, casablanca,
Morocco; 2 Service des urgences viscérales, CHU Ibn Rochd de casablanca, Casablanca,
Morocco; 3Service de microbiologie, CHU Ibn Rochd de casablanca, Casablanca, Morocco
Correspondence: Reda Hafiane - hafiane.reda89@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P153
Introduction Intra abdominal sepsis is a dangerous condition causing a high mortality
rate even with surgery and post operative care improvement.
The aim of the study is to assess the bacteriological and epidemiological profile
of this population.
Patients and methods It’s a prospective observational study performed during 6 months
(02/2016–08/2016) in visceral emergency operating rooms.
Inclusion criteria: adults admitted with intra-abdominal infectious disease diagnosed
with biological and radiological means.
Exclusion criteria: post operative peritonitis and deceased patients before their
admittance.
Studied parameters: demographic data (gender, age…), the time management, co morbidities,
number of organ failure, intraoperative incidents and postoperative evolution.
Results During this period, we admitted 302 patients, the mean age: 41.14 ± 17 years.
Male predominance was noticed in our population: 69.9%.
Main emergencies are reported in the attached Table 3. Concerning the bacteriological
profile: we had 121 positive samplings. Enterobacterias were the most frequent strain.
E coli was predominant: 43%, Enterococcus faecalis: 25%, Streptococcus (viridians
and acidominimus): 14%, we had 1 case of Acinetobacter baumanii resistant to imipenem.
6 cases of yeasts were found (Candida albicans).
Table 3
Main emergencies with epidemiological profile
Disease
Number (n)
Sex ratio (M/F)
Age (years)
Time management (days)
Number of organ failure (n)
APACHE II score
Number of deaths (n)
Peptic perforation peritonitis
48
47
42.5
1.54
1
10
1
Appendicitis
100
1.43
31.7
2.95
0
7
0
intestinal perforation peritonitis
18
0.63
36
5.6
3
19
6
Biliary peritonitis
10
0.43
62.2
7.2
2
16
4
Post traumatic peritonitis
6
6
25
3.1
3
15
2
Necrotizing fasciitis
28
13
55.9
20
0
12
0
Antibiotic use was: Ampicilline: 44%, Ceftriaxone 41%, metronidazole: 76% and tazocilline:
4%.
Discussion In our context, community acquired intra abdominal sepsis leads to a high
death rate. We noticed relevant parameters: a late time management, high gravity scores,
some surgical procedures not directed by supervisors. Therefore, we have to establish
therapeutic protocols tailored to each disease in order to improve patients’ management
and help to reduce the mortality rate.
Conclusion Early diagnosis and care for intra abdominal sepsis represent a major way
to prevent complications. Bacteriological proof is necessary to adjust post operative
antibiotherapy.
Competing interests None.
P154 Conformity of antibiotic prescribing in emergency room
Fatma Kaaniche Medhioub1, Rania Allela2, Najla Ben Algia3, Samar Cherif4
1Faculté de médecine de Sfax, Sfax, Tunisia; 2Hopital régional mahres, Faculté de
médecine de Sfax, Sfax, Tunisia; 3Intensive care, hopital régional Gafsa, Sfax, Tunisia;
4Intensive care, hopital régional mahres, Sfax, Tunisia
Correspondence: Fatma Kaaniche Medhioub - fatma_kaaniche@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P154
Introduction The development of bacterial resistance is a major public health problem
due to unreasonable use of antibiotics. The introduction of appropriate antibiotic
therapy has a positive impact on patient survival and a significant economic impact.
The objective of this study is to evaluate the compliance of antibiotics prescribed
in emergencies.
Patients and methods Prospective study conducted on 1 year (01/01/2015–31/12/2015).
We have included patients admitted to the emergency with hyperthermia (>38°), hypothermia
(<36°) or two criteria of systemic inflammatory response syndrome. Were collected
in the emergency department: history, presence of prior antibiotic therapy, demographic
and clinical characteristics at admission, prescription of antibiotics in emergencies
and its modalities and the discharge diagnosis. During hospitalization were collected:
the introduction, modification or discontinuation of the antibiotic, the reasons for
this change and certainty diagnosis. The compliance analysis of antibiotic therapy
was performed by an expert group (two infectiologists, a bacteriologist and an emergency
doctor) with regard to the current recommendations. Two groups were defined and compared:
group of patients receiving complies antibiotic therapy and group with antibiotics
considered improper. The criteria associated with non-compliance were sought.
Results Four hundred and twenty-two patients were enrolled. The final diagnosis retained
an infectious etiology in 356 patients (84%). The mean age was 62.4 ± 18 years. Blood
cultures were taken in 370 cases (87.7%). Infectious sites were most often lung (52%)
and urine (32%). Severe sepsis was diagnosed in 14 patients (3.3%). A complies prescription
was found in 335 patients (79.4%). Antibiotic therapy was started in 302 patients
(71.5%) at the emergency and classified complies with 234 (55.4%). Among the 68 patients
(16.1%) with an illegal antibiotic, it was continued in 24 (35.3%) during hospitalization.
Among 120 patients (28.4%) did not receive antibiotics, this attitude was classified
complies in 115 patients (95.8%). Non-compliance was related to the presence of antibiotics
in the last 3 months and the presence of renal failure.
Conclusion Particular attention should be paid to the antibiotic prescription in patients
subject to prior exposure to these. Dose adjustments should be respected in cases
of renal failure. Regular evaluation of the antibiotic prescription in the emergency
is necessary.
Competing interests None.
P155 Pulmonary resections’ bacterial cartography
Mohamed Taoufik Slaoui1, Souhail Boubia2, Y. Hafiani1, A. Khaoudi1, R. Cherkab1, W.
Elallam1, C. Elkettani1, L. Barrou.1, M. Ridaii2
1Anesthesia service surgical resuscitation, chu ibn rochd, Casablanca, Morocco; 2
Thoracic surgery, chu ibn rochd, Casablanca, Morocco
Correspondence: Mohamed Taoufik Slaoui - dr.t.slaoui@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P155
Introduction The study of the bacterial cartography in thoracic surgery is extremely
important for the treatment of post-operative infections due to the severity of the
underlying pathology, the fragility of patients after surgery in addition to the choice
of the empiric antibiotic therapy.
Materials and methods We led a prospective study following all the patients who underwent
a pulmonary resection surgery for a period of 7 months from January to July 2016,
jointly with the microbiology department, CHU Ibn Rochd, Casablanca. The bronchial
secretions were collected by a protected distal bronchial sample using a (Combicath)
after the intubation.
Results During the period of the study, 92 patients underwent a pulmonary resection,
65% for a neoplastic pathology.
The medium age was 43 years ±8 and 58% of our sample were male. 48% of our patients
had smoking habits and 16 of them had pulmonary tuberculosis, 12 had repeated respiratory
infections. The antibiotics used in pre-operative: 58% of beta-lactams; 22% of fluoroquinolones;
5% of macrolides.
Moreover, 60% of our patients were classified ASA1.
Of the 92 obtained samples, 22 were positive (23.9%). The most frequently observed
germs were the Acinetobacter baumannii (8.7%), Pseudomonas aeruginosa (6.5%), Klebsiella
pneumoniae (4.3%), Staphylococcus aureus (4.3%). The Acinetobacter baumannii was the
most resistant germ (60% sensibility to carbapenem).
These patients were followed until their D30 after surgery, 12 of them developed a
post-operative pneumonitis with 4 cases of multi-resistant Acinetobacter Baumanii,
2 of which deceased.
Conclusion Pneumonitis after pulmonary resection are common and severe that’s why
it is necessary to establish a global prevention strategy mainly based on general
patricians and pneumologists’ awareness concerning the choice of the prescribed antibiotics,
in order to avoid the spread of multi-resistant germs.
Competing interests None.
P156 The Acinetobacter baumannii (AB) in the severe burns
Rihi El Mehdi1
1Intensive care unit, IBN ROCHD, Casablanca, Morocco
Correspondence: Rihi El Mehdi - mehdi_44@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):P156
Introduction Infection is a major cause of morbidity and mortality in burned. The
bacterial ecology varies among centers. Despite the progress in the management of
severe burned, mortality remains very high. The aim of this study is to establish
the pathogenic profile of AB in this population.
Materials and methods Single-center retrospective study of 7 months, including any
serious burned hospitalized for more than 48 h in intensive care, and who benefited
from bacteriological samples during his stay.
Infectivity was retained on a range of clinical and biological arguments (CDC criteria)
changed). They excluded all burned died for non-infectious causes, and patients with
isolated settlement.
Results Sixty-two (72) patients were infected by the AB during our study period. The
sex ratio (M/F) was 1.7 and the mean age was 39 ± 23 years. Nosocomial pneumonia was
present in 61.11% of cases. Urinary tract infection was present in 18.05% of cases.
Bacteremia was present in 12.5% of cases. Skin infection was present 8.33% of cases.
The resistance profile was marked by 100% of cases of resistance to third-generation
cephalosporins (C3G), 88% of cases of resistance to fluoro-quinolones (FQ), 74% of
cases of resistance to imipenem and 64, 28% of cases of resistance to tigecycline.
Conclusion The incidence of infection with Acinetobacter baumannii in our unit remains
high compared to that of intensive care units. Colonization and infection by the AB
are significantly associated with increased length of stay, and mortality, and given
the gravity of hospitalized patients, failure to comply with hygiene and abusive use
of antibiotic prophylaxis.
Competing interests None.
Reference
Coignard B, Lepoutre A, Desenclos JC. Lessons learned from implementing a mandatory
notification of hospital acquired infections in France [cited June 11, 2006]. Lyon,
France.
P157 Clinical impact of extended-spectrum β-lactamase producing Enterobacteriaceae
colonization on pneumonia in ICU
Caroline Schimpf1, Assaf Mizrahi2, Benoît Pilmis2, Alban Le Monnier2, Kelly Tiercelet1,
Mélanie Cherin3, Cédric Bruel1, Francois Philippart1
1Réanimation, Groupe Hospitalier Paris Saint-Joseph, Paris, France; 2Unité de microbiologie
clinique et dosages des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris,
France; 3Réanimation polyvalente adulte, Centre Hospitalier Intercommunal André Grégoire,
Montreuil, France
Correspondence: Francois Philippart - fphilippart@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P157
Introduction ESBL are enzymes mostly found in Enterobacteriaceae and confer resistance
to all beta lactams antibiotics except cefoxitin and carbapenems. Recently, a significant
increase in the rate of ESBL-related infections in ICU makes difficult the choice
of empiric antibiotic therapy, especially in patients colonized by extended-spectrum
β-lactamase producing Enterobacteriaceae (ESBLe) [1]. Notably, very few data are currently
available regarding the role of ESBLe colonization on further pneumonia involving
the same bacteria [2]. The aim of our study was to describe the incidence of ESBLe
infections among ESBLe-colonized ICU patients.
Patients and methods This study was conducted retrospectively from January 1st 2011
to May 1st 2016, in our intensive care department. All admitted ESBLe-colonized patients
who develop an infection during their ICU stay have been included in the study. The
only exclusion criterion was an antibiotic treatment for an ESBLe infection at ICU
admission.
Results During the period of the study, 386 stays were associated with an ESBLe colonization
in 384 patients. 148 infections were diagnosed in patients colonized by ESBLe, among
which 78 pneumonias. In 18 cases (23%) the ESBLe was involved in the pulmonary infection
(PN-ESBLe+) and was the only responsible bacterium in 66% of cases. The ESBLe was
the same in screening and pneumonia in 15 cases (83%). The PN-ESBLe+ was associated
with septic shock in 9 (50%) cases, acute respiratory distress syndrome in 2 (11%)
cases and neurologic failure in 7 (39%) cases. Episodes were ventilator-associated
pneumonia in 56% (10 cases) of PN-ESBLe+ and 52% (31 cases) of PN-ESLBe-. The most
common pathogens involved were Escherichia coli, Klebsiella pneumoniae, and Enterobacter
cloacae in both groups. Comparing groups (PN-ESBLe+ or PN-ESLBe−), only the notion
of prior antibiotic therapy within 30 days (OR 3.9 [1.07–18.3]; p = 0.03) and colonization
by ESBL Klebsiella pneumoniae (OR 4.04 [1.02–16.1]; p = 0.04) were more frequent in
PN-ESBLe+. At least one empiric antibiotic was effective on the ESBLe in 83% of cases.
In vitro antibiotic susceptibility tests demonstrate 100% efficiency of the association
of piperacillin/tazobactam and amikacin on ESBLe involved in pneumonia.
Mortality at day 28 was 24% for PN-ESBLe+ and 44% for PN-ESBLe−. Hospital mortality
was 53 and 38% respectively (p = NS).
Among 70 extra-pulmonary infections, ESLBe take part in 30 (43%) cases. The involvement
of ESBLe was significantly lower in pneumonia than in other infections (p = 0.01).
Discussion Due to the single center character of our study, results cannot be extrapolated
to the whole ICU population. Nevertheless, the observed incidence of colonizing ESBLe
in our study is close enough from others studies. This point consolidates reflection
about ICU pneumonia empiric treatment.
Conclusion The involvement of colonizing-ESBLe in ICU pneumonia is rare in our population
and significantly lower than in other infections. Identified risk factors for PN-ESBLe + are
a prior antibiotic therapy within 30 days and colonization with K. pneumoniae. Alternative
associations to carbapenem remain efficient in all cases of pneumonia in our ICU and
should probably be kept in mind.
Competing interests None.
References
Bretonniere C, Leone M, Milesi C, Allaouchiche B, Armand-Lefevre L, Baldesi O, et
al. Strategies to reduce curative antibiotic therapy in intensive care units (adult
and paediatric). Intensive Care Med 2015;41(7):1181–96.
Depuydt PO, Vandijck DM, Bekaert MA, Decruyenaere JM, Blot SI, Vogelaers DP, et al.
Determinants and impact of multidrug antibiotic resistance in pathogens causing ventilator-associated-pneumonia.
Crit Care 2008;12(6):R142.
P158 Risk factors of resistance for Gram negative bacilli responsible for ICU: acquired
bacteremia—analysis of a large French ICU network
Sébastien Bailly1, Jc Lucet2, Alain Lepape3, François L’hériteau4, Martine Aupée5,
Caroline Bervas6, Sandrine Boussat7, Anne Berger-Carbonne8, Anaïs Machut9, Anne Savey10,
Jean-François Timsit11, REA-RAISIN Study group
1Iame team 5, INSERM UMR 1137, Paris, France; 2Hygiène hospitalière, Hôpital Bichat-Claude
Bernard (AP-HP), Paris, France; 3Réanimation, Hospices Civils De Lyon, Lyon, France;
4Médecine interne, Hôpital Bichat-Claude Bernard (AP-HP), Paris, France; 5Hygiène
hospitalière, C.H.U de Rennes, Rennes, France; 6Pharmacie, CHU - Hôpitaux de Bordeaux,
Bordeaux, France; 7Réanimation, CHRU Nancy, Nancy, France; 8Dgos, Ministère des Affaires
sociales et de la Santé, Paris, France; 9Cclin sud est, Hospices Civils De Lyon, Lyon,
France; 10Cclin, Hospices Civils De Lyon, Lyon, France; 11 Réanimation médicale et
infectieuse, Hôpital Bichat-Claude Bernard, Paris, France
Correspondence: Sébastien Bailly - sbailly@chu-grenoble.fr
Annals of Intensive Care 2017, 7(Suppl 1):P158
Introduction Immediate adequate treatment of ICU-acquired Gram negative bacilli (GNB)
bloodstream infections (BSI) improves patients’ prognosis. Risk factors of resistance
of GNB-BSIs should be better assessed.
Materials and methods Data from a large French national ICU network were explored
during a 10-year period (2005–2014). Patients with a GNB-BSI were included and were
divided into two groups according to the resistance (R) profile (BSI due to a R isolate
or not). The following three groups were considered: (1) all GNB-BSI including Pseudomonas
spp., Acinetobacter spp., Stenotrophomonas spp. and Enterobacteriacae (Eb) for which
the following R were considered: ticarcillin (Pseudomonas spp., Acinetobacter spp.,
Stenotrophomonas spp.); ceftazidime (cefta) (P. aeruginosa (PA), Acinetobacter spp.,
Stenotrophomonas spp.), third generation cephalosporin (3GC) (Eb) and imipenem (all
GNB, during the period 2011–2014 only), (2) PA cefta R from 2005 to 2014 and (3) Eb
species resistant to 3GC from 2005 to 2014. Univariable hierarchical logistic models
with two levels (random center and region effects) were used to select variables associated
with resistance using a p value threshold of 0.2. Selected variables were further
introduced in multivariable analyses using a hierarchical model with two random effects.
Results From 265,035 patients admitted in an annual median of 158 French ICUs, 9553
experienced an ICU-acquired (>48 h.) BSI, 5062 (53%) BSI due to GNB, including 1764
(35%) BSI due to R isolates. PA was identified in 1167 (23%) BSIs (480 (41%) R) and
Eb in 3298 (65%) BSIs (1226 (34%) R). The median annual incidences of R GNB BSIs/10,000
ICU patients were: 68 for all R GNB BSI, 41 for Eb 3GC-R BSIs and 9.2 for PA cefta-R
BSI. There was a significant increase of annual incidence for all GNB R and Eb 3GC-R
BSI.
Independent factors associated with all R GNB BSI were: 1) ICU variables: percentage
of patients with an immunosuppression other than neutropenia (7.9–14%: OR 1.23; 95%
CI, [1.04–1.46]; >14%: 1.31 [1.09–1.57]); percentage of resistant GNB the previous
year (55–66%: 1.87 [1.59–2.2]; >66%: 2.93 [2.43–3.53]) and 2) patient-variables: antimicrobial
therapy at ICU admission (1.79 [1.55–2.08]); presence of an invasive device (CVC or
intubation) (1.99 [1.25–3.16]) before infection; and one protective factor: trauma
at ICU admission (0.76 [0.65–0.89]). The year effect was significant both for all
R GNB and 3GC-R Eb but not for R PA. This effect was more pronounced for 3GC-R Eb,
with an increase in the risk of R from 2005 to 2014 (Fig. 2). The duration from ICU
admission to infection was the main risk factor of R for all BGN and sub-groups (Eb
and PA): the probability of having a BSI due to a R strain increased with the time
in ICU before infection (Fig. 3). ICU-based random effect remains significant indicating
major impact of local epidemiology.
Fig. 2
Evolution of the risk to have a BSI due to a resistant strain according to the year
of ICU admission
Fig. 3
Days from ICU admission to infection
Limitation The absence of information about antibiotic consumption may partly explain
the remaining significant center random effect in the final models.
Conclusion The duration from ICU admission to BSI was a main risk factor for a resistant
isolate in GNB BSI. Resistance rates increased over time, especially for 3GC-R Eb
and were highly dependent of local previous epidemiology.
Competing interests None.
P159 Sepsis at ICU admission due to extended-spectrum β-lactamase producing enterobacteriaceae
among colonized patients: prevalence, risk factors and prognosis
Keyvan Razazi1, Jérémy Rosman1, Nicolas de Prost1, Guillaume Carteaux1, Chloe Jansen2,
Jean Winoc Decousser3, Christian Brun-Buisson1, Armand Mekontso Dessap1
1Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 2Cepi, Hospital Henri
Mondor, Créteil, France; 3Microbiologie, Hôpital Henri Mondor, Créteil, France
Correspondence: Jérémy Rosman - jeremy.rosman@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P159
Introduction Prevalence of Extended-spectrum beta-lactamase-producing Enterobacteriaceae
(ESBL-PE) carriers dramatically increases all over the world with a spread to the
community. The increasing prevalence of ESBL-PE carriage at Intensive Care Unit (ICU)
admission raises important questions on empiric therapy strategies in patients presenting
with infection, which may include the use of a carbapenem as first-line therapy. Data
on ESBL-PE sepsis at ICU admission among colonized patients are lacking.
Patients and methods We prospectively assessed between 2009 and 2015 the prevalence,
risk factors and prognosis of ESBL-PE sepsis among ESBL-PE carriers at ICU admission.
The following data were collected: demographic characteristics, which included sex,
age, simplified acute physiology score (SAPS II), location before ICU admission, antibiotic
exposure, surgery during the previous year, presence of underlying disease, Charlson
comorbidity index, presence of indwelling devices and outcomes.
Results A total of 597 patients had ESBL-PE carriage detected at admission, corresponding
to 9.5% of admitted patients. Among these patients, 325 patients had sepsis at ICU
admission. Fifty patients (15.4%) had ESBL-PE related sepsis at ICU admission. ESBL-PE
infection included 23 (46%) urinary tract infections, 14 (28%) pulmonary infections,
9 (18%) abdominal infections and 4 (8%) other infections. All but two ESBL-PE pneumonia
cases were hospital-acquired (86%) while community-acquired ESBL-PE urinary tract
infection was not uncommon (12/36 = 33%).
By multivariable analysis, prior urinary tract disease [OR 3.0 (1.1–8.0)], hospital-acquired
sepsis at admission [OR 2.9 (1.4–5.7)], treatment with fluoroquinolone within the
past 3 months [OR 2.8 (1.2–6.4)] past ESBL-PE infection [OR 2.8 (1.2–6.5)] were independent
predictive factors for ESBL-PE sepsis at admission, whereas a pulmonary source of
sepsis [OR 0.30 (0.15–0.61)] was protective. The final model showed a good calibration
(chi2 = 3.7, p = 0.45) and discrimination (area under the curve = 0.85). Patients
with ESBL-PE related sepsis had more often septic shock and bacteraemia at admission.
ESBL-PE related sepsis was also more often associated with more frequent inadequate
empirical therapy (68 vs 87%, p < 0.001). However, mortality did not differ significantly
between patients with ESBL-PE infection and others (20 vs 22%).
Conclusion At ICU admission, ESBL-PE related sepsis was relatively infrequent among
colonized patients. Our predictive factors for ESBL-PE may help choosing empiric therapy
for sepsis among ESBL-PE carriers at ICU admission. The study did not show a significant
association between ESBL-PE infection at admission and mortality.
Competing interests None.
Reference
Goulenok T, Ferroni A, Bille E, Lécuyer H, Join-Lambert O, Descamps P, Nassif X, Zahar
JR. Risk factors for developing ESBL E. coli: can clinicians predict infection in
patients with prior colonization? Hosp Infect. 2013;84(4):294–9.
P160 Carbapenemase-producing Enterobacteriaceae: experience of a Tunisian intensive
care unit
Amira Ben Jazia1, A. M’rad1, Zouhour Ouali2, Manel Barghouth1, Y Blel1, N Brahmi1
1Department of intensive care and toxicology, Centre d’Assistance Médicale Urgente,
Tunis, Tunisia; 2Department of biology, Centre d’Assistance Médicale Urgente, Tunis,
Tunisia
Correspondence: A. M’rad - mrad.aymen@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P160
Introduction Carbapenemase-producing Enterobacteriaceae (CPEc) are increasingly reported
worldwide and constitutes a real challenge antibiotic for clinicians to preserve the
bacterial ecology. Its incidence has remarkably increased in our intensive care unit
during the last 5 years.
This work aims to focus on the impact of CPEc increasing in our intensive care unit.
Patients and methods A retrospective and descriptive study conducted in a Tunisian
intensive care unit, including all hospitalized patients infected by an Enterobacteriaceae.
We have determined annual incidence of CPEc from January 2008 to December 2015.
Results One thousand two hundred and three episodes of Enterobacteriaceae infections
were eligible in 748 patients (324 male/424 female) aged between 14 and 88 years.
The global prevalence of CPEc across study period was 4.48% (54/1203).The prevalence
of CPEc in each site was respectively of 23% in hemocultures, 18% in coproculture,
12% in catheters, 3.3% in respiratory tract, and 3% in urinary tract.
The overall incidence of (CPEc) increased from 0.69% (1/144) in 2008 to 7.77% (15/193)
in 2015 (Fig. 4).
Fig. 4
CPEc increasing from 2011 to 2015
Conclusion
Our study confirms the rapid spread of CPEc in Tunisian hospital and the urgent need
for a well-structured and coordinated national surveillance plan in order to limit
their dissemination.
Competing interests None.
P162 Extended spectrum beta lactamase producing enterobacteriacae (ESBL-PE) infections
in ICU
Achille Kouatchet1, Rafael Mahieu2, Emmanuel Weiss3, David Schnell4, Jean-Ralph Zahar5
1Service de Réanimation médicale et Médecine hyperbare, Centre Hospitalier Universitaire
d’Angers, Angers, France; 2Réanimation médicale, Centre Hospitalier Universitaire
d’Angers, Angers, France; 3Département d’anesthésie-réanimation, Hôpital Beaujon,
Boulevard du Général Leclerc, Clichy, France, Clichy, France; 4Réanimation médicale,
CHU de Strasbourg, Strasbourg, France; 5Laboratoire de bacteriologie-virologie-hygiene,
Hôpital Avicenne, Bobigny, France
Correspondence: Achille Kouatchet - ackouatchet@chu-angers.fr
Annals of Intensive Care 2017, 7(Suppl 1):P162
Introduction The ESBL spread has a major consequence in term of antibiotic choices.
Carbapenem antibiotic are regarded as the most effective treatment. However numbers
of authors suggest that alternatives antibiotics (i.e. noncarbapenems) could be used
in ESBL-PE infections. There are some conflicting data regarding the use of alternatives
in case of ESBL-PE infections. Moreover as far as we know, there are no data in ICU.
Objectives the aim of this study was to describe ESBL-PE infections in ICU and therapeutic
options chosen in these specific situations.
Patients and methods Prospective multicentric observational cohort study conducted
in volunteers ICU. All consecutive patients hospitalized in ICU with ESBL-PE infection
according to CDC definitions were included. Severity of illness was defines according
to bone criteria, SAPS II and SOFA. Demographic datas, empirical and definitive antibiotic
therapy (ET and DT), clinical evolution, and outcome were recorded. In vitro antimicrobial
susceptibility testing was performed by the disk diffusion method or the Vitek 2 system
according to the guidelines of the Antibiogram Committee of the French Microbiologic
society.
Results During the study period 146 patients with ESBL-PE infection met eligibility
criteria with respectively a median age and SAPS II score of 63 (51–74) and 50 (38–70).
The median SOFA Score at first day of antibiotic therapy and ICU admission were 7
(4–11) and 7 (5–11) respectively. The most frequent site of infection were respiratory
tract (45%), urinary tract (20%) and abdominal (17%). The most frequent isolated species
were: Escherichia coli (43%), Klebsiella sp (37%) and Enterobacter sp (18%). Respectively
50, 23 and 27% patients had septic shock, severe sepsis and sepsis according to Bone
criteria.
Among ESBL-PE, 98.6% were carbapenem and 46.5 were BLBI sensitive. Among the whole
population, 47 (48%) patients received a carbapenems as ET. 66 (68%) received a DT
with carbapenems and 31 (32%) patients received an alternative DT. The most frequent
reasons for maintaining carbapenems as DT were: Antibiotic susceptibility tests (38%
of cases), severity level (33% of cases) immunosuppression (8% of cases). The Median
length of ICU stay after infection was respectively 12 (6–27) and 11 (7–16) days for
carbapenems and alternatives DT (p = 0.1). The D28 mortality was 24% for patients
with carbapenems DT and 24% for patients with alternatives DT (p = 0.02).
Surprisingly, there were no differences between the 2 groups (carbapenems vs alternatives)
in term of severity.
Conclusion Alternatives are frequently used for ESBL-PE infections in ICU. In our
cohort 31 (32%) patients received antibiotics other than carbapenems regardless of
the severity.
Competing interests None.
P163 Extended-spectrum beta-lactamase-producing enterobacteriaceae cross-transmission
in the absence of private room in intensive care unit
Margaux Artiguenave1, Paktoris-Papine Sophie1, Florence Espinasse2, Faten El Sayed3,
Aurélien Dinh4, Cyril Charron1, Guillaume Geri5, Antoine Vieillard-Baron1, Xavier
Repessé1
1Réanimation médico-chirurgicale, Assistance Publique - Hôpitaux de Paris, Hôpital
Ambroise Paré, Boulogne-Billancourt, France; 2Equipe opérationnelle d’hygiène hospitalière,
Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt,
France; 3Service de microbiologie, Assistance Publique - Hôpitaux de Paris, Hôpital
Ambroise Paré, Boulogne-Billancourt, France; 4Equipe mobile de microbiologie, Assistance
Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France;
5Réanimation Médicale, Hôpital Cochin, Paris, France
Correspondence: Xavier Repessé - xavier.repesse@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):P163
Introduction Multidrug micro-organisms are responsible for longer hospitalisations
and poorer outcomes in intensive care unit (ICU). The transmission of extended-spectrum
beta-lactamase producing enterobacteriaceae (ESBL-PE) is prevented by the application
of additional contact precautions, mainly relying on isolation in a private room and
hand hygiene with waterless alcohol-based solution. Contact isolation cannot be achieved
in our 12-bed ICU only composed of two twin bedrooms. We aimed at reporting the ESBL-PE
acquisition in this peculiar architectural form of ICU and at studying the impact
of twin bedrooms on ESBL-PE cross-transmission.
Patients and methods An observational and non-interventional study was prospectively
conducted in the 12-bed ICU of a university hospital Ambroise Paré (Boulogne-Billancourt,
France). Inclusion criteria were: (1) adult patients and (2) a period of hospitalisation
allowing the patient to be nursed by at least two paramedical teams. Characteristics
of patients at admission (age, sex, SAPSII) and clinical data during hospital stay
(duration of mechanical ventilation, duration of ICU stay, outcome) were prospectively
collected. Microbiological data concerning ESBL-PE imported and acquired carriage
were monitored by rectal swabs collected at admission and once weekly every Monday
for the whole duration of the ICU stay. ESBL imported carriage was defined as a first
screening positive for ESBL whereas ESBL acquired carriage as a negative first screening
at admission followed by at least one positive rectal swan. Mechanistic of a potential
cross-transmission was studied following a three-step process consisting in (1) identifying
patients considered as possible ESBL sources (index patients) for transmission, (2)
classifying each ESBL strain according to the CTXm 1 and 9 groups and (3) diagnosing
potential cross-transmission by gene sequencing of remaining cases of possible transmission.
Results From June 2014 to April 2015, 550 patients were admitted in the ICU, among
which 470 followed the inclusion criteria. The rate of ESBL colonization at admission
was 13.2% (n = 62), mainly with Escherichia coli. Two hundred and twenty-one non-colonized
patients were screened at least twice. The incidence of ESBL acquisition was 4.1%
(9 patients on 221), also mainly with Escherichia coli. Mortality did not differ between
ESBL carriers and non-carriers. In univariate analysis, ESBL acquisition was associated
with the Injury Global Score II (IGSII) and the Sequential Organ Failure Assessment
(SOFA) at admission, the need for catecholamine and the ICU length of stay (LOS).
In multivariate analysis, ICU LOS and IGSII at admission were the strongest risk factor
for ESBL acquisition. The nine ESBL-acquired carriers had one to three index patients
defined as a patient hospitalized who shared at least 1 day hospitalization. The CTXm
grouping of the ESBL strains excluded a cross-transmission for 4 patients. The gene
sequencing did it for 3 others and confirmed a cross-transmission in only two patients
(0.8%). The cross-transmission emanated from the same source of a CTXm 1 ESBL-producing
E. coli. This patient shared 1 day in a different unit with the first acquired carrier
and 2 days in the same unit with the other. No case of cross-transmission in the same
room was observed.
Conclusion The rate of 13.2% of ESBL carriage on admission was comparable to other
rates in French ICUs (15%). Despite the absence of contact isolation, the incidence
of ESBL acquisition was 4.1% which is actually lower than transmission rates previously
published in other ICUs. A cross-transmission concerned two ESBL-acquired carriers
only and resulted from the same index patient during short shared hospitalizations
of 1 day in a different unit and 2 days in the same unit. Our results question whether
the contact isolation in private rooms plays a major role for the prevention of ESBL
cross-transmission in ICU, although the external validity of our results could be
questionable.
Competing interests None.
P164 Prevalence of colonization with extended spectrum B-lactamase producing bacteria
and subsequent ICU acquired infection in French Guiana
Hatem Kallel1, Claire Mayence1, Stéphanie Houcke1, Pascal Guegueniat1, Didier Hommel1
1Intensive care unit, Hospital, Cayenne, French Guiana
Correspondence: Hatem Kallel - kallelhat@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P164
Introduction Bacterial resistance to antibiotics is a common problem worldwide. In
South America, this prevalence is reported to be the highest in the world. However,
in French Guyana, there is no data on the epidemiology of colonization and infection
caused by extended spectrum B-lactamase producing enterobacteriaceae (ESBL-PE). We
conducted this study to investigate the prevalence of colonization with ESBL-PE and
subsequent ICU acquired infection in French Guiana.
Materials and methods A 24 months (January 2014 to December 2015) observational study
in a 14 beds ICU in a general hospital. Our unit, is the sole and the referral one
of all French Guiana department.
Results Over the study period, 670 patients were admitted to ICU and 603 of them (90%)
were hospitalized more than 48 h. The mean occupancy rate was 82.5 ± 20.6% and the
mean colonization index (with ESBL-PE) was de 37 ± 18.1%. The mean age was 43.4 ± 21.1 years.
The sex-Ratio (M/F) was 1.3. The mean IGS II calculated at admission to ICU was 44.6 ± 24.2.
The most recorded organ failures at admission to ICU were respiratory and hemodynamic
ones (56.7 and 37.2% respectively). At admission to ICU, 44.2% of patients presented
active infection and 57.3% received antibiotics. Multidrug resistant (MDR) bacteria
carriage was found in 88 patients (13.4%) at ICU admission and was acquired in ICU
in 89 other patients (13.4%). The most isolated MDR bacteria at admission were ESBL
producing E coli and K. pneumoniae. However, the most isolated MDR bacteria during
ICU stay were ESBL producing K. pneumoniae and E cloacae. During the ICU stay, 98
patients (14.6%) had presented 147 episodes of ICU acquired infections (ICU-AI). Over
the 177 patients carrying MDR bacteria, 159 (89.8%) carried ESBL-PE and 66 developed
ICU-AI. ESBL-PE caused 21.2, 37.5, 20, and 66.7% of 1st, 2nd, 3rd and 4th ICU-AI episodes
respectively. Statistical analysis didn’t show any link between ESBL-PE carriage and
a first episode of ICU-AI caused by ESBL-PE.
Conclusion Our study show a high prevalence of ESBL-PE bacteria carriage at admission
in our ICU. ESBL-PE carriage was not associated to higher prevalence of ICU-AI caused
by the same microorganism. This finding can help to reduce the inappropriate use of
carbapenems in such conditions.
Competing interests None.
P165 On-line hemofiltration versus conventional hemofiltration in septic shock patients:
clinical safety and effectiveness
Kaouther Dhifaoui1, Zied Hajjej1, Amira Fatnassi1, Walid Sellami1, Iheb Labbene1,
Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospital of Tunis,
Tunisia, Tunis, Tunisia
Correspondence: Zied Hajjej - hajjej_zied@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P165
Introduction The implementation of hemofiltration (HF) as a renal replacement therapy
in septic shock patients requires the supply of large quantities of replacement solutions.
These solutions are either industrially prepared in autoclaved expensive plastic bags
(conventional hemofiltration, CHF) or continuously provided in unlimited amounts at
the dialysis machine directly from the water treatment plant to form the replacing
solutions (on-line hemofiltration, OLHF).The aim of our study was to evaluate the
safety and effectiveness of on-line hemofiltration compared to conventional hemofiltration
in septic shock patients.
Patients and methods The investigative protocol was approved by the Institutional
Ethics Authorities and all patients or their legally authorized representatives provided
written informed consent. It was a prospective, randomized, clinical study, including
septic shock patients with acute renal failure. Patients were randomized to receive
either on-line hemofiltration (n = 8) or conventional hemofiltration (n = 25) for
renal replacement therapy during 4 days. Hemodynamic monitoring was conducted by conventional
devises, including: electrocardiogram and a radial arterial catheter for invasive
arterial pressure every 6 h during period study. We collected serum samples also every
6 h (urea, potassium and sodium levels, troponin, hemoglobin, platelets, C-reactive
protein and lactates).
Results The evolution of heart rate (HR), mean arterial pressure (MAP), biological
markers were comparable between the two groups over time except a significant decrease
in MAP in the OLHF group compared to CHF group only at H6 (P = 0.008) and H12 (P = 0.015)
and a significant decrease in C-reactive protein level in the OLHF group at H48 (P = 0.02).
Conclusion On-line hemofiltration seems to be a safe and reliable method of renal
replacement therapy in septic shock patients. It may be associated with attenuated
pro-inflammatory cytokine profile (C-reactive protein).
Competing interests None.
P166 Usefulness of biological testing during renal replacement therapy in ICU patients
Fahmi Dachraoui1, Sabrine Nakkaa1, Abdelwaheb M’ghirbi1, Ali Adhieb1, Dhouha Ben Braiek1,
Kmar Hraiech1, Ali Ousji1, Islem Ouanes1, Hammouda Zaineb1, Saousen Ben Abdallah1,
Lamia Ouanes-Besbes1, Fekri Abroug1
1Réanimation polyvalente, CHU Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Fahmi Dachraoui - dachraoui.fahmi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P166
Introduction Clinical and biological monitoring of efficacy and safety of RRT sessions
is thought useful and in many ICUs biological testing at mid RRT session and at its
end is routinely performed. The aim of the present study is to evaluate the impact
of laboratory tests performed during RRT session on clinical decision making and treatment
alteration.
Patients and methods Retrospective study including all consecutive patients hospitalized
in the medical ICU of the University Hospital Monastir, Tunisia between January 2015
and September 2016, requiring intermittent hemodialysis performed in the ICU. For
each patient we collected demographic characteristics (age, sex, SAPS III, diagnosis,
comorbidities), indication of the RRT, clinical and biological parameters before,
during and at the end of RRT session. Based on the patient monitoring records during
each RRT session we identified therapeutic interventions started before the end of
the RRT session in the light of the results of laboratory tests performed during the
session (usually in the middle the session): infusion of glucose, potassium, transfusion,
extension of the session.
Results During the study period, 370 patients were admitted to the ICU. Of these 24
patients required acute hemodialysis. The median age of these patients were 54 years
(IQR = 31), 53% of them were female. The main comorbidities were hypertension, diabetes,
chronic renal failure (CRF) with preserved diuresis, respectively in 55, 38 and 36%.
¾ of the patients included were in septic shock and had median SAPS III score of 92
(IQR = 34). Anuria, pulmonary oedema, hyperkalemia, and acidosis indicated RRT sessions
respectively in 47.1, 24.5, 8.8, 9.8 and 9.8%. Results of laboratory tests performed
during RRT sessions prompted a specific attitude in the following rates: infusion
of glucose in 35.7%, addition of potassium in 22%, and extension of the session duration
15.2%.
Conclusion The practice of laboratory tests during the RRT sessions seems useful since
it could impact clinical decision making in more than one-third of sessions.
Competing interests None.
P167 Feasibility of regional citrate anticoagulation for membrane-based therapeutic
plasma exchange in ICU
Simon Klein1, Mattéo Miquet1, Jean-Marc Thouret1, Vincent Peigne1
1Réanimation, Centre Hospitalier Métropole-Savoie, Chambéry, France
Correspondence: Vincent Peigne - vincentpeigne@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P167
Introduction Therapeutic plasma exchange (TPE) is crucial for the management of auto-immune
diseases like thrombotic thrombocytopenic purpura or myasthenia gravis. TPE is performed
either by centrifugation, with specific machines which are not routinely available
in ICUs, or by using specific plasma separation membranes with widely spread in ICUs
hemofiltration machines. Regional citrate anticoagulation for TPE is well established
with centrifugation but has been seldom described for membrane TPE. We are reporting
the experience of our ICU in this field.
Patients and methods Retrospective study including all patients who received TPE with
citrate regional anticoagulation between 2013 and 2016 in an 18-bed ICU. TPE is performed
solely in the ICU in our institution.
Results 26 patients were included. TPE was required for thrombotic microangiopathy
(13 patients), vasculitis (6 patients), hyperviscosity syndrome (2 patients), Guillain–Barré
syndrome (2 cases) and others (3 patients). Mean SAPS2 score was 32 [standard deviation
(SD) 16.6]. 281 TPE were performed, with a mean number of 10.5 (SD 11.5; range 2–57)
TPE per patients. Coagulation of the circuit of TPE occurred in 10 (38%) patients.
Coagulation of the circuit occurred in 10.3% (29/281) of the TPE. Minor adverse events
have been reported in two patients: one had a rash during the first TPE (no recurrence
during the 56 next TPEs) and the other had paresthesia during the first two TPEs (the
calcium infusion was increased and there had been no recurrence during the 25 next
TPEs). No serious adverse events related to citrate were observed.
Conclusion Regional anticoagulation with citrate allowed us to perform TPE in 26 patients,
without significant adverse events. The rate of circuit coagulation was 10.3% per
TPE.
Competing interests None.
P168 Modelization of the cost-effectiveness of anti-thrombin to reduce the incidence
of membrane thrombosis during continuous hemofiltration
Vincent Peigne1, Jean-Louis Daban2, Mathieu Boutonnet2, Bernard Lenoir3
1Réanimation, Centre hospitalier Métropole Savoie, Chambéry, France; 2Réanimation,
Hôpital d’Instruction des Armées Percy, Clamart, France; 3Département d’anesthésie-réanimation,
Hôpital d’Instruction des Armées Percy, Clamart, France
Correspondence: Vincent Peigne - vincentpeigne@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P168
Introduction A reduced incidence of membrane thrombosis after injection of Anti-thrombin
(AT) has been reported in septic patients with acquired deficit in AT undergoing continuous
hemofiltration. As this strategy was routinely performed in our unit until 2012, we
investigated its cost-effectiveness.
Patients and methods Data about the use of hemofiltration, the consumption of AT and
hemofiltration devices during 2011 (period with routine use of AT) and 2012 (period
with use of AT only if a membrane thrombosis occurred) were extracted from the administrative
database of the institution. A decisional tree was built to modelize the impact of
AT on the consumption of hemofiltration devices and blood products. The decisional
tree took into account the probability of membrane thrombosis with and without AT
and the probability of transfusion after membrane thrombosis. Costs were obtained
from the pharmacy of the institution (AT, hemofiltration devices) and from the literature
(blood products).
Results During 2011, 77 days of hemofiltration were performed, with the use of 45
doses of AT (23,202€) and 76 hemofiltration devices (11,632€). During 2012, 76 (−1%)
days of hemofiltration were performed, with the use of 5 (−89%) doses of AT (2578€)
and 85 (+10%) hemofiltration devices (13,443€). The mean cost of 1 day of hemofiltration
decreased from 449€ to 211€ with the diminution of the use of AT.
According to the decisional tree, AT was almost never cost-effective. The only circumstances
associated with a benefit for the use of AT was the association of a probability of
thrombosis with AT inferior to 0.1, of a probability of thrombosis without AT equal
1, of a probability of transfusion after thrombosis equal 1 and a cost of transfusion
of 424€. In these extremely favorable circumstances, AT could decrease the daily cost
of hemofiltration of 2.22–19.30€.
Discussion The model has several limits: the losses of utility related to transfusion
and to interruption of hemofiltration due to thrombosis were not taken into account;
the cost of AT measurement was not estimated; the work load of changing a membrane
and of transfusion after membrane thrombosis was not analyzed.
Conclusion Our results suggest that anti-thrombin is not cost-effective to reduce
the costs of hemofiltration related to membrane thrombosis.
Competing interests None.
P169 Vascular access sites for acute renal replacement in intensive care unit
Amira Ben Jazia1, Amira Jamoussi2, Takoua Merhbene3, Dhouha Lakhdhar4, Jalila Ben
Khelil2, Mohamed Besbes2
1Medical ICU, Hospital Abderrahmen Mami De Pneumo-Phtisiologie, Ariana, Tunisia; 2Réanimation
médicale, Hôpital Abderrahmen Mami, Ariana, Tunisia; 3Réanimation respiratoire, Hôpital
Abderrahmen Mami de pneumo-phtisiologie, Ariana, Tunisia; 4Service de réanimation
médicale, Centre d’assistance médicale-urgente, Tunis, Tunisia
Correspondence: Amira Ben Jazia - amira26juillet@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P169
Introduction Several temporary venous catheterizations are sometimes required for
acute renal replacement therapy (RRT) in the intensive care unit (ICU). This study
compares catheterizations in the femoral and jugular veins in terms of patient safety.
Materials and methods This was a descriptive retrospective review of dialysis sessions
(DS) records monitoring performed in patients older than 17 years hospitalized in
medical intensive care unit between April 2011 and December 2015.
A study of dialysis catheter, was conducted in critically ill adults requiring RRT
was performed.
Catheter insertion site, catheter age and urea reduction ratio (URR) were analyzed.
Results URRs were analyzed from 330 dialysis sessions (n = 64 patients). The mean
rate of URRs was 52.8 ± 12.4. Only 31.4% of dialysis sessions (DS) were efficient
with URR ≥ 60.
This study analyzed 64 patients who underwent two different sites of catheterization:
the femoral and jugular site.
The mean age of cathéters was 1.613 days.
No significant difference (P = 0.18) in the efficiency of (DS) was detected between
sessions performed through femoral (n = 225; 68%) and jugular (n = 105; 32%) dialysis
catheters.
Conclusion Femoral and internal jugular acute vascular access sites are both acceptable
for RRT therapy in the ICU. The effectiveness of (DS) in the ICU is low (31.4%). An
analysis of predictive factors of inefficiency of (DS) is expected to improve our
results.
Competing interests None.
Reference
Ridel C, Baldea MC, Rondeaua E, Vinsonneaub C. La dose de dialyse en réanimation:
existe-t-il vraiment un idéal? Dose of dialysis in intensive care unit.
P170 Renal replacement therapy protocol with regional citrate anticoagulation: observational
study of efficacy with a new post-filter ionized calcemia target
Celine Derreumaux1, Thierry Seguin1, Jean-Marie Conil1
1Réanimation polyvalente, Hopital Rangueil, Toulouse, France
Correspondence: Celine Derreumaux - celine.derreumaux@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P170
Introduction In Intensive Care Unit (ICU), some patients suffering from acute kidney
injury need renal replacement therapy (RRT). It requires the circuit anticoagulation,
this could be done by a regional citrate method. Today, this is a recommended approach
for the everyday care, even if the technique isn’t widespread yet [1]. The ionized
calcemia dosing through the filter (“post-filter” ionized-calcemia) is used to monitor
the technique efficacy, with a target of 0.25–0.35 mmol/L showing a good filter anticoagulation.
The objective of our study was the assessment of efficacy and safety of our regional
citrate anticoagulation protocol, with a less restrictive post-filter ionized calcemia
target (0.3–0.6 mmol/L). The main goal was the analysis of the circuit lifespan, considering
a lifespan above 24 h, as well as the search of some clinical and biological factors
affecting the technique efficacy. Moreover, we analyzed the side effects incidence
of the protocol (hypernatremia, metabolic alcalosis), and their consequences. The
study received the scientific ethical agreement of University Hospital of Toulouse,
and is registered with number 18-0214.
Patients and methods 57 patients, admitted to one of the two University Hospital ICUs
of Toulouse, needing a continuous RRT method, without any need for systemic heparin
anticoagulation, and without severe hepatocellular failure, were included in the study.
103 filters included over a 1-year period were analyzed.
Results Results show a mean filter lifespan of 48 h, with a lifespan above 24 h for
85.4% of all filters. Coagulation was the cessation reason for 29.1% of filters, most
of them before 24 h of the filter use. A value of post-filter ionized calcemia at
day 1 below 0.54 mmol/L was the main factor influencing a filter lifespan above 24 h.
An age older than 51 and a SAPS II severity score below 80 were other factors conditioning
a filter lifespan of more than 24 h. Side effects of citrate were rare and didn’t
have any clinical impact among our patients.
Discussion These results suggest that citrate used for anticoagulation in RRT could
have an additional anti inflammatory effect through the induced hypocalcemia, as well
as an energetic gain which could lead to a renal protection against ischemia–reperfusion
mechanism [2]. Moreover, these results call into question the need of post-filter
ionized calcemia dosing for the monitoring of citrate anticoagulation efficacy, since
the method safety is monitored by the total-to-ionized calcium ratio.
Conclusion During continuous RRT in ICU, a regional citrate anticoagulation protocol
with a non-restrictive post-filter ionized calcemia target seems to be efficient and
could reduce side effects. These results need to be confirmed with a randomised control
study.
Competing interests None.
References
KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney international Supplements,
2012.
Oudemans-van Straaten, HM et al. Citrate anticoagulation for continuous venovenous
hemofiltration. Crit Care Med, 2009;37(2):545–52.
P171 Impact of the use of an oXiris filter versus an AN69ST filter on the duration
of hemofiltration in intensive care
Charlotte Kelway1, Valery Blasco1, Cyril Nafati1, Karim Harti1, Laurent Reydellet1,
Jacques Albanese1
1RPPF, Hopital de la Timone, Marseille, France
Correspondence: Charlotte Kelway - chakel@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P171
Introduction Continuous veno-venous haemofiltration (CVVH) is used to treat acute
kidney injury in critically ill patients. To optimize its efficiency, CVVH requires
effective anticoagulation. Systemic anticoagulation with standard heparin, the most
used, can lead to major bleeding complications. Hemofilters that are able to adsorb
heparin molecules on their surface such as AN69ST and oXiris membranes represent an
alternative. The objective of this study was to compare these two types of filters
in terms of duration, efficiency, dysfunctions and cost.
Materials and methods From October 2012 to May 2014, we conducted a retrospective,
observational, and non-interventional study. All patients admitted in the intensive
care unit needing CVVH were included. The primary endpoint was the filter lifespan:
AN69ST versus oXiris. The secondary endpoint was the filter efficiency (urea reduction
ratio: URR). The main analysis did not consider the anticoagulation type. We conducted
a subgroup analysis taking into account the use or not of an anticoagulation.
Results 181 sessions in 93 patients were carried out using 386 filters representing
10,706 h of treatment. The mean AN69ST filter lifespan was 27 ± 20 h and 28 ± 22 h
for oXiris filters (p > 0.05). There is no significant difference in terms of duration
between the two filters. The subgroup analysis taking into consideration the use or
not of anticoagulation did not show any difference either. The mean URR was 48 ± 23%
in the AN69ST group and 44 ± 25% in the oXiris group (p > 0.05). Concerning the dysfunctions,
there were no significant difference between the two filters. One hundred and seventy-six
AN69ST filters were used for a total cost of 24,288 euros. Two hundred and ten oXiris
filters were used for a total cost of 39,060 euros.
Conclusion The AN69ST and oXiris lifespans are not significantly different. They were
as efficient in terms of blood epuration and had as many dysfunctions. The use of
an oXiris filter rather than an AN69ST to extend the circuit’s lifespan in the same
clinical conditions is not justified considering the extra cost generated.
Competing interests None.
References
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2015;27(5);343–8.
Intensive Care Med 2012; 38(11):1818–25.
PLoS One 2014;9(5):e97187.
P172 Effects of early use of diuretics in patients at risk of acute renal failure
and oliguria
Narjess Ben Aicha1, Khaoula Meddeb1, Ahmed Khedher1, Jihene Ayachi1, Nesrine Fraj1,
Nesrine Sma1, Imed Chouchene1, Mohamed Boussarsar2
1Réanimation médicale, CHU Farhat Hached, Sousse, Tunisia; 2Réanimation médicale,
CHU Farhat Hached. Research Laboratory N° LR14ES05. Faculty of Medicine, Sousse, Tunisia
Correspondence: Mohamed Boussarsar - hamadi.boussarsar@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P172
Introduction Because oliguria is a poor prognostic sign in patients with acute renal
failure (ARF), diuretics are often used to increase urine output in patients with
or at risk of ARF. From a pathophysiological point of view there are several reasons
to expect that loop diuretics could have a beneficial effect on renal function. However,
a review of literature shows that the use of loop diuretics in patients with ARF has
been associated with inconclusive results despite the theoretical benefits [1].
To assess the adjunctive effect of diuretics, to alter the progression to kidney injury
or failure, in patients at risk for acute renal failure.
Patients and methods This is a retrospective chart review of consecutive patients
who developed ARF with oliguria in the intensive care unit. Chart abstractors were
well trained residents. Two chart reviewers (senior intensivists) studied all the
charts. An explicit protocol was used to precise all needed definitions. Uniform handling
of data was ensured especially for conflicting, missing or unknown data. Oliguria
was defined as urine output lower than 0.5 ml/kg/h for at least 3 h.
RIFLE score was assessed before and after urinary output normalisation. Therapeutic
intervention to optimize pre-renal perfusion was described. Mean arterial blood pressure
(MBP) before and after therapeutic initiation, oliguria duration, delay from oliguria
onset to diuretic administration, delay from diuretic administration to urinary output
normalisation were measured.
Results 23 patients were studied over a 2 years period. They were 63 [24, 87] median
(IQR) aged, with diabetes mellitus, 22%; hypertension, 47.8%; cardiac failure, 32%
and chronic respiratory failure, 43%. Chronic and obstructive kidney diseases were
excluded. Median SAPS II was 37 [23, 75]. 80% were on mechanical ventilation.
RIFLE score before diuretics administration was assessed at oliguria onset as (patients
without risk, zero; R, 69%; I, 17%; F, 10%; L, 4%; E, zero). Fluid resuscitation after
oliguria onset was administered in 77% and vasopressors in 80%. Median (IQR) delay
from oliguria onset to diuretic administration was 5 [0.5, 22] h while optimization
of pre-renal hemodynamic disturbances was already achieved.
The median (IQR) MBP before and after therapeutic intervention was respectively, 74
[46, 100] and 95 [69, 110] mmHg. Median (IQR) delay from initiation of therapeutic
intervention and MBP improvement was 1.5 [0, 3] h. The delay from diuretic administration
to urinary output normalization was 3 [0.5, 27] h.
After resumption of diuresis, RIFLE score was assessed as (patients without risk,
74%; R, 17%; I, 8%; F, 1% L, zero; E, zero) (Fig. 5). Increased serum creatinine level,
above 1.5 fold normal range, was observed only in 6 (26%) patients.
Fig. 5
Progression of RIFLE score classes respectively from baseline to after therapeutic
intervention
Conclusion Rapid optimization of pre-renal hemodynamic disturbances associated with
short delay administration of diuretics could significantly alter the progression
to kidney injury or failure in at risk acute renal failure ICU patients.
Competing interests None.
Reference
Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia.
2010;65(3):283–93. doi:10.1111/j.1365-2044.2009.06228.x. Epub 2010 Jan 19.
P173 Epidemiology and risk factors of Acinetobacter baumannii ventilator associated
pneumonia
Walid Sellami1, Zied Hajjej1, Soumaya Ben Yedder2, Walid Samoud1, Bousselmi Radhouene1,
Bousselmi Mariem3, Iheb Labbene1, Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospital of Tunis,
Tunisia, Tunis, Tunisia; 2Department of critical care medicine and anesthesiology,
Military hospital of tunis, tunisia, Tunis, Tunisia, Tunisia; 3Department of critical
care medicine and anesthesiology, Military Hospital of Tunis, Tunisia, tunis, Tunisia
Correspondence: Walid Sellami - drsellamiwalid@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P173
Introduction The ventilator associated pneumonia (VAP) is a common and severe complication
of assisted ventilation. It’s the leading cause of nosocomial infections in intensive
care unit and remain responsible for a high morbidity and mortality because of the
emergence of multi-drug resistant (MDR) bacterial agent such us Acinetobacter baumannii
(AB). The aim of this study was to determine the incidence, risk factors and prognosis
of AB VAP.
Patients and methods Retrospective study extending over a 5 year period (January 2010–January
2016) that included all patients over 18 years and ventilated more than 48 h and developing
AB VAP. Patients were divided into two groups: one consisting of patients who developed
VAP to AB and the second developed VAP to another bacterial pathogen.
Results One hundred and forty patients developed VAP. The incidence rate of AB VAP
was 15.3% with a density of incidence of 20.3 per 1000 ventilator days. Age, male
gender, the time between hospitalization and mechanical ventilation and the medical
pathology were risk factors for developing AB VAP. AB was resistant to ceftazidime
in 100%, to imipenem in 65%, tobramycin in 70% and netilmycin in 35.3%, rifampin in
85% with a sensitivity to colistin in 100% of cases. The resistance of this germ to
imipenem increased from 35% in 2010 to 88.5% in 2016. The evolution of patients with
AB VAP developed frequently septic shock compared to other patients (44 vs 19.3%;
p = 0.038). The AB VAP mortality was higher (50 vs 33%; p = 0.03).
Conclusion The increasing incidence of multi-drug resistant AB VAP is responsible
for a high morbidity and mortality. So we need to identify risk factors and to strengthen
the means of prevention of hand contamination and cross transmission during invasive
procedures.
Competing interests None.
P174 Incidence and risk factors of central line associated bloodstream infections
and its risk factors in a Tunisian medical intensive care unit
Nesrine Sma1, Asma Ammar2, Khaoula Meddeb1, Asma Ben Cheikh2, Hend Ben Lakhal1, Jihene
Ayachi1, Ahmed Khedher1, Nesrine Fraj1, Messaouda Khelfa1, Yamina Hamdaoui1, Imed
Chouchene1, Nabiha Bouafia2, Mohamed Boussarsar3
1Réanimation médicale, CHU Farhat Hached, Sousse, Tunisia; 2Hospital hygiene unit,
Farhat Hached Hospital, Sousse, Tunisia; 3Medical intensive care unit, Farhat Hached
Hospital. Research Laboratory N° LR14ES05. Faculty of Medicine, Sousse, Tunisia
Correspondence: Mohamed Boussarsar - hamadi.boussarsar@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P174
Introduction Central line associated bloodstream infections (CLABSI) are among the
serious hospital-acquired infections. The aim of this study is to determine the incidence
of CLABSI, the pathogens and the risk factors that play a role in the development
of BSI among patients followed in a Tunisian medical intensive care unit.
Patients and methods All patients admitted for more than 48 h were included in the
study over a 1-year period in an 8-bed medical ICU. The enrollment was based on clinical
and laboratory diagnosis of BSI. Blood samples were collected from catheter hub of
all patients for culture, followed by identification and antibiotic sensitivity testing
of the isolates. For all subjects, age, sex, underlying diseases, SAPS II score, ICU
length of stay, invasive procedures and their durations (mechanical ventilation, central
catheterization, urinary catheterization) were recorded. Risk factors were evaluated
by a multivariate logistic regression model.
Results Among a total of 237 admissions from September 15th 2015 to September 15th
2016, 163 (68.7) patients were eligible. One hundred twenty-five (76) patients had
a central line. A total of 27 episodes of CLABSI were assessed in 23 (18.4) patients.
The mean SPASII of patients with CLABSI was 33 ± 15.4. Their mean CHARLSON index was
1.8 ± 1.7, median duration of catheterization was 4 [1.5–7] days and 8 (34.8) had
more than one catheterization attempt. The rate of CLABSI was 19.2/1000 catheter.days.
Gram positive bacteremia was determined in 13% of BSI patients. Of these isolates,
3 were Staphylococci. Gram negative bacteremia was determined in 35% of these isolates,
4 were Acinetobacter baumannii, 3 were Klebsiella pneumonia and 1 was Proteus mirabilis
and in 56% of cases BSI was diagnoses clinically. A univariate analysis identified
ventilator-associated pneumonia, sedation, and longer interval between onset of CLABSIs
and the duration of catheterization as risk factors of CLABSIs. In multivariate analysis,
the independent factors of CLABSI which are the duration of catheterization (OR, 1.06;
95% CI, [1.003–1.139]; p = 0.042) and catheterization attempt number (OR, 1.99; 95%
CI, [1.18–3.37]; p = 0.01). Thirteen (56.5) patients developed septic shock and they
all died.
Discussion The rate of CLABSI in our ICU (19.2/1000 catheter.days) was higher compared
with the mean rate of CLABSI in ICU reported by the NNIS system surveillance for 2004,
which is 3.9/1000 catheter.days [1]. Duration of catheterization, frequent manipulation
of catheter, catheter location, catheter type, underlying diseases, suppression of
immune system, and types of fluids administered through the catheter are significant
risk factors in development of BSIs [2]. In our study both duration of catheterization
and number of attempts are independent factors for CLABSI.
Conclusion In a monocenter cohort, CLABSI had a moderate density rate but are associated
with poor outcome. Identifying the risk factors is necessary to find solutions for
this major health problem.
Competing interests None.
References
National Nosocomial Infections Surveillance (NNIS) system report, data summary from
January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470–85.
Öztürk F, Gündeş S, Işık C. Prospective evaluation of the risk factors, etiology and
the antimicrobial susceptibilities of the isolates in nosocomial bacteriemic patients.
Mikrobiyol Bul.2008;42:17–27.
P175 Is prehospital endobronchial intubation a risk factor for subsequent ventilator
associated pneumonia?
Timothée Trampont1, Thomas Lafon2, Thomas Daix3, Vincent Legarçon1, Paul Claverie1,
Henri Hani Karam1, Nicolas Pichon3, Philippe Vignon3, Bruno François3
1Service urgences adultes/samu-smur, C.H.U de Limoges, Limoges, France; 2Services
urgences adultes/samu-smur/inserm cic1435, C.H.U de Limoges, Limoges, France; 3Inserm
cic 1435/réanimation polyvalente, C.H.U de Limoges, Limoges, France
Correspondence: Timothée Trampont - timothee.trampont@orange.fr
Annals of Intensive Care 2017, 7(Suppl 1):P175
Introduction According to some studies, field-intubated patients have 1.5–3 times
greater risk of ventilator associated pneumonia (VAP). Endobronchial intubation (EI)
can be unrecognized by the physicians and may result in complications such as atelectasis
which in turn could increase the risk of VAP. The aim of our study was to confirm
this hypothesis.
Patients and methods This monocentric retrospective study included all consecutive
patients >18 years who underwent an out-of-hospital tracheal intubation before their
admission to the intensive care unit (ICU) between January 2012 and December 2015.
Exclusion criteria were suspected aspiration or pneumonia on admission, patients who
died within the first 5 days of ICU stay, extubation in less than 48 h and underlying
disease making radiological interpretation difficult for VAP diagnosis. VAP were divided
into early onset (<7 days) and late onset (≥7 days) events and were independently
diagnosed by two experienced intensivists who had no access to the initial chest X-ray
performed to check the position of the tracheal tube, based on the Clinical Pulmonary
Infection Score. Onset of ventilator associated tracheobronchitis (VAT) was also noted.
Inadvertent endobronchial intubation was determined by another independent physician
based on the interpretation of admission chest X-ray.
Results 397 patients were intubated out-of-hospital. Of the 284 patients excluded,
104 had an extubation in less than 48 h, 114 were died within the first 5 days, 22
had a suspicion of pneumonia, 28 a suspicion of aspiration and 8 an underlying disease
making radiological interpretation difficult. Of the 121 patients included, 28 (23.1%)
had an EI upon admission. No significant difference was observed between the EI and
non-EI group for gender, age, SAPS2, comorbidities and diagnostic category (cardiorespiratory
arrest, trauma, coma and cardiorespiratory failure). Early-onset VAP were diagnosed
in 43% in the EI group and in 29% of non-EI patients (p = 0.085). Adding early onset
VAT, the respiratory infection rate was 61% in the EI group and 44% in the non-EI
group (p = 0.061) (Fig. 6). Late-onset VAP were observed in 8.6% in the non-EI group
and 7.1% in the EI group, without difference between groups (p = 0.403). There was
no inter-group difference in the duration of ventilation, duration of ICU stay and
ICU mortality. Staphyloccocus aureus was the most prevalent pathogen in patients with
early-onset VAP (23.1%, only one strain was methicillin-resistant).
Fig. 6
Rate of early-onset VAP + VAT depending of the position of the tube
Conclusion This study found a high rate of inadvertent prehospital endobronchial intubation
with a higher incidence of early-onset VAP. These results support the implementation
of specific procedures to decrease the incidence of EI.
Competing interests None.
References
Bissinger U, Lenz G, Kuhn W. Unrecognized endobronchial intubation of emergency patients.
Annals of Emergency Medicine. 1989;18(8):853–55.
Sitzwohl C, Langheinrich A, Schober A, et al. Endobronchial intubation detected by
insertion depth of endotracheal tube, bilateral auscultation, or observation of chest
movements: randomised trial. BMJ. 2010;341(nov091):c5943–c5943.
P176 Early versus late-onset ventilator-associated pneumonia: causative pathogens
and resistance profiles
Hend Ben Lakhal1, Aymen M’rad1, Fatma Essafi1, Nasreddine Foudhaili1, Hafedh Thabet2,
Youssef Blel1, Nozha Brahmi1
1Department of intensive care and toxicology, Centre d’Assistance Médicale Urgente,
Tunis, Tunisia; 2Service de réanimation, centre d’assistance médicale-urgente, Tunis,
Tunisia
Correspondence: A M’rad - mrad.aymen@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P176
Introduction Ventilator-associated pneumonia (VAP) is associated with increased hospital
stay and high morbidity and mortality in critically ill patients. The classic dichotomy
between early and late onset VAP is no longer helpful available. The aims of this
study were to determine the incidence of multidrug-resistant pathogens in the first
episodes of VAP and to assess potential differences in bacterial profiles of subjects
with early-onset versus late-onset VAP.
Patients and methods Retrospective cohort study over a period of 18 months including
all patients who had a first episode of VAP confirmed by positive culture. Subjects
were distributed into 2 groups according to the number of intubation days: early-onset
VAP (<5 days) or late-onset VAP (≥5 days).The primary endpoint was the nature of causative
pathogens and their resistance profiles.
Results Sixty patients were included, 29 men and 31 women. The average age was 38 ± 16 years.
The IGS 2 at admission was 40.5 [32; 44] APACHE 19 [15; 22]. Monomicrobial infections
were diagnosed in of 46 patients (77%).Two different bacteria were isolated in 14
cases (13%). A. baumannii was the most frequently isolated in 53% (n = 32) of patients;
followed by P. aeruginosa in 37% (n = 22), Enterobacteriaceae in 28% (n = 17) and
S. aureus in 5% (n = 3). The isolated bacteria were multidrug-resistant in most cases
(58/60). The VAP group comprised 36 episodes (60%) of early-onset VAP and 24 episodes
(40%) of late-onset VAP. A. baumannii was isolated in 47% of early VAP (n = 17) versus
62% of late VAP (n = 15) (p = NS), P. aeruginosa in 36% of early VAP (n = 13) versus
37% of late VAP (n = 9) (p = NS) and Enterobacteriaceae in 30% of early VAP (n = 11)
versus 25% of late VAP (n = 6) (p = NS). For the resistance profile of the different
pathogens isolated, there was no difference between early and late onset VAP.
Conclusion According to new data from the literature, there were no microbiological
differences in the prevalence of potential multidrug-resistant pathogens or in their
resistance profiles associated with early-onset versus late-onset VAP.
Competing interests None.
P177 Nosocomial infection in the sever burns
Rihi El Mehdi1
1Intensive care unit, IBN ROCHD, Casablanca, Morocco
Correspondence: Rihi El Mehdi - mehdi_44@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):P177
Introduction The bacterial nosocomial infection is a major cause of morbidity and
mortality in burned. The bacterial ecology in an ICU has a major impact in terms of
morbidity and mortality, particularly in the center of burned or length of stay of
patients is increased compared to a general intensive care.
Materials and methods We conducted an observational study spread over 7 months in
ICU for severe burned burnt including any who have spent more than 48 h with nosocomial
infection (modified CDC criteria), and in which all biological and bacteriological
samples were taken. The different types of infections studied were: skin, urinary,
lung and bloodstream infections. They excluded all patients belatedly supported or
having stayed in other healthcare facilities.
Results One hundred twenty (120) patients showed nosocomial infection during this
period. The sex ratio (M/F) was 1.7 and the mean age was 39 ± 23 years. Bacteremia
was present in 44.84% of cases, followed by the urinary tract infection that was present
in 21.21% of cases, followed by the cutaneous infection in 10.30% of cases, and last
pulmonary infection in 9% of cases. Infection was polymicrobial in 14.5% of cases.
The main bacteria identified were: Acinetobacter baumanii (43.45%) of which 74% is
resistant to imipenem, Enterobacteriaceae (31.5%), Pseudomonas aeruginosa (24%) of
which 83.25% is resistant to ceftazidime and 68.2% is resistant to imipenem, Enterococcus
(16%) and Staphylococcus Aureus (14.29%).
Conclusion The incidence of nosocomial infection is very high compared to literature.
The rate of resistance to common antibiotics is very high. A drastic management of
antibiotics in our context, the selection of patients and the frequent use in the
operating room for skincare allow a better management of these patients.
Competing interests None.
Reference
Wurtz R, Karajovic M, Dacumos E, Jovanovic B, Hanumadass M. Nosocomial infections
in a burn intensive care unit. Burns. 1995;21:181–84.
P178 Ventilator acquired pneumonia: diagnosis treatment and bacterial ecology in a
Moroccan intensive care unit
Hanane Ezzouine1, Mahmoud Kerrous1, Saad El Haoui1, Soufiane Ahdil1, Abdellatif Benslama1
1Anesthesiology and intensive care department, University Teaching Hospital IBN Rushd-Casablanca,
Casablanca, Morocco
Correspondence: Hanane Ezzouine - ezzouinehanane@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P178
Introduction The management of ventilator acquired pneumonia is a diagnostic and therapeutic
challenge. Antibiotic therapy is a key link. The objective of this work is to study
the epidemiological, clinical patients who developed VAP during their stay in the
Medical Intensive Care Unit of the CHU Ibn Rushd in Casablanca and are features of
the bacterial ecology of VAP during the 2015.
Patients and methods It is a retrospective descriptive study and analytical spread
over 1 year, from January 2015 to December 2015. Were included all patients with pneumonia
Ventilator, with or without bacteraemia, after hospitalization for more than 48 h.
Were collected clinical, biological, radiological, bacteriological and scalable patients
included.
Results The average age of the patients was 42.19 years with a sex ratio (M/F) 1.47
APACHE II score average was 16.4, the average SAPSII was 31.12 and the average was
2.39 SOFA. 86.5% of patients were intubated on admission in intensive care. 3.5% were
intubated within less than 5 days notice after admission and the average time to onset
of VAP was 3.76 days. The VAP were early in 68.4% of cases. The average hospital stay
of patients being 19.63 days. 73.68% in the sample used in our patients was bronchial
aspiration. The most offending germs are 27.2% Acinetobacter baumannii, Pseudomonas
aeruginosa 16.3%. 100% of patients received empirical antibiotic therapy chosen according
to the ecology of the service. 77.4% died. 43.8% of deaths were directly related to
VAP.
Conclusion Ventilator acquired pneumonia is main problem in our ICU. The bacteriological
ecology must be usually known. In our unit Acinetobacter baumanii is the main germ
associated.
Competing interests None.
P179 Determinants and prognostic factors of Acinetobacter baumannii ventilator-associated
pneumonia
Khalid Abidi1, Tarek Dendane1, Ssouni Oussama1, Jihane Belayachi2, Naoufal Madani2,
Redouane Abouqal2, Amine Ali Zeggwagh1
1Medical intensive care unit, Mohamed V University Hopital Ibn Sina, Rabat, Morocco;
2Service des urgences médicales hospitalières - ibn sina – université mohamed v –
rabat, Hopital Ibn Sina, Rabat, Morocco
Correspondence: Tarek Dendane - tdendane@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P179
Introduction
Acinetobacter baumannii (AB) ventilator-associated pneumonia (VAP) is common in critically
ill patients. The aims of this study were to describing the epidemiological characteristics
of AB-VAP, to identify risk factors for acquisition and factors predictive of a poor
outcome.
Materials and methods A retrospective-prospective study was conducted at the Medical
Intensive Care Unit of the University Hospital Ibn Sina, Rabat-Morocco from January
2013 to December 2015. They were included in the study that all patients developed
VAP with identified germ. For identification of risk factors of acquisition of AB
VAP, two groups of patients were compared: patients with AB VAP versus patients with
VAP caused by other germs. To identify factors associated with mortality, two other
groups were compared: Survivors versus died.
Results 122 patients presented VAP among which 60 were caused by Acinetobacter baumannii.
Among isolates of AB, 8.3% were drug susceptible, and 16.7% were multidrug-resistant
while 75% were extensively drug-resistant. They were Independent risk factors for
acquisition of AB VAP in multivariate analysis: the presence of a central venous catheter
before the occurrence of VAP, duration of prior hospitalization ≥4 days and ICU duration
of stay ≥5 days. The mortality rate of AB VAP was 85%. The independent risk factors
for poor outcome in multivariate analysis were: duration of antibiotic treatment >7 days,
the reintubation and the presence of a previous hospitalization.
Discussion Our data were similar to those of the literature with a high incidence
of VAP due to the AB (49%) and a high rate of resistance to this bacterium particularly
to carbapenems. However, and compared to the literature, the VAP AB were responsible
for a death rate much higher (85%).
Conclusion Our data were similar to those of the literature with a high incidence
of VAP due to the AB (49%) and a high rate of resistance to this bacterium particularly
to carbapenems. However, and compared to the literature, the VAP AB were responsible
for a death rate much higher (85%).
Competing interests None.
P180 Ventilator-associated pneumonia in the elderly: a study of the prognosis
Hatem Ghadhoune1, Anis Chaari2, Guissouma Jihene1, Hend Allouche1, Insaf Trabelsi1,
Habib Brahmi1, Mohamed Samet1, Hatem El Ghord1
1Réanimation médicale bizerte, Faculté de médecine de Tunis, Bizerte, Tunisia; 2Intensive
care unit, King Hamad University Hospital, Muharraq, Bahrain
Correspondence: Hatem Ghadhoune - ghadhoune@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P180
Introduction Ventilator-associated pneumonia (VAP) is common in critically-ill patients.
In fact, 10–20% of patients requiring invasive mechanical ventilation develop this
complication. The onset of VAP has been reported to be associated with increased mortality.
However, data related to critically-ill elderly patients are scarce. The aim of this
study is to assess the prognostic impact of VAP in critically-ill elderly patients.
Patients and methods Mono-center, retrospective study conducted from 01/012014 to
30/09/2015. All old patients (age ≥65 years) requiring mechanical ventilation were
included. Two groups were compared: Patients who developed VAP (VAP (+) group) and
those who did not develop VAP (VAP (−) group).
Results During the study period, 86 patients were included. The causes of admission
in the intensive care unit (ICU) were shock (n = 30), acute respiratory failure (n = 41)
and disturbed level of consciousness (n = 15). Diabetes mellitus, hypertension and
chronic obstructive pulmonary disease were the most common comorbidities (44.2, 32.6
and 40.7% respectively). Mean age was 73.3 ± 6.5 years. Sex-ratio (M/F) was 1.8. Mean
APACHE(II) score was 24 ± 9. The mean duration of mechanical ventilation was 10 ± 15 days.
Thirty patients (34.9%) developed VAP. ICU-mortality was significantly higher in the
VAP (+) group (90 vs 55.4%; p = 0.001). Multivariate analysis identified two independent
factors predicting ICU mortality: Shock on admission (OR = 22.7, CI 95% [5.1–101.2],
p < 0.001) and VAP (OR = 5.7, CI 95% [1.2–28.1], p = 0.033).
Conclusion VAP is common in critically-ill elderly patients and is associated with
worse outcome. Therefore, preventing its onset is of paramount importance.
Competing interests None.
Reference
Magill SS, Li Q, Gross C, Dudeck M, Allen-Bridson K, Edwards JR. Crit Care Med. 2016
Aug 10. [Epub ahead of print].
P181 Epidemiologic characterization and prognosis factors of Acinetobacter baumannii
ventilator-associated pneumonia
Ben Sik Ali Habiba1, Nouira Hajer2, Najla Tilouch2, Sondes Yaakoubi2, Oussama Jaoued2,
Rim Gharbi2, Mohamed Fekih Hassen2, Souheil Elatrous2
1Réanimation médicale, EP taher sfar, Mahdia, Tunisia; 2Réanimation médicale, EPS
Taher Sfar Mahdia, Mahdia, Tunisia
Correspondence: Mohamed Fekih Hassen - mohamed.fekihhassen@rns.tn
Annals of Intensive Care 2017, 7(Suppl 1):P181
Introduction Ventilator associated pneumonia (VAP) is the most frequent nosocomial
infection in critically ill patients. It is associated with high mortality, prolonged
mechanical ventilation, length of stay, and increased health-care costs. Among pathogens
responsible of VAP, Acinetobacter baumannii which is characterized by its ability
to spread in the hospital environment and to acquire resistance leading sometimes
to therapeutic impasses is associated with a particularly high mortality reaching
30–75%.
Objective To describe the epidemiological characteristics of A. baumannii VAP, to
determine their prognosis and identify factors associated with mortality.
Patients and methods It is a monocentric observational study conducted over a period
of 13 years in a Tunisian intensive care unit (ICU) including mechanical ventilated
patients for more than 48 h with confirmed A. baumannii VAP.
Results One hundred and twenty-three patients were included in the study. A. baumannii
was responsible for 31% of VAP in our ICU. The VAP were late in 59% of cases. More
than 90% of isolates pathogens were resistant to ticarcillin, piperacillin, piperacillin–tazobactam,
ceftazidime and ciprofloxacin. Sixty percent of germs were sensitive to imipenem.
Resistance to imipenem has increased consistently from 0% at the beginning of the
study to 88% in 2015. All pathogens were susceptible to colistin. A. baumannii VAP
was complicated by septic shock in 63% of cases. The median duration of mechanical
ventilation and of ICU stay were 17 (IQR: 11–25) and 25 days (IQR: 17–41) respectively.
The use of parenteral nutrition was the only factor associated with the occurrence
of A. baumannii VAP resistant to imipenem (odds ratio 2.27, 95% CI [1.07–4.80], p = 0.033).
ICU mortality was 45%. It was higher in patients with A. baumannii VAP resistant to
imipenem (55 vs 39%, p > 0.05). In the multivariate analysis, the age, the use of
renal replacement therapy and the occurrence of VAP relapse have been identified as
factors associated with mortality.
Conclusion
A. baumannii resistance to imipenem became threatening. The use of parenteral nutrition
was the only factor associated with the occurrence of A. baumannii VAP resistant to
imipenem. The choice of empiric antimicrobial for VAP caused by this pathogen must
take in consideration the epidemiologic data of each country and each ICU. A. baumannii
VAP was associated with high mortality. The age, the use of renal replacement therapy
and the occurrence of VAP relapse have been identified as predictive of poor outcome.
Competing interests None.
P182 Admission in intensive care unit for severe adverse drug event: what finding?
Julien Arcizet1, Bertrand Leroy1, Caroline Abdulmalack2, Catherine Renzullo1, Maël
Hamet2, Jean-Marc Doise2, Jérôme Coutet1
1Pharmacy unit, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône, France; 2Intensive
care unit, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône, France
Correspondence: Julien Arcizet - julien.arcizet@ch-chalon71.fr
Annals of Intensive Care 2017, 7(Suppl 1):P182
Introduction Adverse drug events (ADE) remain a serious public health problem. They
represent between 0.16 and 15.7% of hospital admissions and between 0.37 and 27.4%
of intensive care unit (ICU) admissions. They are defined as any injury related to
a drug, and include both adverse drug reactions, expected or not, but also underuse,
overuse and misuse, unintended or undesired, preventable or not. Indeed, mortality
from iatrogenic event would rise between 2.0 and 28.1%, whereas these ADE that resulted
in ICU hospitalization could be prevented in 17.5–85.7% of cases. These unplanned
admissions overload ICU, limit access to health care for other patients and have serious
economic consequences for the health system. It is therefore necessary to study these
ADE to know their main causes and attempt to find a solution to avoid them.
The main objectives of our study were to clinically and pharmaceutically analyze and
stratify the different ADE leading to hospitalization in our ICU.
Patients and methods This is a monocentric prospective study, between June 2014 to
January 2016, in medico-surgery ICU. From all admissions, we had included patients
admitted in our hospital for involuntary ADE (plausible, likely and very likely causal).
We had collected clinical aspects (Failure mode, IGSII score, mortality in ICU) and
pharmaceutical aspect (number of drug, offending drugs) at daily medical staff meeting.
Results On 1545 admissions, 154 patients were hospitalized for unintended ADE. The
average age was 70 years old [26; 95], with a men/women ratio equal to 1.8. The clinical
severity IGSII score found was 51 [13; 120]. Average length of stay in ICU was 5.5 days
[1; 28] on average in this unit. The main reasons of admission were: hematologic failure
(in particular hemorrhagic) (29.9%), metabolic failure (19.5%), renal failure (11.0%),
neurological failure (11.0%) and sepsis (10.4%). Respiratory, hepatic, hemodynamic
failures and hypersensitivity reactions represented respectively less than 10% of
cases. 34 patients (22%) included died during their stays in ICU. On average, 7.6
drugs were found in the usual treatment of the patient. 32.5% of this population had
a known cognitive disorder and 62% of them self-management of their treatment. The
main drugs involved were: furosemide (16.9%), metformin (13.0%), perindopril (9.1%),
lysine acetylsalicylate (8.4%), warfarin (8.4%) and fluindione (7.8%). The most common
drug families involved were: drugs of the cardiovascular system (33.8% of cases),
anticoagulants and antiplatelet agents (31.8%), antidiabetics (16.9%) and psychotropic
(13.6%).
Conclusion Hospitalizations in ICU for ADE are still too common despite their preventability
for most cases. Many patients with known cognitive disorder manage their treatment
themselves and this is probably one of the reasons of iatrogenic events. Anticoagulants
and antiplatelet agents, by side effects, misuse, underuse or overuse are very often
involved. The onset of kidney failure from dehydration and the continuation of nephrotoxic
and antidiabetic treatment also remain one of the most common causes. Consequently,
it is necessary to continue and develop primary, secondary and tertiary prevention
strategies to prevent their appearance, to limit their consequences and to reduce
recidivism.
Competing interests None.
P183 Prolonged intensive care unit stay: prognostic factors
Chaigar Mohammed Cheikh1, Zakaria Quechar1, Hanane Ezzouine1, Abdellatif Benslama1
1Anesthesiology and intensive care department, UNIVERSITY TEACHING HOSPITAL IBN RUSHD-CASABLANCA,
Casablanca, Morocco
Correspondence: Chaigar Mohammed Cheikh - chaigarmed@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P183
Introduction Intensive care unit (ICU) is usually identified as a place of acute care,
concentrated over a short period. For many reasons, a prolonged stay in the ICU has
a pejorative connotation for the intensivist physician. The aim of our study is to
describe the epidemiological, clinical, paraclinical profile of patients hospitalized
for a long time in ICU (over 15 days) and to identify the main prognostic factors
and those that can predict the duration of stay in ICU.
Patients and methods We conducted a retrospective study, over a period of 5 years
and 6 months (January 2010 to June 2015), enrolling patients whose length of stay
was greater than or equal to 15 days in medical ICU of the UH Ibn Rochd of Casablanca.
Statistical analysis was performed using SPSS 21.0.
Results We enrolled 151 patients witch correspond to 8.2% of all admissions. The sex
ratio was 1.6, the average age was (43.2 ± 18.5 years). The majority of patients (75%)
were transferred from the emergency department. Medical pathology was the main motive
of admission (82.1% of cases). Means of severity scores were calculated as follows:
APACHE III (56.2 ± 22.9), IGS III (40 ± 9.6), OSF (0.6 ± 0.7). The average length
of stay was (42.2 ± 59.7 days). The incidence of nosocomial infection was 82.8%, the
average day of onset was 9.34 ± 8.7 days. Pneumonia, bacteremia and vascular catheter
infections were the main sites, Gram-Negative Bacilli were the most frequently identified,
dominated by Acinetobacter baumanii (27.9%). Mechanical ventilation (91.4%) and vascular
catheterization (84.1%) are the most used invasive devices. Antibiotics (92.1%), sedation
(91.4%) and vasopressors (60.9%) were the main administrated treatments. The outcome
was favorable in 37.7% of cases. Hemodynamic instability (64.2%) and respiratory complications
(61.6%) were the complications most frequently observed, septic shock occurred in
49% of cases. Mortality rate was 55%. In univariate analysis, the variables that have
emerged as risk factors of mortality were: sex, length of hospitalization, severity
scores (APACHE III, IGS III, OSF), the Charlson comorbidity score adjusted to age,
traumatic pathology, the occurrence of nosocomial infection, septic shock, hemodynamic
instability, neurological worsening, use of vasopressors, and tracheostomy. In multivariate
analysis: nosocomial infection (p = 0.04), hemodynamic worsening (p = 0.03), use of
vasopressors (p < 0.01) and antibiotics (p < 0.01) appeared to be risk factors of
mortality.
Conclusion Although patients hospitalized in ICU for more than 15 days are few, they
represent a serious problem of care and an important part of the activity of intensive
care (bed occupancy, care costs).
Competing interests None.
P184 Admissions and readmissions to the intensive care unit of patients with hematologic
malignancies: a 5 years retrospective study
Magalie Joris1, Dimitri Titeca Beauport1, Loay Kontar1, Delphine Lebon2, Bérengère
Gruson2, Michel Slama1, Jean-Pierre Marolleau2, Julien Maizel1
1Réanimation médicale, Centre Hospitalier Universitaire, Amiens, France; 2Hématologie
clinique et thérapie cellulaire, Centre Hospitalier Universitaire, Amiens, France
Correspondence: Magalie Joris - joris.magalie@chu-amiens.fr
Annals of Intensive Care 2017, 7(Suppl 1):P184
Introduction Despite an improvement in prognosis of patients with hematologic malignancies
for the last decade, mortality of such patients admitted to the intensive care unit
(ICU) remains high. Yet, it seems that a first ICU stay does not modify prognosis
of the malignancy. Until now, there is no data on readmission in the ICU of such patients
and its effect on short and long term prognosis impact.
Patients and methods This retrospective, single-center study conducted on a 5 years
period in the medical ICU from our university hospital included 265 patients with
hematological malignancies admitted for a first stay. Objectives were to evaluate
the ICU, day 28 and 6 months mortality, to identify prognostic factors associated
with mortality within uni- and multivariate analysis, to evaluate readmission rate
within the 60 days after discharge, to indentify the admission risk factors associated
with ICU readmission and the prognosis factors associated with mortality during the
second ICU stay.
Results The mean age was 58.6 ± 14.8 years, with a male–female ratio of 1.55. The
most represented malignancies were acute leukemia (40.8%) and non-Hodgkin lymphomas
(26.8%); 16.2% were hematopoietic stem cell transplant recipients. 54% of patients
had newly diagnosed malignancy, 20.8% were in complete remission (CR), 11.7% had stable
disease or partial remission and 13.6% had progressive disease. 46.4% of patients
presented with severe neutropenia at the time of ICU admission. The main life-threatening
complications precipitating ICU admission were acute respiratory failure for 43.8%,
sepsis for 51.7%, acute kidney injury for 14%, neurological disturbance for 18.1%
and preventing tumor lysis syndrome for 15.8%. 11.3% presented with hemophagocytic
lymphohistiocytosis (HLH). 34.3% of patients received non-invasive ventilation, 46.8%
mechanical ventilation (MV), 54.3% needed vasoactive drugs administration and 40.8%
had renal replacement therapy. ICU, day 28 and 6 months mortality were 39.8, 46.4
and 63.4% respectively. By multivariate analysis poor performance status, IGS II,
HLH, MV and anti-fungal administration were associated with increased ICU mortality,
infections with Pseudomonas were associated with higher day 28 mortality. Catheter
related infections were associated with better ICU survival and CR was associated
with lower day 28 mortality. 38 of 132 (28.9%) candidate patients for ICU readmission
after a first stay were readmitted within the 60 days following discharge. Median
overall survival was lower in readmitted versus non readmitted patients. 6 months
mortality was 73.8% for readmitted versus 13.8% for no readmitted patients (p < 0.0001).
The second ICU stay mortality was 60.5% and 6 month mortality was 78.9%. By multivariate
analysis, only MV was associated with prognosis. The 6 months mortality rate of patients
who survived to the second ICU stay was significantly higher than the patients who
survived to the first admission but were not readmitted (46.7 vs 13.8%, p = 0.0007).
Conclusion Main features, short and long term mortality and prognostic factors associated
with ICU admission are in lines with previous studies. Early readmission rate was
high with a negative impact on survival. Despite admission in the ICU of patients
with hematologic malignancies seems not to affect long term prognosis, early readmission
seems to have a pejorative impact on the course of the malignancy.
Competing interests None.
Reference
Azoulay E. Outcomes of critically ill patients with hematologic malignancies: prospective
multicenter data from France and Belgium—a groupe de recherche respiratoire en réanimation
onco-hématologique study. J Clin Oncol. 2013;31:2810–18.
P185 Prognosis of lung cancer patients admitted to ICU
Julie Gorham1, Lieveke Ameye,2, Thierry Berghmans,1, Marianne Paesmans2, Jean-Paul
Sculier,1, Anne-Pascale Meert1
1Intensive Care and Thoracic Oncology, Institute Jules Bordet, Brussel, Belgium; 2Data
centre, Institute Jules Bordet, Brussel, Belgium
Correspondence: Anne-Pascale Meert - secret.sculier@bordet.be
Annals of Intensive Care 2017, 7(Suppl 1):P185
Introduction Lung cancer is among all types of cancer, the most common solid tumour
admitted in intensive care [1]. Recent studies showed that the prognosis of patients
with lung cancer during intensive care unit (ICU) stay has improved [2]. The aim of
our study was to determine the causes of ICU admission of lung cancer patients, their
prognosis and to identify factors predicting hospital mortality and survival after
hospital discharge.
Patients and methods We conducted a retrospective study including all patients with
lung cancer admitted for a medical or surgical complication in the intensive care
unit of a cancer hospital between September 1, 2008 and December 31, 2013. mbol’ > [1].
Recent studies showed that the prognosis of patients with lung cancer during intensive
care unit (ICU) stay has improved [2]. The aim of our study was to determine the causes
of ICU admission of lung cancer patients, their prognosis and to identify factors
predicting hospital mortality and survival after hospital discharge.
Results During this period, 212 ICU admissions occurred in 180 patients with lung
cancer. The majority of them were men (64%), had non small cell lung cancer (80%)
and metastases at the time of admission (81%). 54% received an antineoplastic therapy
during the month preceding the ICU admission. 47 patients (26%) died during hospitalisation
with 36 deaths in the intensive care unit and 11 in the hospital ward after ICU discharge.
The three main reasons of admissions were: cardiovascular problems (32%), respiratory
failure (29%) and neurological (16%) complications. The SAPS II score (OR 1.07; 95%
CI 1.04–1.11) as continuous covariate and the presence of respiratory complications
(OR 4.00; 95% CI 1.76–9.07) were the 2 factors independently affecting hospital mortality
in multivariate analysis. Median overall survival since ICU admission was 3.7 months
(95% CI, 2.8–4.4). Median overall survival for patients discharged alive from ICU
was 4.8 months (95% CI, 3.9–5.6 months). Considering patients discharged alive from
the hospital, only the presence of metastases was a statistically independent prognostic
factor in multivariate analysis (HR 2.3; 95% CI 1.44–3.65).
Discussion The prognosis of patients with lung cancer admitted in ICU improved probably
due to a better selection of these patients eligible for intensive care. As already
observed in general cancer patients’ population, prognosis factors for hospital mortality
are related to the acute complications but survival after hospital discharge is dependent
from the cancer stage.
Conclusion Lung cancer patients are admitted in critical care in over half of the
cases for cardiovascular and respiratory complications. The hospital mortality rate
of these patients admitted in ICU was 26%. However survival after hospital discharge
remains low and dependent of the cancer metastatic status. ICU admission should be
considered for patients with lung cancer.
Competing interests None.
References
Kress JP, Christenson J, Pohlman AS et al. Outcomes of critically ill cancer patients
in a university hospital setting. Am J Respir Crit Care Med. 1999;160:1957–61.
Adam AK, Soubani AO. Outcome and prognostic factors of lung cancer patients admitted
to the medical intensive care unit. Eur Respir J 2008;31:47–53.
P186 Treatment intensity may not predict prognosis for patients admitted in ICU with
relapsed acute myeloid leukemia
Max Guillot1, Marie-Pierre Ledoux2, Thierry Braun1, Quentin Maestraggi1, Baptiste
Michard1, Vincent Castelain1, Raoul Herbrecht2, Francis Schneider1
1Réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg, France;
2Département d’oncologie et d’hématologie, C.H.R.U. Hôpitaux Universitaires Strasbourg,
Strasbourg, France
Correspondence: Max Guillot - max.guillot@me.com
Annals of Intensive Care 2017, 7(Suppl 1):P186
Introduction Admission of cancer patients with poor prognosis in intensive care units
(ICU), like acute myeloid leukemia (AML) resistant to the first course of induction
chemotherapy, continue to be controversial. The ICU trial may be an alternative in
this case to ICU refusal. The ICU trial is a full-code ICU admission followed by reappraisal
of the level of care. The objective of this study was to find variables available
at ICU admission and at day 3 in order to predict prognosis of critically ill medical
patients with relapsed acute myeloid leukemia.
Patients and methods Retrospective monocentric study of consecutive patients with
a relapsed AML admitted to the 30 beds medical ICU of an academic hospital. We evaluated
hematological treatments, organs supports and mortality in ICU.
Results Between 2002 and 2014, 24 patients with relapsed AML were admitted in the
ICU. At admission, patients were 54 years old, IGS 2: 64 ± 24, Lactates: 4.9 mmol/L
(±4.7). Eight patients underwent bone marrow transplant (BMT). Five patients had graft-versus-host
disease (GVHD). 12 patients were admitted for septic shock, 7 patients for acute respiratory
failure, 2 for cardiac arrests, 1 for coma, 1 for acute kidney injury and 1 for hemorrhagic
shock. BMT was significantly associated with higher mortality [Odds ratio (0R) 13.0
(95% confidence interval (95% CI) 1.7–99, 43)—p: 0.02]. 7 BMT patients died in ICU.
Neutropenia [OR 0.33 (95% CI 0.05–1.87)—p: 0.4] and GVHD (OR 2.0 [95% CI 0.07–51.6)—p:
1.0] were not able to predict mortality in ICU. The first day in ICU: 15 patients
were under mechanical ventilation, 17 patients need vasopressor perfusion and 3 patients
dialysis. Mortality in ICU was 37%. 4 patients died from acute illness before day
3. Among the 24 patients admitted in ICU, none of the life-sustaining interventions
at admission were associated with mortality: invasive mechanical ventilation [OR 9.14
(95% CI 0.9–92.4) - p: 0.08], vasopressor perfusion [OR 6.2 (95% CI 0.6–62.2)—p: 0.18]
and renal replacement therapy [OR 4.8 (95% CI 0.3–65.8)—p: 0.27]. On day 3, life supports
were not associated with higher mortality: invasive mechanical ventilation [OR 3.7
(95% CI 0.32–41.1)—p: 0.35], vasopressor perfusion [OR 2.0 (95% CI 0.27–14.7)—p: 0.64]
and renal replacement therapy [OR 1.2 (95% CI 0.08–16.45)—p: 1.0].
Conclusion Mortality in ICU was 37% in patients with relapsed AML. In fact, temporary
full-code ICU management in patients with relapsed AML seems to be appropriate. None
of the life-sustaining interventions at admission and on day 3 were able to predict
survival. An ICU trial of 3 days might not be enough to appraise precisely the outcome.
Bone marrow transplant was associated with a high mortality in our study. In case
of relapsed AML with BMT, ICU management is still challenging.
Competing interests None.
Reference
Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the
cancer patient: recent achievements and remaining challenges. Ann Intensive Care.
2011;1(1):5.
P187 Mortality analysis of the chronically critically ill patients: an epidemiological
prospective study
Severine Couffin1, David Lobo2, Nicolas de Prost3, Nicolas Mongardon4, Gilles Dhonneur5,
Roman Mounier2
1Surgical intensive care, Hospital Henri Mondor, Créteil, France; 2Anesthesia and
surgical intensive care, Hospital Henri Mondor, Créteil, France; 3Réanimation Médicale,
Hôpital Henri Mondor, Créteil, France; 4Service de réanimation médicale, Hôpital Cochin,
Paris, France; 5Anesthesia and intensive care medicine, CHU Henri Mondor, Créteil,
France
Correspondence: Severine Couffin - scouffin@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P187
Introduction The growing population of chronically critically-ill patients has a poor
prognosis despite all the resources mobilised [1]. Our primary objective was to analyse
the prognostic value of different definitions used to describe them. Our secondary
objective was to look for early clinical and biological factors that could be associated
with the in-hospital mortality.
Patients and methods We conducted an epidemiological prospective study in 3 intensive
care units (neurosurgical, cardiosurgical and medical) of a large French teaching
hospital (Henri Mondor, Créteil). We included all the patients hospitalized for at
least 7 days. We tested 5 definitions: the prolonged mechanical ventilation, the definition
taken up by Kahn et al. [2], the prolonged length of stay, the persistent critical
illness and the persistent inflammation-immunosuppression and catabolism syndrome.
Two biological examinations were performed: upon entering the study and 1 week later.
The study endpoint was the in-hospital mortality.
Results Thirty patients were included between April and July 2016. Among them, only
40% matched the definition of prolonged mechanical ventilation, which is still the
most used in the literature. Further, it was not associated with the mortality, but
the prolonged length of stay was, with 59% of these patients, that did not survive
to their hospital stay. Other parameters that were significantly different between
the patients who died and those who survived were an advanced age, an elevated IGS
II score at hospital admission, an elevated SOFA score at study entry, a late healthcare-associated
infection and several biological variables: a high C reactive protein, low albumin
and prealbumin and a poor percent of monocytes expressing HLA-DR, all measured at
day 7.
Conclusion The in-hospital mortality of chronically critically-ill is still high.
A prolonged length of stay is the only definition who may be helpful to identify the
patients with the poorest outcome. Among the early factors associated with mortality,
we found a late healthcare-associated infection and a low percent of monocytes expressing
HLA-DR, pointing to the value of studying the immune system of these patients.
Competing interests None.
References
Nelson JE. Chronic critical illness. Am J Respir Crit Care Med. 2010; 182(4):446–54.
Kahn JM. The epidemiology of chronic critical illness in the United States. Crit Care
Med. 2015;43(2):282–7.
P188 Clinical characteristics and outcome of nonagenarians and centenarians in a medical
ICU
Pierrick Le Borgne1, Sophie Couraud1, Jean-Etienne Herbrecht2, Quentin Maestraggi2,
Alexandra Boivin2, François Lefebvre3, Pascal Bilbault1, Francis Schneider2
1Service d’accueil des urgences, Hôpitaux Universitaires de Strasbourg, Strasbourg,
France; 2Réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg,
France; 3Département d’information médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg,
Strasbourg, France
Correspondence: Pierrick Le Borgne - pierrick_med@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P188
Introduction As a result of demographic transition, the proportion of «very elderly»
(≥90 years) patients is increasing worldwide and more of these patients are nowadays
admitted to intensive care units (ICU). Among physicians the discussion about appropriateness
of these ICU admissions still remains controversial mostly due to questionable outcome,
limited resources and costs. The aim of the study was to determine and evaluate the
clinical characteristics and outcome in a very old population admitted to a medical
ICU in an urban teaching hospital.
Patients and methods We present here a monocentric, retrospective and observational
study. We reviewed the charts of all patients (≥90 years) admitted to a medical ICU
between 2000 and 2015 (16 years). We collected epidemiological, clinical and biological
parameters and all therapeutic measures during the ICU stay. A long-term survival
follow-up was also performed. Two hundred eighty-four patients were included for statistical
analysis. Multivariate Cox regression was also performed to identify risk factors
for 28-day outcome.
Results A total of 284 patients were included, which represented 1.8% of admissions
to the ICU during the period of the study. The mean age was 92.6 ± 2.1 years, the
sex ratio was 0.41. Most of patients (41%) were admitted from the Emergency Department.
20% of these admitted patients suffered of previous dementia. The mean Charlson comorbidity
score was 7.7 ± 1.7 and the mean McCabe score was 1.33 ± 0.5. The admission diagnosis
in the ICU was mainly respiratory distress (51%), septic shock (11%), cardiac arrest
(10%) and coma (8%). The mean SAPS-II score within 24 h of ICU admission was 55.9 ± 21.7.
Half of these patients required support by mechanical ventilation (mean duration 7.3 days)
and vasoactive drugs and 6% of patients received renal replacement. ICU and in-hospital
mortality rates were 38 and 44% respectively. Overall survival at 6 months after hospital
discharge was 33%. Multivariate regression revealed necessity of catecholamines and
mechanical ventilation as independent risk factors and urinary sepsis as protective
factor for 28-day outcome. In fine, for 34% of these patients, a limitation of active
treatment was decided (on average after 2 days of stay). For all others there was
no justification for limiting care because of a well-established treatment plan (with
family, GP, ICU team).
Conclusion The proportion of elderly patients remains low, but they are increasingly
being treated in intensive care units. Nevertheless, the in-hospital mortality is
high compared to the average mortality in our ICU over the same period (20%). The
prognosis is often not as poor as initially perceived by physicians. The indication
for ICU treatment in our study was mostly justified; in the setting of consistent
patient care and good clinical practice. It remains therefore appropriate to discuss
every single ICU admission of elderly patients without any restriction related to
age. Thus, the ongoing cluster-randomized trial of ICU admissions for the elderly
patients (ICE-CUB 2 study) is deeply awaited to confirm or not these results [1].
Keywords Intensive care; prognosis; outcome; elderly patients; over 90-years old.
Competing interests None.
Reference
Boumendil A, Woimant M, Quenot J-P, Rooryck F-X, Makhlouf F, Yordanov Y, et al. Designing
and conducting a cluster-randomized trial of ICU admission for the elderly patients:
the ICE-CUB 2 study. Ann Intensive Care. 2016;6(1):74.
P189 The hemorrhage postpartum: inventory
Setti-Aouicha Zelmat1, Djamila-Djahida Batouche2, Fatima Mazour3, Belkacem Chaffi4,
Nadia Benatta5
1Réanimation, etablissement hospitalier spécialisé 1er novembre, oran, Algeria; 2Réanimation
pédiatrique, Centre Hospitalier et Universitaire d’Oran, Oran, Algeria; 3 Anesthesie
-réanimation chirurgicale, EHS 1er Novembre, oran, Algeria; 4Service de gynéco-obstétrique,
EHS 1er Novembre, oran, Algeria; 5Cardiologie, Centre Hospitalier et Universitaire
d’Oran, Oran, Algeria
Correspondence: Setti-Aouicha Zelmat - settiaouichazelmat@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P189
Introduction Regardless of the route of delivery, the postpartum hemorrhage (PPH)
is defined as blood loss ≥500 ml after childbirth, and severe PPH as blood loss ≥1000 ml.
PPH is the leading cause of maternal mortality in Africa. The aim of this prospective
study was to assess the quality of the initial management of PPH in Algeria in Oran
EHU and to determine the factors of care with the severity of this complication.
Patients and methods We conducted a prospective cohort study between April 2014 and
September 2014 at the EHU ORAN. All women who delivered vaginally and showed HPP including
the suspected cause was uterine atony were included. The severe PPH was defined as
bleeding that required invasive surgical treatment (hysterectomy, arterial ligation),
a transfusion, a transfer to an intensive care unit or death of the patient. The quality
of care was evaluated using objective criteria defined by a delay of diagnosis and
care and mortality.
Results Among the 466 women who delivered vaginally during the study period, 23 had
a PPH, link with uterine atony alleged at diagnosis, 18 of which presented signs of
severity. In 41% of cases, the delay in diagnosis of PPH was less than 30 min; 70%
of women received oxytocin within 10 min after diagnosis. The tranexanique acid was
used in 1 case. The examination of the cervix, uterine exploration and uterine massage
was performed in 67, 99 and 97%, respectively. The failure of first line treatment
involved 24% of patients. Among them, the time between the diagnosis of PPH and administration
of blood derivatives was greater than 1 h in a third of cases. The administration
of oxytocin delay exceeds 10 min multiplied by 2.5 the risk of severe PPH. However
we had 2 deaths in our series.
Discussion In our study the optimal period of care was not adequate, obtaining blood
derivatives in our institution remains among the factors aggravating Among the main
risk factors for PPH, uterine atony was the main source of complication. Bleeding
postpartum aggravated in our two patients has led to the deaths from late diagnosis
and care that was not optimal. These hemorrhages PP is the leading cause of mortality:
21% of obstetric deaths (25% in the confidential survey 1996–1997) [1].
A hysterectomy was indicated after failure to conservative treatment. The death rate
is estimated at 8% following a disorder complicated hemostasis of disseminated intravascular
coagulation (DIC). In some series, the mortality rate is estimated between 2 and 4%
[2].
Conclusion The management of PPH in obstetrics gynecology service The EHU Oran was
not optimal. The issue of timing of diagnosis and initial treatment is crucial. Solutions
must be sought locally to ensure the administration of essential medicines in time,
especially the injection of oxytocin within 10 min after diagnosis.
Competing interests None.
References
Bouvier-Colle MH, Deneux C, Szego E, et al. Estimation de la mortalité maternelle
en France: une nouvelle méthode. J Gynecol Obstet Biol Reproduction, 2004;33:421–9.
Rossi AC, Lee RH, Chmait RH. Emergency postpartum hys-terectomy for uncontrolled postpartum
bleeding. ObstetGynecol 2010;115:637—44.
P190 Evolution of the management and prognosis of patients admitted in intensive care
unit for exacerbation of chronic obstructive pulmonary disease
Ali Habiba Sik1, I Talik1, Najla Tilouch1, Sondes Yaakoubi1, Rim Gharbi1, Oussama
Jaoued1, Mohamed Fekih Hassen1, Souheil Elatrous1
1Réanimation Médicale, EPS Taher Sfar Mahdia, Mahdia, Tunisia
Correspondence: Mohamed Fekih Hassen mohamed.fekihhassen@rns.tn
Annals of Intensive Care 2017, 7(Suppl 1):P190
Introduction Chronic obstructive pulmonary disease (COPD) is a common pathology that
would represent the third cause of death worldwide by 2020. Its evolution is interspersed
with episodes of acute exacerbations (AECOPD) that may indicate an admission in intensive
care unit in the most.
Objective To study the evolution of management modalities of patients admitted in
our intensive care unit for AECOPD, to determine their prognosis and to identify factors
associated with mortality.
Patients and methods It is a retrospective, monocentric study, performed in a Tunisian
intensive care unit (ICU) over a period of 10 years. We including all patients admitted
in ICU for AECOPD. Parameters collected were demographic features, comorbidities,
regular treatment, dyspnea assessed by the MRC scale, initial clinical severity reflected
by SAPS II and APACHE II scores, modalities and ICU admission deadlines, initial arterial
blood gas analysis, management of patients in the ICU (ventilation modalities, prescription
of antibiotics, use of vasoactive drugs) and their outcomes (incidence of nosocomial
infections and their sites, length of stay and ICU mortality).
Results A total of 512 patients, which represents 17.5% of all hospitalizations, with
mean age of 72 years (IQR: 66–77) were admitted for AECOPD during the study period.
The mean SAPS II and APACHE II were respectively 32 (IQR: 24–45) and 18 (IQR: 14–24).
Of these, 60% were ventilated with NIV whose overall failure rate was 48% with a significant
decrease between the beginning and the end of the study (94 vs 31% p = 0.001). Sixty-four
percent of patients received antibiotics at admission. The prescription rate of antibiotics
has decreased significantly over the years from 82 to 36%. The incidence of nosocomial
infections was 18%. It remained steady between 11 and 27%. Their sites were pulmonary
in 83% of cases. ICU mortality was 16%. In multivariate analysis, ICU admission deadlines,
NIV failure and the use of vasoactive drugs were identified as factors associated
with mortality.
Conclusion Our study showed the importance of AECOPD in the activity of our ICU. The
management of these patients has evolved over the years, which was reflected by the
significant decrease in the prescription of antibiotics and the enhancement of NIV
success rate. This result could be attributed to the combination of several factors:
precocious management of patients, experience of the healthcare team and the use of
efficient ventilators. ICU admission deadlines, NIV failure and the use of vasoactive
drugs were identified as factors associated with mortality.
Competing interests None.
P191 Music therapy improves the tolerance of non-invasive ventilation during its introduction
Maxime Perrier1, Eliane Gouteix1, Claude Koubi1, Annabelle Escavy1, Victoria Guilbaut1,
Jean-Philippe Fosse1
1Réanimation surveillance continue, Hôpital Privé Gériatrique Les Sources, Nice, France
Correspondence: Jean-Philippe Fosse - janfilipfos@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P191
Introduction Aim. Investigate the effect of music therapy on the tolerance of non-invasive
ventilation (NIV) during its introduction.
Patients and methods
Type of study Prospective, randomized, single blind, monocentric.
Thirty patients who needed NIV introduction were included.
They were divided into two groups (15 with music and 15 without music) and randomized
by block of 4.
The patients were all equipped with headphones and half of them received a 60 min
session of music therapy of their choice, and the other half had to keep the headphones
on without music.
The main outcome measure was the number of non-programmed interventions by the caregivers
during the hour.
Patient’s and caregiver’s feeling were evaluated at the end of the session by a semi-quantitative
scale:
+2 very difficult; +1 difficult; 0 normal; −1 easy; −2 very easy
Pulse rate, systolic and diastolic blood pressure, respiratory rate, pain, peripheral
oxygen saturation, arterial blood gas parameters, Glasgow Coma score and Richmond
scale were reported before and after the session.
Results Music therapy allowed a significant reduction of the number of non-programmed
interventions during the hour (0.6 ± 0.74 against 1.73 ± 1.62; p < 0.05).
The patient’s and the caregiver’s feeling of the session was better under music therapy
(−1.07 ± 0.88 and −1.07 ± 1.03 against 0.13 ± 0.83 and 0.07 ± 1.03; p < 0.05).
The other parameters were not statistically significant.
Discussion Our study showed that music therapy allows a better tolerance of the NIV’s
introduction in a quantitative and a qualitative way.
Conclusion Music therapy allows a 65.3% reduction in the number of non-programmed
interventions by the caregivers, during the first hour of the NIV’s introduction,
and a better feeling of the session.
Competing interests None.
References
Bradt J, Dileo C. Music interventions for mechanically ventilated patients. In: The
cochrane collaboration. Wiley. 2014.
Jaber S, Bahloul H, Guétin S, Chanques G, Sebbane M, Eledjam J–J. Effets de la musicothérapie
en réanimation hors sédation chez des patients en cours de sevrage ventilatoire versus
des patients non ventilés. Annales Françaises d’Anesthésie et de Réanimation. 2007;26:30–38.
P192 Non-invasive ventilation in acute exacerbations of Obesity-Hypoventilation Syndrome
(AE/OHS)
Jihene Ayachi1, Ahmed Khedher1, Rahma Ben Jazia2, Khaoula Meddeb1, Ahmed Abdelghani2,
Imed Chouchene1, Mohamed Boussarsar3
1Réanimation médicale, CHU Farhat Hached, Sousse, Tunisia; 2Pneumologie, CHU Farhat
Hached, Sousse, Tunisia; 3Réanimation médicale, CHU Farhat Hached. Research Laboratory
N° LR14ES05. Faculty of Medicine, Sousse, Tunisia
Correspondence: Mohamed Boussarsar - hamadi.boussarsar@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P192
Introduction Although NIV is effective in acute hypercapnic COPD-related respiratory
failure, its efficacy in AE/OHS has been less demonstrated.
The aim of the study was to evaluate efficacy of NIV in AE/OHS and to identify factors
associated with poor prognosis in non-invasive-ventilated AE/OHS patients.
Patients and methods A retrospective analysis of all consecutive patients admitted
to ICU for AE/OHS. Clinical, ABG’s and outcome characteristics were collected. Factors
associated with poor prognosis were identified.
Results One hundred patients were included over a 13 years period. 44 patients underwent
NIV. They were 66.6 ± 12.6 years aged; BMI, 40.6 ± 7.7 kg/m2; SAPSII, 29 ± 13; pH,
7.33 ± 0.08; pCO2, 69 ± 22 mmHg. They were scored with grade II encephalopathy score
on admission. Mean duration of NIV was 5.1 ± 4.4 days. 14 (32%) patients failed NIV
and were intubated with a delay of 85.6 ± 156.7 h. 11 (25%) died and length of stay
was 10.7 ± 9.5 days. Four factors were significantly associated with mortality, mMRC,
(47 vs 14%; p = 0.02); encephalopathy score, (60 vs 15%; p = 0.008); NIV failure,
(64 vs 7%; p = 0.0001); inotropic agents, (58 vs 12.5%; p = 0.004).
Conclusion NIV in AE/OHS demonstrates rather efficient. However delay of intubation
seems to be of poor prognostic value.
Competing interests None.
P193 Oxygenotherapy with an oxygen concentrator in intensive care unit: a prospective
study
Pierre-Julien Cungi1, Julien Bordes1, Cédric Nguyen1, Candice Pierrou2, Maximilien
Cruc1, Alain Benois3, Eric Meaudre1
1Intensive care unit and anesthesiology, Hôpital d’Instruction des Armées Sainte-Anne,
Toulon, France; 2Intensive care unit and anesthesiology, Hôpital d’Instruction des
Armées Laveran, Marseille, France; 3Anesthésie réanimation, Hôpital Médico Chirurgical
Bouffard, Djibouti, Djibouti
Correspondence: Pierre-Julien Cungi - pjcungi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P193
Introduction Oxygen therapy is an essential issue for the French Military Health Service
(FMHS). Wounded soldiers are severe trauma patients often burnt and suffering from
haemorrhagic shock. They need all along their management oxygen therapy. The theatres
of external operations are isolated with limited resources. Their supply is difficult.
Currently, 50% of the trauma are intubated. Thirty-three percent of the patient admitted
in intensive care suffers from acute respiratory distress syndrome (ARDS). The FMHS
chose oxygen concentrator as oxygen source in addition to oxygen pressurized bottles.
Their supply can be uncertain in conflict areas. Insufficient data are available concerning
the use of oxygen concentrator in intensive care unit.
The primary endpoint was to determine over the total duration of oxygen therapy, the
number of days on which the use of pressurized oxygen was needed for patients oxygenated
by oxygen concentrator. The secondary endpoints were to identify when pressurized
oxygen was needed, describe the characteristics of the population with oxygen therapy
and estimate the oxygen quantity economised thanks to the use of oxygen concentrator.
Materials and methods The study took place in the forward surgical unit of Bouffard.
It’s a French role 3 located in Djibouti Republic in Africa. All patients over 15
admitted in the intensive care and needing oxygen therapy were included. All the patients
were oxygenated with an oxygen concentrator. The oxygen concentrators used were Sequaltm
Integra 10 OM, that could deliver up to 10 l/min of normobaric oxygen. The ventilator
used were Pulmonetictm LTV 1000 and 1200.
Results Thirty-six patients were included over the 6 months’ study period. Sixty percent
of the patients were men with an average age of 38 (15–90). Sixty percent of them
were medical admissions, 22.9% were trauma and 17.1% were surgical admissions. Eight
persons died which represented 22.9% of the patients. The mean SAPS II was 38.8. The
mean length of stay in intensive care was 9 days (0–44). The mean time of mechanical
ventilation was 6 (1–35) days. Among the patients, 76.5% were intubated. Eight patients
(22.8%) needed noninvasive ventilation, for six (17%) of them it was after extubation.
Two hundred and fifty-one days represents the total number of days of oxygen therapy
divided into 142 days of invasive ventilation, 15 days of noninvasive ventilation
and 94 days of oxygen mask. The use of pressurized oxygen was necessary 19 times over
the 251 days of oxygen therapy which represents 7.5% of the total time. The causes
of its use were in ten cases (52.6%) criteria of severe ARDS, in six cases an emergency
intubation and in three cases a transfer. One dysfunction of an oxygen concentrator
happened during our study. The oxygen concentrator produced 1024 m3 of oxygen over
the study period, which represents 104 oxygen pressurized bottles of 50 litres. This
enabled an economy of 10,000 euros.
Conclusion It is safe to use oxygen concentrator to take care of critically ill patients
in limited resources environment. The use of pressurized oxygen is still compulsory
in two situations: in case of electricity failure and in case of high FiO2 (above
60%). Oxygen concentrators are sufficient in 92.5% of the time. They enable to deliver
oxygen any time which is essential when supply is uncertain in conflict areas.
Competing interests None.
P194 Evaluation of fractional delivered oxygen between nasal cannula and nasal oxygen
catheter
Frédéric Duprez1, Thierry Bonus1, Grégory Cuvelier2, Sandra Ollieuz1, Sharam Machayekhi1,
Frédéric Paciorkowski1, Gregory Reychler3
1ICU, C.H. Epicura Hornu, Hornu, Belgium; 2Laboratoire de l’effort et du mouvement,
Condorcet, Tournai, Belgium; 3Irec, pôle de pneumologie, ucl, Cliniques Universitaires
Saint Luc, Bruxelles, Belgium
Correspondence: Frédéric Duprez - dtamedical@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P194
Introduction Oxygen therapy is the main supportive treatment of hypoxia. Nasal cannula
(NC) and nasal oxygen catheter (NOC) were used to administer oxygen therapy in hypoxia.
Few studies have examined the difference in fractional delivered oxygen (FDO2) between
these two systems. The aim of our study was to compare the difference of FDO2 between
NC and NOC.
Materials and methods On a bench study, a two-compartment model of adult lung (Dual
Test Lung DTL, Michigan Instrument) was connected to a Servo i® Ventilator. The ventilator
was set in volume-controlled mode. Three minute ventilation (MV: 6/9/12 l/min at Ti/Ttot = 0.33)
and two oxygen flow rate (OFR: 2 and 4 l/min) were analyzed. OFR was analyzed with
a thermal mass flow meter Vogtlyn™ Red Y. The compliance of the artificial lung was
set to 70 ml/cmH2O and the resistance set to 5 cmH2O/l s−1. The FDO2 and MV measurements
were made using an iWorx® acquisition system (GA207 gas analyzer and analog/digital
IX/228 s) and LabScribe II® software. To simulate the anatomic dead space of the nasopharynx
(±50 ml for an adult) we have used a 15 cm length corrugated tubing ISO 22 mm (CT22)
at the level of inflow of DTL. NC was introduced at the entry of the CT22 while the
NOC was introduced totally into the CT22. Statistical: ANOVA on ranks followed by
Student–Newman–Keuls.
Results
Conclusion In oxygen therapy, with NC or NOC, for a Ti/Ttot = 0.33, FDO2 is influenced
by MV, OFR and oxygen system delivery. For the same level of OFR and system delivery,
when MV increases, FDO2 decreases (see Table 4). For the same MV and level of OFR,
FDO2 was more efficient with NOC than NC. The differences of FDO2 between NOC and
NC decrease with increasing MV. The FDO2 fluctuations according to the value of the
MV are greater with the NOC to 4 L/min.
Table 4
FDO2 comparison between NC and NOC at different OFR and MV
VE(L/min)
NC2 L/min
NOC2 L/min
NC 4 L/min
NOC4 L/min
6
31% (0.5)
37% (0.5)
38% (0.6)
43% (0.5)
9
29% (0.7)
34% (0.6)
34% (0.5)
39% (0.7)
12
26% (0.6)
30% (0.6)
30% (0.7)
34% (0.5)
ANOVA on ranks: p < 0.05, except between: NOC2 (VE 9 L/min) and NOC4 (VE12 L/min)/NC2
(VE 9 L/min) and NOC2 (VE12 L/min)/NOC2 (VE12 L/min) and NC4 (VE12 L/min)/NC4 (VE
9 L/min) and NOC4 (VE 9 L/min)/NOC2 (VE 9 L/min) and NC4 (VE 9 L/min)
In clinical situation, NOC is less used than the NC. Compared to the NC, NOC is an
alternative to increase the FDO2 with the same OFR. NOC is more efficient than NC
because during expiratory time, anatomical dead space it fills with O2, which increases
the FDO2. However, if the respiratory frequency increases then expiratory time decreases,
filling with O2 decreases which reduces FDO2. Note that NOC may become uncomfortable
at OFR greater than 5 L/min.
Competing interests None.
Reference
Tiep BL, Nicotra B. Evaluation of a low-flow oxygen-conserving nasal cannula. Am Rev
Respir Dis. 1984;130(3):500–2.
P195 Variability of fractional delivered oxygen (FDO2) with nasal cannula
Frédéric Duprez1, Thierry Bonus1, Grégory Cuvelier2, Sharam Machayekhi1, Sandra Ollieuz1,
Gregory Reychler3
1ICU, C.H. Epicura Hornu, Hornu, Belgium; 2Laboratoire de l’effort et du mouvement,
Condorcet, Tournai, Belgium; 3 Irec, pôle de pneumologie, ucl, Cliniques Universitaires
Saint Luc, Bruxelles, Belgium
Correspondence: Frédéric Duprez - dtamedical@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P195
Introduction Nasal Cannula (NC) is an option to deliver oxygen therapy. According
to American Thoracic Society (ATS), standard NC delivers a fractional delivered oxygen
(FDO2) of 24–40% at supply oxygen flows ranging from 1 to 5 L/min. An equation was
proposed by ATS to predict oxygen delivery: FDO2 = 20% + (4 * O2 L/min). Moreover,
for ATS, FDO2 is also influenced by respiratory frequency (Rf), tidal volume (Vt)
and ratio Ti/Ttot. However, the equation of ATS does not take into account these parameters.
Our hypothesis is that these parameters can significantly affect the FDO2. The aim
of this study was to determine the effect of Rf, Vt and Ti/Ttot on FDO2.
Materials and methods The study was conducted on bench with NC connected to a two
compartment adult lung model (Dual Test Lung®) (DTL) controlled by a Maquet Servo
I® ventilator. One oxygen flow rate (OFR) (5 L/min) and 3 min ventilation (MV: 6/9/12 L/min)
with two Ti/Ttot (0.33 and 0.25) were investigated. All settings of MV were generated
by modifying Rf (10–40 CPM) and Vt (0.3 and 0.6 L). Inspiratory flows rate (IFR) obtained
with settings range from 18 to 48 L/min. OFR was analyzed by a thermal mass flow meter
Vogtlyn™ Red Y. FDO2 and MV measurements were made using a iWorx® acquisition system
(GA207 gas analyzer) and LabScribe II® software. Compliance of DTL was set to: 0.07 L/cmH2O
and resistance to: 5 cmH2O/L s−1. Statistical: ANOVA repeated measures followed by
Newman Keuls method.
Results FDO2 comparisons between: Ti/Ttot 0.33 and 0.25 and three MV: 6–9–12 L/min
at OFR: 5 L/min.
Conclusion IFR and OFR are the main determinants of FDO2. Equation of ATS is correct
when IFR is equal to 18 L/min.
When IFR is different of this value, Equation of ATS is not appropriate.
In our experiment, with an OFR of 5L/min, when IFR = 18 L/min (MV = 6 L/min and Ti/Ttot = 0.33),
the FDO2 is equal to 41% (±1%) (see Table 5). To this value of IFR, the FDO2 is in
accordance with the formula of ATS, but when IFR increase beyond 18 L/min, the FDO2
decrease and the formula is not in accordance with ATS. This can be explain because
during inspiratory phase, air room (Fractional oxygen = 0.21) entry in airway mixes
with OFR (FO2 = 1), which modifies the FDO2. In this case, when IFR increase then
FDO2 decrease and vice versa. Medical and paramedical staff must be aware that with
patients who receive OFR by nasal cannula, any change of OFR and/or inspiratory flow
changes the FDO2. In this case, for maintain the same FDO2, it is necessary that modify
the value of OFR.
Table 5
FDO2 comparisons between diffferent TI/Ttot and MV at OFR 5 L/min
MV (L/min)
Ti/Ttot = 0.33
Ti/Ttot = 0.25
RfxVt
FDO2
RfxVt
FDO2
RfxVt
FDO2
RfxVt
FDO2
6
10 × 0.6
41% (a)
20 × 0.3
42% (d)
10 × 0.6
36% (g)
20 × 0.3
37% (j)
9
15 × 0.6
36% (b)
30 × 0.3
35% (e)
15 × 0.6
32% (h)
30 × 0.3
32% (k)
12
20 × 0.6
31% (c)
40 × 0.3
30% (f)
20 × 0.6
30% (i)
40 × 0.3
29% (l)
Rf respiratory frequency (in CPM), Vt tidal volume (in Liter)
ANOVA RM results: p < 0.05. No statistical difference are found between: (a–d)/(b–e)/(c–f)/(g–j)/(h–k)/(i–l)/(b–j)/(b–g)/(f–k)/(c–k)/(f–h)/(f–l)/(f–i)/(c–i)/(c–l)/(e–g)
Competing interests None.
Reference
Wagstaff T, Soni N. Performance of six types of oxygen delivery devices at varying
respiratory rates. Anaesthesia, 2007;62: 492–503.
P196 How to assess FiO2 delivered under oxygen mask in clinical practice?
Remi Coudroy1, Arnaud W Thille1, Xavier Drouot2, Véronique Diaz2, Jean-Claude Meurice3,
René Robert1, Jean-Pierre Frat1, the FLORALI study group
1Réanimation médicale, CHU de Poitiers, Poitiers, France; 2Neurophysiology, CHU de
Poitiers, Poitiers, France; 3Pneumologie, CHU de Poitiers, Poitiers, France
Correspondence: - Remi Coudroy remi.coudroy@chu-poitiers.fr
Annals of Intensive Care 2017, 7(Suppl 1):P196
Introduction The actual FiO2 delivered under oxygen mask in patients with acute respiratory
failure and the factors that may influence the FiO2 are poorly known. In clinical
practice, different methods including formula or conversion tables based on oxygen
flow can be used to estimate delivered FiO2. We aimed to assess first the factors
influencing measured values of FiO2, and second the best method to estimate FiO2 in
patients breathing under oxygen mask.
Patients and methods We included ICU patients admitted for acute hypoxemic respiratory
failure from a previous prospective trial [1] in whom FiO2 was measured under oxygen
mask using a portable oxygen analyzer. We collected demographic variables and respiratory
parameters that may influence measured FiO2. Low FiO2 was defined according to the
median measured FiO2.
For each patient, measured FiO2 was compared to “Calc + 3%” formula (FiO2 = oxygen
flow in liters per minute × 0.03 + 0.21) to “Calc + 4%” formula (FiO2 = oxygen flow
in liters per minute × 0.04 + 0.21), and to a conversion table [2]. A ± 10% limit
of agreement for each estimation method was arbitrarily considered acceptable.
Results Among the 265 patients included, median measured FiO2 was 65% [60–73]. After
adjustment on oxygen flow, the three variables independently associated with low measured
FiO2 using multivariate analysis were patient’s height, a low PaCO2, and a respiratory
rate greater than 30 breaths/min.
Using paired analysis, each estimation methods differed significantly from measured
FiO2 (p < 0.0001 for each). Values outside the limits of agreement accounted for 55%
of cases for the Calc + 3% formula, 69% for the Calc + 4% formula, and 94% for the
conversion table (p < 0.0001).
Conclusion Independently from oxygen flow, the 3 major physiologic variables associated
with low FiO2 delivered under mask were tallness, high respiratory rate and low PaCO2.
None of the tested methods estimated accurately measured FiO2 in patients with acute
respiratory failure breathing oxygen through a mask.
Competing interests None.
References
Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen
through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–96.
Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al. International
study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302(21):2323–9.
P197 Hyperglycemia in ICU: incidence and impact prognosis
Olfa Turki1, Mabrouk Bahloul2, Kais Regaieg3, Chtara Kamilia2, Hmida Chokri Ben2,
Hedi Chelly2, Mounir Bouaziz2
1SFAX, CHU HABIB BOURGUIBA, Sfax, Tunisia; 2Réanimation polyvalente, Faculté de médecine
de Sfax, Sfax, Tunisia; 3ICU, CHU Habib Bourguiba, Sfax, Tunisia
Correspondence: Olfa Turki - olfa.turki.rea@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P197
Introduction Acute hyperglycemia is common in intensive care. It was associated with
poor prognosis and increased mortality.
The purpose of our study is to investigate the frequency of hyperglycemia in our ICU,
to determine the main causes of high blood sugar and to analyze the impact of this
hyperglycemia.
Patients and methods Our study is prospective during 3 months. It was conducted in
the intensive care unit of the University Hospital Habib Bourguiba Sfax-Tunisia. Were
included in our study all patients admitted to the service during the period of the
study. For each patient included were collected from the ICU admission, clinical and
biological data.
Results During the study period, 194 patients were hospitalized in our ICU and the
diagnosis of hyperglycemia (>8 mmol/l) was admitted in 93 patients (48%). The comparison
between patients who developed hyperglycemia and those free hyperglycemia group showed
that, the patients of the first group were significantly older (p < 0.001). Additionally,
hyperglycemic patients had more medical history including history of diabetes (p < 0.001),
a higher SAPS II (p < 0.05), a more significant frequency of active infections (p < 0.05).
Moreover, the presence of hyperglycemia was associated with shock (p < 0.05) and respiratory
distress (p < 0.05).
Their evolution was marked by the significantly higher frequency of infectious complications
(p < 0.05), thromboembolic complications (p < 0.05) and acute renal failure (p < 0.05).
The average duration of mechanical ventilation and the length of stay were also significantly
prolonged in hyperglycemia group patients (p < 0.05 for both).
Finally, the presence of hyperglycemia was significantly associated with a higher
mortality rate.
Conclusion We concluded that hyperglycemia is correlated with poor prognosis of morbidity
and mortality. But strict glycemic control remain controversial. Thus, further studies
on this subject will be recommended to define the exact place of glycemic control
in intensive care.
Competing interests None.
P198 Acute kidney injury following orthotopic liver transplant: impact of preservation
solutions as a risk factor
Mona Assefi1, Romain Deransy1, Hélène Brisson1, Antoine Monsel1, Filomena Conti2,
Olivier Scatton3, Olivier Langeron1
1Réanimation chirurgicale polyvalente, Groupe Hospitalier Pitié-Salpêtrière, Paris,
France; 2Hépato-gastro-entérologie et médecine de la transplantation, Groupe Hospitalier
Pitié-Salpêtrière, Paris, France; 3Chirurgie digestive, hépato-bilio-pancréatique
et transplantation hépatique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
Correspondence: Mona Assefi - monaassefi@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P198
Introduction Acute kidney injury (AKI) is a common complication after orthotopic liver
transplantation that can increase morbidity and mortality rates. Identification of
AKI risk factors is important to prevent renal failure. The composition of preservation
solution for organ transplants limiting ischemia and reperfusion injuries, may play
an important role in the development of AKI and has never been studied before. The
aim of this study was first to evaluate the impact of four preservation solutions
(SCOT, Solutions de Conservations des Organes et Tissus; UW, University of Wisconsin;
Celsior; IGL-1) on the occurrence of early AKI after liver transplant, second to identify
perioperative risk factors transplant, and third to determine urine biochemical profiles.
Materials and methods In this prospective observational study, we analysed clinical
and laboratory data, during the preoperative, intraoperative and postoperative periods,
from 168 liver transplant recipients, between February 2009 and June 2012. AKI was
defined by KDIGO criteria [1].
Results AKI was reported in 86 patients (51.2%) in the 7 days after orthotopic liver
transplant. In univariate analysis, SCOT was a risk factor for development of AKI.
There was no difference with the other preservation solutions. The other risk factors
for AKI occurrence were: MELD score, female gender, Body Mass Index (BMI) and preoperative
serum total bilirubin. After fitting a forward stepwise regression model, the type
of preservation solution was not anymore an independent risk factor for development
of AKI, unlike MELD score, female gender and BMI (p ≤ 0.05). The 1-year mortality,
duration of mechanical ventilation, intensive care unit (ICU) and hospital length
of stays were significantly increased among patients who developed AKI. Urine biochemistry
profiles, although disturbed by the use of diuretics, could highlight an early inadequate
renal perfusion after liver transplantation. See Fig. 7.
Fig. 7
See text for description
Discussion In this study, a high incidence of post-liver transplant AKI in ICU during
the first week after surgery was noted and risk factors of AKI were identified. However,
this study failed to demonstrate an impact of preservation solution on AKI occurrence
after liver transplant. Risk-factors (MELD, female gender and BMI) are only related
to the patient characteristics. Our results should be interpreted with caution given
the small sample size, and the monocentric character of the study.
Conclusion Solution for organ preservation has no impact on AKI occurrence in ICU
within 7 days following orthotopic liver transplant. Because of many factors that
can influence AKI, a new study with largest sample size is necessary to demonstrate
or eliminate a possible impact of preservation solution.
Competing interests None.
Reference
KDIGO. Kidney Int Suppl. 2012;2:7–24.
P199 Management of acute kidney injury and application of RIFLE criteria in a Tunisian
medical intensive care unit
Hassen Ben Ghezala1, Salah Snouda2, Chiekh Imen Ben3, Moez Kaddour2
1Réanimation Médicale, Hôpital Henri Mondor, Avenue du Maréchal de Lattre de Tassigny,
Créteil, France; 2Réanimation Médicale, Hopital regional zaghouan, faculté de médecine
de Tunis, Zaghouan, Tunisia; 3Teaching department of emergency and intensive care,
Regional hospital of Zaghouan, Zaghouan, Tunisia
Correspondence: Hassen Ben Ghezala - hassen.ghezala@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P199
Introduction Despite the advances made in recent years in the definition and classification
of acute renal failure (ARF), epidemiological data remain varied and imprecise. These
data basically vary with the population studied and the pathologies that are responsible
of the ARF can be particularly complex and intricated especially in emergency and
intensive care units (ICU).The aim of our study was to describe the clinical, etiologic,
and therapeutic and outcome of ARF, to apply the RIFLE classification (Bellomo and
col, Crit Care 2004) to our population of kidney failure patients admitted to intensive
care, and assess its relevance in terms of hospital mortality risk.
Materials and methods We conducted a retrospective analysis over a period of 48 months
(January 2011–December 2014), of records of patients who experienced ARF. The ARF
is defined according to the RIFLE classification. We picked up all the clinical and
laboratory data, the need for renal replacement therapy, the complications and the
disease progression.
Results During this study period, 82 out of 1269 patients admitted to our ICU were
hospitalized for ARF. They were classified into RIFLE R (30 patients or 37%); RIFLE
I (15 patients or 18%) and RIFLE F (37 patients or 45%). The initial reason for visiting
the emergency was asthenia (41%), followed by disorders of consciousness and dyspnea.
The average age of our patients was 67 ± 13 years with a sex ratio of 2.9. Most found
risk factors were hypertension (50%), diabetes (39%) and heart disease (35%). The
ARF was essentially functional (56%). The main origin was septic (28%) followed by
hypovolemia. Renal replacement therapy was required by 34 patients (41%).
Overall mortality in our population was 45%. Most RIFLE F patients died (62%). Among
the risk factors associated with a severe prognosis, we definitely include the RIFLE
classification (OR 4.2; CI 95% [2.66–6.65]). The other factors associated with mortality
were SAPS II score (OR 6.45; CI 95% [2.77–7.32]) and use of vasopressor agents (OR
3.34; CI 95% [2.07–5.41]).
Conclusion ARF is a serious pathology burdened with a heavy morbidity and mortality.
It is essentially functional and its main causes are sepsis and hypovolemia. RIFLE
classification can predict morality in our Tunisian critically ill patients.
Competing interests None.
P200 Death rate risk factors of acute renal failure in intensive care department
Anwar Armel1, Lafrikh Youness1, Bensaid Abdelhak2, Miloudi Youssef2, Al Harrar Najib2,
Amouzoun Mustapha3, Mtioui Noufel3, Zamd Mohamed3, El Khayat Salma3, Medkouri Ghizlane3,
Benghanam Mohamed3, Ramdani Benyounes3
1Anesthésie réanimation, CHU Ibn Rochd, Casablanca, Morocco; 2Anesthésie réanimation,
Hopital 20 Aout CHU IBN Rochd, Casablanca, Morocco; 3Néphrologie hémodialyse et transplantation
rénale, CHU Ibn Rochd, Casablanca, Morocco
Correspondence: Anwar Armel - armelanwar@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P200
Introduction Acute renal failure (ARF/IRA) is a frequent complication in intensive
care unit. Despite of many technical innovations, mortality remains important.
Our study’s aim is to establish the different mortality risk factors ARF/IRA in intensive
care.
Materials and methods It is a descriptive cross-sectional study interesting 76 patients
admitted at the ICU of the 20 August UHC Ibn Rochd, who showed out (ARF/IRA) according
to RIFLE classification, on admission or have developed it during hospitalization.
The study was made over a period of 18 months.
It excluded all patients with chronic or pre-terminal renal failure.
Statistical analysis used the epi-info test with significance level P < 0.05.
Results During the study period, 423 patients were enrolled, 76 of which have completed
our inclusion criteria, that is an incidence of 17.96%. Patients average age was 54.57 ± 19.78 years
with a male predominance. Antecedents most found are diabetes (43.4%) and high blood
pressure (28.94%). Most of the cases were in class F (65.6% of the cases). Classes
I and R are 21.9 and 12.5% respectively. Death rate was 64.47%, septic shock was death’s
cause in 22.36% of them.
Mortality risk factors selected were age, the disease’s medical background, diabetes
or pre-renal failure history, presence of hemodynamic failure, RIFLE stage F and organic
nature of the acute renal failure.
Conclusion Acute renal failure occurrence in intensive care is a critical step with
a very derogatory prognosis significance. A better understanding of its risk factors
and prognosis is basic for more effective management.
Competing interests None.
P201 Early management of tumor lysis syndrome in intensive care unit
Dhouha Lakhdhar1, Florent Montini1, Sébastien Moschietto1
1Reanimation, Centre Hôspitalier Henri Duffaut, Avignon, France
Correspondence: Dhouha Lakhdhar - lakdardoha@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P201
Introduction Tumor lysis syndrome (TLS) occur with tumor breakdown usually by response
to chemotherapy. It may also occur spontaneously. The rapid destruction of malignant
cells release intracellular content into the extracellular compartment, inducing metabolic
and electrolytic imbalances, which result in acute kidney injury. Early prophylactic
therapy is essential to ovoid the occurence of TLS and prevent life threatening complications.
The aim of this study was to prove the value of the early management and monitoring
of patients with high risk of TLS in intensive care units (ICU).
Patients and methods This was a mono-centric, descriptive and retrospective study.
During a 3 year period, from January 2013 to June 2016, case notes of fifteen patients
with hematologic malignancies were reviewed. They were admitted in intensive care
unit for chemotherapy induction for patients with high risk of TLS, or for established
TLS. We collected informations regarding clinical and biological presentation, treatment
and outcome.
Results Fifteen patients were included. The median age was 65 [45–73] years, with
IGS II score at the admission 40 [31–51]. Mainly male (87%). The major part had acute
myeloid leukemia and highly aggressive lymphoma. Twelve patients were admitted in
ICU for chemotherapy induction. Four patients had spontaneous TLS and three patients
had TLS after chemotherapy started in oncology department. Concerning patients who
had acute myeloid leukemia the median rate of white blood cells count was 84,000 [15,000–166,000]
white blood cells per microliter. Seven patients had tumoral renal infiltration. The
median CKD-epi score was 77 [23.9–95.6] mL/min/1.73 m2. According to KDICO score,
five patients were in stage G1, five were in stage G4, four were in stage G2 and one
in stage G3a. At the time of admission, seven patients had hyperphosphatemia, nine
had hypocalcemia, five had hyperuricemia, and only one had hyperkalemia. Chemotherapy
was started in ICU for twelve patients. The median hydration amount was 2.5 [1–3] l
the first 48 h. The aggressive IV hydration was monitored with daily heart ultrasound
examination and urine output. Recombinant urate oxidase (rasburicase) was given to
all patients, the number of doses depended on urecemia levels. Six patients needed
only one dose of rasburicase. Seven patients had renal replacement therapy (RRT) and
it lasted 48 [48–72] h. The RRT was prophylactic in four cases started when phophatemia
was more than 2 mmol/L, and therapeutic for renal failure and established TLS in three
cases. The median duration stay in ICU was 5 [4–7] j. Thirteen patients left the ICU
without major metabolic dysfunction. Two patients deceased due to infectious complications.
Discussion Monitoring of electrolytes was done on average, three times a day which
is hard to do in onco-hematology unit. The early use of rasburicase and the aggressive
IV hydration helped to prevent TLS for seven patients. The aggressive IV hydration
was made according to echocardiography data and close monitoring of vital signs and
urine output which has allowed to avoid volume overload and acute pulmonary edema.
The early prophylactic RRT prevented renal failure and metabolic complications.
Conclusion Early management of TLS in ICU can prevent TLS and most of its serious
complications and should be considered in TLS prophylaxis recommendations.
Competing interests None.
P202 The added value of plasma or urinary NGAL concentration in clinical practice
Emilien Gregoire1, Guillaume Claisse2, Julien Guiot3, Philippe Morimont3, Jean-Marie
Krzesinski1, Christophe Mariat4, Bernard Lambermont3, Etienne Cavalier5, Pierre Delanaye6
1Nephrology, C.H.U de Liège - Sart Tilman, Liège, Belgium; 2Nephrology, Hospital Center
University De Saint-Étienne, Saint-Priest-en-Jarez, France; 3Medical intensive care,
C.H.U de Liège - Sart Tilman, Liège, Belgium; 4Néphrologie, Centre Hospitalier Universitaire
de Saint-Étienne, Saint-Étienne, France; 5Biologie clinique, C.H.U de Liège - Sart
Tilman, Liège, Belgium; 6C.H.U de Liège - Sart Tilman, Liège, Belgium
Correspondence: Pierre Delanaye - pierre_delanaye@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P202
Introduction Plasma and urinary NGAL concentrations have been proposed for the early
diagnosis of acute kidney injury (AKI). However, the added value of these parameters
on simple usual clinical data (such as baseline serum creatinine and/or diuresis)
has been questioned [1].
Patients and methods We measured both urinary and plasma NGAL concentration (Bioporto,
Gentofte, Denmark on Roche Cobas 6000) in 98 patients admitted to the medical ICU
of an Academic Hospital. The measurement was done in the first 24 h after ICU admission.
Renal transplanted and dialysis patients were excluded. AKI was defined according
to serum creatinine criteria of the KDIGO guidelines (1.5–1.9 times baseline or ≥0.3 mg/dL
increase).
Results Three patients were excluded from the analysis because of early (in the first
24 h) death. For the 95 patients, median [IQR] age was 64 years [20], mean (SD) SAPSII
score was 46 (17), 39% were septic, median baseline (=at admission in ICU) serum creatinine
was 9.7 [8.4] mg/dL, and median first 24 h diuresis was 1432 [1340] mL. ICU mortality
was 14.7%. Prevalence of AKI stage 1 was 21%. Both urinary (expressed as the ratio
of NGAL on urinary creatinine) and plasma NGAL were predictive of AKI Stage 1. Predictive
value of plasmatic measurements was higher than the urinary one (AUC of 0.627 and
0.758, respectively, p = 0.0273 between AUC), but not higher than either baseline
serum creatinine (AUC = 0.737) or 24 h diuresis (AUC = 0.735). Backward multivariate
regression showed that plasma NGAL concentration was associated with serum creatinine,
CRP and albumin, whereas urinary NGAL was associated with leucocyturia and baseline
creatinine.
Discussion Previous positive studies with NGAL did not compare the performance of
this costly biomarker with simple usual clinical parameters to predict AKI. Moreover,
several parameters were associated with NGAL concentrations with a high risk of collinearity
(CRP) and/or false positive results (leucocyturia).
Conclusion Our data do not support any added value of NGAL concentration over baseline
serum creatinine or urine output to predict AKI.
Competing interests None.
Reference
Vanmassenhove J. Urinary and serum biomarkers for the diagnosis of acute kidney injury:
an in-depth review of the literature. Nephrol Dial Transplant, 2013;28:254–273.
P203 Interest of the resistivity index in the detection of renal aggression in intensive
care
Soumia Benbernou1, Sofiane Ilies1, Abdelkader Azza2, Khalida Bouyacoub3, Meriem Louail4,
Houria Mokhtari-Djebli5
1URGENCES MEDICALES CHUORAN, Faculté de médecine d’Oran, Oran, Algeria; 2Emergencies,
CHU ORAN, Oran, Algeria; 3Urgences medicales, Chu Oran, oran, Algeria; 4Anesthésie
réanimation chirurgicale, EHU 1er Novembre, Oran, Algeria; 5Urgences Médicales et
réanimation, Centre Hospitalier et Universitaire d’Oran, Oran, Algeria
Correspondence: Soumia Benbernou - gsoumia@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P203
Introduction Acute renal failure (ARF) is a common entity in intensive care, concern
that the heavy morbidity and mortality it is associated [1].
Early diagnosis of this entity remains difficult, neither diuresis and creatinine
are early parameters in the diagnosis of ARF. The kidney is an organ that suffers
long to become faulty, the priority is to recognize renal aggression and to achieve
a therapeutic allowing reversibility of the infringement.
A number of markers have been developed for the diagnosis of the IRA but costs remain
high not allowing their routine use. The measurement of resistance index with the
renal Doppler could be a solution for the diagnosis of aggression and also of the
etiology.
Patients and methods Performed prospective study in the intensive care unit of emergency
room from January 2016 to June 2016. Bringing together ninety-two patients.
The material used, PHILIPS brand with cardiac ultrasound probe of 3.5 MHz.
Three patient groups are made selon their renal resistive index, group A with IR < 0.75,
group B, 0.75 < IR < 0.90, and Group C with IR3 to 0.90.
Results Patients in group A number of 33 patients showed no impairment of renal function.
Patients in group B at number 41 which are supported effectively do not progress to
the group C.
Five patients progressed to group C.
Patients in group C at number eighteen, lives with a higher resistance index of 0.90
or required an extra renal purification.
Patients in group C are classified as risk or failure check the RIFLE classification,
eleven have a persistent hyper hydration seven with persistent hypovolemia.
The elevation of creatinine was seen later within 48 h after the IR >90.
Discussion In our series the resistance index has a value of early diagnosis of renal
prognosis aggression in the occurrence and development of renal failure. Renal doppler
associated with a strictly applied standardized protocol achieves the two goals of
monitoring who aid in the diagnosis and guide treatment. Although the recommendations
of experts to this tool provides that it should probably not use the resistance index
measured by renal doppler to diagnose or treat an IRA (Grade 2) [2]. Identifying the
cause of kidney aggression is a prerequisite before any therapeutic action. Hypovolemia
and soda hydro overload are the causes principales. Excess filling hyper intra thoracic
pressure and hypoxia are the main causes of kidney congestion.
Conclusion Doppler is an early renal medium in the diagnosis of renal aggression.
A larger series could assert this observation.
Competing interests None.
References
Demiselle J. Diagnostic strategies for renal impairment in the intensive care unit.
Réanimation. 2015;24:625–35.
Recommendations formalized expert Acute renal failure in the perioperative and intensive
care (excluding extrarenal purification techniques). Anesth Reanim. 2016;2:184–205.
P204 Peri-partum thrombotic microangiopathic syndrome: diagnosis and treatment in
intensive care unit, a single center retrospective study
Romain Arrestier1, Fabrice Daviaud1, Xavier Laborne Francois2, Elsa Brocas1, Gérald
Choukroun1
1Réanimation polyvalente, C.H. Sud Francilien, Corbeil-Essonnes, France; 2Samu, C.H.
Sud Francilien, Corbeil-Essonnes, France
Correspondence: Romain Arrestier - arrestier_romain@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P204
Introduction Peri-partum thrombotic microangiopathic syndrome (PP-TMA) is a frequent
situation in intensive care unit, mainly with HELLP syndrome. Other syndromes as Thrombotic
Thrombocytopenic Syndrome (PTT) and atypical Hemolytic and Uremic Syndrome (aHUS),
need specific treatments. When PP-TMA is diagnosed there are no clear guidelines about
the right treatment to start after foetal extraction. Plasma exchange (PE) should
be used to treat PTT. The prognosis of patients is improved when this technique is
started early in the course of the disease but several days are necessary to obtain
results of diagnosis tests. The aim of our study was to evaluate characteristics of
the patients with PP-TMA who were treated by PE in ICU and to define the characteristics
associated with the beginning of PE.
Patients and methods We conducted a retrospective analysis of all the women with PP-TMA
admitted in ICU between 2012 and 2016, in a hospital with a level 3 maternity with
about 5000 deliveries a year and the possibility to perform plasmatic exchanges. We
have differentiated 2 groups, with PE and without PE.
Results 38 patients were admitted in our unit with PP-TMA. 33 were treated without
PE and 5 with PE. 32/33 patients in the no PE group had a diagnosis of HELLP and 4/5
in the other group. PE group had a greater IGS2 score (21.62 [8–84] vs 34 [13–52]),
had significantly more pre-eclampsia, 4/5 (80%) versus 7/33 (21%) p = 0.0187. PE were
started at an average of 1.6 days after foetal extraction, and with an average of
5 sessions. Patients of the PE group had significantly lower nadir of hemoglobin but
also lower hemoglobin level at day 2 and day 5. Nadir of platelets count was also
lower and level remain lower at days 1, 2, 3 and 5. Acute kidney injury (using Kdigo
classification) was more frequent with a higher rate of dialysis in ICU, in the PE
group (4/5 (80%) vs 3/33 (9%) p = 0.0022) with a more frequent need for dialysis at
the exit of ICU. Proteinuria was significantly higher in the PE group (862.8 mg/mmol
vs 308.41 mg/mmol, p = 0.0134). ADAMTS13 dosage was done only in patients with PE.
We find a diminution of ADAMTS13 activity (before PE) with an average of 53% [40–70]
in this group. There was no death, and adverse effects were not significantly different.
Discussion This study shows that PE was used when diagnosis was uncertain in the most
severe form of PP-TMA. Low hemoglobin, low platelets, acute kidney injury and high
level of proteinuria are the main factors associated with the decision to begin PE.
This technique was safe and not associated with major adverse events. Several studies
show that there are physiopathological crossovers between diseases associated with
PP-TMA, for example low ADAMTS13 activity in HELLP or mutation in alternative complement
pathway which induced HELLP. Moreover, studies and case reports show a benefit of
PE in HELLP syndrome. Our study did not find significant difference in adverse events
(maybe due to a lack of power), but this is another argument to discuss PE in the
management of PP-TMA in severe patients. The main limits of our study are that none
of the patients who had a plasmatic exchange had a diagnosis of PTT and that diagnosis
tests were not performed in all patients with PP-TMA (complements level, ADAMTS13…).
Conclusion PP-TMA treated with PE has lower hemoglobin, lower platelets, higher rate
of kidney injury and proteinuria than those treated without PE. No difference were
found for adverse events. Begining of PE should be discussed for management of a PP-TMA
without amelioration after fœtal extraction.
Competing interests None.
Reference
Fakhouri F, Vercel C, Frémeaux-Bacchi V. Obstetric nephrology: AKI and thrombotic
microangiopathies in pregnancy. Clin J Am Soc Nephrol. 2012;7(12):2100–6.
P205 Which patients with acute respiratory distress syndrome (ARDS) have diffuse alveolar
damage?
Arnaud W Thille1, Oscar Peñuelas2, José-Angel Lorente2, Pablo Cardinal-Fernandez2,
José-Maria Rodriguez3, José-Antonio Aramburu3, Andres Esteban2, Fernando Frutos-Vivar2
1Réanimation Médicale, CHU de Poitiers, Poitiers, France; 2Departamento de cuidados
intensivos, Hospital Universitario de Getafe, Getafe, Spain; 3Departamento de anatomía
patología, Hospital Universitario de Getafe, Getafe, Spain
Correspondence: aw.thille@gmail.com Arnaud W Thille
Annals of Intensive Care 2017, 7(Suppl 1):P205
Introduction Diffuse alveolar damage (DAD) is the typical histological feature of
acute respiratory distress syndrome (ARDS). However, in a previous study including
356 patients with criteria for ARDS, we found that only 45% of them had DAD at autopsy
exanimation [1]. It has been shown that patients with ARDS and DAD on open lung biopsy
had higher mortality than those without DAD [2]. Thus, we aimed to identify markers
associated with DAD in patients with ARDS.
Patients and methods We included the 356 patients who met criteria for ARDS at time
of death in our large database of clinical autopsies [1]. We assessed the proportion
of DAD according to the severity of ARDS including the degree of hypoxemia and the
4 ancillary variables from the Berlin definition: use of high levels of positive end-expiratory
pressure (PEEP at least 10 cmH2O), radiographic severity (3 or 4 quadrants on chest
radiograph), altered respiratory system compliance (≤40 mL/cmH2O), and large dead
space defined as a corrected expired volume per minute (≥10 L/min).
Results DAD was associated with all the severity markers above-mentioned using univariate
analysis. After multivariable logistic regression, the three markers independently
associated with presence of DAD were the gender with an odds ratio (OR) of 1.76 [1.08–2.86]
for females (p = 0.02), the degree of hypoxemia with an OR of 3.88 [1.51–9.94] for
moderate and 7.22 [2.83–18.3] for severe ARDS (p < 0.01 for both), and the radiographic
severity with an OR of 3.56 [1.88–6.72] (p < 0.01) for patients with diffuse opacities
involving the 4 quadrants. DAD was found in 67% of patients with PaO2/FiO2 ≤ 100 mmHg
and diffuse opacities.
Conclusion DAD was significantly more frequent in females. In addition to the severity
of hypoxemia, diffuse infiltrates involving the 4 quadrants was a significant marker
of DAD.
Competing interests None.
References
Thille AW, Esteban A, Fernandez-Segoviano P, Rodriguez JM, Aramburu JA, Penuelas O,
Cortes-Puch I, Cardinal-Fernandez P, Lorente JA, Frutos-Vivar F. Comparison of the
Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir
Crit Care Med. 2013;187:761–67.
Cardinal-Fernandez P, Bajwa EK, Dominguez-Calvo A, Menendez JM, Papazian L, Thompson
BT. The presence of diffuse alveolar damage on open lung biopsy is associated with
mortality in patients with acute respiratory distress syndrome: a systematic review
and meta-analysis. Chest. 2016;149:1155–64.
P206 Functional imaging of lung macrophage inflammation during high-volume ventilation
using PET/CT
Laurent Bitker1, Nicolas Costes2, Didier Le Bars2, Franck Lavenne2, Mojgan Devouassoux3,
Jean-Christophe Richard1
1Réanimation médicale, Hospital Croix-Rousse, Lyon, France; 2Positron emission tomography
department, CERMEP, Bron, France; 3Service d’anatomo-pathologie, Hospital Croix-Rousse,
Lyon, France
Correspondence: Laurent Bitker - laurent.bitker@chu-lyon.fr
Annals of Intensive Care 2017, 7(Suppl 1):P206
Introduction Ventilation Induced Lung Injury (VILI) is responsible for an increased
mortality in ARDS [1]. Mechanical ventilation may trigger an inflammatory response,
comprising alveolar macrophage activation and recruitment, which may be specifically,
repeatedly and spatially assessed by functional imaging techniques such as Positron
Emission Tomography combined with Computerized Tomography (PET/CT) [2]. 11C-PK11195
is a PET radiotracer with potential to quantify macrophage inflammation. We aim to
assess its performance to detect lung macrophage recruitment in an experimental high-volume
VILI model.
Materials and methods VILI was performed in 5 anesthetized pigs under neuromuscular
blockade by rapidly increasing the tidal volume (Vt) to obtain a transpulmonary pressure
(TPP) between 35 and 40 cmH2O under zero end-expiratory pressure. PET/CT acquisitions
were performed before (T1) and after 4 h of high-volume ventilation (T2), and image-derived
measurements were realized on the whole lungs, and regionally on 6 distinct lung regions
(divided along the anteroposterior and the cephalocaudal axes). 11C-PK11195 lung uptake
was estimated using the Standardized Uptake Value (SUV), normalized to the CT-derived
tissue fraction in the region of interest (ROI). Mechanical lung aggression was estimated
by CT-derived dynamic and static strains, and tidal alveolar hyperinflation (expressed
as a fraction of the tidal variation in the ROI volume). After euthanasia, alveolar
damage and macrophage recruitment were assessed in the 6 lung regions, using semi-quantitative
scores.
Results Between T1 and T2, VT and TPP significantly increased from 6.0 ± 0.1 to 49.4 ± 2.9 ml/kg
and 8.6 ± 1.5 to 37.8 ± 4.4 cmH2O, respectively. SUV on the whole lung significantly
increased from 1.8 ± 0.6 to 3.0 ± 0.5 between T1 and T2 and dynamic strain from 0.36 ± 0
to 2.1 ± 0.2, whereas static strain did not significantly vary. Tidal alveolar hyperinflation
significantly increased from 18 ± 4 to 68 ± 3% on the whole lung between T1 and T2.
Regionally, dynamic strain, and tidal alveolar hyperinflation significantly differed
between regions, as well as between T1 and T2. Regional SUV differed between T1 and
T2 but not between regions. Regional static strain did not differ between regions,
nor between T1 and T2. In multivariate analysis, regional SUV was independently and
significantly associated with dynamic strain and tidal alveolar hyperinflation. Histologic
analysis showed significant regional differences in alveolar damage but not in macrophage
recruitment. SUV was positively associated with macrophage recruitment but not with
alveolar damage.
Discussion In this experimental VILI model, 11C-PK11195 SUV was significantly increased
after 4 h of injurious ventilation, and was significantly and positively associated
with high-volume CT-derived mechanical parameters, such as dynamic strain and tidal
alveolar hyperinflation. The radiotracer’s specificity for macrophages is confirmed
by the SUV significant association with macrophage recruitment and the lack of association
with alveolar inflammatory edema.
Conclusion 11C-PK11195 is a macrophage-specific PET radiotracer, with potential to
dynamically and specifically assess alveolar macrophage inflammation induced by high-volume
ventilation.
Competing interests Research founded by the French society of intensive care medicine
(SRLF) and La Fondation pour la Recherche Médicale (DEA20140630499).
References
ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal
volumes for acute lung injury and the acute respiratory distress syndrome. N Engl
J Med. 2000;342(18):1301–8.
Frank JA, Wray CM, McAuley DF, Schwendener R, Matthay MA. Alveolar macrophages contribute
to alveolar barrier dysfunction in ventilator-induced lung injury. Am J Physiol Lung
Cell Mol Physiol. 2006;291(6):L1191–8.
P208 Reverse triggering on mild and severe ARDS patients
Malika Mechati1, Marc Gainnier1, Laurent Papazian1, Christophe Guervilly1
1Reanimation des urgences et medicale, CHU la Timone 2, Marseille, France
Correspondence: Malika Mechati - malikamechati@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):P208
Introduction The reverse triggering (RT) is the term used to name the contractions
reflexes of the muscle diaphragmatic provoked (“triggered”) by the periodic insufflations,
delivered by the ventilator, at sedated patients under mechanical ventilation [1].
The RT constitutes a new form of patient–ventilator interaction clinically difficult
to detect and little known. The RT could have potential implications during the management
of acute respiratory distress syndrome (ARDS). At present, the management of severe
ARDS consists among others, on the use of an early and systematic perfusion of neuromuscular
blockade agents (NMBA) during a 48 h’ period, continuation to the ACURASYS essay which
showed a reduction of the mortality in the group of the severe ARDS patient receiving
NMBA. The reason of the beneficial effect of curare is not perfectly known. It is
possible that the phenomenon of RT is a mechanism implied in the deleterious role
of the mechanical ventilation during ARDS. The abolition of this phenomenon by NMBA
could explain the beneficial effect of NMBA in ARDS [2]. The objective was to look
for the phenomenon of RT in two groups of ARDS patients: a group receiving NMBA and
a group not receiving NMBA.
Patients and methods Physiological observational and comparative study in intensive
care units. We record continuous signals of airflow, airway pressure, and esophageal
pressure during 24 h of consecutives patients with ARDS criteria and PaO2/FiO2 ratio
≤150 at a positive end-expiratory pressure (PEEP) of 5 cmH2O evolving for less than
48 h under mechanical ventilation.
Results Recording of esophageal pressure of 21 consecutives moderate to severe ARDS
patients were blinded analyzed (group NMBA n = 11; group unless NMBA n = 10). Any
phenomenon of RT was observed in the group of mild ARDS patients receiving NMBA (Fig. 8a).
We confirmed the existence of RT on 3 patients of 10 in the group of mild ARDS who
not receiving NMBA (p = 0.05) (Fig 8b).
Fig. 8
Recording of continuous signals of airflow, airway pressure, esophageal pressure,
transpulmonary pressure and tidal volume. a NMBA group; b unless NMBA group
Discussion One of the main limits was the quality of the collection of the signal
of esophageal pressure. The monitoring of esophageal pressure is technically difficult,
and can d influence the quality of the signal and the reliability of the results.
Conclusion This study confirms the existence of the phenomenon of reverse triggering
among deeply sedated patients not receiving NMBA with a 30% incidence. More research
is needed to determine if the reverse triggering is a risk factor independent from
VILI, associated with the bad prognosis of severe SDRA patients and, if a strategy
of early treatment based on NMBA, could improve the prognosis of reached patients.
Competing interests None.
References
Akoumianaki E. Mechanical ventilation-induced reverse-triggered breaths: a frequently
unrecognized form of neuromechanical coupling. Chest. 2013;143(4):927–38.
Papazian L. Neuromuscular blockers in early acute respiratory distress syndrome. N
Engl J Med. 2010;363(12):1107–16.
P210 Airway and transpulmonary driving pressure selected by INTELLiVENT-ASV after
recruitment in ARDS patients
Aude Garnero1, Jean Michel Arnal1
1Réanimation polyvalente, Hôpital Sainte Musse, Toulon, France
Correspondence: Aude Garnero) - aude.garnero@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P210
Introduction In acute respiratory distress syndrome (ARDS), airway driving pressure
(ΔPAW = Plateau pressure (PPLAT) minus total PEEP) reflects the strain applied to
the respiratory system. ΔPAW below 15 cmH2O is associated with increased survival
[1]. However, transpulmonary driving pressure (ΔPTP) is a better assessment of the
strain applied to the lung. Treatment strategy leading to ΔPTP below 8 cmH2O seems
associated with increased survival [2]. INTELLiVENT-ASV is a fully closed loop ventilation
mode that adjusts minute volume according to PETCO2 and select tidal volume according
to respiratory mechanics. This prospective physiological study aimed to verify if
the combination of an optimal recruitment strategy and a closed loop ventilation mode,
namely INTELLiVENT-ASV could achieve a lung protective ventilation. Thus ΔPAW and
ΔPTP selected by INTELLiVENT-ASV after recruitment were measured in moderate and severe
ARDS patients.
Patients and methods The study was conducted in the general ICU of Hopital Sainte
Musse, Toulon, France. Eligible participants were adults aged 18 or over, with early
onset moderate or severe ARDS, invasively ventilated for less than 24 h at the time
of inclusion. Exclusion criteria were contraindication to insert nasogastric tube,
bronchopleural fistula, emphysema, pneumothorax, increased intracranial pressure,
acute corpulmonale, hemodynamic instability, pregnancy. Patients were sedated and
ventilated in controlled mode. An esophageal balloon was inserted and position was
controlled by an occlusion test. A 10 s sustained inflation recruitment maneuver was
performed targeting a transpulmonary pressure at 27 cmH20 during the maneuver. Then
a decremental PEEP trial was performed to determine the level of PEEP associated with
end-expiratory transpulmonary pressure (PTP TE) at 1–2 cmH2O. At this level, airway
and esophageal pressure (PESO) were measured at end-inspiration and end-expiration
using 5 s end-inspiratory and end-expiratory occlusions, respectively. Transpulmonary
pressure was calculated as airway minus esophageal pressure at end-inspiration and
end-expiration. ΔPTP was calculated as the difference between PTP TI and PTP TE.
Results Fourteen patients were included between February 2016 and August 2016, 8 moderate
and 6 severe ARDS, 13 were paralyzed. Sex ratio = 11/3, Age = 59 ± 18 years, SAPS
II = 56 ± 22, BMI = 26 ± 5.
For the total respiratory system: PEEP TOT = 17 ± 4 cmH2O, P PLAT = 26 ± 5 cmH2O,
ΔPAW = 9 ± 1 cmH2O, VT = 6.0 ± 1.0 mL/KgPBW, P PEAK = 29 ± 5 cmH2O, CRS = 48 ± 15 ml/cmH2O.
For the chest wall: PESO TI = 18 ± 5 cmH2O, PESO TE = 15 ± 5 cmH2O.
For the lungs: PTP TI = 8 ± 3 cmH2O, PTP TE= 2 ± 2 cmH2O, ΔPTP = 6 ± 2 cmH2O, CL = 81 ± 39 ml/cmH2O.
Conclusion After a recruitment maneuver and a PEEP set to achieve positive PTP TE,
INTELLiVENT-ASV selected low and safe ΔPAW and ΔPTP in moderate to severe ARDS patients.
This strategy seems lung protective.
Competing interests None.
References
Amato MB. Driving pressure and survival in the acute respiratory distress syndrome.
N Engl J Med. 2015;372:747–55.
Baedorf Kassis E. Mortality and pulmonary mechanics in relation to respiratory system
and transpulmonary driving pressures in ARDS. Intensive Care Med. 2016;42:1206–13.
P211 BIPAP-APRV airway pressure release ventilation with spontaneous ventilation in
ARDS patients under VV-ECMO
Hadrien Roze1, Jean Christophe Richard2, Benjamin Repusseau1, Antoine Dewitte1, Olivier
Joannes-Boyau1, Alexandre Ouattara1
1Sar 2, réanimation médico-chirurgicale magellan, CHU de Bordeaux, Bordeaux, France;
2Departement des urgences, C.H. Annecy Genevois, Annecy, France
Correspondence: Hadrien Roze - hadrien.roze@chu-bordeaux.fr
Annals of Intensive Care 2017, 7(Suppl 1):P211
Introduction Because gas exchanges under ECMO are partially controlled independently
of mechanical ventilation (MV), opposite strategies can be considered from fully controlled
MV to early spontaneous ventilation (SV). To limit the risks associated with fully
controlled ventilation, we changed our MV strategy by choosing a mode facilitating
SV: BiPAP-APRV. This study in severe patients compared two consecutive strategies
with or without early SV under ECMO.
Patients and methods Fully controlled MV used pressure assist control ventilation
(PAC) without SV whereas SV was promoted with BiPAP-APRV using the same settings of
controlled ventilation plus 40% of SV. In both group high inspiratory pressure was
24cmH20, PEEP was around 12 cmH2O with a driving pressure strickly below 14cmH20 and
respiratory frequency was 12 cycles/min.
Results 14 similar patients were analysed, 7 in each group. Patients in BIPAP-APRV
spent 78% (40–88) of their time with SV under ECMO, this time was inversely correlated
with weaning time under pressure support ventilation after ECMO removal, R2 0.54,
p = 0.04. Duration of sedation was similar in both groups. At SV initiation with APRV
Sedation Agitation Scale was 1 (1–2). In the 500 cycles recorded, controlled and spontaneous
VT were 1.6 (1.3–2.7) and 1.2 (1.1–1.5) ml kg−1 PBW respectively (p < 0.0001) and
the % of SV was 39 (30–48) %. Patients spent the same time under ECMO in both groups
but the weaning time under pressure support ventilation (PSV) after ECMO removal had
a significant median reduction of 3 days in the BIPAP-APRV group, p = 0.03 (Fig. 9).
Fig. 9
Circles are PAC group, rhombus are APRV group. MV mechanical ventilation, PSV pressure
support ventilation. Data are presented as median (IQR), Comparison between the 2
groups at each time Mann–Whithney Test, *p < 0.05
Discussion
We reported the feasibility of a protocol based on BIPAP-APRV aiming at resuming SV
as soon as possible in ARDS patients under ECMO. The occurrence of spontaneous inspiratory
efforts in ARDS patients can major variability of transpulmonary pressure and as result
jeopardise VT and driving pressure control. This might be an issue if protective ventilation
is not guaranteed anymore. VT with BiPAP-APRV remains within safe range when the ratio
of spontaneous minute ventilation to total minute ventilation is between 30 and 40%
[1].
BiPAP-APRV is more efficient than PSV to increase lung aeration in patients with ARDS
[1]. Recruitment of dependent region is more likely to achieve if SV is not supported
by synchronized positive airway pressure as during BiPAP-APRV [2]. Our strategy targeting
a percentage of SV between 30 and 40% with high PEEP could be viewed as a compromise
in order to promote SV and protective ventilation at the same time.
Conclusion Protective ventilation combined with SV under ECMO by using a specific
protocol based on BiPAP-APRV is feasible and safe. It may facilitate weaning and thus
reduce the time under MV after ECMO. To what extend this beneficial effect is directly
due to the presence of SV deserve further investigations.
Competing interests None.
References
Intensive Care Med. 2013;39:2003–10.
Anesth Analg. 2009;109:1892–1900.
P213 Evolution of family refusal to organ donation from subject in a state of brain
death
Nadia Harbouze1, A. M. Amine1, A. G. Olandzobo1, R. Cherkab1, C. Elkettani1, L. Barrou1
1Anesthesiology and intensive care departmen, UNIVERSITY TEACHING HOSPITAL IBN RUSHD-CASABLANCA,
Casablanca, Morocco
Correspondence: Nadia Harbouze - nadialina_@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P213
Introduction Since the first transplant from a patient in a state of brain death conducted
in 2010 at the University Teaching Hospital IBN RUSHD of Casablanca, the number of
transplants has increased. However, it is still inadequate meet the growing needs
of organs. The refusal of families remains the main obstacle to the developpement
of organ transplantation in Morocco. The aim of our study is to monitor and analyse
the evolution of family refusal to organ donation in a brain dead patient.
Patients and methods This is a retrospective and comparative study from August until
December 2014.The data were collected from records of brain dead patients candidates
for organ donation at the 7 intensive care units on IBN RUSHED Hospital. The coordination
registers were also studied. A questionnaire was distributed to families who refused
organ donation to investigate the causes of the refusal.
Results During this period, 79 patients with brain death have been identified and
78 families had been approached. 61 families (78%) refused organ donation. The main
causes of refusal were: fear of body mutilation (35%), lack of will (24%) and religious
causes in 28% of cases.
The refusal rate for families decreased from 85% in 2010 to 50% in 2014. Only 2 patients
experienced cardiac arrest before transplantation. During this period, 22 cornea transplants
from brain-dead patient were conducted with 20 kidney transplants and two liver transplants.
Discussion The evolution of the refusal of families saw a decline through awareness
and communication campaigns for organ donation.
Conclusion Improvements to our health care system must be proposed including strengthening
detection of potential donors and relationships with the donor’s family and effective
communication policy.
Competing interests None.
Reference
Le Nobin J, et al. Organ donation, reasons for family refusal: a retrospective study
in a French organ harvesting center. Progrès en Urologie. 2014;24(5):282–87.
P215 Thank-you letters from relatives in the ICU: a qualitative analysis with regards
to the patient–relatives–caregiver relationship
Alexandre Herbland1, Marie Richard2, Nicolas Girard3, Lucile Lambron1, Olivier Lesieur1
1Réanimation, Centre Hospitalier la Rochelle, La Rochelle, France; 2Clinical psychology
department, Centre Hospitalier la Rochelle, La Rochelle, France; 3Clinical research
unit, Centre Hospitalier la Rochelle, La Rochelle, France
Correspondence: Alexandre Herbland - alexandre.herbland@orange.fr
Annals of Intensive Care 2017, 7(Suppl 1):P215
Introduction In the ICU, three major actors are involved in the caring relationship:
patient, relatives and caregivers. Acting as spontaneous testimonials of the lived
experience, thank-you letters from relatives may be considered by ICU teams as a source
of original information which could help in improving care for critically ill patients
and families. This study aimed to investigate the qualitative content of thank-you
letters from relatives of patients who stayed in the ICU. Specifically, our research
questions were, with regards to the letters’ content, (1) how is the caring relationship
tackled and characterized by relatives? (2) to what extent does this relationship
impact their experience of ICU?
Materials and methods The study took place in a 16-beds ICU during a 6-month period.
The research team consisted in a care assistant, a nurse (also clinical research associate),
a psychologist (not working in the ICU) and an intensivist. The corpus consisted in
twenty thank-you letters received in the ICU. We conducted a qualitative study according
to the thematic inductive approach. The process of coding was intended to create established
meaningful patterns.
Results Two main themes emerged as specific determinants of the caring relationship:
(1) the temporality, comprising the time dedicated to the patients and their family,
the time spent with the ICU team, the striking time corresponding to significant events
for relatives needed to be shared with the staff, the extension of the link with caregivers
by evocating a new life after ICU stay, the writing time as a counter-gift to the
caregivers; (2) the caregivers behaviour, including human skills detailed in many
core values (kindness, availability, devotion, attention, goodwill, sensitivity) psychological
support, emotional sharing, capabilities to give informations. Relatives feel to be
“at the center of all attention” in the same way as their loved ones.
Through the narration of ICU experience, the caring relationship is characterized
as follows: (1) the caregiver becomes a close person with an equal relationship (feelings
of friendship, emotional closeness); (2) the ICU team becomes a new family (contrasting
with the poor living environment of ICUs); (3) the relative becomes a caregiver (with
appropriation of medical terms or speaking of his loved one as a patient); (4) the
caregiver is seen as a “super-hero” through an asymmetrical relationship with an overstatement
of personal dedication and investment of the staff members (abnegation, vocation,
involvement).
The caring relationship impacts relatives’ experience of intensive care in several
ways: (1) relatives are deeply touched by caregivers’ human behavior, emotional support
being a source of solace and resilience in particular for bereaved families; (2) relatives
express the idea that taking care of humans is not a valued and rewarded task and
the emerging awareness of hospital realities and difficulties of work in the ICU;
(3) the most striking transformational change in relatives is the perception of their
own vulnerability and humanity, leading them to exhibit an outward-looking attitude
(for example filling out their organ-donation card), and encouraging the ICU caregivers
to continue their missions for the others.
Conclusion Thank-you letters provide both encouraging and informative messages for
ICU teams about relational care for patients and families notably the indivisibility
of the families and their critically ill loved ones. The relatives’ experience of
the ICU appears strongly influenced by the caring relationship in the way they express
an authentic revelation of their own humanity and altruistic thoughts. The thematic
content of thank-you letters questions determinants and fundamental values at stake
in the patient–relatives–caregivers relationship.
Competing interests None.
P216 Advance directives and tomorrow’s doctors: perception and potential use
Sarah Wainschtein1, Sidonie Hubert1, Albane Hugues1, Marc Tran2, Kelly Tiercelet2,
Mélanie Cherin3, Cédric Bruel2, Francois Philippart2
1Médecine interne, Groupe Hospitalier Paris Saint-Joseph, Paris, France; 2Réanimation,
Groupe Hospitalier Paris Saint-Joseph, Paris, France; 3Réanimation polyvalente adulte,
Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
Correspondence: Francois Philippart - fphilippart@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P216
Introduction Far from medical paternalism, the doctor-patient relationship has now
evolved to respect “the autonomy and patients’ rights”. Changing behavior has been
gradual, while the law offered the patient the freedom to consent to care and then
of expressing their wishes regarding the therapeutic intensity they would benefit,
in critical situations where consent would not be possible, through advance directives
(AD) [1]. Their use is of paramount interest for intensivist in many critical situations.
Unfortunately, the use of AD remains marginal because of the unfamiliarity of patients
with their use and an appropriation default by clinicians [2]. The aim of our study
was to investigate the perspective of the coming family physician generation on advances
directives.
Patients and methods Population of interest was general practitioner fellow (GPF)
from class of 2012 to 2014. We built an online questionnaire survey about knowledge
and the place they want to give to AD in their forthcoming daily clinical activity.
This questionnaire was sent to GPF emails obtained by universities, unions and via
the official mailing lists of different regionals classes provided by the first contacted.
Descriptive analysis of quantitative data was expressed as mean and standard deviation,
qualitative data in number and percentage. The comparison of continuous variables
was performed by the Student t-test and the comparison of categorical variables by
a Chi2 test. Analyzes were conducted on BiostaTGV website and Microsoft Excel®.
Results 2310 GPF answered the survey, mainly from Ile de France (n = 218), Toulouse
(n = 199) and Lille (n = 169). For GPF the majority of patients do not know the AD
(81.6%) and 54% think that those who know do not know how to use it.
88.4% of GPF think writing AD by patients requires better information. According to
them, the information should concern the support offered in the ICU (77.1%), the use
of mechanical ventilation (58.7%), dialysis (48.2%) and the evolution of patients
after hospitalization in ICU (50.6%). Nevertheless information on the prognosis of
chronic diseases or organ failure seems interesting for only 37 and 20.7% of them
respectively.
89.8% of GPF wish to propose the drafting of AD to their patients. However, only 60.1%
of them are willing to suggest AD to patients with cancer or hematologic malignancies,
56.2% to patients with neurological and/or degenerative disorders, 20.5% to elderly
patients.
Discussion Despite the low proportion of the population we think these observations
to be of interest because we probably selected the GPF the most interested in AD as
the participation was not mandatory.
Conclusion A large majority of young of future general practitioner is willing to
be involved in the implementation of AD with their patients, however the target population
remains very limited, considering that half of them do not want to discuss AD with
patients suffering from diseases potentially associated with ICU admission or therapeutic
intensity discussion.
Competing interests None.
References
Leonetti J. LOI n° 2005–370 du 22 avril 2005 relative aux droits des malades et à
la fin de vie. In; 2005.
Comité consultatif national d’ethique C. Fin de vie, autonomie de la personne, volonté
de mourir. 2013.
P217 Reducing futility in the ICU: practice makes perfect
Olivier Lesieur1, Philippe Bouillard1, Nicolas Girard1, Vlad Loteanu1, Alexandre Herbland1,
Maxime Leloup1
1Réanimation, Groupement Hospitalier La Rochelle Ré Aunis, La Rochelle, France
Correspondence: Olivier Lesieur - olivier.lesieur@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P217
Introduction Substantial variability exists between countries, institutions, and physicians
in the decision to withhold or withdraw (WhWd) life-sustaining treatment in critically
ill patients. Moreover practices and skills may co-evolve over time. This epidemiological
study aims to compare the procedural features of foregoing treatments between two
separate periods at a 4-year interval (2012 vs 2016).
Patients and methods For each of the two periods considered, the characteristics and
outcome of patients qualified for a WhWd procedure were collected in a single 16-bed
ICU.
Results A total of 199 patients (70 ± 13 years, SAPS II 67 ± 22, sex ratio M/F 2.2)
were qualified for a WhWd procedure in the past (84 patients) and current (115 patients)
periods of the study. Differences (CI 95%) or Odds ratio (CI 95%) are given in Table 6
only in case of significant difference observed.
Table 6
characteristics and outcome of patients admitted over the study periods (2012 vs 2016)
Study period ICU admissions
2012 N = 596
2016 N = 403
Odds ratio (CI 95%)
Length of the period (months)
12
8
Mean Age (yrs.)
65
65
Mean SAPS II
54
53
Mean LOS (days)
10.5
9.5
Mortality rate (%)
28
29
Sex ratio M/F
1.6
1.8
Rate of patients qualified for a withholding or withdrawal (WhWd) procedure (%)
14
29
2.4 (1.8–3.3)
Brain deceased patients (N)
25
19
Circulatory deceased patients (N)
143
97
Rate of WhWd patients among circulatory deceased patients (%)
53
87
5.7 (2.9–11.1)
Rate of WhWd patients ultimately discharged alive from the ICU (%)
10
27
3.5 (1.5–8.1)
Rate of unexpected deathsa among circulatory deceased patients (%)
47
13
0.18 (0.09–0.34)
SAPS Simplified Acute Physiology Score, LOS length of stay, WhWd withholding or withdrawal
aUnexpected death: i.e. without previous do-not-resuscitate order
Discussion At a 4-year interval, the proportion of patients dying in the ICU with
a previous instruction “not to resuscitate” substantially increases, such as that
of patients discharged alive after a formal WhWd decision (p < 0.0001). Correlatively,
the rate of unexpected deaths declines. The overall death rate remains unchanged.
The decrease in average length of stay is not statistically significant (p = 0.22).
Conclusion By anticipating unavoidable deaths, our efforts to withhold or withdraw
hopeless treatments in critically ill patients have resulted in a lower rate of failed
resuscitations without any change in global mortality.
Competing interests None.
P218 The specificity of stress factors in intensive care units (ICU)
Alexandra Laurent1, Florent Lheureux1, Alessia Prestifilippo2, Martin Delgado Maria
Cruz3, Rigal Romain4, Massimo Antonelli5, Torra Lluis Blanch3, Franck Bonnetain6,
Maria Grazzia-Bocci3, Jordi Mancebo7, Emmanuel Samain8, Hebert Paul4, Gilles Capellier9
1Psychology, University of Bourgogne Franche-Comté, Besançon, France; 2Icu, Policlinico
A. Gemelli, Rome, Italy; 3Icu, Hospital de Sabadell, Madrid, Spain; 4ICU, CHUM, Montréal,
Canada; 5ICU, Policlinico Universitario A. Gemelli, Università Cattolica Del Sacro
Cuore, Rome, Italy; 6Unité de méthodologie et de qualité de vie en cancérologie, CHRU
de Besançon, Boulevard Alexandre Fleming, Besançon, France, Besançon, France; 7Réanimation
polyvalente, Hospitat Sant Pau, Barcelone, Barcelone, Spain; 8Réanimation chirurgicale,
CHU de Besançon, Besançon, France; 9Réanimation Médicale, CHU de Besançon, Besançon,
France
Correspondence: Alexandra Laurent - alexandra.laurent@univ-fcomte.fr
Annals of Intensive Care 2017, 7(Suppl 1):P218
Introduction Many studies have ever been conducted on the stress factors in health
care settings. These studies have led to the development of stress scales intended
for physicians and nurses (Bonneterre, 2008). However, the serious pathological and
unpredictable states of patients in ICU require specific work and confront ICU professionals
with specific stress factors. In this context, the question is to know if ICUs need
a specific tool to identified stress factors.
Patients and methods This study aims to identify stress factors to the ICU and compare
with the stress factors of the scale used in the international studies (Nursing Stress
Scale (NSS), Nursing Work Index and Derivates, Karasek’s Questionnaire, Effort-Reward
Imbalance Questionnaire, Job stress scale, The Source of Occupational Stress Scale,
Health Professions Stress Inventory…).
This study was conducted in adult intensive care units in public or private hospitals
in four countries: Canada, France, Italy, Spain. In each country, 40 health care professionals
were solicited for an exploratory interview about the sources of stress in the work
environment: 10 senior physicians, 10 residents, 10 experienced nurses (with more
than 2 years of experience in the service) and 10 inexperienced nurses (with less
than 2 years of experience in the service). All the interview transcripts were analysed
using an inductive coding approach.
Results One hundred and sixty professionals (80 physicians and 80 nurses) were included
in the study. Eight themes emerged from the analysis, and they concerned the stress
linked to (1) patient (2) care, (3) team, (4) family, (5) institutional context, (6)
environment, (7) organizational context, (8) individual dimensions. In each theme,
sub-themes have been identified and determine more precisely the difficulties at work.
Discussion Our findings emphasize the complexity of work in ICUs and show the specifics
factors not taken into account in the generic stress scales such as stress in relation
with family relationships, the end of life decisions and inequity of health care.
Conclusion The specific stress scale should allow to better identified stress in ICU
and to develop measures of prevention and support and training programs.
Competing interests None.
Reference
Bonneterre V, Liaudy S, Chatellier G, Lang T, de Gaudemaris R. Reliability, validity,
and health issues arising from questionnaires used to measure Psychosocial and Organizational
Work Factors (POWFs) among hospital nurses: a critical review. J Nurs Measur. 2008;16(3):207–30.
P219 Anxiety and depression in critial care staff of the university hospital of Monastir,
Tunisia
Fahmi Dachraoui1, Abdelwaheb M’ghirbi1, Ali Adhieb1, Sabrine Nakkaa1, Kmar Hraiech1,
Ali Ousji1, Dhouha Ben Braiek1, Saousen Ben Abdallah1, Hammouda Zaineb1, Islem Ouanes1,
Lamia Ouanes-Besbes1, Fekri Abroug1
1Réanimation polyvalente, CHU Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Fahmi Dachraoui - dachraoui.fahmi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P219
Introduction Intensive care units (ICU) is a place where caregivers face many constraints
that can affect their physical and mental health due to the use of specific care and
strong emotional charge related to patient death and pain of the families. The aim
of the present study is to detect anxiety disorders and/or depression among staff
working in ICUs.
Materials and methods On September 2016, a questionnaire was distributed to staff
(medical and paramedical) operating in 5 ICUs in the university hospital Fattouma
Bourguiba Monastir, Tunisia (1 medical ICU, 1 surgical ICU, 2 cardiologic CCUs and
1 nephrologic intermediate care unit). This questionnaire included demographic data
of participants (age, sex, marital status, length of service, psychiatric history,
consumption of anxiolytic and/or antidepressant) and the Hospital Anxiety and Depression
Scale (HAD: scale composed by 14 items to screen the anxiety (A) and/or depression
(D) among hospital staff).
Results During the study period, 106 participants completed the questionnaire (82%),
58% of them were women, the median age was 32 years ± 8.4. Forty-nine participants
were doctors (the majority of them residents: 41/49). 12.3% of participants (all paramedics)
worked on night shift, seniority of more than a year in the ICU was found in 59% of
participants. 53.8% of staff interviewed were married and only 14.2% of them reported
consumption of anxiolytics and/or antidepressants. 65.9 and 63.2% of the participants
had respectively symptoms suggesting anxiety and depression. The median HAD score
was 19 (IQR = 8); The medical function seems to be significantly associated with the
occurrence of symptoms of anxiety and depression compared to paramedics, however the
type of ICU (medical/surgical ICUs vs cordiologic/nephrologic ICUs) does not appear
to be related to the occurrence of symptoms of anxiety or depression (Table 7).
Table 7
Relationship between the type of ICU, the function and the occurrence of symptoms
of anxiety or depression in ICUs
Anxiety, n (%)
Depression, n (%)
Medical/surgical versus cardiologic/nephrologic ICU
36 (70%) versus 36 (65.4%); p = 0.54
40 (78%) versus 37 (67.2%); p = 0.13
Medical versus Paramédical
47 (83.9%) versus 25 (51%); p = 0.001
46 (82%) versus 20 (41%); p < 0.001
Conclusion Anxiety and depression are common symptoms among caregivers in ICUs. Improved
conditions of work in these units should be a target to avoid Burn Out Syndrome.
Competing interests None.
P220 Life-threatening 3,4-methylenedioxy-methamphetamine (MDMA) poisoning: clinical
features and prognostic value of MDMA and its major metabolite concentrations on admission
Taissa Zavgorodniaia1, Marion Soichot2, Isabelle Malissin1, Sebastian Voicu1, Pierre
Garçon1, Antoine Goury1, Lamia Kerdjana1, Nicolas Deye1, Emmanuel Bourgogne2, Bruno
Megarbane1
1Department of medical and toxicological critical care, Lariboisière Hospital, Paris,
France; 2Laboratory of toxicology, Lariboisière Hospital, Paris, France
Correspondence: Bruno Megarbane - bruno.megarbane@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):P220
Introduction The 3, 4-methylenedioxy-methamphetamine (called MDMA) is a widely consumed
recreational amphetamine derivate. The objectives of our study were to describe the
features of life-threatening MDMA poisonings admitted to the intensive care unit (ICU)
and to investigate the prognosticators on admission including the plasma concentrations
of MDMA and its main active metabolite, the 3, 4-methyldioxyamphétamine (MDA).
Patients and methods We conducted a retrospective single centre observational study
including all MDMA-poisoned patients admitted to the ICU from 2007 to 2016. Plasma
MDMA and MDA concentrations were determined using high-performance liquid chromatography
coupled to mass spectrometry. Comparisons were performed using Chi-2 and Mann–Whitney
tests. Pharmacokinetics was modeled using PKsolver® software and the usual parameters
calculated.
Results Twenty patients (16M/4F; age: 25 years [21; 36] (median [25; 75 percentiles];
poly-intoxications: 80%) were included. On admission, patients presented marked consciousness
impairment (Glasgow Score: 3 [3; 14]), hyperthermia (45%; 37.6 °C [37.3; 39.4].),
serotonin syndrome (35%) and seizures (25%). Three patients (15%) experienced pre-hospital
cardiac arrest. Management mainly consisted in the administration of adequate supportive
care: massive fluid repletion (60%), mechanical ventilation (55%; duration: 1 day
[1; 4]), sedative drugs (50%), external cooling (40%), catecholamines (35%), defibrillation
(20%), massive transfusions (20%) and arterio-venous ECMO (20%). Cyproheptadine, the
antidote of the serotonin syndrome, was administered to 20% of the patients. During
the ICU stay, the following complications were observed including aspiration pneumonia
(40%), cardiovascular failure (30%), disseminated intravascular coagulation (30%),
acute renal failure (30%), liver failure (30%), rhabdomyolysis (25%), hemorrhages
(20%), ventilator-acquired pneumonia (20%) and nerve/vessel compressions (10%). Five
patients (25%) died in the ICU and among the survivors, one patient developed significant
neurological sequellae. Based on a univariate analysis, pre-hospital cardiac arrest
onset (p = 0.009), massive hyperlactatemia (p = 0.01) and marked coagulation disturbances
(p = 0.004) on ICU admission were associated to death. Plasma MDMA (638 ng/mL [167;
989]) and MDA concentrations (25 ng/mL [17; 39]) on admission did not significantly
differ according to the final outcome. The pharmacokinetic analysis showed that all
the patients were in the elimination phase when admitted to the ICU, with prolonged
MDMA and MDA half-lives in relation to the liver and renal failures and possibly to
the elevated ingested doses of MDMA too.
Conclusion MDMA poisoning may be life-threatening and even fatal despite optimal ICU
management. Strengthening the information among the youth about the dangers of MDMA
use still remains a public health necessity.
Competing interests None.
P221 Emergency carbon monoxide poisoning: clinical presentation and outcomes
Fatma Essafi1, Aymen M’rad1, Olfa Mejri1, Marwa Ben Hmida1, Hafedh Thabet2, Youssef
Blel1, Nozha Brahmi1
1Department of intensive care and toxicology, Centre d’Assistance Médicale Urgente,
Tunis, Tunisia; 2Department of emergency, Centre d’Assistance Médicale Urgente, Tunis,
Tunisia
Correspondence: A. M’rad - mrad.aymen@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P221
Introduction Carbon monoxide (CO) poisoning is one of the common causes of poisoning
specially in the cold season, which leads to a significant morbidity and mortality.
Patients and methods We retrospectively reviewed the medical data of patients who
presented to the toxicology emergency department with CO poisoning during January
2015 to March 2016. We analyzed patients’ characteristics, management, and outcomes.
Results A total of six hundred and sixty-six patients (523 female and 143 male), aged
of 34 ± 14 years, were included; poisoning occurred between December and February
in 75% of cases, secondary to an indoor heating system exposure in the majority of
cases (89%). The estimated duration of exposure was 2.5 ± 2 h [0.5–13 h], with a mean
carboxyhaemoglobin (COHb) level on arrival at 18.6 ± 17%.
Neurological changes were the most presenting symptoms including headache (n = 652,
98%), dizziness (n = 272, 40%), seizure (n = 15, 2.3%) and loss of consciousness (n = 81,
12.2%). Digestive disorders involving vomiting and nausea were observed in 32.1% (n = 214).
One woman without cardiovascular risk factors developed non ST-segment elevation myocardial
infarction complicated by lung edema. The majority of patients (n = 601, 90%) received
normobaric oxygen during 6 h (n = 535) and 12 h (n = 66). Hyperbaric oxygen therapy
was administered at 2.5 ATA during 1 h to 65 patients for neurological changes (n = 24),
pregnancy (n = 22) and elevated COHb ≥ 25% (n = 19). Mechanical ventilation was required
for 5 patients, and admission into intensive care unit in 39 patients (6%). Death
occurred in 5 cases (0.7%).
Conclusion The carbon monoxide poisoning is a common reason for emergency department
visits in winter. The physician should be aware of the serious neurological and cardiovascular
complications, if symptomatic treatment and oxygen therapy regimens were not respected.
Competing interests None.
P222 Neuro-respiratory toxicity of baclofen in the rat: study of the concentrations/effects
relationships and role of GABAergic receptors
Salma Tannous1, Lucie Chevillard1, Laurence Labat1, Patricia Risede1, Isabelle Malissin2,
Bruno Megarbane2
1Inserm u1144, Paris-Descartes University, Paris, France; 2Department of medical and
toxicological critical care, Lariboisière Hospital, Paris, France
Correspondence: Bruno Megarbane - bruno.megarbane@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):P222
Introduction Baclofen, a GABA-B receptor agonist is used as muscle relaxant agent
and recently for the treatment of alcohol dependence. The number of poisonings has
significantly increased since this new indication. Clinical presentation of poisoning
mainly includes sedation, hypotonia, respiratory depression and seizures. To characterize
the neurorespiratory toxicity of this molecule at high doses, we aimed at investigating
alterations in Sprague–Dawley rat ventilation and brain electrical activity after
baclofen administration and studied their reversal by GABA-receptor antagonists.
Materials and methods Rat ventilation was investigated using plethysmography and arterial
blood gas analysis while brain electrical activity was studied using EEG with one
implanted frontal electrode. Three baclofen doses were used including 43.5 mg/kg (30%
lethal dose-50%), 72.5 mg/kg (50%) and 116 mg/kg (80%). Baclofen concentrations were
obtained using HPLC-MSMS assay. We modeled baclofen pharmacokinetics and analyzed
the doses/effects and effects/concentrations relationships.
Results Baclofen induced early-onset and prolonged dose-dependent sedation (p = 0.0002),
hypothermia (p = 0.004), EEG and respiratory depression (0.001) characterized by significant
increase in the inspiratory (p = 0.0001) and expiratory times (p = 0.02). Significant
increase in PaCO2 and decrease in arterial pH and PaO2 were observed at 116 mg/kg
(p = 0.001), peaking at 240 min. EEG showed signal slowing, burst-suppression aspects
and spikes peaking at 5–6 h post-injection without normalization at the end of the
experiment at 24 h. We did reverse baclofen-induced decrease in tidal volume with
saclofen (a GABA-B receptor antagonist) and interestingly no alteration of baclofen-induced
respiratory depression was observed with flumazenil (a GABA-A receptor antagonist).
Pharmacokinetic parameters of baclofen were obtained at the three doses and were dose-dependent.
Significant but non-linear relationships were observed between baclofen-induced effects
and concentrations.
Conclusion Baclofen causes dose-dependent neurorespiratory toxicity in rats. However,
due to increased poisonings, its safety profile at high doses remains to be established
in humans.
Competing interests None.
P223 Baclofen poisoning: an epidemiological retrospective study in intensive care
unit
Messaouda Khelfa1, A M’rad1, Hana Fredj1, Youssef Blel1, Nozha Brahmi1
1Department of intensive care and toxicology, Centre d’Assistance Médicale Urgente,
Tunis, Tunisia
Correspondence: Youssef Blel - blelyoussef@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P223
Introduction Baclofen is commonly used as treatment of spasticity, and recently prescribed
in treatment of alcohol withdrawal. It has spasmolytic action resulting from antagonistic
activity at presynaptic GABA receptors of the spinal cord. Because it’s widely prescription,
it became one of the principal agents of poisoning. We present a retrospective study
that aims to report the clinical outcomes and management of twenty cases of baclofen
poisoning requiring ICU admission.
Patients and methods Retrospective review of medical observations of patients admitted
to our intensive care unit for baclofen poisoning.
Results Between January 2013 and June 2016, 20 patients were enrolled in this study.
Mean age was 28.2 ± 11 years. Sex ratio was 0.53. Mean APACHE II scale was 8.7 ± 4.
Mean IGSII scale was 22.35 ± 11. Poisoning was deliberate in 100% of cases. Mean ingested
dose was 448.5 ± 349 mg. The majority of patients presented to the emergency room
at 4.8 ± 5 h after ingestion. Digestive decontamination was performed in 9.6% (n = 2)
of patients.
Clinical presentation was dominated by neurological symptoms; including coma (n = 15),
hypotonia (n = 5), hyporeflexia (n = 5), agitation (n = 5), seizures (n = 3) and delirium
in 1 case. Hemodynamic manifestations included bradycardia in 12 patients, three of
them required atropine infusion. One patient presented with hypotension responding
to vascular resuscitation.
Sixteen cases required mechanical ventilation. Aspiration pneumonia was noted in 6
cases. Mean duration of ventilation was 36.6 h ± 27. Mean hospital length of stay
was 62 h ± 25. Complications included ventilation associated pneumonia in one case
and moderate rhabdomyolysis in 3 cases. All patients evolved favorably. There is no
correlation between coma and assumed ingested dose.
Conclusion Baclofen overdose causes mainly neurological effects and except for bradycardia
cardiovascular effects were uncommon. Prognosis is good if full supportive care is
administered properly.
Competing interests None.
P224 Baclofen overdose: a retrospective multicentric study
Maxime Léger1, Marion Brunet2, Gaël Le Roux2, David Boels2, Nicolas Lerolle1
1Réanimation médicale, C.H.U. d’Angers, Angers, France; 2Centre antipoison, C.H.U.
d’Angers, Angers, France
Correspondence: Maxime Léger - mxmleger@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P224
Introduction The lack of an effective treatment for the maintenance of abstinence
from alcohol has led physicians to take an interest in baclofen. Beyond efficacy,
safety of baclofen, prescribed in high doses, is a concern, especially in case of
drug overdose. Indeed, patients with chronic alcohol abuse frequently develop psychiatric
disorders, and are at risk of voluntary drug intoxications. Thus, we set up a retrospective
study to describe morbidity and mortality associated with baclofen overdose.
Patients and methods A case was defined as exposure to baclofen in self-harm attempt
with or without symptoms between January 2008 and December 2015. This study was based
on data collected by the Poison Control Center (PCC) of Angers University Hospital
during telephone responses to toxicological exposure and during patient follow-up,
supplemented by reports from clinical staff in hospital. The mortality rate of baclofen
poisoning cases was compared to the 31,859 non-baclofen voluntary drug poisoning cases
declared to the PCC of Angers University Hospital over the same period. Baclofen elimination
half-lives were calculated in patients with multiple samplings.
Results 190 cases (median age: 40 years; gender (female): 46.8%) of voluntary intoxications
were reported, including two deaths diagnosed at first medical assessment. Over years,
number of baclofen poisoning grew up from 8 cases in 2008 to 91 cases in 2015. 111
patients (59%) had GCS ≤12 at admission and 77 had GCS >12 (41%). Eighty patients
required mechanical ventilation (42.6%). Neurological severity (GCS ≤ 12 or >12) was
significantly associated with higher suspected ingested dose (400 [IQR 190–685 mg]
vs 120 [IQR 80–300 mg], p < 0.0001) and higher baclofen blood concentration (3.24 mg/l
[min–max = 0.05–14.82 mg/l] vs. 0.32 mg/l [min–max = 0–1.66 mg/l], p < 0.001). Seizures
were frequently observed in patients with GCS < 12 (n = 24, 22% vs. n = 2, 3%, in
patients with GCS >12, p < 0.001). Three patients died in the hospital (hospital mortality
rate 1.6%, total mortality rate 2.6%). Non-baclofen cases had lower rate of endotracheal
intubation (n = 1833, 6%, p < 0.001 for comparison) and mortality rate (n = 299, 0.1%,
p = 0.02 for comparison).
Spontaneous baclofen elimination half-life was calculated in six patients with normal
serum creatinine and was 5.57 h [min–max = 3.2–8.3 h]. In the five patients who underwent
dialysis for toxicological reason without evidence of renal failure, baclofen half-life
was 3.46 h [min–max = 2.4–4.43 h]. Comparison between these two data showed a significant
difference (p = 0.03).
Conclusion Baclofen, prescribed in high doses, may lead to severe intoxications: self-poisonings
frequently require endotracheal intubation and are associated with an increased risk
of death. Dialysis decreases baclofen elimination half-time but clinical relevance
of this difference could not be determined.
Competing interests None.
P225 Baclofen poisoning in the intensive care unit: clinical features and investigation
of the relationships between the toxic encephalopathy and the plasma baclofen concentration
Souaad Farah1, Lucie Chevillard2, Hélène Amiel-Niemann3, Laurence Labat2, Isabelle
Malissin1, Nathalie Kubis3, Xavier Declèves2, Bruno Megarbane1
1Department of medical and toxicological critical care, Lariboisière Hospital, Paris,
France; 2Inserm u1144, Paris-Descartes University, Paris, France; 3Department of physiological
investigations, Lariboisière Hospital, Paris, France
Correspondence: Bruno Megarbane - bruno.megarbane@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):P225
Introduction Baclofen, a GABA-B receptor-agonist with muscle relaxant properties established
since 1974, has been recently used at elevated doses to treat dependence to ethanol.
The number of prescriptions has exponentially increased without an exact evaluation
of its toxicity. We aimed to describe acute baclofen poisoning requiring intensive
care unit (ICU) admission and study the relationships between the toxic encephalopathy
and the plasma baclofen concentration.
Patients and methods We conducted a single-centre retrospective study including all
baclofen-poisoned patients admitted to the ICU in 2013–2016. When requested by the
clinical situation, repeated electroencephalograms and measurements of the plasma
baclofen concentrations were performed. Toxic EEG encephalopathy on a scale of zero
to five was graded according to the international rating system (Markand, 1984). Plasma
baclofen concentration was determined using liquid chromatography coupled to mass
spectrometry in tandem developed with a Quantum Ultra apparatus (Thermo Fisher Scientific)
and electrospray source ionization in positive mode (limit of quantification: 5 ng/mL).
Linear regression and Chi-2 or Mann–Whitney tests were used as requested for subgroup
comparisons. Baclofen pharmacokinetics and the relationships between the toxic encephalopathy
and the plasma baclofen concentration were modeled using WinNonlin software v.5.3
(Pharsight Corporation, CA).
Results Twenty-eight patients (17 M/11F; age: 41 years [32; 49] (median [25th; 75th
percentiles]) were included. Poisoning was mainly multidrug ingestion (92%) by suicidal
attempt (63%) occurring in chronic alcoholic patients (71%). The presumed ingested
dose of baclofen was 210 mg [109; 460] and the initial plasma concentration 1425 ng/mL
[206; 2298]. Poisoning features included coma (Glasgow coma score: 3 [3; 11]) with
hypotonia (46%), seizures (39%), abnormal pupil diameter (75%), sinus bradycardia
(39%), aspiration pneumonia (21%) and EEG disturbances (43%) including the presence
of burst suppressions, spikes, spike-waves, background slowing and even prolonged
isoelectric trace in one severely poisoned patient. Management was supportive including
mechanical ventilation (54%) which duration was related to the plasma concentration
of baclofen (r2 = 0.67). One patient was dialyzed. No patient died. Baclofen half-lives
of elimination (7 h [4; 9]) were closed to the observed values reported at therapeutic
doses. The relationship between baclofen-induced encephalopathy as a function of the
baclofen concentrations was described using a sigmoidal Emax model.
Conclusion Baclofen poisoning may be life-threatening. Toxic encephalopathy is well-described
with EEG and its grade correlated to the baclofen concentration. Prescribers should
be aware of the dangers of baclofen which benefits to treat dependence to alcohol
are still lacking.
Competing interests None.
P226 Outbreak of facio-troncular dystonia in central Africa due to counterfeatured
drug with haloperidol
Nicoals Peyraux1, Frederic Baud2, Micaela Serafini1, Jean-Claude Alvarez3, Annette
Heinzelman4
1Geneva, Médecins Sans Frontières, Genève, Switzerland; 2SAMU de Paris, Réanimation
polyvalente, Paris, France; 3Paris, Assistance Publique Hôpitaux de Paris, Paris,
France; 42, rue saint-sabin, Médecins Sans Frontières, Paris, France
Correspondence: Frederic Baud - baud.frederic@wanadoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P226
Introduction During week 52, 2014, in the northeast of the Democratic Republic of
Congo, an African area included in the “Meningitis belt of Africa” and in which malaria
is endemic, patients with suspected but atypical meningitis were reported. In January
2015, Médecins sans Frontières (MSF) Geneva was approached by the Ministry of Health
to support the outbreak.
Patients and methods At the scene, data were collected on individual chart file records.
Thereafter, at MoH and MSF case-management sites, information for each patient was
recorded in a standardized Excel line-list. Patients’ demographic characteristics,
clinical features, and discharge were recorded in an epidemiological study. At per
request of the attending physician, cerebrospinal fluid was analysed for evidence
of meningitis and blood for malaria. Owing to the atypical clinical features, on the
advice of the MSF referent toxicologist, urine and medicine samples were collected
in symptomatic patients. Toxicological analysis included liquid chromatography-mass
spectrometry and high performance liquid chromatography/UV spectrometry. The study
was approved by the Ethical Committee of the Ministery of Health of the Republic Democratic
du Congo, including treatment of adults and children with specific antidote.
Results Initial examination suggested that an illness other than bacterial meningitis
was the cause of patients’ complaints. First hypothesis was meningitis receiving uncomplete
dosage regimen of antibiotics. Thereafter owing to apparent loss of consciousness
with abnormal eyes movements, non-tonico-clonic seizures were considered meanwhile.
The ratio of individuals less 5 y-o to those equal to and greater was 33/67%. The
male to female ratio was 46/53%. The mean duration of hospitalisation was 3.4 ± 0.8 days
(extremes 1–10 days). Extrapyramidal syndrome predominant on the upper part of the
body was noted by paediatrician neurologists who suggested considering a genetic disease.
However, signs and symptoms were present in people from different families in different
areas at the same time. The definitive diagnosis made on pictures and videos of children
and adults and was facio-troncular dystonia resulting from drug-induced adverse effect.
Four urine samples were collected in children and sent to a toxicological laboratory
in France. All urine samples were positive for haloperidol meanwhile the other causes
of facio-troncular dystonia were excluded, including other neuroleptics, metoclopramide,
antidepressants, amodiaquine, anti-histaminic drugs, anti-epileptics, and cocaine.
From January to August 2015, 1021 hospitalisations were recorded in 925 patients.
Looking for the source of haloperidol showed that tablets sold as ‘diazepam’ and consumed
by symptomatic patients contained haloperidol as the sole active pharmaceutical ingredient,
suggesting that this large outbreak was due to haloperidol toxicity from falsified
diazepam. Initial treatment was diazepam to relieve severe facio-troncular dystonia
which was efficient but resulted in long-lasting sedation more especially in children.
A dosage regimen using bipéridène administered by intravenous and oral route was refined
to prevent adverse effects related to this anticholinergic agent used in children.
The complete reversal of the facio-troncular dystonia was the antidotal evidence supporting
the toxicological diagnostic. The mortality rate was less than 5% meanwhile the direct
causal relationship with ADR is questionable. An epidemiological study, including
toxicological analysis in controls in ongoing. Indeed, facio-troncular dystonia induced
by haloperidol does not result from a drug overdose but is an ADR occurring in about
20% of patients treated with haloperidol. WHO is involved in the inquiry related to
this counterfeature involving different countries. The cause of the error is presently
under investigation.
Discussion This outbreak emphasizes the need to consider toxicity resulting from counterfeatured
medicines when facing collective atypical signs and symptoms in countries with unrestricted
access to medication with limited control of qualities of the medicinal drugs.
Conclusion Counterfeatured medicinal drug may result not only in poor efficacy but
also in onset of unexpected outbreak of unknown diseases that should suggest a toxic
origin.
Competing interests None.
P227 Dosage regimen of biperiden to treat haloperidol-induced severe facio-troncular
dystonic syndrome in children
Frederic Baud1, Nicoals Peyraux2, Micaela Serafini2, Annette Heinzelman3
1SAMU de ParisRéanimation polyvalente, Paris, France; 2Geneva, Médecins Sans Frontières,
Genève, Switzerland; 32, rue saint-sabin, Médecins Sans Frontières, Paris, France
Correspondence: Frederic Baud - baud.frederic@wanadoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P227
Introduction In late 2014-early 2015, Médecins Sans Frontières (MSF) had to face an
outbreak of severe facio-troncular dystonic syndrome (FTDS) in North-East Congo. This
outbreak resulted from counterfeature of pills sold as diazepam. Toxicological analysis
revealed one pill contained about 10 mg of haloperidol. FTDS induced by haloperidol
does not result from a drug overdose but is an adverse drug reaction (ADR) occurring
in about 20% of patients treated with haloperidol. Nine-hundred and twenty-five individuals
were admitted in MSF structures for 1021 FTDS. The ratio of individuals less than
5 y-o and equal to or greater of age was 33/67%, including 35 (3.4%) of children less
than 1 y-o. Initial treatment was based on diazepam which relieved FTDS but resulted
in long-lasting sedation, preventing given any drug by the oral route. Owing to the
definitive diagnosis, a shift to the use of a more specific antidote was chosen. Biperiden
was selected as existing in the intravenous and oral form in the Swiss pharmacopea.
The study was approved by the Ethical Committee of the Ministery of Health of the
Republic Democratic du Congo.
Patients and methods As a whole, biperiden was used in 223 cases (84% of the total).
Treated children presented with severe dystonia as evidenced by inability to cooperate
and to swallow. Verbal informed consent was obtained from relatives. The dosage regimen
to treat drug-induced dystonic syndrome in the Swiss pharmacopea is as follows: for
parenteral use in children, intravenously or intramuscularly: 0.040 mg/kg or 1.2 mg/m2
BSA every 30, according to response and tolerance; a maximum of four doses per day
should be used. The internal MSF recommendations for biperiden use in children were
0.01–0.05 mg/kg of body weight that might be repeated four times a day. Initially,
biperiden administration was administered under medical supervision by the MSF referent
at the scene.
Results There was no pediatric preparation of biperiden. Accordingly, the adult preparation
was used in children. The preparation contained 5 mg of biperiden in one milliter
of solvent. The initial planned dose for children of 1 y-o and less and those up to
5 y-o were 1 and 2 mg, respectively. The 5 mg (1 ml) of biperiden was diluted in 4 ml
of saline resulting in a final dilution of 1 mg/ml. Six children were treated according
this dosage regimen. However, the one 1 mg dose was either of limited efficacy while
being associated in others of signs suggestive of ADR, including agitation, heart
rate greater than 160 b/min, the upper limit for children aged of 1 y-o and less.
Two children greater than 1 y-o presented severe abnormal behavior resulting in an
attempt at escape. Owing to question about safety, the dosage regimen was changed,
as follows: 5 mg (1 ml) of biperiden was diluted with 9 ml of saline resulting in
a final dilution of 0.5 mg/ml. An initial dose of 0.5 mg was administered intravenously
as a bolus dose. The effects were looked for over 15 min. In the absence of improvement
in facial dystonia, a second bolus dose of 0.5 mg was administered, a third dose could
be considered 15 min later if the FTDS did not resume. The cumulative initial dose
should not be greater than 2 mg. In addition to the reversal of facial dystonia, the
therapeutic effect of biperiden included the return of swallowing to normal allowing
to give further doses of biperiden by the oral route for three days. The first oral
dose was administered no less than 12 h after the last initial dose at a dose equal
to the efficient initial cumulative dose. The following doses were halved every 12 h.
No ADR related to biperiden were reported using this dosage regimen. The mean duration
of hospitalisation was 3.4 ± 0.8 days.
Discussion The bioavailability of biperiden by the oral route is equal to 33%. Accordingly,
the corresponding intravenous dose should be divided by a factor three. Dosage regimen
of anticholinergic drugs in children are poorly documented. The dosage regimen recommended
by the pharmacopea resulted in frequent and severe ADR. Titration of biperiden resulted
in efficient and safe dosage.
Conclusion When biperiden administration is required by intravenous route in children
of 5 y-o and less, biperiden should be administered intravenously and titred using
bolus dose of 0.5 mg till the therapeutic effect is obtained.
Competing interests None.
P228 Acute poisoning with rodenticides in the intensive care unit
Hassen Ben Ghezala1, Salah Snouda2, Moez Kaddour2, Chiekh Imen Ben3
1Réanimation Médicale, Hôpital Henri Mondor, Avenue du Maréchal de Lattre de Tassigny,
Créteil, France, Créteil, France; 2Réanimation Médicale, Hopital regional zaghouan,
faculté de médecine de Tunis, Zaghouan, Tunisia; 3Teaching department of emergency
and intensive care, Regional hospital of Zaghouan, Zaghouan, Tunisia
Correspondence: Hassen Ben Ghezala - hassen.ghezala@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P228
Introduction Severe poisoning by rodenticides is frequent. It represents nearly 30%
of patients admitted to the new intensive care unit (ICU) of the region. That is why
we decided to perform this study. The aim of this work was to describe the epidemiology,
clinical features and management of all patients admitted to our unit for acute poisoning
with rodenticides.
Patients and methods It was a retrospective study performed in the year 2013 from
January to December. The study included all patients admitted in the ICU for rodenticide
poisoning.
Results 32 patients were enrolled in the study. Our patients were young with a mean
age of 30 ± 2 years. Poisoning was more common in females (n = 24; 75%). The mean
delay between rodenticide poisoning and first medical contact was about 2 ± 2 h in
the cases where this information. Most of our patients (91%) attended the emergency
department of Zaghouan with a non-medical transportation. It was a suicide attempt
in most cases (62%) and an accidental poisoning in 32% of patients. The most frequent
cause of poisoning in our study was organophosphorus pesticide (n = 24; 75%). The
second cause was alpha-chloralose poisoning with seven cases (22%). One patient ingested
accidentally an anticoagulant rodenticide. Most of patients had ingested (oral route)
the rat poison (n = 23; 78%). Clinical examination found normal vital signs in ten
cases (31%). Nine patients (28%) had a shock, eight patients (25%) had an acute metabolic
disorder and five patients (16%) had acute respiratory failure or were comatose. All
patients enrolled in the study were admitted in the ICU for a period of clinical observation
of 24 h. Stomach pumping (gastric lavage) was performed in 30 patients (93%). An antidote
which was atropine was needed in twelve patients. Three patients (9%) who ingested
alpha-chloralose needed intubation and mechanical ventilation. All patients had a
good outcome and were discharged from ICU and from hospital. The mean ICU length of
stay was 2 ± 3 days.
Conclusion This is the first study of acute poisoning with rodenticides admitted in
the new ICU. The results of our study were similar to those published in recent literature.
Cases of acute poisoning with rodenticides reported in this work were not severe.
Competing interests None.
P229 Hemodynamic correlates of the left ventricular mean ejection pressure: a carotid
tonometric study
Mathieu Jozwiak1, Sandrine Millasseau2, Jean-Louis Teboul1, Jean-Emmanuel Alphonsine1,
François Depret1, Nathalie Richard2, Pierre Attal3, Christian Richard1, Xavier Monnet1,
Denis Chemla4
1Service de réanimation médicale, inserm umr s_999, université paris-sud, Hôpital
de bicêtre, hôpitaux universitaires paris-sud, Assistance publique – Hôpitaux de Paris,
Le Kremlin-Bicêtre, France; 2Alam medical, ALAM Medical, Vincennes, France; 3Otolaryngology-head
and neck surgery, Shaare-Zedek Medical Center and Hebrew University Medical School,
Jerusalem, Israel; 4Service de physiologie, inserm umr s_999, université paris-sud,
Hôpital de bicêtre, hôpitaux universitaires paris-sud, Assistance publique – Hôpitaux
de Paris, Le Kremlin-Bicêtre, France
Correspondence: Mathieu Jozwiak - mathieu.jozwiak@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):P229
Introduction The systemic arterial load imposed to the left ventricle (LV) is a major
determinant of normal/abnormal cardiovascular function. The LV mean ejection pressure
(LVMEP) is the best estimate of load faced by the LV throughout ejection. The contribution
of the steady and pulsatile blood pressure (BP) component of arterial load to LVMEP
is debated. We studied the hemodynamic correlates of LVMEP using carotid tonometry.
Intensive care unit patients equipped with an indwelling catheter were studied, thus
allowing precise calibration of the tonometer.
Patients and methods Carotid tonometry (Complior Analyse® ALAM Medical, France) was
prospectively performed on 28 hemodynamically stable, spontaneously breathing patients
(12F, mean age ± SD = 64 ± 18 years). Carotid waveforms were calibrated from diastolic
BP and time-averaged mean BP invasively obtained at the radial (n = 18) and femoral
(n = 10) artery. All patients were free of aortic stenosis. LVMEP was the area under
the systolic part of the carotid pressure waveform divided by ejection time.
Results LVMEP (111 ± 17 mmHg) was strongly related to central systolic BP (126 ± 21 mmHg;
r2 = 0.97) and was also related to mean BP (r2 = 0.82), peripheral systolic BP (r2 = 0.83),
peripheral (r2 = 0.35) and central (r2 = 0.50) pulse pressure (each P < 0.05). The
LVEMP was not related to age, heart rate and stroke volume. Systolic pulse wave amplification
ratio from carotid to periphery was 1.07 ± 0.08.
Conclusion LVMEP was most strongly related to central systolic BP, which combines
the influences of the steady and pulsatile components of central arterial load (r2 = 0.97).
LVMEP was less strongly related to peripheral systolic BP, which may be less informative
given variable systolic pulse wave amplification across patients.
Competing interests None.
P230 Prognostic value of high-sensitivity troponin I in patients with septic shock
Ali Jendoubi1, Ahmed Abbes1, Salma Jerbi1, Wafa Khedhiri1, Hatem Necib1, Salma Ghedira2,
Mohamed Houissa2
1Anesthesia and Intensive Care, Charles Nicolle Teaching Hospital, Tunis, Tunisia;
2Intensive care, Charles Nicolle Hospital, Tunis, Tunisia
Correspondence: Ali Jendoubi - jendoubi_ali@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P230
Introduction Myocardial dysfunction is one of the main predictors of poor outcome
in septic patients, with mortality rates next to 70%. Many pathological findings were
found in the sepsis induced cardiomyopathy including myocardial ischemia, alterations
in microcirculation and proinflammatory cytokines.
The aim of this study was to assess the prognostic value of a recently developed highly
sensitive cardiac troponin I (hsTnI) assay in patients with septic shock.
Patients and methods We performed a prospective observational study in septic shock
ICU patients within 72 h of admission. Exclusion criteria were age >18 years; pregnancy;
post-cardiac arrest and brain-dead. HsTnI was measured soon after admission and 12,
24, 48 and 72 h after. Patients were subjected to transthoracic echocardiography (TTE)
at study inclusion and regular biochemical and hemodynamic assessments were performed.
Pearson’s Chi square and Fisher’s Exact tests were used. P < 0.05 was considered significant.
Results Thirty-three patients (M/F = 25/8) with septic shock were included in the
study. Significant differences in demographic and biochemical (laboratory and metabolic)
parameters, severity scores, life-support therapies (vasopressors, ventilation), and
length of ICU stay were compared between survivors and non-survivors at 28 days. 15
patients (45.45%) showed an elevated HsTnI on admission time. The level of HsTnI at
72 h was significantly higher in non-survivors (n = 12) than survivors (n = 21) (median
69.6 [16.7–118.8] vs 9.6 [4.2–21.4] ng/L, P = 0.049). HsTnI level elevation was mainly
correlated with lactate serum and hemodynamic parameters. Besides, the clearance of
creatinine was significantly lower in non-survivors patients at 28 days (median 48.15
[27.5–121.5] vs 110 [90–135] ml/min, P = 0.022). Right heart abnormalities existed
in non-survival patients but were not associated with elevated hsTnI. Tricuspid Annular
Peak Systolic Velocity was significantly lower in non survivors than survivors (median
16 [13–16.1] vs 17 [15.75–24] cm/s, P = 0.042).
Conclusion Circulating hs-cTnI is present in patients with septic shock. A rise of
HsTnI may be an indicator of poor outcome. Also, right heart functional abnormalities
exist in patients with septic shock.
Competing interests None.
P231 Evolution of the right distribution width as a pronostic marker during the differents
state of shock
Paolo Scarfo1, Charles Chevalier2, Michael Piagnerelli3
1Internal medicine, Hospital André Vésale, Montigny-le-Tilleul, Belgium; 2Biologie
clinique, Hôpital Civil Marie Curie, Charleroi, Belgium; 3Réanimation polyvalente,
Hôpital Civil Charleroi, Charleroi, Belgium
Correspondence: Paolo Scarfo - paoloscarfo@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):P231
Introduction Right distribution Width (RDW) has been recently proposed as a pronostic
factor in different pathologic situations and especially to the septic patients who
stay in ICU. Some works substantiate the relationship between an alteration of the
red blood cell rheology during the septic shock and a severe state of the disease.
No one has studied the RDW between the differents shocks yet.
We are going to determinate the relationship between RDW and APACHE II score, mortality
rate in the Intensive Care Unit (ICU), at the hospital, at the day 30 and 90.
Materials and methods We investigated those parameters near 228 patients who were
admitted at the ICU and needed norepinephrine between the first of March and the 31st
of December.
They were stratified in différent groups: septic shock n = 101, cardiogenic shock
n = 100, hemorragic shock n = 20 and obstructive shock n = 7.
Results We did not observe any correlation between the RDW and the ICU mortality,
hospital mortality and at the day 30 and 90. Only a poor significant correlation has
been found between the cardiogenic shock and the mortality rate: at the hospital (p = 0.01),
at day 30 (p = 0.01) and at the day 90 (p = 0.05) but not in the ICU (p = 0.89). The
Receiver Operating Characteristics (ROC) curves do not show significant differences
between RDW, APACHE II score and ICU mortality rate or intra hospital.
The sample of the hemorrhagic shock and obstructive shock was not usable for this
calculation. Compared to other studies which were focused on the septic shock where
the mortality was approximately 20%, we determinated a mortality rate near 50%.
Conclusion The delta of the RDW D3/D1 did not present any correlation with the mortality
rate. In our study, the RDW in the different kind of shocks do not look like to be
a good predictive marker of the mortality, except for the patients included in the
cardiogenic shock where a poor significant correlation could be highlighted.
Competing interests None.
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Antonelou MH, Kriebardis AG, Papassideri IS. Aging and death signalling in mature
red cells: from basic science to transfusion practice. Blood Transfus. 2010;8(Suppl
3):s39–47.
Demir A, Yarali N, Fisgin T, Duru F, Kara A. Most reliable indices in differentiation
between thalassemia trait and iron deficiency anemia. Pediatr Int. 2002;44(6):612–6.
P232 Prognostic factors in patients hospitalized in the intensive care unit for complicated
acute myocardial infarction
Alexandre Lafont1, Antoine Galy2, Thomas Daix3, Claire Mancia2, Nicolas Pichon2, Bruno
François3, Antoine Vieillard-Baron1, Philippe Vignon3
1Réanimation médico-chirurgicale, Assistance Publique - Hôpitaux de Paris, Hôpital
Ambroise Paré, Boulogne-Billancourt, France; 2Service de réanimation polyvalente,
Centre Hospitalier Universitaire de Limoges, Limoges, France; 3Inserm cic 1435/réanimation
polyvalente, C.H.U de Limoges, Limoges, France
Correspondence: Philippe Vignon - sarah.demai@chu-limoges.fr
Annals of Intensive Care 2017, 7(Suppl 1):P232
Introduction Prognostic factors in patients admitted to the Intensive Care Unit (ICU)
with a complicated Acute Myocardial Infarction (AMI) have been scarcely described.
The aim of our study was to determine independent factors of hospital death in this
specific population.
Patients and methods This two-center retrospective study included all consecutive
patients who were admitted to the ICU between January 2000 and December 2015 for a
complicated AMI. Exclusion criteria were an inaugural cardiac arrest revealing AMI,
a peri-operative AMI, and patients transferred to the ICU after emergency coronary
artery bypass grafting (CABG) for AMI. Patients with ventricular arrhythmias responsible
for transient circulatory arrest during their management, with rapid recovery of normal
consciousness were studied. In each patient, comorbidities, SAPS2 score, SOFA score
upon ICU admission, and AMI complications including cardiogenic shock, transient circulatory
arrest, pulmonary edema and mechanical complications (i.e., ruptured papillary muscle,
ventricular septal defect, tamponade) were recorded. Multivariate regression analysis
was performed to determine independent factors of hospital death.
Results Among 358 patients admitted to the ICU with complicated AMI, 91 were excluded
for inaugural cardiac arrest with sustained coma requiring therapeutic hypothermia
(n = 60), emergency CABG for AMI (n = 17), or AMI after surgery (n = 43). Finally,
267 patients (1.4% of all admissions) were studied (180 men; mean age: 67 ± 12 years;
SAPS2: 57 ± 21; SOFA: 8 ± 4), 82% of them being ventilated. AMI complications were:
cardiogenic shock (n = 191), pulmonary edema (n = 124), transient circulatory arrest
(n = 60), and mechanical complication (n = 29). Prompt coronary angiography was performed
in 215 patients (81%) and angioplasty in 167 of them (78%). Coronary angiography was
not performed in 52 patients for hemodynamic instability preventing patient transportation
(n = 40) or expired time of potential revascularization (n = 12). Only two of these
patients had cardiogenic shock. Hospital mortality reached 46% (n = 122). Non survivors
were older, had higher severity scores, were more frequently under mechanical ventilation
and catecholamines, had lower ejection fraction (27 ± 13 vs 37 ± 12%: p = 0.0004),
and exhibited higher lactate (8.1 ± 5.1 vs 4.6 ± 3.3 mmol/l: p = 0.0001) and creatinine
levels (178 ± 122 µmol/l vs 136 ± 103 µmol/l: p = 0.0027) than survivors. Independent
prognostic factors were: SAPS2 score (OR 1.13 per point [95% CI 1.05–1.22; p = 0.002),
serum creatinine >150 µmol/l upon admission (OR 1.82; 95% CI 1.0–3.32; p = 0.05),
and cardiogenic shock (OR 3.37; 95% CI 1.72–3.32; p = 0.0004).
Conclusion Cardiogenic shock was the most frequent complication of AMI who led to
ICU admission, whereas mechanical complications are rare at the era of early coronary
reperfusion strategies. In addition to severity score, serum creatinine and cardiogenic
shock appeared as independent factors of hospital death.
Competing interests None.
P233 Place in the thrombolysis embolism pulmonary high risk
Nadia Benatta1, Djamila-Djahida Batouche2, Amel Zerhouni3, Kheira Tabeliouna2, Setti-Aouicha
Zelmat4
1cardiologie, Centre Hospitalier et Universitaire d’Oran, Oran, Algeria; 2Réanimation
pédiatrique, Centre Hospitalier et Universitaire d’Oran, Oran, Algeria; 3Reanimation,
EHS CANASTEL, Oran, Algeria; 4Anesthésie réanimation chirurgicale, EHU 1er Novembre,
Oran, Algeria
Correspondence: Djamila-Djahida Batouche - khedidjabatouche@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P233
Introduction Pulmonary embolism (PE) in high-risk is a partial or total obliteration
of the pulmonary arterial network by a fibrin-clot cruoric more than 50%, the management
requires a rapid reduction of pulmonary arterial resistance and right ventricular
post load through rapid revascularization by thrombolysis. Our aim is to determine
the value of thrombolysis in pulmonary embolism and describe the clinical, paraclinical
and outcome pulmonary embolism at high risk.
Patients and methods This is a descriptive study of 20 cases of pulmonary embolism
at high risk admitted to the cardiology department to CHU Oran between 2008 and 2014.
Signs of gravity of (PE) comprising: syncope, circulatory collapse, cardiogenic shock
or acute pulmonary sonographic sign of heart. It was confirmed in chest CT. All patients
received thrombolysis using the protocol accelerated by two types of molecules: streptokinase
or actilyse.
Results The sex ratio was 0.11; mean age 44 years, ranging from 20 to 80 years; Risk
factors were dominated by contraception was 35% and the postoperative 30% the clinical
picture was dominated by cardiogenic shock in 75% of cases. 20% cardiovascular collapse
and syncope in 5%; Doppler echo all patients had signs of dysfunction of the right
ventricle represented by the dilatation of the right cavities and pulmonary hypertension.
The CTA found a (PE) bilateral in 70% right in 20%. Thrombolysis using actilyse in
12 patients and streptokinase in 8 cases.
The outcome was favorable in 16 patients; with two cases that are complicated by chronic
pulmonary heart and the death of 2 patients with cancer.
Discussion The female predominance is explained by the increase of risk factors hormonal
contraception, whose first generation combination hormonal. Our patient had a high
probability with clinical signs of severity based on the score WELLS [1]. This diagnosis
was confirmed by chest CT; which shows the vascular bed obstruction degree with a
very good sensitivity and specificity.
The suspect patients with severe PE and that presented signs of acute pulmonary heart
ultrasound have effectively (PE). The indication of thrombolysis was chosen on hemodynamic
criteria; success is found in 80% of patients with improved hemodynamics dice the
early hours. This success is explained by the role of thrombolytic in lysis clot to
obtain pulmonary arterial revascularization; and reduce pulmonary arterial resistance
and the right ventricular afterload which accelerates the healing of right heart failure
and improvement of pulmonary capillary volume. The 02 cases who developed a chronic
pulmonary heart; it was done immediately a right ventricular dysfunction with pulmonary
arterial outset of very high pressures suggestive that the embolism occurred on an
already pathological right heart. No cases of massive bleeding were noted in our series.
Conclusion Severe pulmonary embolism is burdened with high mortality; diagnosis is
based on the stratification of risk score, was facilitated by the non-invasive strategies
that articlent around the Doppler echocardiography and CT angiography; thrombolysis
can reduce the high mortality related to severe pulmonary embolism.
Competing interests None.
Reference
Meyer G, Sanchez O. Stratification du risque dans l’embolie pulmonaire aiguë.Realites
Cardiologiques • N° 219 - Cahier 1 • Septembre 2006.
P234 Hypertensive peaks of diabetics in the emergency
Fatma Kaaniche Medhioub1, Najla Ben Algia2, Rania Allela3, Samar Cherif4
1Faculté de médecine de Sfax, Sfax, Tunisia; 2Intensive care, hopital régional Gafsa,
Sfax, Tunisia; 3Hopital régional mahres, Faculté de médecine de Sfax, Sfax, Tunisia;
4Intensive care, hopital régional mahres, Sfax, Tunisia
Correspondence: Fatma Kaaniche Medhioub - fatma_kaaniche@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P234
Introduction Hypertension is a frequent motif for admission to emergencies. The diabetic
is increasingly exposed to this risk [1]. The objective of this study is to evaluate
the proportion of diabetic patients presenting to the emergency department with high
blood pressure (BP) and to identify their epidemiological and clinical characteristics.
Patients and methods Prospective study conducted over a period of 3-month (1/01/2016–31/03/2016).
After measuring vital signs in the emergency, patients included had a systolic BP ≥ 140 mmHg
and/or diastolic BP ≥ 90 mmHg with diabetes. A BP control was performed 30 min after
the inclusion. If hypertension persists, patients were admitted to cardiology or general
medicine department.
Results We included 75 patients. Thirty-eight patients (50.6%) had persistent hypertension.
The most common background were: dyslipidemia, coronary disease and kidney failure
associated with diabetes and hypertension. The average age of patients was 58 ± 13 years.
The sex ratio was 2.8. The average duration of diabetes was 8 ± 3.5 years. It was
a type 2 diabetes in 64% of cases and type 1 in 36% of cases. Among the degenerative
complications: coronary disease in 14.7%, arterial disease of the limbs (10.7%), stroke
(5.3%), retinopathy (5.3%) and nephropathy (4%). All patients had at least one cardiovascular
risk factor. Hypertension was classified: grade I (33%), grade II (45%), grade III
(22%). The IEC was the antihypertensive most prescribed in our series with a monotherapy
in 56% of cases, 24% in bitherapy and 20% in triple therapy.
Conclusion Hypertension is a disease frequently associated with diabetes. It worsens
the prognosis of diabetics from where the need for optimal control of blood pressure
and management of other risk factors.
Competing interests None.
Reference
Norman RCC, Guanmin Ch. Canadian efforts to prevent and control hypertension. Can
J Cardiol. 2014;26:14C–17C.
P236 The value of Doppler ultrasound parameters of portal vein and hepatic artery
in the prediction of liver dysfunction in patients with septic shock
Ali Jendoubi1, Ali Gaja2, Bassem Hamrouni3, Abir Malouch1, Sami Fourati1, Salma Jerbi1,
Rihab Messaoud1, Salma Ghedira3, Mohamed Houissa3
1Anesthesia and Intensive Care, Charles Nicolle Teaching Hospital, Tunis, Tunisia;
2Medical imaging department, Charles Nicolle Teaching Hospital, Tunis, Tunisia; 3Intensive
care, Charles Nicolle Hospital, Tunis, Tunisia
Correspondence: Ali Jendoubi - jendoubi_ali@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):P236
Introduction Sepsis associated liver dysfunction (SLD) is usually attributed to systemic
and/or microcirculatory disturbance. Hypoxic hepatitis, also known as shock liver
or ischemic hepatitis, is a life threatening event associated with high morbidity
and mortality. Doppler ultrasonography is a non invasive method to measure Doppler
hepatic hemodynamic parameters. The primary objective of this study was to assess
the accuracy of the hepatic hemodynamic parameters (portal venous blood flow PVBF
and resistance index of the hepatic artery HARI) in predicting SLD in septic shock
patients. The secondary aims were to identify factors associated with SLD, investigate
the effects of volume expansion (VE) on systemic and intrahepatic hemodynamics and
to assess the intra- and interoperator reproducibility. We also analyzed 28-day mortality.
Patients and methods In a prospective design, we included 30 consecutive patients
with septic shock (24 males; median age: 36.5 years) admitted to the ICU with septic
shock in Charles Nicolle Hospital of Tunis from February to July 2015. All patients
were resuscitated following the Surviving Sepsis Campaign guidelines. We measured
systemic hemodynamic variables (Mean arterial pressure (MAP), and cardiac index (CI))
and performed hepatic Doppler before and after volume expansion. We measured PVBF
and computed the HARI. We recorded the liver function tests (ALT, AST and Bilirubin)
for 48 h. SLD was defined as an increase in serum Bilirubin ≥ 20 µmol/l (Hepatic SOFA ≥ 1).
Accuracy of the hepatic hemodynamic parameters to predict SLD was measured by the
area under the ROC curve. P < 0.05 was taken to indicate statistical significance.
Results The median SOFA score at T0 was 8 points and the median IGS2 score was 38
points. The sources of infection were as follows: the lungs (n = 19), the abdomen
(n = 4) and the urinary tract (n = 3). The incidence of SLD in our cohort was 33.3%
(n = 10). There was no significant difference between “SLD group” and “No-SLD group”
in all hepatic hemodynamic parameters especially the PVBF and the HARI. Lactate levels
were significantly higher in patients with SLD (median 3.55 vs. 0.85 mmol/l). Similarly,
the platelet count was significantly lower in the “SLD group” [mean (± SD) 149.2 ± 103.9
(109/l) vs. 242.8 ± 104.1 (109/l); p = 0.039]. There was no difference in duration
of mechanical ventilation, ICU length of stay and 28-day mortality between the 2 groups.
The PVBF was significantly lower in patients who died before D28 (median: 558 vs.
826 l/min in the survivors; p = 0.014).
Volume expansion caused a significant increase in CI, mean hepatic artery velocity
and the PVBF.
The intra- and interoperator reproducibility was good to excellent for the systolic
and mean velocities of the hepatic artery, portal vein diameter and the PVBF.
Conclusion Our results don’t support the hypothesis that the hepatic sonography is
predictive of SLD in septic shock. Our pilot study showed higher lactate levels and
hematologic SOFA in SLD group. The PVBF was significantly lower in patients who died
before D28. More experience will be necessary to define the ultimate role of Doppler
ultrasonography in the evaluation of hepatic perfusion in patients with septic shock.
Competing interests None.
P237 Postoperative care and risk factors after multiple valve surgery for advanced
rheumatic heart disease in 150 patients
Youssef Zarrouki1, Amra Ziadi1, Manal Rhezali1, Zahira Zouizra2, Drissi Boumzebra2,
Mohamed Abdennasser Samkaoui1
1Anesthesiology and intensive care, caddi ayyad university Mohammed VI teaching hospital,
Marrakesh, Morocco; 2Cardio vascular surgery, caddi ayyad university Mohammed VI teaching
hospital, Marrakesh, Morocco
Correspondence: Youssef Zarrouki - zarroukiyoussef@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):P237
Introduction Early surgery is the current trend for management of patients with valvular
disease. That said many of them, particularly from developing countries, are still
operated at a very advanced stage of disease. Despite improvements in myocardial protection
and surgical techniques, postoperative care after multiple valve surgery (MVS) for
advanced rheumatic heart disease (RHD) remains to be a clinical challenge. We conducted
a study to determine postoperative complications and morbidity-mortality risk factors
in this subgroup of patients.
Patients and methods Through a retrospective study over a period of 8 years, from
June 2007 to October 2015, patients admitted in intensive care after aortic and mitral
valve surgery combined with tricuspid repair for RHD, were included if at least one
the following criteria is found. Criteria for selecting patients: exertional dyspnea
grade III or IV of the NYHA; cardiomegaly; low left ventricular ejection fraction
(LVEF); severe pulmonary hypertension (PHT) and or right ventricular dysfunction;
deterioration of more than one vital function. Preoperative clinical and ultracardiosonographic
features are assessed. Surgical difficulties are evaluated, as well as risk factors
for occurrence of complications and causes of death.
Results 150 patients (out of 1025 admitted during the same period) are eligible to
be included. Patients clinical profile and ultrasonographic data are summarized in
Tables 8 and 9.
Table 8
Patients clinical profile
Age
37 years (21–64 years)
Gender
F: 81 (54%), M:69 (46%)
Medical history
Systemic hypertension: 21 (14%); diabetes: 18 (12%); Stroke: 17 (11.33%); acute lower
limb ischemia: 4%; recurrent heart failure: 97 patients(64.6%); Hepatic dysfunction:
15 (10%); renal insufficiency: 18 (12%); infective endocarditis: 17 (11.33%); Prior
mitral valve surgery: 9 (6%)
Symptoms
Exertional dyspnea III–IV: 123 (82%)
chest x-ray
Cardiomégaly with CTR > 0.7: 128 (85%)
ECG
Atrial fibrillation: 135 (90%)
Table 9
preoperative ultracardiosonographic data
Cause
Exclusively rheumatic advanced multiple valvulopathy
Impact of the Valvular disease
PHT: 70 mmHg (60–120 mmHg);RV dilatation with moderate to severe dysfunction: 68 (45.33%)
with moderate to severe functional tricuspid regurgitation; LVEF: 42% (22–65%); Left
Atrium dilatation: 54.6% + thrombus 12%; Ascending aortic aneurysm:2%
The surgical procedure consisted mostly in a double mitral and aortic valve replacement
with tricuspid valve repair. Additional procedures are realized in 59 patients (39%).
The average ICU length of stay is 7 days (2–30 days) with a mean mechanical ventilation
duration of 48 h (1–10 days) and an inotropic support in 100% of patients. Additive
therapies like nitric oxyde is used in 35 patients and sildenafil in 42.
Early postoperative complications occured in 63 patients: low cardiac output Sd in
12 cases and acute right sided heart failure in 7 patients. Bleeding with redo in
10 patients. Infections are noted in 19 patients with 7 cases of septic shock. Acute
kidney failure requiring dialysis in 5 patients. Dysarythmias and transient atrioventricular
block are observed in 23 patients and serious neurologic events in 5 patients.
In hospital mortality is 18.6% (28 patients). Deceased patients profile is listed
in Table 10.
Table 10
Deceased patients profile
Age
44 years old (30–64 years)
Symptoms
Exertional Dyspnea grade III- VI;HF renal insufficiency; Liver dysfunction; ascites;
acute lung edema and refractory HF
Preoperative echocardiography findings
Severe PHT: 9 patients; severe mitral regurgitation caused by infective endocarditis
with severe LV dysfunction: 1 case; Massive Ao regurgitation with severe LV dysfunction:
2 cases
Causes of death are: severe LV dysfunction (5 patients); severe RV dysfunction (15
patients); severe pneumonia (3 patients); septic chock (2 patients); stroke (1 patient);
intraventricular hemorrhage (1 patient); fulminant hepatitis (1 patient).
Discussion In the European Registry of the Euro Heart Survey, patients with very advanced
heart valvular disease accounted for 8% of all valvular heart disease. In our series,
they represent 22%.
Conclusion The operative mortality was typically very high, but new surgical technologies
and intensive care standards should improve outcome. Generally the postoperative mortality
is very significantly lower than spontaneous mortality. Thus the indication of surgery
should not be rejected in this subgroup of patients.
Competing interests None.
.
E-posters
S1 Extracorporeal life support for refractory cardiac arrest: a 10-year study
Jennifer Brunet1, Bertrand Canoville2, Pierre Verrier1, Aurélie Joret2, Calin Ivascau3,
Amélie Seguin2, Xavier Valette2, Damien Du Cheyron2, Cedric Daubin2
1Anesthesiology, Centre Hospitalier Universitaire de Caen, Caen, France; 2Medical
intensive care, Centre Hospitalier Universitaire de Caen, Caen, France; 3Thoracic
and cardiovascular surgery, Centre Hospitalier Universitaire de Caen, Caen, France
Correspondence: Cedric Daubin - daubin-c@chu-caen.fr
Annals of Intensive Care 2017, 7(Suppl 1):S1
Introduction We aimed to identify factors associated with ICU survival among selected
patients receiving Extra Corporeal Life Support (ECLS) for in-hospital or out-of-hospital
refractory cardiac arrest.
Patients and methods All consecutive patients treated with ECLS for refractory cardiac
arrest in the Caen University Hospital in northwestern France over the last decade
(2005–2015) were included in a retrospective cohort study.
Results Sixty-two patients were included: 25 with out-of-hospital refractory cardiac
arrest and 37 with in-hospital refractory arrest. The initial rhythms was shockable
rhythm in 25 (40%) cases. At ECLS initiation, the mean no flow was 0.8 ± 3.9 min and
mean low flow (time between the time of refractory cardiac arrest and time at which
an ECLS flow was provided) was 71 ± 37 min. The mean ECLS flow rate was 4.17 ± 1.31
L/min. Initial blood test results were: arterial pH = 7.04 ± 0.20 and plasma lactate = 12.8 ± 5.9 mmol/L.
Eleven (18%) patients survived (4/30 (13%) acute coronary syndrome, 4/8 (50%) severe
poisoning due to drug intoxication, 1/4 (25%) dilated cardiomyopathy, and 2/20 (10%)
others). Survival was lower for patients with out-of-hospital refractory cardiac arrest,
2 of 25 (8%), than for patients with in-hospital refractory cardiac arrest, 9 of 37
(24%), respectively, p = 0.17. As expected, out-of-hospital refractory cardiac arrest
was associated with a more prolonged low flow (89 ± 40 min vs 60 ± 30 min, p < 0.01)
and a more profound acidosis (pH 6.9 ± 0.2 vs 7.1 ± 0.2, p = 0.01 and arterial lactate
14.7 ± 6.1 vs 11 ± 5, p = 0.05).
In univariate analysis, survival was lower for patient with refractory cardiac arrest
unrelated to drug intoxication, 13 vs 50%, respectively, p = 0.03. In addition, mortality
was associated with arterial pH (7.01 ± 0.2 vs 7.14 ± 0.15, p = 0.025) and low flow
(75 ± 40 vs 55 ± 12 min, p = 0.005).In multivariate analysis, two factors was associated
with survival: drug intoxication as the reason for ECLS [Adjusted Odds Ratio, 8.34;
95% CI, 1.25–71; p = 0.01], and low flow [Adjusted Odds Ratio, 0.98; 95% CI, 0.95–1;
p = 0.14].
Conclusion In a highly selected group of critically ill patients with refractory cardiac
arrest, the potential beneficial effect of ECLS could be due only to its clinical
impact on reversible causes of circulatory failure (i.e. severe drug intoxication
in our cohort). Further studies are needed to clarify whether the use of ECLS could
be considered as a disproportionate tool, specifically in patients with out-of-hospital
refractory cardiac arrest due to acute coronary syndrome or associated with prolonged
low flow or a profound acidosis.
Competing interests None.
S2 Post-cardiac arrest shock treated with veno-arterial extracorporeal membrane oxygenation:
an observational study and propensity-score analysis
Wulfran Bougouin1, Nadia Aissaoui2, Alain Combes3, Nicolas Deye4, Lionel Lamhaut5,
Daniel Jost6, Carole Maupain7, Frankie Beganton,8, Adrien Bouglé(), Florence Dumas9,
Eloi Marijon1, Xavier Jouven10, Alain Cariou11, Sudden Death Expertise Center
1Cardiologie, Hôpital Européen Georges-Pompidou, Rue Leblanc, Paris, France, Paris,
France; 2Réanimation médicale, Hopital Europeen Georges-Pompidou, Paris, France; 3Service
de Réanimation Médicale, Groupe Hospitalier Pitié Salpêtrière, Paris, France; 4Réanimation
Médicale et Toxicologique, Hôpital Lariboisière, Paris, France; 5Réanimation adulte,
Hôpital Necker - Enfants Malades, Paris, France; 6Bspp, B.s.p.p., Paris, France; 7Cardiologie,
Pitié-Salpêtrière Hospital, Paris, France; 8Paris descartes, Inserm U970, Paris, France;
9Service d’accueil des urgences, Hôpital Cochin, Paris, France; 10Cardiologie, Hôpital
Européen Georges-Pompidou, Paris, France; 11Réanimation Médicale, Hôpital Cochin,
Paris, France
Correspondence: Wulfran Bougouin - wulfran.bougouin@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S2
Introduction Post-cardiac arrest (CA) shock is a mixed shock, including vasoplegia
and myocardial dysfunction. Several authors reported the reversibility of post-CA
myocardial dysfunction, described as a myocardial stunning. This complication often
requires inotropic support, mostly dobutamine, combined with vasoactive drugs. However,
these treatments are sometimes insufficient to control the circulatory failure. Veno-arterial
extracorporeal membrane oxygenation (VA-ECMO) has been proposed in the most severe
cases but the level of evidence is very low. We assessed characteristics, outcome
and prognostic factors of patients treated with VA-ECMO for post-CA shock.
Patients and methods Using a large regional registry, we focused on all CA admitted
in ICU. Post-CA shock was defined as the need for continuous norepinephrine or epinephrine
infusion to maintain mean arterial pressure above 60 mmHg for more than 6 h following
ROSC, despite adequate fluid loading. Among patients who developed a post-CA shock,
prognostic was compared according to VA-ECMO use, using logistic regression and propensity
score. Specific prognostic factors were identified among VA-ECMO patients.
Results Among 2988 patients admitted after CA, 1489 developed a post-CA shock, and
were included. They were mostly male (68%), with mean age 63 years (SD = 15). 52 patients
(3.5%) were treated with VA-ECMO, mostly patients with ischemic cause of CA (67%).
Among patients with post-CA shock, 312 (21%) were discharged alive (25% in VA-ECMO
group, 21% in control group, P = 0.45). After adjustment for pre-hospital and in-hospital
factors, survival did not differ among patients treated with VA-ECMO (OR for survival = 0.9,
95% CI 0.4–2.3, P = 0.84). Results were consistent after propensity-score matching.
Among patients treated with VA-ECMO, initial arterial pH (OR 1.7 per 0.1 increase,
95% CI 1.0–2.8, P = 0.04) and implantation of VA-ECMO over 24 h after ROSC (OR 20.0,
95% CI 1.4–277.3, P = 0.03) were associated with survival (Fig. 10).
Fig. 10
See text for description
Conclusion Post-CA shock is frequent and is associated with a high mortality rate.
When used in selected patients, we observed that VA-ECMO may be an appropriate treatment.
Competing interests None.
S4 Esophageal cooling after cardiac arrest
Antoine Goury1, Florent Poirson1, Ulriikka Chaput2, Pierre Garçon1, Thomas Beeken1,
Lamia Kerdjana1, Sebastian Voicu1, Isabelle Malissin1, Leclerc Maxime1, Oueslati Haikel1,
Dominique Vodovar1, Jonathan Chelly1, Philippe Marteau2, Bruno Megarbane1, Nicolas
Deye3
1Réanimation médicale et toxicologique, Hôpital Lariboisière (AP-HP), Paris Cedex
10, France; 2Hépato-gastro-entérologie, Hôpital Saint-Antoine, Paris, France; 3Réanimation
Médicale et Toxicologique, Hôpital Lariboisière (AP-HP), Paris, France
Correspondence: Antoine Goury - gouryantoine@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S4
Introduction Targeted temperature management (TTM) between 32 °C and 36 °C is recommended
in comatose patients successfully resuscitated after out-of-hospital cardiac arrest
(OHCA). Advanced cooling methods of TTM seem the most effective. This prospective,
monocentric, observational, open clinical study aimed to assess the feasibility and
safety of a new esophageal device to perform TTM in such patients.
Patients and methods The Esophageal Cooling Device (ECD®, Advanced Cooling Therapy,
USA) is a semi-invasive multichambered silicone heat exchanger device, placed in the
esophagus to provide highly efficient heat transfer, replacing the usual standard
gastric tube. ECD is connected to a heat exchanger console Medi-therm III® (Gamida,
France) performing the temperature’s automatic feedback control. Main inclusion criteria
were: OHCA from presumed cardiac cause needing TTM, delay between CA and return of
spontaneous circulation (ROSC) <60 min, delay between ROSC and inclusion <240 min.
Main exclusion criteria were: known esophageal disease, unstable ROSC and hemodynamic
condition, severe cardiac conductive disorder requiring pacing. After achieving sustained
ROSC and performing coronarography ± CT-scan, ECD was inserted as soon as possible.
A target temperature (TT) of 33 °C was maintained for at least 24 h followed by a
controlled rewarming (rate <0.5 °C/h). No cold fluids had to be used during TTM. Normothermia
was maintained during the first 3 days after CA. Esophagogastroduodenoscopy was performed
systematically after removal of ECD.
Results 18 patients were enrolled in the study and 17 completed the study (median
[IQR 25–75], age: 60yo [54–65], SAPSII: 69 [61–75], time to ROSC: 20 min [14–30],
shockable rhythm 53%). Time to reach the TT was 15 h [10–17], with a mean cooling
rate to reach TT of 0.26 °C/h [0.19–0.36]. The average time spend in the 32–34 °C-target
range was 26 h [21–28]. All patients reached the 32–34 °C-target range (3 patients
did not reach 33 °C). The temperature deviation out of the 33 °C-TT during the maintenance
phase was 0.1 °C [0.03–0.20]. Five patients (36%) presented an episode of minor deviation
(0.5°–1 °C), and one patient (6%) a deviation >1 °C versus the TT. Rewarming time
was 16 h [12–20] and the mean rewarming rate was 0.20 °C/h [0.18–0.22]. Average time
between introduction and removed of the ECD was 50 h (42–56). Among the 16 esogastroduodenoscopy
performed, 9 (56%) were strictly normal. Endoscopy showed minor gastric injuries in
6 patients (38%). Within these patients, 3 (19%) also presented minor esophageal injuries.
Esogastric injuries characteristics were mostly similar to usual orogastric probe
injuries. One patient (6%) experienced a serious ulcerous esophagitis mimicking a
peptic esophagitis, not firmly related to the ECD. No patients necessitated hemostatic
local procedure and no significant gastrointestinal bleeding was observed. Eight patients
(47%) were alive at D90, including 5 patients (29%) with a Cerebral Performance Category
score of 1. This compares favorably to outcomes from previous studies.
Conclusion ECD seems an interesting and safe semi-invasive method of cooling in OHCA
patients treated with 33 °C-TTM. Although it seems slower than more invasive devices
to reach 33 °C, ECD was able to strictly maintained the TT within the maintenance
phase of TTM. Further studies will be necessary to define the exact place of this
new device within the cooling strategy in patients necessitating a precise TTM-strategy.
Competing interests None.
References
Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, et al. European
Resuscitation Council Guidelines for Resuscitation 2015: Section 1. executive summary.
Resuscitation. 2015;95:1–80.
Kudenchuk PJ, Sandroni C, Drinhaus HR, Böttiger BW, Cariou A, Sunde K, et al. Breakthrough
in cardiac arrest: reports from the 4th Paris international conference. Ann Intensive
Care. 2015;5(1):22.
S5 Are characteristics of receiving hospitals associated with outcome after cardiac
arrest? Insights from the Great Paris registry
Richard Chocron1, Wulfran Bougouin2, Frankie Beganton,3, Philippe Juvin,1, Thomas
Loeb,4, Frederic Adnet5, Eric Lecarpentier,6, Lionel Lamhaut7, Daniel Jost,8, Xavier
Jouven9, Eloi Marijon10, Alain Cariou2, Florence Dumas11
1Urgences, Hôpital Européen Georges-Pompidou (AP-HP), Paris, France; 2Réanimation
Médicale, Hôpital Cochin, Paris, France; 3Paris descartes, Inserm U970, Paris, France;
4Samu92, Hôpital Raymond-Poincaré (AP-HP), Garches, France; 5Samu-smur 93, Hôpital
Avicenne, Bobigny, France; 6Samu94, Hôpital Henri Mondor, Créteil, France; 7Réanimation
adulte, Hôpital Necker - Enfants Malades, Paris, France; 8Bspp, B.s.p.p., Paris, France;
9Cardiologie, Hôpital Européen Georges-Pompidou, Paris, France; 10Cardiologie, Hôpital
Européen Georges-Pompidou, Rue Leblanc, Paris, France, Paris, France; 11Service d’accueil
des urgences, Hôpital Cochin, Paris, France
Correspondence: Florence Dumas - florence.dumas@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S5
Introduction Since post-cardiac arrest care might influence the outcome, characteristics
of receiving hospitals should be integrated in survival evaluation of patients transported
in hospital. We aimed at assessing the influence of care level center on survival
at discharge in a regional registry of out-of-hospital cardiac arrest (OHCA).
Materials and methods We prospectively collected Utstein and in-hospital data for
all non-traumatic OHCA patients, in whom a successful Return of Spontaneous Circulation
(ROSC) had been obtained, from a large metropolitan area (Great Paris). Receiving
hospitals were categorized in 3 groups (A, B, C) depending on their respective characteristics
(annual volumes, 24/7 catheterization availability and temperature management use).
We compared patients’ characteristics in the 3 groups and performed a multivariable
logistic regression using discharge survival at endpoint.
Results During the study period (May2011–Dec2013), 1476 patients were admitted in
48 hospitals (917 in group A, 428 in group B and 91 in group C). Overall survival
rate at discharge was 433/1436 (30%). Patients’ baseline characteristics significantly
differed, as hospitals from group A treated younger patients and more frequent shockable
rhythms (p < 0.001). Unadjusted survival rate differed significantly among the 3 groups
of hospitals (respectively 34, 25 and 15.4% for A, B, C, p < 0.01). However in multivariable
analysis, the category of hospital was no longer associated with survival.
Conclusion In this population-based study, characteristics of receiving hospitals
are not associated with survival rate at discharge. This could result from the strategy
used for triage, which aims in matching patients’ characteristics and resources.
Competing interests None.
S6 Can urinary [TIMP-2]*[IGFBP7] predict early acute kidney injury after cardiac arrest?
Dimitri Titeca Beauport1, Magalie Joris1, Loay Kontar1, Antoine Riviere1, Bertand
De Cagny1, Thierry Soupison1, Michel Slama1, Julien Maizel1
1Réanimation médicale, Centre Hospitalier Universitaire, Amiens, France
Correspondence: Dimitri Titeca Beauport - titeca.dimitri@chu-amiens.fr
Annals of Intensive Care 2017, 7(Suppl 1):S6
Introduction Acute kidney injury (AKI) commonly occurs after cardiac arrest and is
associated with an increased mortality and a delayed awaking. Early recognition of
AKI remains challenging, given that serum creatinine increases belatedly after aggression.
The aim of this study was to test the hypothesis that urinary [TIMP-2]*[IGFBP7] can
predict early AKI after cardiac arrest.
Materials and methods We conducted a monocentric prospective study from August 01,
2015 to August 31, 2016. Urinary [TIMP-2]*[IGFBP7] was measured within the 6 h following
the cardiac arrest. Were excluded moribund, anuric, early RRT indication, CKD stage
4–5 and renal transplant recipients. The primary end point was to assess the predictive
value of urinary [TIMP-2]*[IGFBP7], to identify early AKI defined by a KDIGO stage
3 within the first 48 h of observation.
Results Among forty patients analyzed, 17 (42.5%) reached KDIGO stage 3. An urinary
[TIMP-2]*[IGFBP7] above 1.13 can predict KDIGO stage 3 with a sensitivity of 76.5%
(50.1–93.2), specificity of 91.3% (72.0–98.9) and AUROC at 0.87 (0.73–0.96). Baseline
serum creatinine above 81 µmol/l and baseline urinary output ≤0.62 ml/kg/h achieved
respectively AUROC at 0.72 and 0.78. Pairwise comparisons of ROC curves were non-significant,
between these 3 parameters.
Conclusion Early urinary [TIMP-2]*[IGFBP7] dosage achieved good performance to detect
patients with high risk of AKI after cardiac arrest. However, in the limits of this
study, its performances were not statistically different from baseline serum creatinine
or 6 first hours urinary output.
Competing interests None.
S7 Out-of-hospital cardiac arrest between prepubescent, pubescent and adults patients:
data from a national French registry (RÉAC)
Elodie Privat1, Joséphine Escutnaire2, Cyrielle Dumont3, Valentine Baert2, Christian
Vilhelm4, Hervé Hubert4, Stéphane Leteurtre5
1Pediatric Intensive Care Unit, Hôpital Jeanne de Flandre PARKING, Lille, France;
2French national out-of-hospital cardiac arrest registry (réac), French national out-of-hospital
cardiac arrest registry (réac), Lille, France; 3Public health department, Université
Lille 2 - Faculté de Médecine Henri Warembourg, Loos, France; 4Public health department,
Université Lille 2 - Faculté de Médecine Henri Warembourg, Lille, France; 5Réanimation
pédiatrique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
Correspondence: Elodie Privat - elodie.privat@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S7
Introduction Out-of-hospital cardiac arrests (OHCA) are an absolute urgency and have
a very poor prognosis. Pediatric guidelines differ from adult guidelines for cardiac
arrest management. Since 2005, adult guidelines apply from the onset of puberty. The
main objective was to describe the epidemiological characteristics and outcome of
OHCA victims while taking puberty into account. The secondary objective was to determine
the prognostic factors for survival at D30.
Materials and methods All patients less than 65 years of age, victims of OHCA between
July 1, 2011 and September 1, 2015 care by a Mobile Emergency and Resuscitation Service
(SMUR) participating in French National Cardiac Arrest registry (RéAC) were included.
Patients were split into 3 groups: Prepubescent patients (named “Children”: Girls
0–9 years, Boys 0–11 years), Pubescent patients (named “Adolescents”: Girls from 10
to 17 years and Boys from 12 to 17 years) and “Adults” (men and women 18–64 years).
The “Adolescents” group was consecutively compared to the “Children” group and to
the “Adults” group.
Results 644 children, 256 adolescents and 16,566 adults under the age of 65 have been
included. OHCA in Adolescents occurred more often on public roads (30%) or in public
places (15%) and were more often traumatic (46%) than those in children and adults.
Respiratory causes were more frequent in children (27%) than in adolescents (18%)
and adults patients (18%). The proportion of shockable rhythm increased with age (3,
7 and 10% for children, adolescents and adults respectively). Survival at D30 was
greater in adolescents (12%) than in children (7%) and adults (8%) (p = 0.01 and p = 0.02
respectively). In the 3 studied groups, initial shockable rhythm was a survival factor
at D30 (respectively OR 18.97, 95% CI [3.84–93.78], OR 29.51, 95% CI [8.02–108.64]
and OR 14.11, 95% CI [11.39–17.48] for children, adolescents and adults). Other risk
factors are described in Table 11.
Table 11
Risk factors of survival at day 30
Odds Ratio
IC 95%
p
Children
Initial rhythm
No shockable
Ref.
Shockable
18.97
[3.84–93.78]
<10–3
Resuscitation duration
>30 min
Ref.
≤30 min
16.81
[3.91–72.21]
<10–3
Adolescent
Low flow
>15 min
Ref.
≤15 min
45.65
[5.77–361.27]
<10–3
Initial rhythm
No shockable
Ref.
Shockable
29.51
[8.02–108.64]
<10–3
Adults
No flow
>10 min
Ref.
<5 min
1.27
[1.03–1.56]
0.03
5–10 min
1.51
[1.18–1.93]
<10–3
Initial rhythm
No shockable
Ref.
Shockable
14.11
[11.39–17.48]
<10–3
Resuscitation duration
>30 min
Ref.
≤30 min
3.03
[2.29–4.02]
< 10–3
Ref. reference
Conclusion Adolescents had better survival at D30 than the 2 others groups. Adolescents
and adults had shockable rhythm more often than children. Moreover, respiratory failure
was less frequent in adolescent and adults patients compared to children. Puberty
seems to be a good limit to differentiate pediatric patients with OHCA.
Competing interests None.
S8 Non-invasive ventilation in clinical practice: a 8-year experience in a French
medical intensive care unit
Marion Fresco1, Michael Bubenheim2, Gaetan Beduneau3, Dorothée Carpentier3, Steven
Grange3, Elise Artaud-Macari3, Benoit Misset1, Fabienne Tamion4, Christophe Girault3
1Medical intensive care unit, Hospital Center University Hospital, Rouen, France;
2Department of clinical research support, biostatistics unit, Hospital Center University
Hospital, Rouen, France; 3Réanimation médicale, Centre Hospitalier Universitaire Rouen,
Rouen, France; 4Réanimation médicale, Hospital Center University Rouen, Rouen, France
Correspondence: Marion Fresco - fresco.marion@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S8
Introduction Non-invasive ventilation (NIV) is an effective alternative to endotracheal
mechanical ventilation (MV) in the management of acute respiratory failure (ARF) patients.
Nevertheless, it can be still difficult to assess its real feasibility, application
and outcome in daily clinical practice. Therefore, we report our clinical experience
with routine use of NIV since the last national recommendations (2006). Our aims were
to evaluate the clinical efficacy and outcome of NIV, and to identify predictive factors
for NIV failure based on a daily use.
Patients and methods We conducted an observational retrospective single-center cohort
study by reviewing all medical records from January 2006 to December 2013 in our 22-bed
medical intensive care unit (ICU). Eligible patients were those having received NIV
during their ICU stay. Two groups were defined according to the indication of NIV:
NIV for hypoxemic or hypercapnic ARF (ARF-NIV), and NIV used in the post-extubation
period for weaning, prevention or treatment of post-extubation ARF (post-extubation
NIV).The main evaluation criteria were the incidence of NIV use, success/failure rate
of NIV and risk factors for NIV failure in each group. NIV failure was defined as
the need for stopping NIV whatever the reason (intubation, intolerance, death) within
3 days after its initiation.
Results Of the 5031 MV performed in 8 years, 979 (19.5%) NIV trials were included:
805 (82.2%) for ARF-NIV (399 hypoxemic, 406 hypercapnic) and 174 (17.8%) for post-extubation
NIV. The main causes for ARF were pulmonary infections (35.5%) and acute cardiogenic
pulmonary edema (24.3%). The overall incidence of NIV use increased from 25.5% of
ARF in 2006–36.4% in 2013 (maximum of 59.0% in 2012). The failure rate was 23.6% for
the ARF-NIV group (27.8% for hypoxemic ARF, 19.5% for hypercapnic) and 14.9% for the
post-extubation NIV group (p = 0.0009). Efficacy of NIV was similar despite an increased
severity of patients (SAPSII) during the study period. The median length of ICU stay
was 5 days (2; 9), and was longer in the post-extubation NIV group (11 days (6; 19))
than in the ARF-NIV (5 days (3; 9) for hypoxemic ARF, 4 (2; 6) for hypercapnic) (p < 0.001).
The overall ICU mortality was 11.0% (15.8% in hypoxemic group, 8.1% in hypercapnic
group, and 6.9% in post-extubation NIV group) (p = 0.0005).
In multivariate analysis, the main risk factors for ARF-NIV failure were: SAPS II
on admission (p < 0.0001), absence of cardiologic history (p = 0.0274) and the cause
of ARF (p = 0.0016) with a higher failure rate for pulmonary infections than acute
cardiogenic pulmonary edema (OR 2.94, p = 0.0004). For post-extubation NIV, the only
independent risk factor for failure was normocapnia before NIV initiation (p = 0.0011).
Conclusion Our large longitudinal study demonstrates the feasibility and efficacy
of NIV applied in daily clinical practice. Provided it is performed in a suitable
environment by an experienced team, NIV should be considered as a first-line ventilatory
treatment in various etiologies of ARF and a very useful ventilatory support in the
post-extubation period. Nevertheless, risk factors for NIV failure should be known
by ICU clinicians, hypoxemic ARF remaining the more difficult indication to manage
with NIV.
Competing interests None.
References
Demoule A, Chevret S, Carlucci A, Kouatchet A, Jaber S, Meziani F, et al. Changing
use of noninvasive ventilation in critically ill patients: trends over 15 years in
francophone countries. Intensive Care Med. 2016;42:82–92.
Schnell D, Timsit J-F, Darmon M, Vesin A, Goldgran-Toledano D, Dumenil A-S, et al.
Noninvasive mechanical ventilation in acute respiratory failure: trends in use and
outcomes. Intensive Care Med. 2014;40(4):582–91.
S9 Initial ventilation strategy and risk for intubation in immunocompromised patients
with acute respiratory failure
Guillaume Dumas1, Sylvie Chevret2, Virginie Lemiale1, Djamel Mokart3, Julien Mayaux4,
Frédéric Pène5, Achille Kouatchet6, Martine Nyunga7, Pierre Perez8, Anne-Sophie Moreau9,
Fabrice Bruneel10, François Vincent11, Loay Kontar12, Kada Klouche13, Laurent Papazian14,
Jean Reignier15, Antoine Rabbat16, Elie Azoulay1, Groupe de Recherche Respiratoire
en Réanimation Onco-Hématologique (Grrr-OH)
1Réanimation médicale, Hôpital Saint-Louis, Paris, France; 2Service de biostatistique
et information médicale, Hôpital Saint-Louis, Paris, France; 3Réanimation, Institut
Paoli-Calmettes, Marseille, France; 4Réanimation médicale, Hôpital Pitié-Salpêtrière,
Paris, France; 5Réanimation Médicale, Hôpital Cochin, Paris, France; 6Service de Réanimation
médicale et Médecine hyperbare, Centre Hospitalier Universitaire d’Angers, Angers,
France; 7Réanimation polyvalente, Centre Hospitalier de Roubaix, Roubaix, France;
8Réanimation polyvalente, C.H.U. de Nancy, Nancy, France; 959, C.H. Régional Universitaire
de Lille (CHRU de Lille), Lille, France; 10Réanimation médico-chirurgicale, Centre
Hospitalier de Versailles, Le Chesnay, France; 11Réanimation polyvalente, Groupe Hospitalier
Intercommunal Le Raincy-Montfermeil, Montfermeil, France; 12Réanimation médicale,
Centre Hospitalier Universitaire, Amiens, France; 13Service de réanimation, CHU Lapeyronie,
Montpellier, France; 14Service de réanimation-détresses respiratoires et infections
sévères, Hôpital Nord, Marseille, France; 15Réanimation, Centre Hospitalier Départemental
- site de La Roche-sur-Yon, La Roche-sur-Yon, France; 16Réanimation pneumologique,
Hôpital Cochin, Paris, France
Correspondence: Guillaume Dumas - dumas.guillaume1@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S9
Introduction Acute respiratory failure (ARF) is the leading cause for ICU admission
in immunocompromised patients. In these patients, oxygenation strategy is of major
interest to avoid the need for mechanical ventilation (MV), which is associated with
high mortality rates. In that setting, use of non-invasive ventilation (NIV) and oxygen
therapy with High Flow Nasal cannula (HFNC) could be interesting alone or in association,
but data about initial ventilation strategy in immunocompromised patients are controversial.
Patients and methods To assess how initial oxygenation strategy actually influences
the risk of MV on the coming day within the three first days of ICU stay. The study
end-point was the need for MV on the coming day. We restricted analyses to these first
three ICU days given, based on our own experience, most of MV was expected to occur
by then.
We performed a post hoc analysis combining three prospective studies of critically
ill immunocompromised patients (two randomized control trials, the IVNICTUS and the
MINIMAX studies and one prospective cohort, the TRIAL-OH study). We only considered
patients with ARF and a delay between ICU admission and study inclusion less than
48 h. We excluded patients who required invasive MV within the first day, those with
an ICU stay less than 1 day and those with acute pulmonary edema diagnosis at ICU
admission.
In order to estimate and compare the causal effect of daily respiratory management
strategy on the probability of intubation in the coming day, we computed inverse probability
of treatment weights (IPTW) using propensity-score, defined as the probability of
actual treatment selection conditionally on observed covariates. To handle confounding
in such dynamic regimens, we considered marginal structural models (MSM), which have
been proposed to estimate the causal effect of a time-dependent exposure when time-dependent
covariates that can be affected by the previous treatment are present. Two treatment
exposure models were considered: NIV versus oxygen therapy regardless the device (model
1) and HFNC alone, NIV alone versus NIV + HFNC versus standard oxygen therapy alone
(model 2).
Results 847 patients were included in the study. In model 1, there was no difference
between NIV and oxygen groups on MV whatever the landmark time. In model 2, while
the unweighted OR for intubation at day 1 was significantly higher in the NIV group
(OR 2.05, 95%CI 1.29–3.29) and HFNC group (OR 2.85, 95%CI 1.37–5.67) than those in
the standard oxygen alone group, these differences disappeared in the weighted samples.
Using MSM, no effect of the oxygenation strategy on MV was found, regardless of the
oxygenation devices but the landmark time was associated with a reduced occurrence
of MV.
Conclusion We found no evidence of any significant difference from several oxygenation
strategies on mechanical ventilation probability during the first 3 days of ICU in
a large cohort of immunocompromised patients with ARF.
Competing interests None.
S10 Acute hypoxemic respiratory failure: which patients need intubation?
Jean-Pierre Frat1, Remi Coudroy1, Stéphanie Ragot2, Jean-Michel Constantin3, Gwenael
Prat4, Alain Mercat5, Thierry Boulain6, Christophe Girault7, Alexandre Demoule8, Jérôme
Devaquet,9, Saad Nseir10, Julien Charpentier11, Keyvan Razazi12, Laurent Argaud13,
Pascal Beuret14, Jean-Damien Ricard15, René Robert16, Arnaud W Thille1
1Réanimation Médicale, CHU de Poitiers, Poitiers, France; 2Département de biostatistiques
et d’epidémiologie, CHU de Poitiers, Poitiers, France; 3Réanimation adulte, C.H.U.
Estaing, Clermont-Ferrand, France; 4Réanimation médicale, CHRU de Brest, Brest, France;
5Service de réanimation médicale et médecine hyperbare, Centre Hospitalier Universitaire
d’Angers, Angers, France; 6Réanimation médicale polyvalente, Hôpital de La Source,
CHR Orléans, Orléans, France; 7Réanimation Médicale, Centre Hospitalier Universitaire
Rouen, Rouen, France; 8Service de pneumologie et réanimation médicale, Groupe Hospitalier
Pitié-Salpêtrière, Paris, France; 992151, Hospital Foch, Suresnes, France; 10Centre
de Réanimation, Centre Hospitalier Régional Universitaire de Lille, Lille, France;
11Réanimation Médicale, Hôpital Cochin, Paris, France; 12Réanimation Médicale, Hôpital
Henri Mondor, Créteil, France; 13Réanimation Médicale, Hospices Civils de Lyon - Groupement
Hospitalier Edouard Herriot, Lyon, France; 14Réanimation, Centre Hospitalier Général
de Roanne, Roanne, France; 15Service de Réanimation Médico-Chirurgicale, CHU Louis
Mourier, Colombes, France; 16Service de Réanimation médicale, CHU de Poitiers, Poitiers,
France
Correspondence: Jean-Pierre Frat - jean-pierre.frat@chu-poitiers.fr
Annals of Intensive Care 2017, 7(Suppl 1):S10
Introduction The role of noninvasive ventilation (NIV) is debated in the management
of patients with acute hypoxemic respiratory failure. A recent study showed that patients
treated with high-flow nasal cannulae oxygen therapy (HFNC) had lower intubation and
mortality rates than those treated by the association of HFNC with NIV (1). High tidal
volumes (VT) delivered with NIV may be associated with an increased risk of intubation
(2). We aimed to identify risk factors associated to intubation, in hypoxemic patients
with acute respiratory failure and especially the role of VT under NIV.
Patients and methods This is an ancillary study from a multicenter, randomized, controlled
trial including patients with acute hypoxemic respiratory failure (FLORALI-study).
We focused on only patients with moderate or severe hypoxemia (PaO2:FiO2 ratio ≤200 mmHg)
and we excluded those with mild hypoxemia. The criteria for intubation were predetermined
including worsened or persisted respiratory failure, impairment of neurologic status
and hemodynamic instability.
Results After adjustment on the oxygenation strategy, the two factors independently
associated with intubation were the presence of bilateral pulmonary infiltrates at
admission (OR 2.33, 1.10–4.94, p = 0.03) and the respiratory rate (OR 1.04, 1.0–1.09,
p = 0.05).
In patients treated with NIV, a tidal volume exceeding 9 ml/kg 1 h after NIV initiation
was the only variable independently associated with intubation (OR 2.92, 1.05–8.10,
p = 0.04).
In patients treated with HFNC, the respiratory rate was the only variable independently
associated with intubation (OR 1.1, 1.02–1.18, p = 0.02). Patients with a respiratory
rate ≥30 breath/min had a significantly increased risk of intubation (OR 3.30, 1.09–9.97,
p = 0.03).
Conclusion Bilateral pulmonary infiltrates and a high respiratory rate were the two
major factors of intubation in patients with acute hypoxemic respiratory failure.
A high tidal volume (≥9 ml/kg) under NIV was associated with an increased risk of
intubation.
Competing interests Consulting activities with Fisher & Paykel.
References
Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute
hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–96.
Carteaux G, Millan-Guilarte T, De Prost N, et al. Failure of noninvasive ventilation
for de novo acute hypoxemic respiratory failure: role of tidal volume. Crit Care Med.
2016;44(2):282–90.
S11 Stress evaluation during simulated endotracheal intubation: evaluation of different
variables and physiological parameters
Christelle Teiten1, Nicolas Marjanovic2, Nicola Palamin3, Erwan L’Her4
1Urgences adultes, Hospital Center Regional University, Brest, France; 2Urgences,
CHU de Poitiers, Poitiers, France; 3Laboratoire des usages, Irt B-Com, Plouzané, France;
4Réanimation médicale, CHRU de Brest, Brest, France
Correspondence: Erwan L’Her - erwan.lher@univ-brest.fr
Annals of Intensive Care 2017, 7(Suppl 1):S11
Introduction Simulation is a powerful tool for technical skills teaching. No data
exists on how to improve teaching and evaluating the potential impact of stress. Main
objective of our study was to validate stress measurement parameters during two simulated
intubation conditions.
Materials and methods 26 physicians were recruited (10 juniors/16 seniors) and equipped
with various biometric sensors. All simulation sequences were videorecorded and physicians
also weared eye-tracking glasses. Salivar cortisol measurements were performed after
each sequence. Two situations were randomly tested, one in standard and easy intubation
conditions, one under difficult conditions presumed to induce stress (monitoring alarms,
mannikin lying on the floor, difficult intubation). Autoevaluations of video recordings
and mental workload (MWL) were performed retrospectively.
Results Few differences were depicted in-between junior and seniors. Physiological
parameters modifications and a heart rate variability decrease were observed under
the difficult intubation conditions (SDNN for juniors = 41.2 ± 20.9 vs 29.7 ± 12.4 ms;
p = 0.015). Stress was demonstrated to increase MWL (Nasa-TLX = 39 ± 18 vs. 63 ± 15;
p = 0.001), frustration being its determinant component (p = 0.033) (Fig. 11). Video-recordings
depicted significant stress occurence under the difficult conditions, whatever the
operator’s experience.
Fig. 11
See text for description
Conclusion Stress is an important component of success during intubation. Simulation
conditions enables to reproduce its occurence, using different types of tools, from
physiological parameters to heart rate variability and psychocognitive tests. Future
research is required to evaluate the impact of these parameters on teaching.
Competing interests None.
S12 Preoxygenation for intubation in the ICU: an ancillary study of the MACMAN Trial
Arthur Bailly1, Julie Boisramé-Helms2, Benoit Champigneulle3, Toufik Kamel4, Emmanuelle
Mercier5, Jean-Damien Ricard6, Virginie Lemiale7, Aurélie Le Thuaut8, Jean Reignier9,
Jean-Baptiste Lascarrou1, Clinical Research &, Intensive Care Sepsis (CRICS)
1Réanimation, Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon,
France; 2Réanimation, CHU de Strasbourg, Strasbourg, France; 3Service de réanimation
polyvalente, Hôpital Européen Georges-Pompidou (AP-HP), Paris, France; 4Réanimation
médicale polyvalente, Hôpital de La Source, CHR Orléans, Orléans, France; 5réanimation
polyvalente, Centre Hospitalier Régional Universitaire de Tours, Tours, France; 6Service
de Réanimation Médico-Chirurgicale, CHU Louis Mourier, Colombes, France; 7Réanimation
médicale, Hôpital Saint-Louis, Paris, France; 8Biostatistiques, C.H.U. Hôtel Dieu,
Nantes, France; 9Réanimation médicale, Chu Nantes, Nantes, France
Correspondence: Jean-Baptiste Lascarrou - jean-baptiste.lascarrou@chd-vendee.fr
Annals of Intensive Care 2017, 7(Suppl 1):S12
Introduction In ICU, intubation is a high risk procedure associated with high morbidity.
Despite procedure’s improvement with systematic application of fluid loading, early
use of vasopressors and checklist use, morbidity remains high. Preoxygenation and
intubation are the 2 main determinants of complication occurrence. McGrath Mac failed
to improve first pass laryngoscopy success during intubation in ICU as compare to
Macintosh laryngoscope. A predefined post hoc analysis of the MACMAN study was performed
to evaluate quality of preoxygenation with 4 devices allowed: bag valve mask, non-invasive
ventilation (NIV), high flow nasal cannula (HFNC), and non-re-breather mask (NRM).
Patients and methods MACMAN was a multicentre, open-label, randomized controlled superiority
trial. Consecutive patients requiring intubation were randomly allocated to either
the McGRATH MAC videolaryngoscope or the Macintosh laryngoscope, with stratification
by centre and operator experience. An only inclusion criterion was: “Patients must
be admitted to an ICU and require mechanical ventilation through an endotracheal tube”.
Patients were excluded if: contraindication to orotracheal intubation (e.g., unstable
spinal lesion); insufficient time to include and randomize the patient (e.g., because
of cardiac arrest); age <18 years; pregnant or breastfeeding woman; correctional facility
inmate; patient under guardianship; patient without health insurance; refusal of the
patient or next of kin to participate in the study; previous enrolment in a clinical
randomized trial with intubation as the primary end point (including previous inclusion
in the present trial). Post-hoc analysis was performed to assess occurrence of SpO2
<90% during intubation procedure between 4 groups of preoxygenation: BVM (at a minimum
flow of 15 L/min, NIV (100% FiO2), HFNC (at a minimum flow of 60 L/min, with 100%
FiO2), and NRM (at a minimum flow of 15 L/min). Between-groups difference in desaturation
occurrence was adjusted for baseline covariates significantly associated with the
group membership (P < 0.2). Multivariate analysis of the occurrence of a desaturation
(<90%) was performed using logistic regression. Bag-valve mask was considered reference.
Results Baseline characteristics were showed in Table 12. Groups were similar at baseline
except for PaO2/FiO2 ratio. In univariate analysis, age (P = 0.08), SAPS2 (P = 0.02),
PaO2/FiO2 ratio (P = 0.03),SpO2 (P = 0.001) and method of preoxygenation (P = 0.08)
were associated with occurrence of desaturation below 90%. In multivariate analysis,
SpO2 at randomization and method of preoxygenation were only predictors of desaturation
below 90%. BVM and HRM were associated with similar risk of desaturation occurrence
whereas NIV (OR 0.10 [0.01–0.81]) was protective and HFNC (OR 5.75 [1.15–28.75]) was
predictive of desaturation occurrence.
Table 12
See text for description
Bag valve mask N = 157
NIV N = 71
High flow nasal cannula N = 20
Non-re-breather mask N = 71
P value
Age
62 ± 16.4
65 ± 12.2
57 ± 17.7
63 ± 17.6
0.29
Gender male (%)
96 (61.1%)
45 (63.4%)
15 (75%)
43 (60.6%)
0.66
SAPS II score
60 ± 22
57 ± 22
51 ± 20
57 ± 21
0.38
PaO2/FiO2
156 ± 178
102 ± 65
107.5 ± 52
170 ± 157
0.01
SpO2
95 ± 6
95 ± 6
96 ± 5
96 ± 4
0.54
Successful first-pass laryngoscopy
107 (68%)
46 (65%)
16 (80%)
54 (76%)
0.34
At least one SpO2 < 90%
16 (11%)
2 (3%)
4 (20%)
4 (6%)
0.04
At least one mild to moderate complication
12 (8%)
3 (4%)
1 (5%)
2 (3%)
0.51
At least one severe complication
18 (12%)
7 (10%)
5 (25%)
6 (9%)
0.27
Conclusion All methods of preoxygenation were not equal for occurrence of desaturation
below 90% during intubation process. Ours results suggest than NIV could be first
line device during preoxygenation for intubation in the ICU. Further analysis and
research are warranted.
Competing interests None.
Reference
Bailly A, Lascarrou JB, et al. BMJ Open. 2015;5(12):e009855.
S13 Cardiac arrest and mortality related to intubation procedure in critically ill
adult patients
Amélie Rolle1, Audrey De Jong1, Gérald Chanques1, Samir Jaber1
1DAR B, Hôpital Saint Eloi, Montpellier, France
Correspondence: Amélie Rolle - melie9712@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S13
Introduction Intubation procedure is a challenging issue in intensive care unit (ICU)
[1]. Cardiac arrest related to intubation in critically ill adult patients has been
poorly studied. The studies were not powered to conclude on this rare outcome [2].
The main objective of our study was to establish the incidence of cardiac arrest and
to assess the risk factors of cardiac arrest in a large prospective database of intubation
procedures performed in ICU.
Patients and methods Five prospective studies were included, with similar data collected
before, during and after intubation procedures using the same methodology. The primary
outcome was the incidence of cardiac arrest related to intubation. The secondary outcomes
were the death (cardiac arrest without return of spontaneous circulation (ROSC)),
the cardiac arrests with ROSC, the complications related to intubation, the length
of ICU stay and the 28-day mortality. The factors associated with cardiac arrest related
to intubation procedures were assessed by univariate and multivariate analysis based
on patient, provider and practice characteristics.
Results Among the 1847 intubation procedures included, 49 cardiac arrests (2.7%) occurred,
including 35 with ROSC (71.4%) and 14 without ROSC (28.6%). Main patient, provider,
procedure characteristics and outcomes according to cardiac arrest related to intubation
are presented in Table 13. In multivariate analysis, the independent predictors of
cardiac arrest related to intubation were low systolic blood pressure prior to intubation,
hypoxemia prior to intubation, no preoxygenation, overweight or obesity and age >75 years.
Mortality rate at day 28 was significantly lower in patients intubated without cardiac
arrest (30.1%, 541 of 1798) than with cardiac arrests overall (73.5%, 36 patients
of 49, p < 0.001) and cardiac arrest with ROSC (63%, 22 patients of 35, p < 0.001).
Table 13
Main patient, provider, procedures characteristics and outcomes according to cardiac
arrest related to intubation
Overall (n = 1847)
Cardiac arrest (n = 49)
No cardiac arrest (n = 1798)
p value
Age >75 years, n (%)
257 (14)
12 (24)
245 (14)
0.03
SOFA score
6 (3–8)
8 (5–10)
5 (3–8)
0.039
BMI (kg/m2)
25 (22–29)
27 (23–29)
25 (21–29)
0.039
Sp02 < 80%, n (%)
411 (22)
22 (45)
389 (22)
<0.001
Lowest SBP before intubation
98 (78–120)
87 (65–105)
110 (89–130)
<0.001
SBP < 90 mmHg, n (%)
855 (46)
41 (84)
814 (45)
<0.001
MACOCHA score ≥3, n (%)
183/1108
10/28 (35)
173/1080 (16)
0.005
Preoxygenation, n (%)
1517 (82)
30/36 (83)
1487/1797 (96)
0.003
Severe complications during intubation procedure
329 (18)
49 (100)
280 (16)
<0.001
Severe hypoxemia
415 (22)
26 (53)
389 (22)
<0.001
Severe collapse
536 (29)
49 (100)
487 (27)
0.002
Cardiac arrest
49 (2.7)
49 (100)
0 (0)
<0.001
Death
14 (0.7)
14 (29)
0 (0)
<0.001
Moderate complications during intubation procedure
346 (19)
24 (49)
322 (18)
<0.001
Cardiac arrhythmia
58 (3)
15 (31)
43 (2)
<0.001
Inhalation
39 (2)
2 (4)
37 (2)
0.331
Esophageal intubation
86 (5)
4 (8)
82 (5)
0.232
Dental injury
15 (0.8)
0 (0)
15 (0.8)
0.522
Difficult intubation
200 (11)
7 (14)
193 (11)
0.430
Agitation
28 (2)
0 (0)
28 (2)
0.378
Length of ICU stay
15 (7–30)
2 (1–10)
16 (7–30)
0.001
Mortality 28 days
576 (31)
36 (73)
541 (30)
<0.001
Data expressed as median (25–75% IQR) or proportion (%)
Conclusion Cardiac arrest related to intubation in adult ICU is not a rare event occurring
in 2.7% of cases with high immediate mortality of 28.6% and at day 28 of 73.5%. We
identified five independent risk factors to cardiac arrest which 3 of them could be
modifiable. Optimal preparation to intubation procedure could help to prevent those
cardiac arrests.
Competing interests None.
References
De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, et al. Early identification
of patients at risk for difficult intubation in the intensive care unit: development
and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit
Care Med. 2013;187(8):832–9.
Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice
and risk factors for immediate complications of endotracheal intubation in the intensive
care unit: a prospective, multiple-center study. Crit Care Med. 2006;34(9):2355–61.
S14 Orotracheal versus nasotracheal intubation: a prospective observational study
Geoffroy Hariri1, Jean-Luc Baudel1, Vincent Dubée1, Gabriel Preda1, Simon Bourcier1,
Jeremie Joffre,2, Naïke Bigé1, Hafid Ait-Oufella1, Eric Maury1
1Réanimation médicale, Hôpital Saint-Antoine, Paris, France; 2Service de reanimation
médicale, Hôpital Saint-Antoine, Paris, France
Correspondence: Eric Maury - ejhmaury@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S14
Introduction Naasotracheal intubation (NTI) has been progressively given up in favour
of the orotracheal intubation (OTI) in intensive care unit (ICU). This could be explained
by more frequent infectious (sinusitis and ventilator associated pneumonia) and non-infectious
(epistaxis, turbinates bones injury) complications the former being thought to be
more frequent with NTI. However, whereas infectious sinusitis is a risk factor for
VAP, no study has yet demonstrated that OTI decreases the infectious sinusitis rate
compared with NTI. Furthermore, nasal route could improve patient comfort and decrease
auto-extubation. Finally NTI can be performed without laryngoscopy with less risk
of lips and dental injury. In this prospective study, we aimed to compare the complication
of NTI and OTI and to assess the comfort of the patient.
Patients and methods We performed a prospective observational study in a 12-bed medical
ICU including patients requiring endotracheal intubation. The intubation route was
let at the discretion of the physician in care of the patient, however OTI was compulsory
in case of cardiac arrest, severe hypoxemia (P/F < 150 when available) and clotting
perturbation. For each patient, age, sex, SAPSII, mechanical ventilation duration.
intubation route were recorded as well as complications during the placement of endotracheal
tube. Infectious and non infectious complications during invasive ventilation period
were also recorded. In patients who were successfully extubated, pain, burning feeling,
dryness and the wish of tube removal were assessed using visual analogic scales (VAS).Results
are expressed as mean ± SD. Qualitative data were compared using Chi-2 or Fisher’s
exact test while quantitative data comparisons used Student t Test or Mann–Whitney
as appropriate.
Results One hundred and thirty-seven patients were included (60 women, age: 65 ± 17 years,
SAPSII: 49 ± 18, mechanical ventilation duration 4.2 ± 3 days). Among them, 90 received
OTI and 47 NTI. No statistical difference was found between initial characteristics
of the two groups.
During the placement of endotracheal tube, the NTI group received less sedatives (66
vs 91%; p < 0.0006) and less frequently succinyl choline (6 vs 71%; p = 0.0001). NTI
was performed without laryngoscopy in 77% of patients. Selective intubations and desaturation
during the procedure were observed with a similar frequency in the two groups (13.6%
OTI vs 4 NTI p = 0.13).Lips injury were more frequent after OTI (7 vs 0%, p = 0.09).
Epistaxis occurred in 15% of patients in the NTI group vs none in the OTI group (p < 0.05)
and one required a blood transfusion.
While the endotracheal tube was in place, ulcerations caused by the tube or the fastening
system were more frequent in the OTI group [lips ulcerations, n = 27 (30%) versus
nostrils ulcerations in the NTI group, n = 6 (13%) (p < 0.05)]. Tube repositioning
was required in 22% of patients in the OTI group versus 11% in the NTI group (p = 0,
1) while self extubation was observed in 3 patients in each group (p = 0.4). Ventilator-associated
pneumonia occurred in 4% in OTI and 7.5% NTI (p = 0.69). Other infectious complications
were one sinusitis in the NTI group (p = 0.34) and 3 labial herpes in the OTI group
(p = 0.55). Guedel cannula was used only in the OTI group (9 vs 0%, p = .05).
Among the 58 patients successfully extubated, pain caused by the tube was similar
(3, 4/10 in the OTI group vs 3/10 in the NTI, p = 0.6). Burning feeling was similar
(2, 3/10 in the OTI vs) 3, 2/10 in the NTI, p = 0.3), while dryness feeling was more
important in the OTI (VAS 5.4 vs 3.8 in the NTI, p = 0.05). The wish of tube removing
was greater in the OTI group (5/10) and 4/10 in the NTI (p = 0.3).
Discussion In this pilot study, patients in the NTI group required less frequently
sedative and succinyl-choline use during tracheal intubation. During mechanical ventilation,
ulcerations were more frequent in the OTI group. No difference between the two routes
was found concerning the infectious complications while the endotracheal tube was
in place.
Conclusion Despite its small size, and the absence of randomization, the present study
suggests that nasotracheal intubation improves the comfort and the tolerance of tracheal
intubation and is not associated to higher rates of VAP.
Competing interests None.
S15 Effect of mode of hydrocortisone administration in patients with septic shock:
a prospective randomized trial
Oussama Jaoued1, Rim Gharbi1, Najla Tilouch1, Ben Sik Ali Habiba2, Houda Mater1, Mohamed
Fekih Hassen1, Souheil Elatrous1
1Réanimation Médicale, EPS Taher Sfar Mahdia, Mahdia, Tunisia; 2Réanimation médicale,
EP taher sfar, Mahdia, Tunisia
Correspondence: Mohamed Fekih Hassen - mohamed.fekihhassen@rns.tn
Annals of Intensive Care 2017, 7(Suppl 1):S15
Introduction There is a strong biological rationale to support the use of low to moderate
doses of corticoids for the treatment of vasopressor-dependent septic shock. The question
of whether corticosteroids should be given to septic shock patients by continuous
or by bolus infusion is still unanswered.
Objective: to evaluate the effect on morbidity and mortality of mode of hydrocortisone
administration in patients with septic shock.
Patients and methods We conducted a prospective randomized and monocentric study in
the medical intensive care of the teaching Hospital of Taher Sfar in Mahdia between
April 2013 and June 2016. We assigned patients with septic shock to receive hydrocortisone
treatment either by bolus or by continuous infusion with equivalent dose (200 mg/day).
Corticosteroids were continued as long as vasopressors were needed. The primary endpoint
was all cause of ICU mortality. Secondary endpoints included length of stay, number
of vasopressor free days, change in SOFA score, leukocyte count, temperature, plasma
C-reactive protein, and the occurrence of adverse events (Secondary sepsis, hyperglycemia,
hypokalemia, peripheral neuropathy).
Results The trial included 54 patients, of whom 27 were assigned to continuous infusion
of hydrocortisone and 27 to discontinuous mode. The baseline characteristics of patients
were similar between the two groups. Sepsis was secondary to community-acquired infection
in 54% of cases. There was no difference in mortality between groups (74% in continuous
groups and 59% in discontinuous group). SOFA score was significantly higher at days
1, 2 and 5 in discontinuous group. Length of stay, duration of mechanical ventilation,
number of day without vasopressors, and the occurrence of adverse events were similar
in the two groups.
Conclusion The mode of hydrocortisone administration in patients with septic shock
has no influence on morbidity or mortality. The occurrence of adverse events was similar.
Competing interests None.
S16 Changes in platelet counts are not associated with the development of ICU-acquired
infections in patients with severe sepsis and septic shock
Hamid Merdji1, David Grimaldi1, Julien Charpentier1, Christophe Rousseau2, Jean-Paul
Mira1, Jean-Daniel Chiche1, Frédéric Pène1
1Réanimation médicale, Hôpital Cochin, Paris, France; 2Unité 1016, 22 rue méchain,
75014, paris, Institut National de la Santé et de la Recherche Médicale, Paris, France
Correspondence: Hamid Merdji - hamidmerdji@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S16
Introduction Widespread activation of coagulation with platelet consumption is a pathophysiological
feature of severe sepsis and septic shock. Thrombocytopenia, either defined by platelet
count below 150 G/L or by a significant relative 20–40-percent decrease in platelet
count is a potent poor prognostic factor in sepsis. Besides their role in hemostasis,
platelets also carry various immune and inflammatory functions that are likely to
impact on host defense against infections. We aimed to assess whether changes in the
platelet count induced by sepsis is associated with the development of subsequent
nosocomial infections.
Patients and methods Patients were obtained from two prospective studies about immuno
monitoring of dendritic cells and innate-like lymphocytes in critically ill septic
patients (1, 2). Adult patients with severe sepsis and septic shock were included.
Exclusion criteria were any immunosuppressive condition (hematological malignancy,
HIV infection at any stage, bone marrow or solid organ transplantation, daily corticosteroid
therapy >0.5 mg/kg prednisone-equivalent, chemotherapy or any other immunosuppressive
treatments), pregnancy, do-not-resuscitate orders on admission. In addition patients
who died or who received platelet transfusion during the first week after ICU admission
were also excluded. Platelet counts were collected on the day of sepsis diagnosis
(D1) and then on D3, D5 and D7. The relative variation in platelet count at day n
compared to day 1 was calculated as follows: (count at day n − count at day 1) × 100/(count
at day 1). Patients were screened daily for the development of ICU-acquired infections
diagnosed according to usual guidelines (for ventilator acquired pneumonia, urinary
tract infection, intravascular catheter-related infection).
Results 94 patients were included in the study (65 years old, 68% of men, APACHE 2 = 28).
The overall in-ICU mortality rate was 15%. 21 (22%) patients developed ICU-acquired
infections after a median of 8 [7–13] days following ICU admission. Patients with
nosocomial infections were older (68 [62–73] vs. 64 [60–68] years, p = 0.34, had higher
severity at admission (APACHEII 31 [28–34] vs. 27 [25–29], p = 0.09) and finally had
higher mortality rate (29 vs. 10%, p < 0.05).
The average admission platelet count was 239 [210–269] G/L and non significantly dropped
to 185 [158–212] G/L at 3 days, 182 [159–205] G/L at 5 days and 222 [199–246] G/L
at 7 days. Platelet counts at D1, D3, D5 and D7 appeared similar in patients without
and with further nosocomial infections. The relative variations in platelet counts
between between D1 and D3, between D1 and D5 and between D1 and D7 were also similar
between patients with and without ICU-acquired infections (Fig. 12).
Fig. 12
Trends in platelets count over time in patients with and without ICU acquired infection
Discussion In this preliminary study from selected cohorts of non-immunocompromised
patients, sepsis resulted in mild alterations in platelet counts, making it unlikely
to become associated with the development of nosocomial infections. It would be relevant
to address this question in larger cohorts of non-selected patients, as well as the
impact of platelet transfusions in this setting.
Conclusion Changes in platelet counts were not associated with an increased susceptibility
towards ICU-acquired infections in non-immunocompromised patients with severe sepsis
and septic shock.
Competing interests None.
References
Grimaldi, et al. Profound and persistent decrease of circulating dendritic cells is
associated with ICU-acquired infection in patients with septic shock Intensive Care
Med. 2011;37(9):1438–46.
Grimaldi, et al. Specific MAIT cell behaviour among innate-like T lymphocytes in critically
ill patients with severe infections. Intensive Care Med. 2014;40(2):192–201.
S17 Sepsis and septic shock: prognostic value of lymphocytopenia
Ines Sedghiani1, A Benabderrahim, Dhekra Hamdi, Asma Jendoubi, Mohamed Ali Cherif,
Youssef Zied El Hechmi, Jerbi Zouheir
1Emergency and intensive care department, Hôpital Babib Thameur, Tunis, Tunisia
Correspondence: Ines Sedghiani - sedghiani.ines@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S17
Introduction Sepsis is the leading cause of mortality in the intensive care unit (ICU)
patients despite the progress regarding their care. The immunodeficiency due to sepsis
with the consequent profound lymphocyte alterations is now well proven. The objective
of this work was to determine the prognostic impact of lymphocytopenia in septic patients
in ICU.
Patients and methods Retrospective study including all patients hospitalized for sepsis
or septic shock between 01/01/2013 and 31/05/2015. The sepsis and septic shock definitions
were adjusted with the third international consensus definitions for sepsis and septic
shock. Were excluded from the study patients of onco-hematology.
Lymphocytopenia was defined as an absolute lymphocyte count less than level of 1500/mm3
during the first 24 h of hospitalization. The prognostic factors analyzed for the
lymphopenic and non lymphopenic patients were in hospital mortality, the occurrence
of nosocomial infections and hospital length of stay.
Results Among the 52 patients, aged 58 ± 17 years, 23 patients were with septic shock
and 29 patients with sepsis. IGSII score and SOFA score were respectively 42 ± 19
and 5 ± 3. Four patients were immunocompromised due to HIV infection in one case and
an immunosuppressive therapy in 3 cases. Lymphocytopenia was observed in 41 patients
(78%). Twenty-eight patients (53%) died within an average of 11 ± 13 days. It was
noted the occurrence of 10 nosocomial infections. The median length of stay was 7 days
with extremes of one and 74 days. The lymphopenic patients were comparable to non
lymphopenic patients in terms of medical history and severity scores. Mortality was
comparable between the 2 groups with a rate of 51% (n = 21) in lymphopenic patients
and 64% (n = 7) in non-lymphopenic patients (p = 0.51). The earliness of death was
correlated with the duration of lymphopenia (R
2 = 0.32, p = 0.007). The occurrence of nosocomial infections was not different between
the two groups: 17% (n = 7) for lymphopenic and 27% (n = 3) for non lymphopenic patients.
The hospital length of stay was not different between the two groups but was correlated
with the duration of lymphocytopenia (R
2 = 0.29, p = 0.000).
Conclusion Lymphocytopenia is frequently found in sepsis. Lymphocytopenia was not
associated with excess of mortality nor with the subsequent occurrence of infectious
complications during the ICU stay. His persistence was associated with an earlier
death and a more prolonged hospitalization.
Competing interests None.
S19 Role of relative adrenal insufficiency in septic cardiomyopathy: a prospective
cohort study
François Bagate1, Keyvan Razazi1, Guillaume Carteaux1, Nicolas de Prost1, Armand Mekontso
Dessap1
1Réanimation médicale, Hôpital Henri Mondor, Créteil, France
Correspondence: François Bagate - francois.bagate@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S19
Introduction Relative adrenal insufficiency (RAI) is common in ICU patients, particularly
during septic shock (1). It has been shown that the RAI also occurs during cardiogenic
shock (2). Septic cardiomyopathy occurs in a significant proportion of septic shock
patients. The aim of this study was to evaluate the role of RAI on septic cardiomyopathy.
Patients and methods Prospective observational study conducted in the intensive care
in one university hospital in France. Patients meeting the criteria for septic shock
without prior corticosteroid therapy and without chronic heart disease were included.
Total blood cortisol levels were assessed immediately before (T0) a short corticotropin
stimulation test (0.25 mg iv of tetracosactrin) and 30 and 60 min afterward. Δmax
was defined as the difference between the maximal value after the test and T0. RAI
was defined as an inappropriate adrenal response with Δmax < 9 µg/dl and septic cardiomyopathy
as the appearance of cardiac systolic dysfunction (left ventricle ejection fraction
<45%) within the first 3 days of septic shock. We performed a multivariable analysis
using backward stepwise logistic regression to identify independent predictors of
septic cardiomyopathy.
Results Of the 52 patients enrolled, 19 (37%) died during ICU stay and 22 (42%) during
hospitalization. Septic cardiomyopathy was revealed in 18 patients (35%). Overall,
RAI occurred in 32 patients (62%) and this prevalence was significantly higher in
patients with septic cardiomyopathy as compared to their counterparts (83 vs. 50%,
p = 0.03) and in non-survivors as compared to survivors (82 vs. 47% p = 0.02). In
the multivariable analysis, RAI was an independent predictor of septic cardiomyopathy
(OR 4.74, p = 0.03), along with SAPS2 (OR 1.06, p < 0.01). Results were similar when
the use of etomidate was forced into the model as a potential confounder.
Discussion Although the definition of RAI is not consensual, a threshold of Δmax at
9 µg/dl has been widely used in septic shock, with or without the use of T0 (1). The
usefulness of substitutive doses of steroids in septic shock is controversial, but
many authors assume this treatment has a potential in reversing overt vasoplegia.
Our data suggest an implication of RAI in septic cardiomyopathy.
Conclusion We found RAI to be an independent predictor of septic cardiomyopathy. These
findings may suggest a new role for substitutive doses of steroids in the hemodynamic
management of septic shock.
Competing interests None.
References
Annane D, Sebille V, Troche G et al. A 3-level prognostic classification in septic
shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000;283:1038–45.
Bagate F, Lellouche N, Lim P et al. Prognostic value of relative adrenal insufficiency
during cardiogenic shock: a prospective cohort study with long-term follow-up. Shock.
2016.
S20 Effects of continuous haemofiltration versus intermittent haemodialysis on microcirculatory
parameters in septic shock: a muscle microdialysis study
Zied Hajjej1, Walid Sellami1, Walid Samoud1, Radhwen Bousselmi1, Iheb Labbene1, Mustapha
Ferjani1
1Department of Critical Care Medicine and Anesthesiology, Military Hospital of Tunis,
Tunisia, Tunis, Tunisia
Correspondence: Zied Hajjej - hajjej_zied@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S20
Introduction Regional perfusion parameters, like lactate, pyruvate and glycerol, may
predict outcome in septic shock patients. Continuous venovenous haemofiltration (CVVH)
has been considered beneficial in septic shock patients. The aim of our study was
to investigate whether CVVH, in comparison to intermittent haemodialysis (IHD), is
able to improve regional perfusion in septic shock patients studied by muscle microdialysis.
Patients and methods It was a prospective, randomized, clinical study, including septic
shock patients with acute renal failure, aged over 16 years. Patients were randomized
to receive either CVVH (n = 10) or IHD (n = 10) for renal replacement therapy. Intermittent
haemodialysis was carried out during the first 4 h of the 24 h study period. Systemic
haemodynamics and interstitial tissue concentrations of lactate, pyruvate, glucose
and glycerol were obtained at baseline, 6, 12, 18 and 24 h after initiation of renal
replacement by using muscle microdialysis.
Results Regarding systemic haemodynamics parameters, CVVH caused a decrease in heart
rate in contrast to IHD after 6 h (−4 ± 2 vs +6 ± 3/mn). There were no changes in
vasopressor support throughout the 24-h study period and so systolic blood pressure
remained stable in both groups.
During the 24 h of all renal replacement therapies there was no significant change
in muscle pyruvate and glucose levels.
During CVVH muscle lactate decreased constantly, as did muscle glycerol levels. This
decrease reaches a significant levels at H12 for muscle lactate and at H24 for muscle
glycerol (Fig. 13).
Fig. 13
Muscle biological data measured by microdialysis during study period
Conclusion Our results suggest that among septic shok patients, CVVH may improves
regional perfusion in comparison with IHD.
Competing interests None.
S21 Hypernatremia as a risk of death during hypertonic fluid resuscitation in septic
shock: post hoc analysis of the “Hyper2S” study
Frédérique Schortgen1, Pierre Asfar2, Boisramé-Helms Julie3, Julien Charpentier4,
Emmanuel Guérot5, Bruno Megarbane6, David Grimaldi7, Grelon Fabien8, Nadia Anguel9,
Lasocki Sigismond10, Henry-Lagarrigue Matthieu11, Frédéric Gonzalez12, Legay François13,
Christophe Guitton14, Maleka Schenck3, Doise Jean-Marc15, Didier Dreyfuss16, Peter
Radermacher17, for the HYPER2S Investigators and REVA research network
1Réanimation médicale, Hôpital Henri Mondor, Créteil, France; 2Réanimation, C.H.U.
d’Angers, Angers, France; 3Réanimation médicale, C.H.R.U. Hôpitaux Universitaires
Strasbourg, Strasbourg, France; 4Réanimation Médicale, Hôpital Cochin, Paris, France;
5Réanimation médicale, Hopital Europeen Georges-Pompidou, Paris, France; 6Service
de Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; 7Service
de réanimation polyvalente, Centre Hospitalier de Versailles, Le Chesnay, France;
8Réanimation, C.H. - Le Mans, Le Mans, France; 9Réanimation médicale, CHU de Bicêtre,
Le Kremlin Bicêtre, France; 10Réanimation chirurgicale, C.H.U. d’Angers, Angers, France;
11Réanimation polyvalente, Hospital Center Departmental De Vendée, La Roche-sur-Yon,
France; 12Réanimation medico-chirurgicale, hopital avicenne, Bobigny, France; 13Réanimation,
C.H. de Saint Brieuc, Saint-Brieuc, France; 14Réanimation médicale, C.H.U. Hôtel Dieu,
Nantes, France; 15Réanimation, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône,
France; 16Réanimation polyvalente, Hôpital Louis-Mourier (AP-HP), Colombes cedex,
France; 17Institut für anästhesiologische pathophysiologie und verfahrensentwicklung,
Universitätsklinikum Ulm, Ulm, Germany
Correspondence: Frédérique Schortgen - frederique.schortgen@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S21
Introduction Acquired hypernatremia (H-Na) is an independent risk of death among ICU
patients (1). In the RCT “Hyper2S” study, we compared normal to 3% hypertonic saline
during the first 72 h in patients with septic shock with normal serum Na concentration
(SNa) at baseline. The study was prematurely stopped for potential harmful effect
associated with more frequent H-Na. We assessed the role of H-Na on mortality.
Patients and methods Data are a post hoc analysis of the “Hyper2S” study database
including 434 patients. SNa was measured at H0, every 12 h for 3 days and then daily
until D7. Study fluids were stopped if SNa >155 or >12 mmol/l increase over 24 h.
Mild, moderate, and severe H-Na were defined as SNa >145 mmol/L, >150 mmol/L and >155 mmol/L,
respectively. SNa profiles were compared between D28 survivors and non-survivors.
Acute kidney injury (AKI) was defined by doubling serum creatinine and/or need for
dialysis.
Results 431 patients with available data were analysed. 234 (54%) developed H-Na (mild:
28%, moderate: 16%, severe: 10%). No matter the absence or presence and its severity,
H-Na did not affect mortality (43, 34, 41, and 35%, respectively without, with mild,
moderate, and severe H-Na, p = 0.41). SNa profiles were similar between survivors
and non-survivors (Table 14). A sensitivity analysis performed among survivors at
D3 did not change the results. Compared to patients without H-Na, AKI occurred in
42% of patients with H-N vs 40% (p = 0.58), atelectasis in 8 versus 10% (p = 0.58)
and ICU acquired weakness in 7 versus 10% (p = 0.23).
Table 14
Serum Na profile in D28 survivors and non-survivors (results are presented as number
and % of patients and medians IQR)
Survivors N = 262
Non-survivors N = 169
OR 95% CI, p
Hypernatremia, n (%)
No
113 (43)
84 (50)
1
Yes
149 (57)
85 (50)
0.77 (0.52–1.13), 0.18
Hypernatremia, n (%)
No
113 (43)
84 (50)
1
Mild
80 (31)
41 (24)
0.69 (0.43–1.10), 0.12
Moderate
41 (16)
29 (17)
0.95 (0.55–1.65), 0.86
Severe
28 (11)
15 (9)
0.76 (0.34–1.66), 0.49
Max SNa (mmol/L)
146 (143–151)
145 (141–149)
0.98 (0.95–1.01), 0.22
Mean SNa (mmol/L)
141 (138–144)
141 (138–145)
1.00 (0.96–1.06), 0.85
Max increase: SNa Max-SNa H0 (mmol/L)
7 (3–13)
6 (1–12)
0.98 (0.95–1.01), 0.15
Max SNa increase rate (mmol/L/h)
0.33 (0.23–0.58)
0.33 (0.17–0.75)
1.31 (0.84–2.07), 0.23
Conclusion Hypernatremia occurrence is not associated with an increased risk of morbidity
and mortality during hypertonic fluid resuscitation in septic shock.
Competing interests None.
Reference
Darmon M, et al. Nephrol Dial Transplant 2010;25:2510–5.
S22 Management of moderate hypokalemia in a medico-chirurgical intensive care unit
Antoine Frère1, Laurent Martin-Lefèvre1, Aurélie Le Thuaut2, Gwenhaël Colin1, Maud
Fiancette1, Matthieu Henry-Laguarrigue1, Jean-Claude Lacherade1, Jean-Baptiste Lascarrou1,
Christine Lebert1, Isabelle Vinatier1, Aihem Yehia1
1Réanimation polyvalente, Centre Hospitalier Départemental - site de La Roche-sur-Yon,
La Roche-sur-Yon, France; 2Unité de recherche clinique, Centre Hospitalier Départemental
- site de La Roche-sur-Yon, La Roche-sur-Yon, France
Correspondence: Antoine Frère - antfrere@live.fr
Annals of Intensive Care 2017, 7(Suppl 1):S22
Introduction Guidelines about the moderate hypokalemia treatment (between 2.5 mmol/l
and 2.9 mmol/l) are based on experts estimations, and non-specific ones for patients
in the intensive care units (ICU). The aim of this study was to evaluate the correction
of the hypokalemia in an ICU and the compliance of recommendations.
Materials and methods An observational epidemiological, retrospective and monocentric
trial has been realized during a period of 13 months (from January 2015 to February
2016). The study population included hospitalized patients in the ICU who have shown
a first moderate hypokalemia episode, all cause considered. Patients who have presented
an acute renal failure with a KDIGO (Kidney Disease: Improving Global Outcomes) score
of three the day of their inclusion were excluded. The main primary study endpoint
was percent correction of the serum potassium after 24 h. The secondary study endpoints
were the incidence rate of moderate hypokalemia and the efficacy about the hypokalemia
correction in accordance with the achieved treatment consistent or not with recommendations.
Results 140 patients had at least one episode of hypokalemia. The incidence rate of
the hypokalemia first episode was 1.8%. The study population included 106 patients.
IGS2 score was 47.1 (± 16). 48 patients required mechanical ventilation at the inclusion.
The serum potassium was greater than or equal to 3.5 mmol/l after 24 h about 34 patients
(32.1%) (corrected group). At 24 h one patient had a serum potassium higher than 5 mmol/l.
The average total potassium was respectively 72.3 mmol/L (±57) in the corrected group
and at 75.4 mmol/l (±53.67) in the non-corrected group (p = 0.96). Among 75 patients
without contraindication to the enteral administration, this one was used in 46.7%
(n = 35) of cases. 47/75 (62.7%) of these patients have received continuous intravenous
infusion of potassium and 7 (6.6%) patients have been a management compatible with
the most common recommendations (input potassium chloride of 100 mmol, use of the
enteral administration and lack of continuous intravenous infusion). The percent correction
of the hypokalemia after 24 h was respectively of 2/7 (28.6%) in the group in which
recommendations had been respected and of 32/99 (32.3%) in the other one (p = 1.00).
Discussion In our knowledge there are no previous studies that have specifically focused
on the correction of the moderate hypokalemia in critically ill patients. In our study
the incidence rate of the moderate hypokalemia was lower than data from the literature
because we have only considered the first episode of the hypokalemia [1]. Among patients
without contraindication to the enteral administration, this one was used in less
than half of the cases. 62% of these patients received potassium with a continuous
intravenous infusion and only 7 patients received medical care conform to the guidelines.
The medium potassium quantity provided was very lower to the guidelines. Only 32%
of the patients have been corrected after 24 h without any difference in the medium
potassium quantity which has been provided in relation to the uncorrected group.
Conclusion Only 32.1% of moderate hypokalemia in ICU are corrected after 24 h. The
intravenous way is considerably used (in 72% of cases) with a poor return. A wide-ranging
study is necessary to determine the best correction modes.
Competing interests None.
Reference
Hessels L, Hoeskstra M, Mijzen LJ, Vogelzang M, Dieperink W, Lansink A, et al. The
relationship between serum potassium, potassium variability and in-hospital mortality
in critically ill patients and a before-after analysis on the impact of computer-assisted
potassium control. Crit. Care. 2015;19(1):4.
S23 Nephrotoxic drug prescription in intensive care units: 1028 patient prospective
cohort
Aurélie Joret1, Julie Boisramé-Helms2, Laurent Martin-Lefèvre3, Nicolas Menunier-Beillard4,
Jean-Etienne Herbrecht5, Dalila Benzekri-Lefevre6, René Robert7, Arnaud Desachy8,
Fréderic Bellec9, Gaëtan Plantefève10, Jean-Pierre Quenot4, Jean-Claude Lacherade3,
Ferhat Meziani2, Elsa Tavernier11, Stephan Ehrmann1, Clinical Research in Intensive
Care and Sepsis (CRICS network)
1Réanimation polyvalente, CHRU de Tours, Tours, France; 2 Réanimation médicale, CHU
de Strasbourg, Strasbourg, France; 3Réanimation polyvalente, CHD de Vendée, La Roche-sur-Yon,
France; 4Réanimation médicale, CHU de Dijon, Dijon, France; 5Réanimation médicale,
CHRU de Strasbourg, Strasbourg, France; 6Réanimation médicale polyvalente, CHR d’Orléans,
Orléans, France; 7Réanimation médicale, CHU de Poitiers, Poitiers, France; 8Réanimation
polyvalente, CH D’Angoulême, Angoulême, France; 9Réanimation, CH de Montauban, Montauban,
France; 10Réanimation polyvalente, CH Victor Dupouy, Argenteuil, France; 11Inserm
cic 1415, CHRU de Tours, Tours, France
Correspondence: Aurélie Joret - aureliejoret@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S23
Introduction Acute Kidney Injury (AKI) is frequent in intensive care unit (ICU) patients
and associated with poor prognosis. Among the various contributing factors, administration
of nephrotoxic drugs is potentially avoidable. A better knowledge of the nephrotoxic
prescription pattern and its contribution to renal injury in ICU patients, may enable
to identify opportunities for improvement. The objective of this study was to describe
the frequency and modality of nephrotoxic drug prescription during the first 7 days
in the ICU.
Patients and methods Prospective observational study including all patients admitted
during two 4 weeks periods, between 2013 and 2015, in 10 ICUs in France. Patients
undergoing chronic dialysis, patients with renal replacement therapy within the preceding
week of ICU admission as well as patients admitted for benign psychotropic poisoning
without organ failure were not included. Nephrotoxic drugs received by the patients
were collected daily. AKI was defined according to the KDIGO (Kidney Disease: Improving
Global Outcomes) criteria.
Results 1028 patients were included. Mean ± SD age was 65 ± 16 years, 64% were male,
mean ± SD SAPS II was 47 ± 20. ICU length of stay was 7 ± 11 days and ICU mortality
rate was 23%. During the first 7 days in the ICU, 60% of patients received at least
one nephrotoxic drug. 31% of patients received one, 18% received two, 9% received
three and 3% received more than three nephrotoxic medications. Diuretics, antibiotics
and iodinated contrast media were the nephrotoxic drugs most frequently administered
to, respectively, 35, 22 and 15% of patients. AKI (KDIGO stage 1 or higher) occurred
in 58% of patients during the first 7 days in ICU. The proportion of patients with
AKI increased with the number of nephrotoxic drugs received: 189/410 (46%) of the
patients not exposed to nephrotoxic drugs developed AKI whereas, respectively, 189/315
(60%), 136/184 (74%), 62/91 (68%) and 24/28 (85%) of the patients receiving one, two,
three, and more than three nephrotoxic drugs developed AKI. The univariate association
between the number of nephrotoxic medication and AKI persisted in the multivariate
analysis adjusted on baseline SAPS II score (p < 0.001).
Conclusion The significant proportion of patients exposed to nephrotoxic drugs and
the observed association with AKI warrants further investigation. Statistical adjustments
for multiple potential confounders is needed in order to assess a potential causal
relationship which would lay foundations for interventional studies.
Competing interests None.
S24 Relationship between ionized calcium and its determinants in septic shock
Nicolas Chudeau1, Tommy Raveau2, Valérie Moal3, Alain Mercat4, Pascal Houillier5,
Nicolas Lerolle2
1Réanimation médico-chirurgicale, C.H. - Le Mans, Le Mans, France; 2Réanimation médicale,
Centre Hospitalier Universitaire d’Angers, Angers, France; 3Laboratoire de biochimie,
C.H.U. d’Angers, Angers, France; 4Service de réanimation médicale et médecine hyperbare,
Centre Hospitalier Universitaire d’Angers, Angers, France; 5Département de physiologie
et radio-isotopes, Hôpital Européen Georges-Pompidou (AP-HP), Paris, France
Correspondence: Nicolas Chudeau - nico.chudeau@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S24
Introduction Hypocalcemia is a common disorder in ICU, especially in septic patients
and it is associated with mortality. The mechanisms underlying this disorder are unknown.
The aim of this study was to investigate the relationship between serum ionized calcium
concentration and its determinants in septic shock patients and notably to study the
kidney response to hypocalcemia.
Patients and methods This prospective, single-center, observational study was conducted
in the medical ICU of the University Hospital of Angers, from May 2013 to September
2015. Two groups of patients were evaluated: a group of septic patients with [Ca2+]
<1.10 mmol/L (hypocalcemia group) in whom physician in charge considered appropriate
as routine care to perfuse calcium chloride (CaCl2) to treat hypocalcemia and a group
of non-septic and normocalcemic patients hospitalized for acute respiratory failure
(normocalcemia group). Exclusion criteria were: age <18 years old, pregnancy and lactation,
chronic disorder of calcium or phosphate homeostasis, major hemodynamic instability,
use of diuretics in the 24 h before inclusion, anuria or renal replacement therapy
and refusal to participate. In the 24 h following ICU admission, calcium metabolism
was compared in the two groups of patients (serum [Ca2 +], parathyroid hormone (PTH),
25 OH vitamin D, calcitriol, phosphorus, magnesium, creatinine and urinary calcium
concentration). These assays were repeated in hypocalcemic patients after an intravenous
infusion of 2 g of CaCl2 over 2 h. Action of PTH on the kidney was assessed by evaluating
nephrogenous cyclic AMP.
Results 32 patients were included in the study, 19 in the hypocalcemia group and 13
in the normocalcemia group. Hypocalcemic patients had lower [Ca2+] than normocalcemic
patients (1.03 [0.95–1.05] vs. 1.15 [1.12–1.20] mmol/L, p < 0.0001). In hypocalcemic
patients, [Ca2+] was significantly increased by the end of the intravenous infusion
of CaCl2 (1.19 [1.07–1.28] mmol/L, p < 0.001 vs. baseline). PTH was significantly
increased in hypocalcemic in comparison to normocalcemic patients (60 [36–130] vs.
43 [25–59] pg/mL, p = 0.02) and significantly decreased after CaCl2 infusion (25 [10–60] pg/mL,
p < 0.01 vs. baseline). No other calcium determinant (25 OH vitamin D, calcitriol,
pH, phosphorus, magnesium) significantly differed between the two groups. PTH was
negatively correlated with [Ca2+] (Rho = −0.6, p < 0.001). Urinary calcium excretion
by 100 mL of glomerular filtrate (GF) was lower in hypocalcemic versus normocalcemic
patients (0 [0–0] vs. 1.4 [0.15–5.85] µmol/100 mL GF, p < 0.001) reflecting an effective
tubular reabsorption of calcium, but remained unchanged after CaCl2 load. Nephrogenous
cAMP, although above upper limit range of normal values, was not significantly different
in hypocalcemia group and normocalcemia group (3.09 [0.91–11.48] vs. 2.96 [1.51–11.54] nmol/100 mL
GF, p = 0.63). Nephrogenous cAMP did not decrease significantly after CaCl2 load (1.7
[0.14–6.7] nmol/100 mL GF, p = 0.15 vs baseline).
Conclusion In septic shock patients with hypocalcemia, we observed an adequate PTH
response to calcium variation and an efficient tubular calcium reabsorption. In the
absence of increased nephrogenous cAMP, persisting tubular calcium reabsorption despite
Ca load and PTH decrease, may suggest that the usual physiological link between PTH,
nephrogenous cAMP and tubular reabsorption is altered in ICU patients. Thus, non-PTH
factors drive tubular Ca reabsorption. Finally, our results show that hypocalcemia
in septic patients is not explained by altered renal tubular calcium transport and
a flux of calcium from serum to soft tissue may be hypothesized.
Competing interests None.
References
Collage RD, Howell GM, Zhang X, Stripay JL, Lee JS, Angus DC, and al. Calcium supplementation
during sepsis exacerbates organ failure and mortality via calcium/calmodulin-dependent
protein kinase signaling. Crit Care Med. 2003;41(11):e352–60.
Zaloga GP. Hypocalcemia in critically ill patients. Crit Care Med. 1992;20(2):251–62.
S25 Kidney cell-cycle arrest biomarkers change after iodinated contrast media infusion
in critically ill patients
Emmanuelle Rouve1, Karim Lakhal2, Charlotte Salmon Gandonnière3, Youenn Jouan3, Laetitia
Bodet-Contentin3, Stephan Ehrmann3
1Réanimation polyvalente, CHU Bretonneau, Tours, France; 2Service de réanimation chirurgicale,
Hôpital Guillaume et René Laënnec, CHU de Nantes, Nantes, France; 3réanimation polyvalente,
CHRU Hôpitaux de Tours, Tours, France
Correspondence: Emmanuelle Rouve - emarouve@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S25
Introduction Iodinated contrast media is considered to be a frequent contributor to
acute kidney injury (AKI) in hospitalized patients (contrast-associated AKI). Recently,
the urinary G1 cell-cycle arrest proteins TIMP2 and IGFBP7 have been identified as
potential key diagnostic markers of AKI. However, the impact of iodinated contrast
media, frequently administered to intensive care unit (ICU) patients on those kidney
biomarkers has not been evaluated. The aim of this study was to evaluate TIMP-2 and
IGFBP-7 urinary concentrations variations before and after iodinated contrast media
infusion for a computed tomographic scan in ICU patients. This setting represents
a unique situation of a calibrated kidney aggression in a population of patients at
increased risk of AKI.
Materials and methods We prospectively enrolled patients undergoing their first contrast
media-enhanced computed tomographic scan during their stay in two ICUs. Measurements
of urinary [TIMP-2]*[IGFBP7] was performed before and 6 h after iodinated contrast
infusion. Patients were followed 5 days for occurrence of AKI (KDIGO classification).
Results We included 77 patients. Before contrast administration, 42 (54.5%) had no
AKI, whereas 20 (26%) had stage 1 and 15 (19%) stage 2 or 3 AKI. Median [TIMP-2]*[IGFBP7]
before contrast was 0.07 [interquartile range (IQR) 0.04–0.27] and individual change
6 h later was −0.01 [−0.11; 0.11] (ng/ml)2/1000, p > 0.1. Fourteen (18%) patients
increased their serum creatinine of more than 26.4 µmol/L and 30 (41%) increased their
KDIGO classification within 72 h after contrast infusion, indicating possible contrast-associated
AKI. [TIMP-2]*[IGFBP7] change over 6 h was not significantly different among patients
developing or no contrast-associated AKI, whatever the definition. Sixteen (21%) patients
had a significant increase (≥0.2 (ng/ml)2/1000) in [TIMP-2]*[IGFBP7] 6 h after contrast.
Among them, 11 (69%) increased their KDIGO score within 72 h of contrast administration,
whereas only 26 (43%) of patients with lower values of [TIMP-2]*[IGFBP7] did so.
Conclusion Changes in urinary concentration of [TIMP-2]*[IGFBP7] within 6 h of contrast
infusion for a computed tomographic scan were modest. Hypotheses advanced for this
finding would be (1) the minimal kidney aggression by current monomeric nonionic low-osmolar
contrast media, late serum creatinine increase being explained by the occurrence of
later (between the 6th and the 72nd hour) kidney injury due to critical illness or
its therapy or (2) insufficient sensitivity of early (6 h) measurements of this biomarker
to detect contrast-associated AKI.
Competing interests partial financial support, no implication in data analysis and
interpretation.
S26 Ketoacidosis: a prognosis and therapeutic study
Adrien Balmier1, Jonathan Messika2, Etienne De Montmollin3, Victorine Pouyet4, Benjamin
Sztrymf5, Bruno Megarbane6, Abirami Thiagarajah,7, Jean-Damien Ricard8, Didier Dreyfuss9,
Damien Roux1
1Réanimation médico-chirurgicale, Hôpital Louis-Mourier - APHP, Colombes, France;
2Service de réanimation médico-chirurgicale, CHU Louis Mourier, Colombes, Colombes,
France; 3Réanimation, C.H. Général Saint Denis hôpital Delafontaine, Saint-Denis,
France; 4Réanimation médico-chirurgicale, René Dubos, Pontoise, France; 5Réanimation
polyvalente, Hôpital Antoine Béclère, Clamart, France; 6Service de Réanimation Médicale
et Toxicologique, CHU Lariboisière, Paris, France; 7Réanimation médico-chirurgicale,
René Dobus, Pontoise, France; 8Service de Réanimation Médico-Chirurgicale, CHU Louis
Mourier, Colombes, France; 9Inserm, iame, umr 1137, Université Paris Diderot, Sorbonne
Paris Cité, Paris, France
Correspondence: Damien Roux - damien.roux@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S26
Introduction Diabetic ketoacidosis, generally resulting from an absolute deficiency
of insulin, is a frequent cause of hospitalization in intensive care unit. Recommendations
for diagnosis of diabetic ketoacidosis, care and site of admission have been published
by the English society of diabetology. ICU admission are recommended if one of the
following criteria is present: GCS < 12, systolic arterial pressure (SAP) <90 mmHg,
SpO2 < 92%, ketosis >6 mmol/L, HCO3 < 5 mmol/L, pH < 7.1, potassium level < 3.5 mmol/L
or anion gap >16 mmol/L. However, it is suspected that adhesion to recommendations
remains low.
In this study, we aimed at describing patients admitted for diabetic ketoacidosis
in ICU. We looked at adhesion to published recommendations regarding admission and
care. We also described metabolic complications and looked for an association between
complications and dose of initial insulin therapy.
Patients and methods We performed a 2-years retrospective analysis of patients admitted
for diabetic ketoacidosis within five ICU in Paris area. Clinical and biological characteristics
at admission, treatment and complications during ICU stay were recorded. Categorical
data are presented as % and continuous data as median [IQ25–IQ75]. Correlation between
hypokalemia and hypoglycemia with insulin dosage was performed using a Spearman test.
Results Among the 118 patients admitted in 2013–2014 for diabetic ketoacidosis, 111
(94%) were admitted from home. Median age was 42 years old. Discontinuation of insulin
therapy was the main cause of ketoacidosis (37%), whereas this condition revealed
diabetes in 30% of patients. Sepsis was responsible for 19% of the cases. One death
(0.8%) was observed over the 2 years study.
Despite convincing data on reliability of venous blood gas for ketoacidosis evaluation,
arterial blood gas was performed before or at ICU admission in 92% of patients without
oxygen desaturation.
At admission, 111/118 patients presented at least a criterion for ICU admission based
on British recommendations. A GCS < 12 was observed in 11% of patients, SAP < 90 mmHg
in 13%, SpO2 < 92% in 9%, HCO3 < 5 mmol/L in 34%, pH < 7.1 in 37%, K + < 3.5 mmol/L
in 9% and anion gap >16 in 93%. Among the 7 patients that did not meet the criteria,
four were admitted in ICU for other medical conditions such as hematemesis, acute
kidney injury or pneumonia. One single patient, pregnant and suffering from hyperemesis
gravidarum had a glycemia below 11 mmol/L at admission.
Treatment At diagnosis of ketoacidosis, 11 patients received sodium bicarbonate, in
which 7 received hypertonic sodium bicarbonate; 9 of them had either a pH < 7.0, EKG
signs of hyperkalemia or hyperkalemia >5.0. Patients received a median of 3000 mL
of NaCl 0.9% in the first 24 h. Initial insulin bolus of 10 UI [8–10] has been injected
in 24% of patients. This was slightly correlated to hyperglycemia (Spearman test,
p = 0.035) but not to pH or kalemia. A continuous infusion of intravenous insulin
was started in all patients at a median of 7 UI/h [6–10].
Complications Hypoglycemia (<3.9 mmol/L) was observed in 48% of patients within the
first 24 h in which 19% were <2.9 mmol/L. This was 47 and 15% of patients between
24 and 48 h of ICU stay. Hypokalemia below 3.5 mmol/L happened in 44% of patients
within the first 24 h and in 52% between 24 and 48 h. Neither hypoglycemia nor hypokalemia
were correlated with initial insulin bolus or initial dosage of continuous intravenous
insulin. Hypophosphatemia <0.30 mmol/L was observed in 15% of patients.
Discussion In this study, admission to ICU was consistent with British recommendations
since most patients presented at least one clinical or biological criterion indicating
ICU admission. Arterial blood gas were sampled in the large majority of patients despite
consistent data showing that venous blood gas might be sufficient in non-hypoxemic
patients. Also, initial insulin bolus and sodium bicarbonate perfusion were performed
in a significant subset of patients despite absence of convincing data or recommendations
supporting their use.
Finally, significant hypokalemia and hypoglycemia were frequent in these patients.
These complications are in theory favored by insulin therapy but we did not observe
a correlation between administration of an insulin bolus or the dose of continuous
intravenous insulin perfusion.
Conclusion In this retrospective multicentre study, patients admitted in ICU for diabetic
ketoacidosis were correctly oriented regarding the British recommendations. Metabolic
complications (hypoglycemia and hypokalemia) were frequent but not correlated with
initial dose of insulin.
Competing interests None.
References
Ayed S, Bouguerba A, Ahmed P, Barchazs J, Boukari M, Goldgran-Toledano D, et al. Diabetic
ketoacidosis traps. Réanimation. 2015;24(6):668–87.
Savage MW, Dhatariya KK, Kilvert A, et al. Joint British Diabetes Societies guideline
for the management of diabetic ketoacidosis. Diabet Med. 2011;28:508–15.
S27 Correction rate of acute severe hypernatremia and outcome in septic shock patients
resuscitated with crystalloids
Frédérique Schortgen1, Pierre Asfar2, Boisramé-Helms Julie3, Julien Charpentier4,
Emmanuel Guérot5, Bruno Megarbane6, David Grimaldi7, Grelon Fabien8, Nadia Anguel9,
Lasocki Sigismond10, Henry-Lagarrigue Matthieu11, Frédéric Gonzalez12, Legay François13,
Christophe Guitton14, Maleka Schenck15, Doise Jean-Marc16, Didier Dreyfuss17, Peter
Radermacher18, for the HYPER2S Investigators and REVA research network
1Réanimation médicale, Hôpital Henri Mondor, Créteil, France; 2Réanimation, C.H.U.
d’Angers, Angers, France; 3Réanimation médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires
de Strasbourg, Strasbourg, France; 4Réanimation Médicale, Hôpital Cochin, Paris, France;
5Réanimation médicale, Hopital Europeen Georges-Pompidou, Paris, France; 6Service
de Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; 7Service
de réanimation polyvalente, Centre Hospitalier de Versailles, Le Chesnay, France;
8Réanimation, C.H. - Le Mans, Le Mans, France; 9Réanimation médicale, CHU de Bicêtre,
Le Kremlin Bicêtre, France; 10Réanimation chirurgicale, C.H.U. d’Angers, Angers, France;
11Réanimation polyvalente, Hospital Center Departmental De Vendée, La Roche-sur-Yon,
France; 12Réanimation medico-chirurgicale, hopital avicenne, Bobigny, France; 13Réanimation,
C.H. de Saint Brieuc, Saint-Brieuc, France; 14Réanimation médicale, C.H.U. Hôtel Dieu,
Nantes, France; 15Réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg,
Strasbourg, France; 16Réanimation, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône,
France; 17Réanimation polyvalente, Hôpital Louis-Mourier (AP-HP), Colombes cedex,
France; 18Institut für anästhesiologische pathophysiologie und verfahrensentwicklung,
Universitätsklinikum Ulm, Ulm, Germany
Correspondence: Frédérique Schortgen - frederique.schortgen@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S27
Introduction The appropriate rate for hypernatremia (H-Na) correction is unknown.
Under-correction could be associated with worse outcome. Experts recommend a rapid
correction of acute (<2 days) and sever (> 150 mmol/l) H-Na with a rate of −2 mmol/l/h
until Na < 146 mmol/l (1). Correction should be, therefore, obtained within 24 h.
In patients with septic shock resuscitated with iso- or hypertonic saline and who
acquired acute severe H-Na, we assessed if the correction rate was associated with
mortality.
Patients and methods Data are a post hoc analysis of the RCT “Hyper2S” database comparing
normal to 3% saline for 72 h in septic shock. Serum Na (SNa) was measured at H0, every
12 h for 3 days and then daily until D7. Patients with severe H-Na and available SNa
control within 24 h were included. SNa evolution was compared between survivors and
non-survivors. Correction and over-correction were defined as SNa <146 and <135 respectively.
Results 94 patients were included with a median SNa of 153 (152–156) mmol/l. H-Na
was corrected within 24 h in 17 (18%) patients with a correction rate of −0.17 (−0.29
to 0) mmol/l/h. H-Na corrected within 24 h was higher in non-survivors (24 vs 15%,
p = 0.31) (table). H-Na correction rate was more rapid in non-survivors, p = 0.05
(Table 15). Over-correction occurred similarly in survivors (15%) and non-survivors
(10%). The time to reach SNa normalization was shorter in non-survivors (p = 0.05).
After adjustment for SAPSII and MacCabe scores, more rapid correction rate remained
significantly associated with mortality: OR 0.16; 95% CI (0.03–0.86), p = 0.048.
Table 15
Characteristics and evolution of H-Na between D28 survivors and non-survivors (results
are number and % of patients and median IQR)
Survivors n = 65
Non-survivors n = 29
OR 95% CI, p
Characteristics of hypernatremia
3% HT saline gp, n (%)
54 (83)
26 (89)
1.77 (0.45–6.88), 0.41
Max SNa, mmol/L
155 (152–157)
155 (152–157)
1.04 (0.94–1.15), 0.40
Max SNa gap, mmol/L
15 (12–20)
18 (12–22)
0.93 (0.86–1.01), 0.10
Evolution of hypernatremia within 24 h
H-Na corrected, n (%)
10 (15)
7 (24)
1.75 (0.59–5.2), 0.31
Correction rate, mmol/L/h
−0.17 (–0.25/0)
−0.25 (−0.42/− 0.13)
0.17 (0.03–0.99), 0.05
Lowest SNa, mmol/L
150 (147–153)
147 (146–142)
0.95 (0.87–1.03), 0.22
Over-corrected, n (%)
0
0
Final evolution of hypernatremia
Finally corrected, n (%)
57 (88)
20 (69)
0.31 (0.11–0.92), 0.03
Time to SNa <146, h
60 (36–84)
36 (24–48)
0.98 (0.96–1.00), 0.05
Over-corrected, n (%)
10 (15)
3 (10)
0.63 (0.16–2.50), 0.52
Conclusion In the context of acute severe H-Na induced by fluid resuscitation, a rapid
correction rate might be associated with even aggravated rather than improved mortality.
Competing interests None.
Reference
Sterns RH. N Engl J Med. 2015;372:55–65.
S28 Myocardial dysfunction in severe attacks of Systemic Capillary Leak Syndrome
Marc Pineton De Chambrun1, Charles-Edouard Luyt1, François Beloncle2, Nathalie Zapella3,
Jean-Paul Mira4, Stanislas Ledochowsky5, Nicolas Terzi6, Jean-Marc Mazou7, Romain
Sonneville8, Sylvie Paulus9, Yannick Fedun10, Anne-Sophie Moreau11, Mickael Landais12,
Antoine Vieillard-Baron13, Jean-Herlé Raphalen14, Laurent Argaud15, Alain Combes1,
Zahir Amoura16, for the EurêClark study group
1Service de réanimation médicale, Groupe Hospitalier La Pitié-Salpêtrière, Institut
de Cardiométabolisme et Nutrition, Assistance Publique Hôpitaux de Paris, Paris, France;
2Département de réanimation médicale et de médecine hyperbare, C.H.U. d’Angers, Angers,
France; 3Service de réanimation médico-chirurgicale, Centre Hospitalier de Versailles,
Le Chesnay, France; 4Service de réanimation médicale, Hôpital Cochin, Assistance Publique
Hôpitaux de Paris, Paris, France; 5Service de réanimation médicale, C.H. Lyon Sud,
Pierre-Bénite, France; 6Service de réanimation médicale, Clinique de Réanimation Médicale,
Grenoble, France; 7Service de réanimation polyvalente, C.H. de Dax - Côte d’Argent,
Dax, France; 8Service de réanimation médicale et infectieuse, Hôpital Bichat-Claude
Bernard, Assistance Publique Hôpitaux de Paris, Paris, France; 9Service de réanimation
chirurgicale, Hopital Louis Pradel, Bron, France; 10Service de réanimation polyvalente,
Centre Hospitalier Bretagne Atlantique, Vannes, France; 11Service de réanimation médicale,
C.H. Régional Universitaire de Lille, Lille, France; 12Service de réanimation médicale,
CHU Hôtel-Dieu Nantes, Nantes, France; 13Réanimation médico-chirurgicale, Assistance
Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France;
14Service de réanimation adulte, Hôpital Necker, Assistance Publique Hôpitaux de Paris,
France; 15Service de réanimation médicale, Hospices Civils de Lyon - Groupement Hospitalier
Edouard Herriot, Lyon, France; 16Service de médecine interne, Groupe Hospitalier La
Pitié-Salpêtrière, Institut IE3 M, Assistance Publique Hôpitaux de Paris, Paris, France
Correspondence: Marc Pineton De Chambrun - marc.dechambrun@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S28
Introduction Systemic Capillary Leak Syndrome (SLCS) is a rare disease characterized
by recurrent life-threatening attacks of capillary hyper permeability in the presence
of a monoclonal gammopathy (MG). During acute episodes, the leak of fluid and proteins
from the intravascular compartment to the interstitium results in clinical signs of
both acute hypovolemia and interstitial edema. Biological profile is pathognomonic
with marked hemoconcentration and paradoxal hypoproteinemia. Hypovolemic shock is
the classical feature of severe SCLS attacks. However, beside this typical hemodynamic
profile, several case report described myocardial dysfunction during SCLS attacks.
The objectives of this study were to assess frequency, characteristics and outcome
of myocardial involvement during severe SCLS attacks.
Patients and methods Multicenter retrospective analysis of data from the European
Clarkson registry (EurêClark). Criteria to retain SCLS diagnostic were; presence of
a MG; ≥1 typical attack with clinical manifestations of hypovolemia and capillary
leak; hemoconcentration with paradoxal hypo protidemia; exclusion of secondary capillary
leak syndrome causes. Patients with severe attacks admitted in ICU were identified
in EurêClark registry. Physician were contacted and offered to include the attack
using a pre-established case report form. Categorical variables are expressed: n (%)
and continuous variable: mean ± SD or median [IQR].
Results Between May 1992 and February 2016, 64 attacks in 39 patients have been included.
In 11 (28%) patients, and 14 (22%) attacks, a myocardial involvement was reported.
Sex ratio was 1.2 with an age of 48.2 ± 13 years. Ten (91%) patients had an IgG MG
with Kappa light chain in 7 (70%) patients. Eight (57%) patients were admitted in
ICU for cardiogenic shock. SAPS II score at admission was 62 [49.2–73] and SOFA score
9.5 [5.7–13]. Admission hemoglobin, protidemia and serum creatinine were 19.1 [17.3–21.5]
g/dL, 44 [28.7–52.5] g/L and 228 [120–294] µmol/L, respectively. Echocardiography
(TTE) was performed in all 14 patients. TTE reveled global hypokinesia in 10 (71%)
patients, focal hypokinesia or dyskinesia in 3 (21%) and ventricular hypertrophy without
hypokinesia in 1 (7%). Left ventricular myocardial dysfunction was present in 13 (93%)
patients with median left ventricular ejection fraction (LVEF): 15 [5–40] %. Pericardial
effusion was reported in 7 (50%) patients. Transient ventricular hypertrophy mimicking
hypertrophic cardiomyopathy was reported in 3 (21%) patients. LVEF returned to normal
in all survivors on follow-up TTE. Troponin was elevated in 12/13 (92%) patients (one
missing data). Twelve patients (85%) required vasopressive amines, 9 (64%) mechanical
ventilation, 6 (43%) renal replacement therapy, 5 (36%) veno-arterial extracorporeal
membrane oxygenation, 1 (9%) intra-aortic balloon pump and 1 (9%) an IMPELLA. Compartment
syndrome occurred in 5 (45%) patients and 4 (36%) died in ICU. We then compared the
11 patients with myocardial involvement to the 28 without Clinical and biological
manifestations were similar in between groups. However, chest pain (54 vs 11%, p = 0.008),
dyspnea (82 vs 39%, p = 0.03) and respiratory failure (54 vs 18%, p = 0.044) were
more frequent in patients with myocardial involvement than in others. There was no
difference between groups regarding treatment received in ICU, complication and outcome
except for the use of VA-ECMO (36.4 vs 0%, p = 0.004).
Conclusion Myocardial involvement seems frequent in patients with severe SCLS attack,
occurring in 22% of the cases. Such patients exhibited classical features of SCLS
attacks. Myocardial involvement was responsible for altered LVEF or transient ventricular
hypertrophy. Myocardial dysfunction could be severe, even requiring mechanical circulatory
support. SCLS attacks should be known as a cause of severe reversible myocardial dysfunction
and hypertrophy.
Competing interests None.
S29 Activated Clotting Time (ACT) versus AntiXa activity for monitoring anticoagulation
in ECMO patients: concordance study
Aemilia Jacquemin1, Jean-Marie Conil1, Felipe Guerrero2, Bertrand Marcheix3, Nicolas
Hernandez1, Olivier Fourcade4, Bernard Georges5, Clément Delmas6
1Réanimation polyvalente, Hopital Rangueil, Toulouse, France; 2Laboratoire d’hémostase,
Hopital Rangueil, Toulouse, France; 3Chirurgie cardio-vasculaire, Hopital Rangueil,
Toulouse, France; 4Réanimation purpan, CHU Toulouse, Toulouse, France; 5Réanimation
polyvalente, Hopital Rangueil, Avenue du Professeur Jean Poulhes, Toulouse, France,
Toulouse, France; 6Cardiologie, Hopital Rangueil, Toulouse, France
Correspondence: Aemilia Jacquemin - aemilia.j@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S29
Introduction In refractory cardiorespiratory emergencies, ECMO appears a good alternative
to conventional treatment. Its extracorporeal circuit justifies curative anticoagulation
explaining haemorrhagic and thrombotic complications. Activated Clotting Time (ACT)
is empirically and commonly used to assess anticoagulation but with large inter and
intra-individual variabilities. In practice, antiXa activity dosage is available to
approach anticoagulant effect of heparin and is less expensive, but data during ECMO
are missing. We sought to demonstrate the lack of correlation between antiXa and ACT
in patients under ECMO support.
Patients and methods We prospectively include patients supported by ECMO in CHU Toulouse,
France, between 01/2014 and 04/2015 for circulatory/respiratory support. Anticoagulation
was achieved by unfractionated heparin: initial bolus then continuous intravenous
infusion (800–1200 IU/h), for antiXa target of 0.2–0.4. Concomitant dosing of antiXa
(laboratory) and ACT (Hemocron®) was conducted two times a day on the same sample
throughout the ECMO period. Relationship between ACT and antiXa was analyzed by Spearman
correlation (Rho). After transformation into categorical variables (obtained target = 1;
outside the target = 0), analyzes were completed by a concordance study (Kappa). As
recognized on literature ACT’s targets were between 180 and 220.
Results 65 patients were included: 46 men (72%), median age 55 yo (53–57). Indications
were veno-arterial (n = 42) and veno-venous ECMO (n = 23). ECMO median duration was
5 days (hours to 30 days). Spearman correlation test found low and inconsistent correlation
between antiXa and ACT (Rho Spearman < 0.4). This correlation lack present from the
day one, worsens over time. Analyzed Kappa showed no discrepancy between the areas
“targets” of ACT and AntiXa confirming the results (Table 16).
Table 16
ACT—AntiXa concordance analysis by Kappa coefficient study for the first 5 days of
ECMO
Morning
J1
J2
J3
J4
J5
ACT
192
196
194
196
194
Median [IC95%]
[181 to 200]
[191 to 204]
[186 to 201]
[183 to 210]
[187 to 207]
Anti Xa
0.21
0.25
0.18
0.21
0.21
Median [IC95%]
[0.17 to 0.34]
[0.20 to 0.32]
[0.14 to 0.23]
[0.17 to 0.25]
[0.16 to 0.24]
Kappa
0.085
0.082
0.069
−0.238
0.115
[IC95%]
[−0.149 to 0.320]
[−0.150 to 0.315]
[0.172 to 0.310]
[−0.530 to 0.054]
[−0.189 to 0.419]
Evening
ACT
195
193
195
196
195
Median [IC95%]
[190 to 205]
[188 to 200]
[189 to 197]
[185 to 204]
[180 to 199]
Anti Xa
0.23
0.19
0.17
0.22
0.19
Median [IC95%]
[0.21 to 0.30]
[0.13 to 0.26]
[0.13 to 0.21]
[0.19 to 0.26]
[0.14 to 0.25]
Kappa
0.034
0.093
0.154
0.208
0.062
[IC95%]
[−0.198 to 0.267]
[−0.113 to 0.301]
[−0.075 to 0.383]
[−0.093 to 0.509]
[−0.283 to 0.408]
Conclusion Use of ACT for ECMO anticoagulation monitoring doesn’t seem appropriate
and high price probably justifies preferential use of antiXa in clinical practice.
Analyzes of relationships between antiXa and bleeding/thrombotic events are needed
to confirm the antiXa place and its target in these indications.
Competing interests None.
References
Chu DC, Abu-Samra AG, Baird GL, Devers C, Sweeney J, Levy MM, et al. Quantitative
measurement of heparin in comparison with conventional anticoagulation monitoring
and the risk of thrombotic events in adults on extracorporeal membrane oxygenation.
Intensive Care Med. 2015;41(2):369–70.
ELSO guidelines for cardiopulmonary extracorporeal life support, version 1.3. Ann
Arbor: Extracorporeal Life Support Organization; 2013.
S30 Outcome, long-term quality-of-life, physical and psychological assessment of patients
supported by extracorporeal life support (ECLS) for postcardiotomy refractory cardiogenic
shock
Sarah Makoudi1, Audrey Genton1, Rémy Bernard1, Adrien Bouglé1, Guillaume Lebreton2,
Julien Amour1
1Département d’anesthésie et de réanimation, Hôpital Universitaire La Pitié-Salpêtrière,
Paris, France;2 Service de chirurgie thoracique et cardiovasculaire, Groupe Hospitalier
Pitié Salpêtrière, Paris, France
Correspondence: Sarah Makoudi - smmakoudi@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S30
Annals of Intensive Care 2017, 7(Suppl 1):S20
Introduction Postcardiotomy cardiogenic shock (CS) has an incidence of 2% to 6% after
routine adult cardiac surgery. In 0.5–1.5% of cases, an venoarterial extracorporeal
life support (VA-ECLS) is requested. The 6-month survival rate is 17.6% (1). Survivors
may suffer of physical and psychological impairments as well as an alteration of quality
of life. This study was designed to assess the outcomes, long-term health-related
quality-of-life (HRQL) and occurrence of anxiety, depression and post-traumatic disorder
symptoms in patients treated by VA-ECLS in postcardiotomy refractory shock.
Patients and methods All patients treated with VA-ECLS in postcardiotomy refractory
CS between June 2014 and December 2015 are included in this study. Baseline patient
characteristics and ICU events were retrospectively analyzed based on patient’s medical
records. Long-term outcomes were assessed prospectively by the mean of a telephone-based
questionnaire including French SF-36 quality-of-life assessment, Post-Traumatic Stress
Scale 10, Hospital Anxiety and Depression Scale and assessment of function, morbidity,
resource use, return to work and usual activities.
Results At all, 78 patients were included. At all, 35 patients (45%) survived to hospital
discharge., 5 died after hospital discharge and 26 answered the telephone-based questionnaire
between July and September 2016 (median follow-up: 512 days). SF-36 evaluation revealed
impaired HRQL compared to the French general population tested by Leplège (2) especially
concerning items related to physical health and social functioning. Patients had significantly
lower mean scores for Physical functioning (p = 0.0004), Role physical (p = 0.0005),
General Health (p = 0.02) and Social functioning (0.01) items. Mean physical and mental
scores were at 57 ± 27 and 64 ± 23 respectively. Anxiety, depression and/or post-traumatic
stress disorder symptoms occur in 30, 15 and 19% of the patients, respectively. Since
ICU discharge, 65% of patients reported physical sequelae., ECLS-related limb pain
occurs in 38% of patients while paresthesia occurs in 23% and chronic-tiredness in
69%. Mean Karnofsky score was 68% (Table 17).
Table 17
See text for description
Scores: mean ± SD
Survivors
Control (2)
p
SF-36: Physical score
57.5 ± 27.5
PF (Physical Functioning)
61.3 ± 31.3
86.5 ± 19.7
<0.0004
RP (Role-Physical)
42.3 ± 48.8
80.6 ± 33.6
<0.0005
BP (Bodily Pain)
69.1 ± 19.7
74.3 ± 25.2
0.1926
GH (General Health)
58.7 ± 20.6
69 ± 20.9
<0.0178
SF-36: Mental score
64.4 ± 22.7
VT (Vitality)
51.9 ± 21.5
61.4 ± 20.3
<0.0333
SF (Social Functioning)
68.8 ± 23.3
80.7 ± 22.5
<0.0153
RE (Role-Emotional)
66.6 ± 47.1
80.9 ± 34.1
0.1368
MH (Mental Health)
70.2 ± 13.2
67.8 ± 19.7
0.3627
PTSS-10 (N < 35)
22 ± 9
HAD-Anxiety Score (N < 7)
6 ± 3
HAD-Depression Score (N < 7)
4 ± 3
Conclusion After VA-ECLS for postcardiotomy cardiogenic shock long-term physical and
psychological sequelae are frequent in survivor patients, impacting their long term
quality-of-life. These results support the necessity to develop and organise a systematic
post-ICU health care.
Competing interests None.
References
Rastan AJ. Early and late outcomes of 517 consecutive adult patients treated with
extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock.
J Thorac Cardiovasc Surg. 2010;139:302–11.
Leplège A. The French SF-36 Health Survey: translation, cultural adaptation and preliminary
psychometric evaluation. J Clin Epidemiol. 1998;51:1013–23.
S31 How to predict weaning success during ECLS support?
Charlotte Mazet1, Jean-Marie Conil2, Bernard Georges3, Nicolas Hernandez2, Fanny Bounes3,
Gurbuz Murat4, Laure Cronier2, Guillaume Robin2, Caroline Biendel2, Stein Silva5,
Clément Delmas4
1CHU Toulouse, Toulouse, France, Toulouse, France; 2Réanimation polyvalente, Hopital
Rangueil, Toulouse, France; 3Réanimation polyvalente, Hopital Rangueil, Avenue du
Professeur Jean Poulhes, Toulouse, France, Toulouse, France; 4Cardiology, Hopital
Rangueil, Toulouse, France; 5Réanimation, Centre Hospitalier Universitaire Toulouse,
Toulouse, France
Correspondence: Charlotte Mazet - charlottemazet@hotmail.com
Annals of Intensive Care 2017, 15(Suppl 1):S31
Introduction Datas concerning extracorporeal life support (ECLS) weaning are scarce.
Nevertheless, early weaning or unjustified maintenance of such support can lead to
own morbidity and mortality. This study would like to determine clinical, biological
and echocardiographic predictive criteria for weaning success.
Patients and methods The pump flow of patients, considered as stabilized, was decreased
to less than 2 L/min during 60 min. A transthoracic echocardiography and a biological
test were made before and after the weaning test. Weaning decision was under the responsibility
of the intensivist in charge of the patient. Objective of the study was to determine
echocardiographic, biological and clinical prognostic value compare to clinical decision.
Results 39 tests have been performed on 31 patients between 05.2014 and 07.2016. Patients
were essentially men (n = 21, 68%), median age of 46 years old (35–57) with classical
cardiovascular risk factors. Indications of ECLS were shared between cardiogenic shock
(n = 22, 71%) and cardiac arrest (n = 9, 29%). Five parameters allowed to distinguish
patients able to be weaned or not (see Table 18 below): age (threshold: 51 years old),
BMI (threshold: 28.6), lactate clearance between ECLS cannulation and test (threshold:
77%), inotrope time perfusion during weaning (threshold: 7 days) and LVEF stability
or slightly rising for patients able to support weaning (threshold −2%).
Table 18
Area under the curve of continuous variables distinguished patients able to be weaned
or not
AUC
CI 95%
p
Threshold
Se
Sp
PPV
NPV
Age (years)
0.738
0.57–0.87
0.0037
≤51
66.67
86.7
88.9
61.9
BMI
0.855
0.7–0.95
<0.0001
≤28.6
80.9
85
89.5
75
Inotrope time perfusion during weaning (days)
0.896
0.75–0.97
<0.0001
≤7
82.6
80
86.4
75
Lactate clearance between ECLS cannulation and test (%)
0.857
0.67–0.96
<0.0001
>76.9
73.7
88.9
93.3
61.5
LVEF after test–LVEF before test (%)
0.753
0.55–0.89
0.0086
>−2
83.33
55.56
78.9
62.5
AUC area under the curve, CI 95% confidence interval 95%, Se sensitivity, Sp specificity,
PPV positive predictive value (probability of death at 1 month when the test is positive),
NPV negative predictive value (probability of survival at 1 month when the test is
negative)
Furthermore, we developed a clinical and biological model for weaning. Patients with
less than 7 days inotrope perfusion during weaning and with LVEF stabilized during
test had 88.2% probability to be weaned of ECMO after the test.
Conclusion A simple multi-parametric result of the weaning trial could help the difficult
ECLS weaning decision. To confirm these data, complementary multi-centric studies
should be performed.
Competing interests None.
References
Cavarocchi NC, Pitcher HT, Yang Q, Karbowski P, Miessau J, Hastings HM, Hirose H.
Weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal
echocardiography. J Thorac Cardiovasc Surg. 2013;146:1474–79.
Aissaoui N, Luyt CE, Leprince P, Trouillet JL, Léger P, Pavie A, Diebold B, Chastre
J, Combes A. Predictors of successful extracorporeal membrane oxygenation weaning
after assistance for refractory cardiogenic shock. Intensive Care Med. 2011;37:1738–45.
S32 Impact of fluid balance on mortality of patients treated with veno-arterial extra
corporeal membrane oxygenation
Samia Boubeche1, Caroline Abriou1, Véronique Wurtz1, Vincent Scherrer1, Nathalie Rey1,
Gioia Gastaldi2, Benoit Veber3, Fabienne Tamion4, Fabien Doguet5, Arnaud Gay5, Bertrand
Dureuil6, Emmanuel Besnier1
1Department of anesthesia and critical care, Chu-Hôpitaux De Rouen, Rouen, France;
2Department of anesthesia and critical care, Centre Hospitalier Universitaire Rouen,
Rouen, France; 3Reanimation chirurgicale, Centre Hospitalier Universitaire Rouen,
Rouen, France; 4Réanimation médicale, Hospital Center University Rouen, Rouen, France;
5Department of cardiac surgery, Chu-Hôpitaux De Rouen, Rouen, France; 6Anesthésie,
Centre Hospitalier Universitaire Rouen, Rouen, France
Correspondence: Samia Boubeche - samia.boubeche@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S32
Introduction Veno-Arterial Extra Corporeal Membrane Oxygenation (VA ECMO) is a mechanical
circulatory support used for critical patients with cardiogenic shock refractory to
conventional therapies. Nevertheless, mortality observed for these patients remains
very high. Contrary to others critical situations, such as sepsis or ARDS, the impact
of fluid balance is little studied, whereas these patients also present and intense
inflammatory stress and often required large amount of fluid resuscitation. The purpose
of this study was to identify fluid balance as a predictor for mortality in patients
under VA ECMO.
Patients and methods We conducted a single-center, retrospective and observational
investigation in the cardiac surgical ICU of Rouen University Hospital. Patients requiring
VA ECMO between March 2013 and May 2016 were included. Pregnant women, patient under
16 years old, patients deceased before 24 h of admission in ICU and ECMO for ARDS
were excluded. The primary outcome was the relationship between 1-day fluid balance
and 28-day mortality. Secondary outcomes were the association between 28-day mortality
and other biological and clinical characteristics after 1, 3 and 7 days in ICU: fluid
balance, weight gain, RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage
kidney disease) score, use of Renal Replacement Therapy (RRT), troponins, bilirubin
and transminases values. Univariate analysis was performed through a Chi-2 or fisher
exact test for qualitative values and a Student t test for continuous variables. Statistically
significant data were then included for multivariate time to death analysis (Cox model).
P < 0.05 was consider as significant.
Results 88 patients were included (52 ± 14 years, 70% male). Overall 28-day mortality
was 53%. Univariate analysis indicated that fluid balance and weight gain at 1-day
were significantly higher for deceased patients (1099 ± 2608 vs 3419 ± 3216 mL, p < 0.0001
and 0.07 ± 2.21 vs 1.78 ± 2.85 kg, p = 0.0033, respectively). Troponins at admission
were five fold higher in deceased patients (11,469 vs 2098 ng/L, p = 0.002). IGS-2
score was higher in deceased patients (79.1 ± 15.2 vs 60.5 ± 15.1, p < 0.0001). Deceased
patients presented worse renal function with higher rifle score (93% of failure or
injury status vs 73%, p = 0.009), lower MDRD score at day 1 (38 ± 20.8 vs 50 ± 25 mL/min/m2,
p = 0.019) but no difference regarding need for RRT. Multivariate analysis wit Cox
regression only identified IGS-2 score as an independent factor associated with 28-days
mortality (HR 1.04 [1.017–1.063]).
Discussion Interest for fluid management is growing in critical patients. Nevertheless,
no study has yet investigated its impact in selected patients with cardiogenic shock
treated with VA ECMO. Our study suggested a possible association between fluid overload
and mortality but lack the power to confirm these results with multivariate analysis.
Conclusion Fluid management is a key therapy during VA ECMO but fluid overload could
be associated with worsen outcomes. Further studies with larger population are warranted
before considering fluid restriction trials.
Competing interests None.
References
Esper SA, Levy JH, Waters JH, Welsby IJ. Extracorporeal membrane oxygenation in the
adult: a review of anticoagulation monitoring and transfusion. Anesth Analg. 2014;118(4):731–43.
Massetti M, Tasle M, Le Page O, Deredec R, Babatasi G, Buklas D, et al. Back from
irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac
Surg. 2005;79(1):178–83; discussion 183–4.
Koning NJ, Vonk ABA, Meesters MI, Oomens T, Verkaik M, Jansen EK, et al. Microcirculatory
perfusion is preserved during off-pump but not on-pump cardiac surgery. J Cardiothorac
Vasc Anesth. 2014;28(2):336–41.
Kurundkar AR, Killingsworth CR, McIlwain RB, Timpa JG, Hartman YE, He D, et al. Extracorporeal
membrane oxygenation causes loss of intestinal epithelial barrier in the newborn piglet.
Pediatr Res. 2010;68(2):128–33.
Hoefeijzers MP, ter Horst LH, Koning N, Vonk AB, Boer C, Elbers PWG. The pulsatile
perfusion debate in cardiac surgery: answers from the microcirculation? J Cardiothorac
Vasc Anesth. 2015;29(3):761–7.
Zangrillo A, Landoni G, Biondi-Zoccai G, Greco M, Greco T, Frati G, et al. A meta-analysis
of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc
J Australas Acad Crit Care Med. 2013;15(3):172–8.
Schmidt M, Bailey M, Kelly J, Hodgson C, Cooper DJ, Scheinkestel C, et al. Impact
of fluid balance on outcome of adult patients treated with extracorporeal membrane
oxygenation. Intensive Care Med. 2014;40(9):1256–66.
Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, et al. Cumulative fluid
balance and mortality in septic patients with or without acute kidney injury and chronic
kidney disease. Crit Care Med. 2016.
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS)
Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden
D, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl
J Med. 2006;354(24):2564–75.
Kielstein JT, Heiden AM, Beutel G, Gottlieb J, Wiesner O, Hafer C, et al. Renal function
and survival in 200 patients undergoing ECMO therapy. Nephrol Dial Transplant Off
Publ Eur Dial Transpl Assoc Eur Ren Assoc. 2013;28(1):86–90.
Villa G, Katz N, Ronco C. Extracorporeal Membrane Oxygenation and the Kidney. Cardiorenal
Med. 2015;6(1):50–60.
McILwain RB, Timpa JG, Kurundkar AR, Holt DW, Kelly DR, Hartman YE, et al. Plasma
concentrations of inflammatory cytokines rise rapidly during ECMO-related SIRS due
to the release of preformed stores in the intestine. Lab Investig J Tech Methods Pathol.
2010;90(1):128–39.
Aso S, Matsui H, Fushimi K, Yasunaga H. In-hospital mortality and successful weaning
from venoarterial extracorporeal membrane oxygenation: analysis of 5263 patients using
a national inpatient database in Japan. Crit Care Lond Engl. 2016;20:80.
Shimizu K, Ogura H. Is the 77.1% rate of in-hospital mortality in patients receiving
venoarterial extracorporeal membrane oxygenation really that high? Crit Care Lond
Engl. 2016;20(1):202.
Schmidt M, Burrell A, Roberts L, Bailey M, Sheldrake J, Rycus PT, et al. Predicting
survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO
(SAVE)-score. Eur Heart J. 2015;36(33):2246–56.
Combes A, Leprince P, Luyt C-E, Bonnet N, Trouillet J-L, Léger P, et al. Outcomes
and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation
for refractory cardiogenic shock. Crit Care Med. 2008;36(5):1404–11.
Luyt C-E, Landivier A, Leprince P, Bernard M, Pavie A, Chastre J, et al. Usefulness
of cardiac biomarkers to predict cardiac recovery in patients on extracorporeal membrane
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S33 Should we stop ECLS for futility for some patients after 24 h of support?
Nicolas Hernandez1, Jean-Marie Conil1, Bernard Georges1, Fanny Bounes1, Antoine Rouget1,
Gurbuz Murat2, Stein Silva3, Clément Delmas2
1Réanimation polyvalente, Hopital Rangueil, Toulouse, France; 2Cardiologie, Hopital
Rangueil, Toulouse, France; 3Réanimation, Centre Hospitalier Universitaire Toulouse,
Toulouse, France
Correspondence: Nicolas Hernandez - herni9@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S33
Introduction Extracorporeal life support (ECLS) has taken an important place in the
treatment of cardiogenic shock (CS) or refractory cardiac arrest (CA). However, ECLS
deplore a high mortality rate in the first days raising important ethic and economic
consequences. In this context, continuation of support should be reassessed precociously.
The aim of this study was the research of prognostic factors of 30-days mortality,
24 h after ECLS implantation for CS or CA.
Materials and methods All patients undergoing ECLS in our tertiary center during a
2-year period were prospectively included. The ECLS were managed with a multidisciplinary
protocol based on consensus. Clinico-biological data were collected just before and
24 h after ECLS implantation. These data were compared between survivors and deceased
at 1 month.
Results 94 patients were included with a males’ predominance (66%) and a median age
of 53 years. ECLS was implanted for CA under resuscitation (29.8%), acute CS (37.2%),
CS after CA (22.3%) and CS due to end-stage heart failure (10.6%). 30-days mortality
was 56.4%. Significant data were selected in univariate analysis. Thanks to a Cox
model (survival model at 30 days), multivariate analysis showed the influence of bilateral
mydriasis before ECLS (RR = 2.87, IC95% [1.34–6.07]; p = 0.006), arterial lactate
rate >6.2 mmol/l 24 h after ECLS (RR = 4.04, IC95% [1.96–8.32]; p < 0.001) as well
as acute pulmonary edema occurrence in the first 24 h after ECLS (RR = 2.37, IC95%
[1.20–4.70]; p = 0.013). CHAID’s segmentation method represented the patients’ survival
using these covariables with a prevision of 75.3% and may help to stop or maintain
ECLS after 24 h of support (Fig. 14).
Fig. 14
Representation of 30-days patients’ survival by the CHAID’s segmentation method using
the variables of interest
Conclusion Simple biological and clinical markers as initial mydriasis, lactate level
at H24 and the occurrence of an acute pulmonary edema during the first 24 h could
serve to predict 1-month mortality for patients under ECLS for CA or CS. At 24 h,
simple parameters could raise the question to stop support.
Competing interests None.
References
Ponikowski P, Voors AA, Anker SD et al. ESC guidelines for the diagnosis and treatment
of acute and chronic heart failure: The Task Force for the diagnosis and treatment
of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed
with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur
Heart J. 2016.
Yancy CW, Jessup M, Wilkoff BL et al. ACCF/AHA guideline for the management of heart
failure: a report of the American College of Cardiology Foundation/American Heart
Association Task Force on practice guidelines. J Am Coll Cardiol. 2013;62(16):147–239.
S34 Prognosis at 6 and 12 months of patients treated by hyperbaric oxygenotherapy
after self-attempted hanging
Guillaume Gantois1, Julien Poissy1, Erika Parmentier-Decrucq1, Raphaël Favory1, Daniel
Mathieu1
1Pôle de réanimation, hôpital salengro, C.H.R.U. - Lille, Avenue Oscar Lambret, Lille,
France, Lille, France
Correspondence: Julien Poissy - julien_poissy@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S34
Introduction Patients surviving a self-attempted hanging present an anoxic encephalopathy
which is recognized as an optional indication for hyperbaric oxygen (HBOT). Previous
studies have shown a total neurological recovery in 57–77% of patients. Mortality
risk factors of post-hanging patients have been identified, but long term morbidity
prognostic factors have not. A follow-up study with neurological evaluation at 6 and
12 months have been undertaken to determinate those factors.
Patients and methods In this observational study, all patients hospitalized for post-hanging
in ICU in a 5-year period were included. Prehospital and ICU data were collected.
Neurological evaluation at 6 and 12 months was performed according to CPC scores.
Factors associated with neurological recovery were determined by comparing CPC 2 + 3+4
(bad recovery) versus CPC 1 (good recovery). Qualitative variables were compared by
X2 tests, and quantitative ones by Mann–Whitney. A p value less than 0.05 was considered
as statistically significant.
Results 231 patients with a median age of 40.3 years [IQR 30–50.2] were included.
104 patients (47%) were found in cardiac arrest (CA). HBOT was performed in 95% of
patients, with a median delay of 120 min [IQR 90–180]. 95 patients died in ICU (41%),
93 (89%) in CA group and 2 (1.6%) in the group without CA. Neurological evaluation
at 6 and 12 months was obtained in 97 of the 136 alive patients. At 6 months, in the
CA group (n = 9), CPC score was respectively 1 for 6 patients, 2 for 2, 4 for 1. At
12 months, CPC score changed only for the 2 patients with a CPC score at 2 (one died
after another suicide attempt, one changed his CPC score to 3). In the group without
CA (n = 88), 79 had normal neurological status at 6 months and 78 at 12 months (one
patient died because of a cancer). Among these patients, 96% returned at home and
77% returned to work. 16 (18%) patients re-attempted suicide in the year. The major
risk factor of mortality is the presence of a cardiac arrest on hanging site. All
the other factors found to be related to mortality are well known risk factors in
cardiac arrest of other origin. In univariate analysis, risk factors of neurological
sequelae at 6 months were a cardiac arrest on hanging site (p = 0.045) an elevated
diastolic blood pressure (87 vs 70 mmHg; p = 0.04), a lower initial Glasgow score
(4 vs 5; p = 0.04), and an elevated blood glucose (1.39 vs 1.13 g/L p < 0.001) at
admission in ICU.
Discussion Our cohort of self-hanging patients can be divided in two parts: a) patients
with CA in the pre-hospital period with a high mortality and a good neurological recovery
in 2/3 surviving patient, but with a small group; b) patients without CA with a very
low mortality and a very good neurological recovery. These results seem to be better
than in the most important cohort [1] published until now in self-hanging patients
without CA and not treated by HBOT (mortality at 9.5% and 3.5% of poor neurological
recovery).
Conclusion Patients surviving a self-attempted hanging who have not presented CA and
treated by HBOT have mainly a good neurological outcome. Randomized control study
should be undertaken to confirm HBOT effectiveness in that indication.
Competing interests None.
Reference
Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries:
a 10-year experience. Injury. 2006;37(5):435–39.
S35 Prognostic value of early intermittent electroencephalography in patients supported
by venoarterial ECMO
Eric Magalhaes1, Ruben Wanono2, Roland Smonig1, Mathilde Lermuzeaux1, Jordane Lebut1,
Andremont Olivier1, Claire Dupuis1, Aguila Radjou1, Bruno Mourvillier1, Mathilde Neuville1,
Marie Pia D’ortho2, Lila Bouadma1, Anny Rouvel-Tallec2, Jean-François Timsit1, Romain
Sonneville1
1Department of intensive care medicine and infectious diseases, Hôpital Bichat-Claude
Bernard-APHP, Paris, France; 2Physiology, Hôpital Bichat-Claude Bernard-AP-HP, Paris,
France
Correspondence: Romain Sonneville - romain.sonneville@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S35
Introduction Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly
used to treat refractory cardiogenic shock or cardiac arrest. Acute brain injury (i.e.
ischemic stroke, haemorrhage and/or failure to awaken because of diffuse brain injury)
may occur in up to 15% of patients on VA-ECMO and is associated with increased mortality
and poor functional outcome in survivors. However, early indicators of neurological
outcome are lacking in this population. We aimed to assess the prognostic value of
early electroencephalography (EEG) alterations during VA-ECMO.
Patients and methods We conducted a prospective single-center study in the medical
ICU of a university hospital on consecutive patients cannulated to VA-ECMO. A standardized
clinical neurological evaluation including the RASS score, the GCS score, the Full
Outline of UnResponsiveness (FOUR) score and brainstem reflexes was coupled to an
intermittent EEG. EEG was recorded as soon as possible within the first 72 h after
VA-ECMO cannulation. EEG characteristics were analyzed by a neurophysiologist who
was blinded to the patient’s condition. A severely altered EEG pattern was defined
as a predominant delta frequency, discontinuous, unreactive and/or an isoelectric
background. The primary endpoint was poor neurological outcome, defined as the composite
of death or acute brain injury on neuroimaging within 28 days. Data are presented
as median (interquartile range) or number (percentage). False-positive rates (FPRs,
corresponding to 1-specificity) of poor neurological outcome were calculated for each
significant predictor, using an exact binomial 95% confidence interval (CI).
Results Sixty-nine (age 58 (50–67) years) patients with a SOFA score of 14 (13–17)
were included. Main indications for ECMO were: post cardiac surgery (n = 25, 36%),
terminal dilated cardiomyopathy (n = 12, 17%), and acute myocardial infarction (n = 11,
16%). Cardiac arrest before ECMO cannulation was noted in 20 (29%) patients. EEG was
recorded 1 (1–2) days after VA-ECMO cannulation and 62 (90%) patients were sedated
at time of EEG. At day 28, 46 (67%) had a poor outcome (n = 37 deaths and n = 9 patients
alive with acute brain injury). In univariate analysis, a lower RASS score (p = 0.003),
a lower FOUR score (p = 0.001), a lower score on the motor component of the Glasgow
coma scale (p = 0.001), and a lack of cough reflex (p = 0.033) at the time of EEG
were significantly associated with a poor outcome. A severely impaired EEG pattern
or presence of a discontinuous background activity were also associated with a poor
outcome (p = 0.015 and p = 0.002, respectively). Indicators of poor neurologic outcome
are presented in the Table 19. Among all parameters, a discontinuous background activity
was the only variable that constantly predicted poor outcome (false-positive poor
outcome prediction rate of 0%, 95% CI 0–15%).
Table 19
Indicators of poor neurologic outcome for patients cannulated to VA-ECMO
Variable
False positive poor outcome prediction rate (%)
95% CI
Motor component of the GCS < 4
19
9–34
Absence of cough reflex
16
5–36
FOUR score < 6
12
4–26
Severely impaired EEG
13
3–34
Discontinuous EEG background
0
0–15
Conclusion Early intermittent EEG has a strong prognostic value for sedated patients
on VA-ECMO. Presence of a discontinuous EEG background activity seems to be more accurate
than clinical alterations to predict a bad neurologic outcome at 28 days.
Competing interests None.
S36 Transjugular intra hepatic porto systemic shunt (TIPS) placement induces modifications
of cerebral multimodal MRI in cCirrhotic patients, even in the absence of development
of hepatic encephalopathy
Marika Rudler1, Nicolas Weiss2, Vincent Perlbarg3, Damien Galanaud,4, Dominique Thabut5,
Brain Liver Pitié-Salpêtrière Study Group (BLIPS)
1,Hepatology and gastroenterology, Pitié-Salpêtrière Hospital, Paris, France; 2Unité
de réanimation neurologique, Hôpital Pitié-Salpêtrière, Paris, France; 3Bioinformatics
and biostatistics platform, ICM Institut du Cerveau et de la Moelle épinière, Paris,
France; 4Neurological icu, Pitié-Salpêtrière Hospital, Paris, France; 5Brain Liver
Pitié-Salpêtrière Study Group (BLIPS), Hôpital Pitié-Salpêtrière, Paris, France
Correspondence: Marika Rudler - marika_rudler@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S36
Introduction Hepatic encephalopathy (HE) may occur after transjugular intrahepatic
porto systemic shunt (TIPS) placement. Multimodal MRI, combining morphologic sequences,
diffusion tensor imaging (DTI), and H proton magnetic resonance spectroscopy (MRS),
is modified in cirrhotic patients even in the absence of patent HE. Our aims were:
(1) To assess if TIPS induces changes in multimodal MRI; (2) To correlate changes
to the development of HE after TIPS.
Patients and methods All consecutive patients with cirrhosis and an indication for
TIPS were prospectively screened. Exclusion criteria were: common counter-indication
to MRI, active drinking, overt HE. Neurocognitive evaluation using Psychometric HE
test score (PHES), were assessed at baseline at inclusion, at the day of MRI, and
3 months after TIPS placement. MRI combined morphologic sequences, DTI, and MRS. DTI
data were processed with standard tools of FSL5 including eddy current correction
and the tensor metrics (Fractional Anisotropy, FA and Mean Diffusivity, MD) computation.
Averaged measures of FA and MD were calculated within the 48 regions of the ICBM-DTI-81
white-matter labels atlas.
Results 25 consecutive patients were prospectively analysed (age 57 ± 8, male gender
68%, Child-Pugh score 7.8 ± 1.6, MELD score 12 ± 4, cause of cirrhosis: OH/virus/others
16/4/5, indication for TIPS placement: Ascites/Varices secondary prophylaxis/other
20/3/2), HE status: no HE/minimal HE (MHE)/patent HE: 20/5/0. 8/25 patients developed
HE after TIPS (1 MHE, 7 patent HE). Baseline metabolites were significantly different
in patients with or without MHE before TIPS: decrease in myoinositol, choline and
increase in glutamate/glutamine. MD and FA were similar according to the presence
of MHE or not before TIPS. TIPS induced significant changes in MRS metabolites as
compared to baseline: decrease in myoinositol, glycerophosphocholine, N-acetylasparte,
increase in glutamate/glutamine. TIPS did neither modify FA nor MD. Baseline metabolites
were not predictive of the development of HE after TIPS. However, baseline FA was
significantly lower in patients who developed HE: in cingulate gyrus, in external
capsule and in fronto-occipital regions.
Conclusion TIPS induced significant changes in cerebral metabolites, even in the absence
of the development of HE. DTI findings before TIPS could help predicting the development
of HE after TIPS. This finding could lead to a targeted prevention therapy in some
patient that undergo TIPS placement.
Competing interests None.
S37 Septic cerebral thrombophlebitis: risk factors and outcome
Emna Rachdi1, Ghada Mhamdi2, Ahlem Trifi1, Rim Abdelmalek2, Sami Abdellatif1, Foued
Daly1, Rochdi Nasri1, Hanene Tiouiri2, Salah Ben Lakhal1
1Réanimation médicale, Centre hospitalier universitaire la Rabta, Tunis, Tunisia;
2Maladies infectieuses, centre Hospitalier universitaire la Rabta, Tunis, Tunisia
Correspondence: Emna Rachdi - e.rachdi@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S37
Introduction Cerebral thrombophlebitis (CTP) is a dramatic and potentially lethal
disease. It occurs mostly in children and young adults. Septic thrombosis of the dural
venous sinuses is a rare accounting for 0.5–1% of all strokes but often catastrophic
complication of a variety of infectious processes. Bacterial meningitis and paranasal
sinusitis may be complicated by superior sagittal sinus thrombosis, an entity associated
with a mortality rate of nearly 80%. Although there is often no direct evidence that
the thrombus itself is infected, cases of cerebral sinus thrombosis are presumed to
be “septic” when the primary process is an infection.
Here in we are interested in bacterial meningitis with or without locoregional infection
complicated by CTP. Our objectives were to determine the risk factors predisposing
to the occurrence of CTP in case of bacterial meningitis.
Patients and methods A retrospective case/control study performed in 2 units (intensive
care and infectious diseases) over 44 months. Were recorded all patients who suffered
from bacterial meningitis. Exclusion criteria were tuberculosis meningitis and meningitis
on immunocompromised. We performed a multivariate logistic regression analysis to
determine firstly the association between risk factors and occurrence of CTP and secondly
between CTP and mortality. Analyse risk factors were: demographic factors, locoregional
infection, craniofacial trauma, pregnancy, co morbidities (Thrombophilia, vascularitis,
and cancer), clinical features (coma, seizures, cephalalgia), scannographic data,
cytobacteriological and biochemical data of cerebro-spinal fluid (CSF) analysis, delayed
diagnosis and/or management.
Results 100 patients were hospitalized with meningitis between Jan 2013 and Aug 2016.
CTP occurred in 13 cases (13%). Age, sex-ratio, SAPS II and SOFA scores did not differ
between patients with meningitis complicated by CTP versus those with meningitis not
complicated by CTP: (39 vs 45 years, p = 0.22), (2.25 vs 1.71, p = 0.76), (28 vs 23,
p = 0.25) and (4.3 vs 2.7, p = 0.08) respectively. Coma, cerebral oedema, cerebral
commitment and positive cerebral spinal fluid (CSF) culture were significantly associated
with the occurrence of TPC. SOFA >3 and contraception were near to significance (joined
Table 20). It was not found a significant association of CTP to mortality (46% in
the case group and 30% in control group, p = 0.08). Other factors that increased mortality
were coma, seizures, shock, oedema, cellularity in CSF >1200 units/mm3. Otherwise,
the ventilation length was prolonged with CTP group (8.7 vs 3.4 days, p = 0.034) and
neurological sequels namely the epilepsy was more frequent with the group CTP: (23
vs 5%, p = 0.028).
Table 20
Factors associated with CTP complicating meningitis by stepwise logistic regression
variables
OR
(95% CI)
P value
Coma
3.73
(1.33–10.48)
0.019
Cerebral oedema
1.82
(1.07–3.39)
0.003
CEREBRAL commitment
1.45
(1.14–1.97)
0.018
Positive CSF culture
1.27
(0.99–1.64)
0.017
SOFA > 3
1.12
(0.95–1.33)
0.11
Oral contraception
1.32
(0.75–2.34)
0.17
Conclusion The occurrence of CTP on bacterial meningitis was significantly associated
with CT scan lesions which seems to be an association be in both directions. Also,
the positive culture predisposed more to the CTP. Mortality was higher with the presence
of CTP but without real significance. The CTP was a factor that extends the ventilation
time and exposed to the post infectious epilepsy.
Competing interests None.
Reference
Med Clin N Am. 2012;96:1107–26.
S38 Rapid diagnosis of bacterial meningitis using a point-of-care glucometer
Geoffroy Rousseau1, Romain Asmolov2, Leslie Grammatico-Guillon3, Adrien Auvet2, Said
Laribi1, Denis Garot2, Youenn Jouan2, Pierre François Dequin2, Antoine Guillon2
1Département de médecine d’urgence, Hospital Trousseau, Chambray-lès-Tours, France;
2Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France; 3Service d’information
médicale, epidémiologie et economie de la santé, CHRU Hôpitaux de Tours, Tours, France
Correspondence: Geoffroy Rousseau - grousseau.tours@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S38
Introduction Acute bacterial meningitis requires rapid triage and therapeutic decision-making.
The aim of this study was to assess the overall ability of a point-of-care glucometer
to determine bacterial infection in cerebrospinal fluid (CSF).
Materials and methods We performed a prospective, observational study. We included
patients for whom an analysis of CSF was indicated by the physician in charge with
blood sampling performed for glucose concentration measurement within 1 h. We simultaneously
measured the glucose concentrations in CSF and blood using a central laboratory and
point-of-care glucometer. The diagnosis of bacterial meningitis was determined by
two physicians after reviewing the complete medical chart. We compared CSF and blood
glucose concentrations and CSF/blood glucose ratios obtained at the bed-side with
a glucometer versus those obtained by the central laboratory. We determined the performance
characteristics of the CSF/blood glucose ratio provided by a glucometer to detect
bacterial infection in the CSF immediately after CSF sampling.
Results We screened 201 CSF collection procedures during the study period and included
172 samples for analysis. Acute bacterial meningitis was diagnosed in 17/172 (9.9%)
of CSF samples. The median turnaround time for glucose concentration analysis with
a point-of-care glucometer was shorter than for the central laboratory: 5 [IQR 2–10]
min versus 112 [IQR 86–154] min (p < 0.0001), respectively. The optimal cut off for
the CSF/blood glucose ratio from central laboratory measurements to identify bacterial
meningitis was 0.44 with a sensitivity of 94.1% [95% CI 71.3–99.9%], a specificity
of 92.3% [95% CI 86.9–95.9%], and a positive likelihood ratio of 12.
The optimal cut off of CSF/blood glucose ratio calculated from a bed-side glucometer
was 0.46 with a sensibility of 94.1% [95% CI 71.3–99.9%], a specificity of 91% [95%
CI 85.3–95%] and a positive likelihood ratio of 10.
Conclusion We demonstrated that the CSF/blood glucose ratio measured by a glucometer
can serve as a clinical decision support tool for the early detection of CSF with
a high probability of bacterial infection. This costless point-of-care method has
the potential to expedite medical decision-making for the triage of adult patients
with suspected meningitis in the emergency department immediately after lumbar puncture.
Competing interests None.
S39 Guillain–Barré syndrome outbreak associated with Zika virus in Martinique
Jean-Louis Fergé1, Gwénolé Abgrall1, Ronan Hinault1, Shazima Vally1, Benoit Roze2,
Agathe Chaplain1, Cyrille Chabartier1, Anne-Charlotte Savidan1, Sabia Marie1, Andre
Cabie2, Dabor Resiere1, Ruddy Valentino1, Hossein Mehdaoui1
1Intensive care unit, C.H.U La Meynard, Fort de France, Martinique; 2Department of
infectious & tropical diseases, C.H.U La Meynard, Fort de France, Martinique
Correspondence: Jean-Louis Fergé - jean.ferge@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S39
Introduction An emergence of Zika virus (ZIKV) infections occured in Martinique, an
400,000 people island of the French West Indies, with more than 35,000 estimated cases
between December 2015 and September 2016. The disease is usually benign and self-limiting
if symptomatic (fever, headache, retro-orbital pain, non-purulent conjunctivitis,
maculopapular rash, arthralgia, and myalgia). ZIKV is strongly suspected to be a cause
of Guillain–Barré syndrome (GBS) based on case–control study describing French Polynesia
outbreak in 2014 (1). Virological investigations were essentially both microsphere
immunofluorescent and seroneutralisation assays for Zika virus and Dengue virus because
of cross reactivity. Since then, numerous publications help to understand time of
detection of ZIKV in biological human samples as blood or urine by Reverse-Transcriptase
Polymerase-Chain-Reaction (RT-PCR) to diagnose ZIKV infection unambiguously. We aimed
to asses the role of ZIKV in GBS outbreak in Martinique.
Patients and methods In this prospective cohort study, cases were patients with GBS
at the French university hospital of Martinique during the outbreak period. Demographic,
clinical, biological and electrophysiologic data, times of endotracheal intubation,
and mechanical ventilation (MV) weaning were collected for all patients. At least
4 early predictors for MV were reached before endotracheal intubation (2). Weaning
was usually decided when maximal minute ventilation was twice the minute ventilation
after a 3–6 h trial of T-tube ventilation. Virological investigations included RT-PCR
in blood and urine, and serological tests for ZIKV. Certainty ZIKV infection diagnosis
was definite by RNA Zika detection by RT-PCR in blood or urine and by a negative screening
for the others common etiologies of GBS (Cytomegalovirus, Epstein-Barr Virus, Human
Immunodeficiency Virus and Human T-cell Lymphotropic Virus 1).
Results 30 patients were diagnosed for SGB during the study period. 21 had a certainty
diagnosis for ZIKV infection. 13 patients were male. Median age was 65.4 years (range
56.7–71.2). 14 patients had clinical manifestations for ZIKV in a median preceding
days of 5 (range 2–7). Immune therapy using immunoglobulins was realized in most of
cases except for two patients who received plasma exchange. The median time before
plateau phase was 8 days (range 6–12). 13 patients were hospitalized in ICU, 10 requiring
MV for a median duration of 11.5 days (range 6–27). 19 patients underwent an electromyography
in a median delay of 14 days (range 10–22). Acute inflammatory demyelinating polyradiculoneuropathy
was diagnosed in 18 cases. 3 of them had axonal involvement.
Discussion Half of the patients had a need for MV. Temporality of events, certainty
of ZIKV infection diagnosis by RT-PCR and exclusion of alternative explanations provide
evidence for ZIKV causability in SGB. Annual incidence of SGB had already double comparing
10 previous years. SGB incidence backward have to be observe after the ZIKV outbreak.
Conclusion This study provides evidence for Zika virus infection causing Guillain–Barré
syndrome. Consistency (same association found in different studies and populations)
is strengthened by our study. At risk countries need to prepare for adequate intensive
care beds capacity to manage patients with Guillain–Barré syndrome.
Competing interests None.
References
Cao-Lormeau VM. Guillain–Barré syndrome outbreak associated with Zika virus infection
in French Polynesia: a case–control study. Lancet. 2016;387:1531–9.
Sharshar T. Early predictors of mechanical ventilation in Guillain–Barré syndrome.
Crit Care Med. 2003;31:278–83.
S40 Prognostic value of standardized EEG features in post-anoxic coma after resuscitated
cardiac arrest
Lucas Benarous1, Marième Soda-Diop2, Fouad Bouzana1, Gilles Perrin1, Jeremy Bourenne1,
Béatrice Eon1, Dominique Lambert1, Agnes Trebuchon2, Marc Gainnier1
1Service de réanimation des urgences et médicale, Hôpital Timone Adulte, Marseille,
France; 2Service de neurophysiologie clinique, Hôpital Timone Adulte, Marseille, France
Correspondence: Lucas Benarous - lucasbenarous@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S40
Introduction Cardiac arrest remains a frequent cause of admission in intensive care
unit. A majority of patients will die during their hospital stay mainly from consequences
of hypoxic-ischemic brain injury after a decision of withdrawal of life sustaining
therapy support by a prediction of poor outcome. The reliability of prognostication
is crucial, but is still a difficult and uncertain exercise. EEG is the most widely
used prognostic tool to support a clinical examination and is accessible in most hospitals.
It is recommended for both prognostication and ruling out subclinical seizures. There
is no high-level evidence for predicting poor prognosis using EEG because of the wide
variety of classification systems used and the interrater variability. Our objective
is to assess the prognostic value of simple EEG features based on the recent American
Clinical Neurophysiology Society (ACNS) standardized classification and to study the
interrater variability.
Patients and methods We conducted a retrospective monocentric observational study
in a 12 bed medical intensive care unit of the university Hospital la Timone, Marseille,
France. All patients aged of more than 18 year-old admitted for a resuscitated cardiac
arrest between November 2012 and July 2014 who underwent therapeutic hypothermia and
a full multimodal prognostic evaluation including a EEG were included in the study.
Outcome was classified according to the Cerebral Performance Category Score measured
at day 28. Unfavorable outcome was defined as death (CPC 5), persistent vegetative
state (CPC 4), or severe neurological disability (CPC 3). Favorable outcome was defined
as moderate neurological disability (CPC 2), or no disability (CPC 1). EEG was performed
in all patients still comatose after rewarming between 48 and 72 h after admission
and after discontinuation of sedation. EEG interpretation was made by 2 independent
senior neurophysiologists, blind to the outcome. EEG features are based on the latest
ACNS classification. For each EEG feature, sensitivity, specificity, positive predictive
value (PPV), negative predictive value (NPV) for predicting an unfavorable outcome
were calculated.
Results During the study period, 122 cardiac arrest were admitted of which 48 patients
went through a full neurologic evaluation and were finally included in the study.
According to neurological outcome, 19% had a favorable evolution, and 81% had an unfavorable
outcome. The presence of burst suppression, and epileptiform activity was constantly
associated with an unfavorable prognostic with a 100% specificity and 0% false positive.
A non-reactive EEG is strongly associated with an unfavorable evolution with a 89%
specificity and 3% false positive. Other features including periodic or rhythmic patterns
and low voltage were inconstantly associated with unfavorable outcome. Kappa score
for all EEG feature was slight or fair and always under 0.4.
Discussion This study allowed us to identify a homogenous cohort of comatose patient
after cardiac arrest who underwent therapeutic hypothermia. We identified simple EEG
features based on the new classification of the ACNS constantly associated with unfavorable
outcome. These features must be known by intensivists to better integrate EEG in the
multimodal evaluation of neurological prognostic. There is important interrater variability
that must lead to caution and to always use multimodal approach to prognostic an unfavorable
outcome.
Conclusion Bedside EEG is an excellent tool for predicting outcome of post-anoxic
coma through simple EEG features. Burst suppression, epileptiform activity and non-reactive
EEG are strongly associated to neurological outcome after cardiac arrest. However,
the interrater variability emphasize the need of being well trained for the standardized
methods of evaluating EEG parameters.
Competing interests None.
References
Westhall E. Neurology. 2016;86(16):1482–90.
Ben-Hamouda N. Chest. 2014;146(5):1375–86.
S41 The air-leak test revisited in childhood: a prospective observational study of
feasibility in a PICU
Géraldine Poncelet1, Fleur Le Bourgeois2, Levy Michael2, Guillot Camille2, Jérôme
Naudin3, Anna Deho4, Stéphane Dauger3
1Pédiatrie, Hôpital Robert-Debré (AP-HP), Paris, France; 2Réanimation et surveillance
continue pédiatriques, Hôpital Robert Debré, Paris, France; 3Réanimation et surveillance
continue pédiatriques, CHU Robert Debré, Paris, France; 4Réanimation et surveillance
continue pédiatriques, CHU Robert Debré, Paris, France, France
Correspondence: Géraldine Poncelet - gege.ponce@orange.fr
Annals of Intensive Care 2017, 7(Suppl 1):S41
Introduction Emergent reintubation is a well-known risk of laryngo-tracheal trauma
and of ventilatory acquired pneumonia. To precisely define its risk before extubation
for each patient is a part of quality of care in intensive care units. The air-leak
test (ALT) around the endotracheal tube (ETT) has been validated in adults to predict
post-extubation adverse events such as stridor, upper airway obstruction or reintubation.
Although the only six studies performed in childhood have shown highly variable results,
this test is often used in pediatric intensive care units (PICU) where cuffed ETTs
are now strongly recommended even in young infants. We report here the feasibility
of different kinds of ALT in critically ill pediatric patients.
Patients and methods We designed a prospective, monocentric, observational study in
our 12 beds-PICU of a University Hospital. From May 2016 to September 2016, we included
all patients aged from 2 days to 18 years and intubated with cuffed ETT. We excluded
patients intubated with uncuffed ETT, who were transferred still intubated to another
PICU or who died during their stay in PICU. ALT was performed in all patients as soon
as they were considered weanable from the ventilator by the intensivist in charge
of the PICU. Thirty minutes before extubation, the intensivist successively tested
two methods, before and after cuff deflation, with patients ventilated under CPAP
(+5 cms H2O) with the FiO2 needed to obtain a saturation above 94%: (i) a qualitative
test based on detection of an audible air-leak around the ETT with and without the
use of a stethoscope placed on the larynx, (ii) a quantitative test known as the percent
of cuff leak either calculated with expiratory tidal volume (VtE) or inspiratory tidal
volume (VtI) (PCL: VtE inflated cuff - VtE deflated cuff/VtE inflated cuff × 100 or
VtI inflated cuff - VtI deflated cuff/VtI inflated × 100). ALT was considered positive
when no air-leak was audible and/or the PCL is less than 10%. Data are reported as
medians [first-third quartiles].
Results During 4 months, 65 patients were mechanically ventilated in the PICU. 21
patients were excluded (11 deaths, 3 transferred still intubated and 7 intubations
with uncuffed ETT). Of 44 patients with inclusion criteria, 43 (98%) were included
(male/female: 30/13; age: 42 [6; 146] months; weight: 16.6 [5.6; 37.1] kg; PIM2 score:
3 [1.4; 5.6]; PELOD score at Day#1: 10 [1; 11]; medical/surgical: 28/15; duration
of mechanical ventilation: 3 [2; 5] days; length of stay in PICU: 4.5 [3; 7] days).
Numbers of cuffed ETT of each diameter were as follow: 1 × 2.5 cm, 8 × 3.0 cm, 7 × 3.5 cm,
5 × 4.0 cm, 7 × 4.5 cm, 3 × 5.0 cm, 3 × 5.5 cm, 3 × 6.0 cm, 4 × 6.5 cm, and 2 × 7.0 cm.
Every 10 senior pediatric intensivists working day or night in the PICU reported that
performing all forms of ALT before extubation was easy, fast and safe. Clinical detection
of an audible air-leak with or without a stethoscope was in agreement in 84% of cases.
During the study period, no patients have been reintubated because of untractable
inspiratory distress resisting to anti-inflammatory treatment (aerosol of epinephrine
and systemic steroids) and non-invasive ventilation. 29 (67%) ALT were negative (presence
of air-leak around ETT) and 14 (33%) were positive (absence of air-leak), with 67%
concordance between qualitative and quantitative test. This concordance may depend
on age (56% if <1 year, 76% if 1–7 years, and 78% if >7 years). With a cut-off of
10%, the result of the PCL calculation was identical using VtE or VtI.
Discussion Quite all patients have been included during the study period. ALT is fast
and easy to safely perform at the bedside in PICU. It doesn’t take too much time for
the intensivist. Audible ALT could be done without the use of a stethoscope which
is difficult to place in front of the larynx on the anterior part of the neck in small
infants. Comparing VtE, a usual parameter systematically measured by all PICU ventilators,
before and after cuff ETT deflation, was the simplest ALT to use in this population.
An average of six consecutive measurements, as performed in adults, could maybe enhance
the test’s specificity. None of these 43 consecutive children representative of PICU
activity has been reintubated. The coming prospective muticentric study which aims
to validate ALT in childhood must precisely define this criteria of evaluation.
Conclusion The different methods of ALT are feasible in real clinical conditions in
PICU. Because of the increasing use of cuffed ETTs in a wide variation of patients
with different body weight, the best ALT to use at the bedside must be definitively
validated in this population.
Competing interests None.
S42 Prognosis for newborns with prolonged mechanical ventilation: preliminary results
of a retrospective single center cohort study
Michaël Sauthier1, Krystale Bergeron-Gallant1, Guillaume Emeriaud1, Philippe Jouvet1
1Paediatric Intensive Care Unit, CHU Sainte-Justine, Chemin de la Côte-Sainte-Catherine,
Montreal, QC, Canada, Montréal, Canada
Correspondence: Michaël Sauthier - michael.sauthier@umontreal.ca
Annals of Intensive Care 2017, 7(Suppl 1):S42
Introduction Prolonged mechanical ventilation (PMV) and chronic mechanical ventilation
(CMV) in neonates is associated with a high morbidity and mortality. The objective
of the study is to identify, among the patients with PMV, those that evolved to CMV,
as well as the adverse respiratory, neurological and feeding sequelae.
Patients and methods We conducted a retrospective study of the last 10 years at the
CHU Sainte-Justine (Montreal, Canada). Chart review included patients with PMV (≥21 days)
using the paediatric definition adapted from the 2005 NAMDRC consensus conference
(1). Demographic and clinical data, including follow-up at 6 and 18 months corrected
age, was collected for each included patient. The evolution of PMV neonates with CMV
(≥125 days) and without (21–125 days) was compared.
Results We identified 174 neonates that met criteria for PMV. Patients born between
2004 and 2011 (n = 110, 63% of the cohort) were analyzed. Around half of the patients
(5–10 patients a year) are transferred from the neonatal unit to the paediatric intensive
care unit. In our center, they represent around 1% of total admissions, but their
length of stay is among the longest. Among these 110 newborns, 79% were preterm (n = 87)
with 45% (n = 50) born before 29 weeks gestation. Of all patients with a malformation
(52%, n = 57), 21 had a thoracoabdominal anomaly and 24 had congenital heart disease.
Thirty-six patients had CMV with mean ventilation time of 239 days (range 125–753 days).
Survival at 18 months corrected age was 66% (49/74) in the PMV group and 72% (26/36)
in the CMV group. At 18 months corrected age, 30% of patients were dependent on artificial
enteral feeding (nasogastric tube or gastrostomy), with 18% in the PMV group and 54%
in the CMV group. Nine percent of patients had oxygen supplementation (2 patients
in the PMV group and 4 in the CMV group), and 7% were mechanically ventilated. Ten
percent of patients had a tracheostomy (5 patients in the PMV group and 2 in the CMV
group).
Discussion Neonates with CMV have more sequelae. Their rapid identification (at 21 days
of ventilation) is essential to implement multidisciplinary development care in order
to minimize neurodevelopment impairment.
Conclusion Most newborns in our PMV cohort have a congenital malformation. Survival
at 18 months corrected age appears equivalent in both PMV and CMV group. Artificial
enteral feeding is more frequent in the CMV group and most patients have no respiratory
support at 18 months corrected age.
Competing interests None.
Reference
Sauthier M, Rose L, P Jouvet. Paediatric prolonged mechanical ventilation: Considerations
for definitional criteria. Resp Care; 2016 (In Press).
S43 Relative value of pressures and volumes in assessing fluid responsiveness in children:
the role of systolic cardiac function
Nicolas Tiebergien1, Matthias Jacquet-Lagrèze1, Jean-Luc Fellahi1
1Anesthésie réanimation, Hôpital Louis Pradel, Bron, France
Correspondence: Matthias Jacquet-Lagrèze - matthias.jl@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S43
Introduction The value of pressures and volumes in assessing the fluid responsiveness
depend on the systolic cardiac function in adult (1). We have studied the relative
value of static filling volume and pressure to predict the fluid responsiveness, according
to systolic cardiac function in children during acute circulatory failure.
Patients and methods Patients under 8 years old with an acute circulatory failure
of two intensive care units during a 1 year period of inclusion were analyzed. An
exhaustive cardiac echography was performed initially (indexed End-diastolic volume
(EDVi) and E/e’ from transmitral and tissue Doppler were recorded), and the stroke
volume index (SVI) was measured before and after a fluid challenge (a 10 ml/kg of
crystalloid over 10 min). SVI was computed as the left ventricular outflow tract velocity
time integer multiplied by the left ventricular outflow tract surface. Patients were
responders to fluid loading if their SVI increased of at least 15%. Patients were
considered to have a low systolic function if their Left Ventricular Ejection Fraction
(LVEF) was under 50% or normal if it was over 50%. R software with pROC package was
used to performed descriptive and analytic statistic. Receiver operative characteristic
curves were built. Bootstrap technic was used to compute the confidence intervals.
p < 0.05 was considered significant. Local institutional review boards approved this
study (CPP Lyon Sud Est II). Written informed consent was obtained from parents.
Results Twenty-five children with acute circulatory failure were included. Fluid responsiveness
occurred in 6 of the 13 fluid loading events with low LVEF, and in 6 of the 12 fluid
loading events with normal LVEF. Pressure approach: For low and normal LVEF, the AUC-ROC
for fluid responsiveness was respectively 0.83 (CI 0.56–1)/0.73 (0.39–1) for a E/e’.The
best thresholds of E/e’ in low LVEF was 7.9 with a sensitivity of 87 (CI 62–100) %
and a specificity of 67 (CI 33–100) %. For low and normal LVEF AUC ROC was respectively
0.6 (CI 0.21–0.99)/0.52 (CI 0.14–0.9) for the PVC.
Volume approach: For low and normal LVEF, the AUC-ROC for fluid responsiveness was
respectively 0.69 (CI 37–1) and 0.74 (0.4–1). The best thresholds in normal LVEF was
an EDVi below 29 ml/m2 wit a Specificity of 83 (CI 50–100) and a sensitivity of 71
(CI 42–100) %.
Discussion Our study shows a variation of the diagnostic value of E/e’ and EDVi according
to the left ventricular systolic function. Therefore, the systolic function should
be taken into account to analysed the E/e’ and EDVi value. Few preload dependency
markers are validated in Children and none for children in spontaneous ventilation
(2). Our study suffers from a lack of power that calls into question the validity
of our results. Another limitation is that both approaches with volume and pressure
are not very discriminant as it is known for static value in adults. Our study illustrates
that, on a pressure–volume curve, when the cardiac inotropism is reduced, the filling
of the Left ventricle is moved to the up and right of the curvilinear diastolic function
curve. Therefore, pressure variations are larger than volume variations. These values
should be monitored on a larger scale to define their exact diagnostic value.
Conclusion Static PVC value is a low preload-dependency surrogate. When LVEF is low
a pressure evaluation based approach seems more accurate. When LVEF is normal a volume
evaluation based approach seems informative as predicted by the slope of the end diastolic
pressure volume curve. Those both static approaches remain of poor diagnosis accuracy.
Competing interests None.
References
Trof RJ. Cardiac filling volumes versus pressures for predicting fluid responsiveness
after cardiovascular surgery: the role of systolic cardiac function. Crit. Care. 2011.
Desgranges F-P. Respiratory variation in aortic blood flow peak velocity to predict
fluid responsiveness in mechanically ventilated children: a systematic review and
meta-analysis. Pediatr Anesth. 2015.
S44 Prone position reduces work of breathing in children with severe bronchiolitis
Florent Baudin1, Guillaume Emeriaud2, Sandrine Essouri2, Jennifer Beck3, Etienne Javouhey4,
Claude Guérin5
1Réanimation pédiatrique, Hôpital Femme Mère Enfant, Bron - Lyon, France; 2Soins intensifs
pédiatriques, CHU Sainte-Justine, Montréal, Canada; 3Keenan research center, St Michael’s
Hospital, Toronto, Canada; 4Réanimation pédiatrique hfme, Hospices civils de Lyon,
Lyon, France; 5Réanimation médicale, Hôpital de la Croix-Rousse, Lyon, France
Correspondence: Florent Baudin - florent.baudin@chu-lyon.fr
Annals of Intensive Care 2017, 7(Suppl 1):S44
Introduction Acute viral bronchiolitis is a primary cause of respiratory distress
in paediatric intensive care unit (ICU). Prone position (PP) is commonly used in neonates
to improve respiratory mechanics and has been found beneficial to adult patients with
acute respiratory distress syndrome. We aimed to evaluate the effect of PP on work
of breathing as compared to supine position (SP) in children with severe bronchiolitis
requiring non-invasive ventilation.
Patients and methods The protocol was approved by our IRB (2015- A01200–49). Fourteen
infants (9 boys) with median age 33 days [first-third quartiles 25–58] with severe
bronchiolitis requiring CPAP were included after written informed consent. Children
were investigated in PP and SP each applied for 1 h in a random order with a washout
period of 10 min between them. Level of CPAP was set at 7 cmH2O in both conditions.
Oesophageal pressure probe was inserted orally (CTO-2 pressure transducer, Gaeltec,
Scotland) to measure oesophageal pressure. Flow and airway pressure (Pmo in Fig. 15)
were simultanuously recorded using a Neurovent data acquisition system (Neurovent
Inc, Toronto, Canada). One hundred breaths were analyzed in each condition, in which
work of breathing was estimated from oesophageal pressure–time product (PTPes) and
oesophageal swings (Fig. 15). Data were expressed as median (first-third quartiles)
and compared by using the Wilcoxon two-sample paired sign test. A p-value below 0.05
was considered significant.
Fig. 15
Example of recording and main analysis (PTP pressure time product)
Results Respiratory rate was not different in PP and SP position (66 [46–78] vs 59
[52–77] breaths/minute, p = 0.40). Between PP and SP, the oesophageal PTP per breath
was 3.5 [2.9–4.2] vs 4.6 [3.4–5.1] cmH2O s, respectively, p = 0.048 and the swings
of oesophageal pressure amounted to 9.3 [8.3–12.8] vs 14.9 [11.0–16.2] cmH2O, respectively,
p = 0.035.
Discussion Work of breathing estimated by using the oesophageal PTP and oesophageal
swing was lower in PP than in SP in children who required non-invasive ventilation
for severe bronchiolitis. This physiologic study suggests that PP may improve respiratory
condition in children with severe bronchiolitis.
Conclusion In children with severe bronchiolitis, the prone position decreased significantly
the work of breathing compared to the supine position during non-invasive ventilation.
Competing interests F. Baudin: has received speaking fees from Maquet critical care.
J. Beck: through Neurovent Research, serves as a consultant to Maquet Critical Care.
She has made inventions related to neural control of mechanical ventilation that are
patented. The license for these patents belongs to Maquet Critical Care. Future commercial
uses of this technology may provide financial benefit to Dr. Beck through royalties.
References
Numa AH, et al. Effect of prone and supine positions on functional residual capacity,
oxygenation, and respiratory mechanics in ventilated infants and children. Am J Respir
Crit Care Med. 1997;156:1185–89.
Gouna, et al. Positioning effects on lung function and breathing pattern in premature
newborns. J Pediatr. 2013;162:1133–7.
S45 Characteristics and initial prognostic factors of abusive head trauma in pediatric
intensive care unit
Marie Lampin1, Ouardia Mamouri,2, Patrick Devos3, Yasemin Karaca-Altintas1, Matthieu
Vinchon,4, Stéphane Leteurtre1
1Service de réanimation pédiatrique, CHRU de Lille, Lille, France; 2Service de pédiatrie,
CH d’Armentières, Armentières, France; 3Service de biostatistiques, CHRU Lille, Lille,
France; 4Service de neurochirurgie pédiatrique, CHRU de Lille, Lille, France
Correspondence: Marie Lampin - marie-emilie.lampin@chru-lille.fr
Annals of Intensive Care 2017, 7(Suppl 1):S45
Introduction Abusive head trauma assigned a frequency to high morbidity and mortality
and it is not uncommon in pediatric intensive care unit. The aim of this study was
to describe the frequency and the characteristics of abusive head trauma from all
head trauma in children under 2 years hospitalized in a pediatric intensive care unit
and define initial prognostic factors of mortality.
Patients and methods We performed a retrospective observational cohort study, including
all patients under 2 years, admitted in pediatric intensive care unit of Lille, France
for head trauma from January 2004 to December 2014. Outcome for initial prognostic
factors was mortality.
Results One hundred forty patients were included, 64% were abusive head trauma and
36% were accidental head trauma. The main differences between the 2 groups were respectively
age (3 vs 12 months), retinal hemorrhages (81 vs 8%), subdural hematoma (94 vs 40%),
location of fractures (long bones: 61 vs 0%; ribs: 46 vs 3%) and location of ecchymosis
(face: 84 vs 8%; skull: 32 vs 96%) (all p < 10–4). Seizures were more common in abusive
head trauma (74%) versus accidental head trauma (24%) (p < 10–4). Patients with abusive
head trauma were mostly boys (sex ratio: 1.4). Mortality rate was higher in abusive
head trauma (26%) versus accidental head trauma (8%). Prognostic factors of mortality
were younger age (p = 0.03), a threshold probability of death PIM 2 of 8% (Se 92%,
Sp 77%) and 12% for the PRISM III score (Se 89% Sp 77%), Glasgow score ≤8 (OR [CI95%]:
7 [53; 424]), lactate level greater than 2 mmol/l and initial hypoxic-ischemic injuries
in cerebral tomodensitometry (CT) (p < 10–4). Only subdural-peritoneal shunt placement
was a protective factor (OR 0.007 [95% CI 0.2, 0.6]; p = 0.003).
Conclusion In our study, abusive head trauma is a frequent cause of head trauma in
children under 2 years (68%) and is more lethal than other head injuries. Young age,
PIM2 or PRISM III score, Glasgow score, lactatemia and hypoxic-ischemic brain injuries
were associated to mortality.
Competing interests None.
S46 High quality electronic database in paediatric intensive care unit: where are
we after 1 year!
David Brossier1, Redha Eltaani1, Michaël Sauthier2, Guillaume Emeriaud1, Philippe
Jouvet1
1Soins intensifs pédiatriques, CHU Sainte-Justine, Montréal, Canada; 2Paediatric Intensive
Care Unit, CHU Sainte-Justine, Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada,
Montréal, Canada
Correspondence: David Brossier david_brossier@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S46
Introduction Since May 2015, we have been able to collect several physiological and
therapeutic data in an electronic database (eDTB) implemented in our paediatric intensive
care unit (PICU) of CHU Sainte Justine using all medical devices at bedside and informatics
network of the hospital. The purpose of this abstract is to present the data after
1 year of exploitation.
Materials and methods The eDTB was implemented after the CHU Sainte Justine ethical
committee approval. Data are collected from admission to discharge, every 5 s from
monitors and every 30 s from mechanical ventilator and infusion pumps. All these data
are linked to medical information retrieved from electronic medical chart.
Results Between May 21th 2015 and July 31st 2016, 993 patients were hospitalised in
our PICU, among them 43 weren’t included in the eDTB for technical and age (over 18 years
old) reasons. Eventually, after 20 exclusions, 930 patients remained in the eDTB.
Mortality was 4.3% (n = 40). The eDTB contained 1063 PICU stays (1048 complete and
15 partial).The median age was 2 years old [0–17], median weight was 12.9 kg [2.3–104.0].
The median ICU stay was 53 h [3–11,720] or 2 days [0–488]. The first motive for admission
was respiratory causes (308, 28.9%) Other principal motives were post-surgery (186,
17.5%) post cardiac surgery procedures (160, 15.1%), neurologic causes (116, 10.9%).
Other motives were under 10% (hemodynamic causes, traumatic injuries, infectious diseases,
intoxications, metabolic causes, cancer, organ transplant, cardiac arrest). The eDTB
contains data from ventilated patients (invasively and non-invasively) and details
concerning ionotropic and sedative treatment during PICU courses.
Discussion As far as we know, this eDTB is currently the only one as exhaustive available
in PICU worldwide. After almost 3 years of multidisciplinary collaboration, we are
able to collect many useful physiological, therapeutic and medical data in an ongoing
eDTB. Although many concerns remain concerning data validation, organisation and exploitation,
this eDTB already contribute to the development of clinical decision support systems
and virtual patient validation and we create international collaborations to further
develop these tools. Three research protocols using the database are ongoing including:
validation of a neuromonitoring clinical decision support system, validation of a
cardio-respiratory simulator, developement and validation of the automatic diagnosis
of pediatric acute respiratory distress syndrome and development of SpO2 forecast
using artificial neuronal network.
Conclusion Thanks to informatics and electronic devices improvement, data gathering
in intensive care units has empowered. We hope that our work in PICU will encourage
other teams on the way of data gathering, in order to build an international PICU
eDTB in a close future.
Competing interests None.
S47 Pre-hospital control of secondary systemic cerebral insults in children referred
to a pediatric trauma center with traumatic brain injury
Sonia Teyssedre1, Meyet Sabine2, Jean-Christophe Bouchut3, Olivier Peguet3, Etienne
Javouhey4
169, Hôpital Femme Mère Enfant, Bron, France; 201, Hospital Center Fleyriat, Bourg-en-Bresse,
France; 369, Edouard Herriot Hospital, Lyon, France; 4Réanimation pédiatrique hfme,
Hospices civils de Lyon, Lyon, France
Correspondence: Sonia Teyssedre - sonia.teyssedre@chu-lyon.fr
Annals of Intensive Care 2017, 7(Suppl 1):S47
Introduction Severe trauma is rare in the pediatric setting (15% of all trauma in
France). However, its morbidity and mortality remain high, in relation to brain injury.
Pediatric traumatic brain injury (TBI) pre-hospital care is challenging for non-pediatric
retrieval teams. Though, we disseminated pediatric TBI pre-hospital care regional
guidelines and thereafter intended to assess severe pediatric trauma pre-hospital
care and secondary cerebral insults control.
Materials and methods We conducted a retrospective study in a single pediatric trauma
center. Children admitted in emergency room with severe trauma and moderate to severe
TBI (Glasgow coma scale ≤12) from June 2014 to March 2016 were included. Pre-hospital
and hospital data regarding primary care, equipment, medications and secondary cerebral
insults control (i.e. blood pressure, oxygenation, CO2 level, temperature, glycemia)
were collected from medical files. Two pediatric transport team experts assessed the
quality of pre-hospital care, based on two major endpoints.
Results Twenty-nine files were analyzed. Median ISS was 34 [9–75]. All the children
had been referred directly from the trauma scene to the pediatric trauma center. They
were all intubated in the pre-hospital setting, 4 (13.7%) presented with SpO2 < 90%
before or at emergency room admission, and 17 (58.6%) presented with a pCO2 >45 mmHg
at admission. At least one peripheral catheter was inserted in all the children. Mean
total fluid bolus was 26.9 mL/kg (± 14). Nor-epinephrine was administered in 16 (55%)
children. Mean blood pressure was below age threshold in 18 (62%) children during
transport or at admission. An intracranial hypertension treatment (apart from sedation)
was delivered in 17 (55%) children before admission. Body temperature was monitored
in 10 patients and 17 were hypothermic at emergency room admission. Experts concluded
on sub-optimal care in 17 children: major endpoint was “respiratory care”, “hemodynamic
care” and “neurologic care” in 13, 12 and 9 patients respectively.
Discussion On this small series, we showed pre-hospital sub-optimal care regarding
secondary cerebral insults control, especially regarding CO2 level, blood pressure
and body temperature. Our results will help to design new care improvement strategies
(e.g. sedation, fluid bolus and ventilation optimization, early use of vasoactive
drugs, systematic body temperature monitoring…).
Conclusion Data on pre-hospital secondary cerebral insults care are rare in the pediatric
setting. Based on our results, we aim to improve quality of care of children presenting
with traumatic brain injury, and to reduce its morbidity and mortality.
Competing interests None.
S48 Failure extubation in intensive care unit: risk factors, incidence and evaluation
of a mechanical ventilator weaning protocol
Lucie Petitdemange1, Anne Sophie Guilbert1
167, University De Strasbourg - Campus Médecine, Strasbourg, France
Correspondence: Lucie Petitdemange - lucie.petitdemange@outlook.fr
Annals of Intensive Care 2017, 7(Suppl 1):S48
Introduction Unsuccessful extubation from mechanical ventilation increases mortality
and morbidity. To reduce the extubation failures in our Intensive Care Unit we used
a mechanical ventilator weaning protocol, based on published data. During the first
part of the study, risk factors and incidence of extubation failure were first described.
Afterwards in the second part, our mechanical ventilator weaning protocol was tested
to determined its efficiency regarding the extubation failure.
Patients and methods A monocentric and observational study, was first conducted. We
included 245 children aged from birth to 18 old, during a period of 15 months and
collected for each patient their medical history, intubation and extubation parameters,
and existing events of extubation failure or extubation complication. The second part
of the study was prospective, we include 70 patients extubated by applying our mechanical
ventilator weaning protocol.
Results Average duration of mechanical ventilation was 51.6 h in the first part of
the study. Using a univariate analysis, duration of mechanical ventilation was a risk
factor of extubation failure with an average duration of 131.6 h in the group with
an extubation failure versus 40.8 h in the group without failure (p = 0.000005). Chronic
respiratory affection (OR 2.46 [1.04; 5.57] p = 0.049), and history of previous intubation
(OR 2.46 [1.26; 7.41] p = 0.005) were found to be failure extubation failure risk
factors. SaO2 was statistically lower for a higher FiO2 in the group with failure
extubation. Use of sedation did not change the risk of extubation failure except for
midazolam. Administration of benzodiazepine at the time of extubation significantly
increased extubation failure (OR 3.06 [1.07; 8.33]; p = 0.02).
In children intubated for respiratory or neurologic distress we observed more extubation
failures compared to children intubated for hemodynamic distress or surgical reasons
(p = 0.02).
Using a multivariate analysis, each mechanical ventilation additional hour increased
of 1.004 the risk of failure extubation [1.001; 1.0081] (p = 0.02). Extubation complications
increase by 10.86 the failure extubation risk [3.947; 29.907] p = 0.000004.
The mechanical ventilator weaning protocol in ICU strongly reduced the risk of extubation
failure (OR 4.55 [1.10; 40.35] p = 0.026). The number needed to treat with the protocol
to avoid one extubation failure is 12 patients. Our protocol did not change the average
duration of mechanical ventilation. (51.6 vs 48 h p = 0.07) neither the incidence
of extubation complications (17.1 vs 10% p = 0.19).
Discussion Our study confirms published data about extubation failure risk factor
like duration of intubation, chronic respiratory affection, history of previous intubation,
and the administration of benzodiazepine. It is the first pediatric study that shows
a reduction of extubation failure by using a specific mechanical ventilator weaning
protocol. The mean bias of our its retrospective and prospective character.
Conclusion Our study shows the interest of a mechanical ventilator weaning protocol
to reduce the incidence of extubation failure. We currently continue the apply our
protocol to include more patients in order to confirm our results.
Competing interests None.
S49 Problem diagnosis and management of stroke in children in the PICU of the hospital
establishment of canastel ORAN
Amel Zerhouni1, Djamila-Djahida Batouche2, Nadia Benatta3, Nabil Tabet Aoul4, Zakaria
Addou5, Nabil Aouffen6
1Reanimation, EHS CANASTEL, oran, Algeria; 2Réanimation pédiatrique, Centre Hospitalier
et Universitaire d’Oran, Oran, Algeria; 3cardiologie, Centre Hospitalier et Universitaire
d’Oran, Oran, Algeria; 4Réanimation pédiatrique canastel, Faculté de médecine d’Oran,
Oran, Algeria; 5Réanimation pédiatrique de Canastel d’oran, Departement de medecine
d’Oran Algerie, Oran, Algeria; 6Anesthésie réanimation pédiatrique, Etablissement
hospitalier spécialisé en pédiatrie Canastel, Oran, Algeria
Correspondence: Djamila-Djahida Batouche - khedidjabatouche@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S49
Introduction Stroke of the child is formidable though it is ten times rarer than in
adults, but this scarcity can have adverse consequences on the speed and quality of
the management and the consequences on later psychomotor development. Our goal is
to describe the clinical and therapeutic aspects of these pediatric stroke while bringing
our experience.
Patients and methods Retrospective study of cases of children hospitalized in general
intensive care unit to the pediatric hospital Canastel Oran for stroke during the
period from January 2014 to January 2016. The clinical, etiological, para clinical,
and scalable were studied and transcribed on a standard electronic form.All patients
had a brain CT. Magnetic resonance imaging(MRI) was possible in 02 patients for lack
of availability of the technical facilities during the study.
Results Ten cases were selected. The mean age was 64 months (1 month to 15 years),
66% are male, 2 patients had a history of CHD like tetralogy of Fallot and complicated
bronchiolitis myocarditis, one patient had a history of petechial purpura, 1 other
was a factor 7 deficiency, headache history was noted in 02 patients, and 04 patients
with no particular antecedent was found.
All patients arrived comatose 11/15 score on the scale of glasgow, isochores reactive
pupils with a motor deficit of hémicorps, 03 patients have degraded their neurological
score with onset of clinical signs of hypertension intra cranial namely anisocoria
and hypertension requiring osmotherapy, sedation and mechanical ventilation with an
average duration of 2–7 day. O1 child arrived brain dead, 03 patients had generalized
tonic–clonic seizures which yielded after taking a benzodiazepine (Diazepam) and phenobarbital
(like gardenal). Cerebral CT was performed in all cases and could we revealed the
nature of the stroke hemorrhagic in 07 cases and ischemic stroke in 03 cases. Two
patients have benefited from an MRI that found a thrombosis of the artery internal
carotid right Sylvian. Besides symptomatic treatment, treatment was initiated based
on the type of stroke, 03 patients received low molecular weight heparin (LMWH) at
0.1 ml/kg in addition to symptomatic treatment, 02 patients received vitamin K. Four
patients died in an array of autonomic disorders and evolved favorably and six patients
were transferred to a pediatric unit.
The average length of stay in ICU was 5.5 days (2–10 days).
Discussion The mortality rate is important since no specialized center for children,
and difficulty especially in the diagnostic imaging field while Suspected stroke should
be confirmed by imaging and the diagnostic delay. Which is due to a poor assessment
of the initial situation in half of the cases by the parents, the other half by the
Swiss magazine consulté.une doctor showed that in a study in 42% of children with
stroke, this diagnosis was not primarily discussed and that in 11% of cases the cause
of the stroke was poorly evaluated [1]. Heart disease certainly represent the second
most important risk factor. A collaboration of a team must be multidisciplinary, death
has affected mostly older children whose age is between 11 and 15 years, who have
a hemorrhagic stroke against by infants who have an ischemic stroke have evolved and
oriented they exceed the acute phase to pediatric services for further investigation
and monitoring.
Conclusion The child may also be having a stroke, which usually reaches the elderly.
This justifies a good knowledge of this disease, and multiply the initial management
efforts to reduce mortality and improve prognosis.
Competing interests None.
Reference
Steinlin M, Wehrli E. Berne. L’accident vasculaire ischémique en pédiatrie. Quand
y penser – quoi faire. Pediatrica. 20(2); 2009
S50 Bacterial nosocomial infections incidence in medicosurgical pediatric intensive
care unit
Anwar Armel1, Benqqa Anas1, Samira Kalouch2, Khalid Yaqini2, Aziz Chlilek2
1Anesthésie réanimation, CHU Ibn Rochd, Casablanca, Morocco; 2Service de réanimation
pédiatrique, Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Anwar Armel - armelanwar@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S50
Introduction Nosocomial infections are a main problem for public health for their
cost as well as for the morbidity and mortality they generate. They are particularly
common in intensive care units due to patient’s lower defenses and of invasive procedures
proliferation.
Work’s purpose:
Determine the epidemiology of bacterial noso-Comiales infections (IBN) in the medico-surgical
pediatric intensive care department of Children’s University Hospital of Casablanca.
To identify factors associated with these infections.
Patients and methods We led a retrospective study of hospitalized patients, spending
more than 48 h in medical-surgical pediatric intensive care department, at the University
Hospital Ibn Rochd of Casablanca, over a period of 12 months from 1 January 2015 to
31 December 2015.
Results During the studied period, 420 patients were admitted at intensive care with
a stay of more than 48 h.
Thirty episodes of INB were recorded. The incidence rate was 7.1% and the incidence
density was 20.6% per 1000 hospitalization’s days.
The admission average age was 4.6 ± 22-month starting from 1 month to 12 years with
a male predominance (60%).
Most of admissions (80%) was related to medical background, 50.3% received from other
hospital department.
Furthermore, 40% of the patients received prior antibiotics, usually prescribed before
ICU admission.
Invasive procedures (intubation, central catheterization) were used in 93.3% of patients,
VVP only in 6.66%, tracheotomy in 33.3 and 6.66% had received surgery.
Gram-negative bacilli (BGN) were isolated for a lot of patients, dominated by Acinetobacter
baumannii. These bacteria were isolated throughout the study year. Risk factors Analysis
underlined that the presence of invasive procedures enhances IN risk, that is central
venous catheter and the need for mechanical ventilation.
Conclusion Nosocomial bacterial infections are dominated by pneumonia and central
catheter infections, and are mainly due to BGN. The factors associated with these
infections were identified.
Competing interests None.
S51 Guillain–Barré syndrome mortality factors in pediatric intensive care
Anwar Armel1, Rchi Abdou2, Samira Kalouch3, Khalid Yaqini3, Aziz Chlilek3
1Département d’anesthésie réanimation, CHU Ibn Rochd Casa, Casablanca, Morocco; 2Anesthésie
réanimation, CHU Ibn Rochd, Casablanca, Morocco; 3Service de réanimation pédiatrique,
Chu Ibn Rochd, Casablanca, Morocco
Correspondence: armelanwar@gmail.com (Anwar Armel)
Annals of Intensive Care 2017, 7(Suppl 1):S51
Introduction The Guillain–Barré syndrome (GBS) is the most common cause of acute flaccid
paralysis in children since the acute anterior poliomyelitis eradication.
Few studies have been held on the topic and knowledge of GBS in children, although
it is recognized that the etiologic mechanisms, and clinicobiological background,
are the same as in adults, prognosis remains different.
Our work’s aim is to study this disease’s mortality factors of children hospitalized
in pediatric intensive care.
Patients and methods It is a retrospective, descriptive, mono centric study to review
35 patients with GBS between January 2009 and December 2015 and hospitalized at pediatric
intensive care department of AbderrahimHarouchi hospital of Casablanca.
The used software is SPSS 16.0 to compare the bivariate variables, we used the khi2
test, and to compare quantitative variables, the ANOVA to 1 factor test was used.
The level of significance was fixed at 5% with 95% confidence interval.
Results The disease was predominant in male with a sex ratio of 1.7 men/women. After
a prodromal event, usually infectious (95.7%) and a free interval of 15 days on average
to start motor disorders.
These are of two types: either a hypo or areflectic flaccid paralysis of the lower
limbs (25.7%) of ascending evolution in 91.4% of the cases. Either flaccid tetraplegia
or hypo areflectic, (74.3%).
Ventilation was required in 65.7% of the cases, and specific treatments based on immunoglobulins
were administered in 88.6% of the cases.
Death’s rate is still high (22.9%) and mainly due to hospitalization complications.
In our study respiratory disease was noted in 65.7% of the cases, also other signs
of serious illness such as swallowing disorders (71.4%) and autonomic disorders (14.3%)
also noted what led to management in intensive care for all our patients.
These patients study allowed to identify some mortality prognosis factors of the disease
in intensive care units (such as male gender, Ig administration duration, the occurrence
of autonomic disorders like blood pressure instability), the most discriminating remains
the occurrence of nosocomial infections.
Conclusion It must be underlined, that in view of our strict inclusion criteria, focusing
only on patients admitted at intensive care and of the relatively small sample size
(35 cases), our results must be qualified and must be enhanced by additional and more
varied studies to better understand this disease in children.
Competing interests None.
S52 Management of infantile refractory intracranial hypertension: decompressive craniectomy
versus medical therapy alone
Perrine Gravellier1, Julie Chantreuil1, Nadine Travers2, Antoine Listrat2, Claire
Le Reun1, Geraldine Favrais1
1Réanimation pédiatrique, Hôpital Clocheville, Centre Hospitalier Universitaire Tours,
Tours, France; 2Chirurgie pédiatrique de la tête et du cou, Hôpital Clocheville, Centre
Hospitalier Universitaire Tours, Tours, France
Correspondence: Julie Chantreuil - j.chantreuil@chu-tours.fr
Annals of Intensive Care 2017, 7(Suppl 1):S52
Introduction Early surgical treatment is recommended for refractory intracranial hypertension
(HTIC) in children to improve vital and functional prognoses, whether traumatic or
vascular cause. The main objective of this study was to compare the mortality and
morbidity of children with severe intracranial hypertension after severe head trauma
(TC) or due to vascular cause after decompressive craniectomy (DC) or medical therapy
alone. The secondary objective was to identify the initial severity factors associated
with higher mortality.
Patients and methods A retrospective study was performed with data collected from
patients aged under 18 years-old admitted to our pediatric intensive care unit for
severe intracranial hypertension of traumatic or vascular cause, between January 2000
and January 2016. They were divided into 2 groups: patients who received medical therapy
alone and those treated with decompressive craniectomy after optimal medical management.
Results A total of 83 children were included. Among them, 17 were treated with DC
(6 HTIC of vascular cause and 11 HTIC of traumatic cause), and 66 were supported by
medical means only (6 HTIC of vascular cause and 60 HTIC of traumatic cause).
In the population “traumatic intracranial hypertension”, we note that children in
the “DC” subgroup are more often in mydriasis upon arrival (p = 0.017) than in the
subgroup treated medically. In this same population, children in the “DC” subgroup
received higher doses of MIDAZOLAM (p = 0.015), of MANNITOL (p = 0.0041) and hypertonic
saline (p = 0.0006) than in the other subgroup. In the population “vascular intracranial
hypertension” the two subgroups were comparable.
In the case of traumatic intracranial hypertension, mortality rate in the “DC” subgroup
was 54.5% against 13.34% for children treated medically (p = 0.0015); “DC” children
had more metabolic complications such as hypernatremia than “not DC” children, p = 0.043.
Mortality rate in the «vascular intracranial hypertension» group was 0% for children
treated with decompressive craniectomy, and 83.3% for children treated medically alone
(p = 0.015). Patients treated surgically in the «vascular intracranial hypertension»
group had longer overall stays (p = 0.009) and longer ICU stays (p = 0.016). POPC
Score (Pediatric Overall Performance Category) upon discharge for children with intracranial
hypertension of traumatic cause treated with decompressive craniectomy was 4.91 ± 1.37
against 3.75 ± 1.31 among children treated medically, p = 0.08. In “DC” children with
intracranial hypertension of vascular cause, POPC upon hospital discharge was 3.66 ± 0.51
against 5.66 ± 0.81 among non-operated children, p = 0.007. The schooling rate was
higher among children treated medically for intracranial hypertension of traumatic
cause, p = 0.012. The severity factors related with higher mortality identified in
the population “traumatic intracranial hypertension” were mydriasis upon admission,
a PIM 2 score higher and a lower temperature (<35.5°); the latter being the only factor
identified for HTIC of vascular cause. In the case of traumatic intracranial hypertension,
ICP monitoring in survivors was 40.35% against 28.6% in children died, with no significant
difference. In the population “vascular intracranial hypertension”, all the patients
who died had not been monitoring PIC.
Discussion The severity factors related with higher mortality identified in the population
“traumatic intracranial hypertension” were mydriasis upon admission, a PIM 2 score
higher and a lower temperature (<35.5°); the latter being the only factor identified
for HTIC of vascular cause. Other studies have related other severity factors as initial
Glasgow scale, tardive decompressive craniectomy.
Conclusion Decompressive craniectomy doesn’t seem to improve the mortality rate or
the outcome in patients with hypertension of traumatic cause in our study but the
DC traumatic subgroup was more serious than the subgroup treated medically. In children
with refractory intracranial hypertension of vascular cause DC significantly improves
survival and outcome. Further studies are needed to clarify the role of decompressive
craniectomy and its timing in the therapeutic management of refractory intracranial
hypertension.
Competing interests None.
Reference
Wang R, Li M, Gao W–W, Guo Y, Chen J, Tian H–L. Outcomes of early decompressive craniectomy
versus conventional medical management after severe traumatic brain injury: a systematic
review and meta-analysis. Medicine (Baltimore). 2015.
S53 Myocardial dysfunction evaluation in pediatric brain death donor
Zoe Coppere1, Stéphane Blanot2, Juliette Montmayeur2, Régis Bronchard3, Stephane Rolando4,
Gilles Orliaguet2
1Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; 2Réanimation neurochirurgicale
pédiatrique, Hospital Necker, Paris, France; 3Agence de Biomédecine, Saint-Denis,
France; 4Service de régulation et d’appui, Agence biomedecine, Malakoff, France
Correspondence: Zoe Coppere - zozocop@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S53
Introduction Shortage of heart grafts is a major problem, leading to a significant
mortality rate in the national waiting list, essentially for young children with low
weight. The potential paediatric brain-dead donors often have myocardial dysfunction
(MD), which seems to be reversible.
The aim of this study is to assess prevalence, causes and consequences of MD when
the potential paediatric donors are taken over, up to multi-organ retrieval, and the
evolution after cardiac transplantation.
Materials and methods This observational, monocentric, retrospective study included
all brain-dead children aged 0–18 years old, who had their myocardial function assessed
through a cardiac ultrasound performed by a cardiologist and identified from 2004
to 2016. All adult patients and those who didn’t undergo a cardiac ultrasound were
excluded.
MD was defined as an LVEF ≤50% with or without abnormal segmented cinetic parameters.
The main evaluation criteria was the prevalence of MD in potential identified donors.
The secondary evaluation criteria were the causes and consequences of MD on heart
retrieval and the origin of this MD.
Results Out of 40 included patients, 11 had MD. Prevalence of MD was of 30%.
There was no significant difference between 2 groups regarding aetiology of brain
death nor administration of catecholamines. Having a cardiopulmonary arrest during
intensive care unit stay was associated with a significant risk of presenting a MD
(p = 0.034). Having a MD had no consequences on organ retrieval in general (p = 0.25),
but was significantly associated with a decrease in heart retrieval opportunities
(p = 0.036). The cause of heart grafts refusal was a poor ventricular function in
50% of cases (3 cases out of 6). The cause for non-retrieval was parental refusal
in one-third of cases. Evolution of the cardiac grafts was favorable in 16 cases on
18, one transplanted patient died (from a non-cardiac cause) and 1 patient was lost
to follow up.
Conclusion MD in paediatric brain-dead patients has direct consequences on heart retrieval
and transplantation, and otherwise, organ shortage is a major ongoing problem. A better
transplant management regarding hemodynamics (with the use of a protocol) could increase
the number of heart transplants, especially in small children, and reduce mortality
rate in national waiting list.
Competing interests None.
S54 Practice survey on prone positioning in French-speaking pediatric intensive care
units (medical part)
Pierre-Louis Leger1, Jérôme Rambaud1, Emilie Thueux1, Alexandra De Larrard1, Véronique
Berthelot1, Julien Denot1, Marie Reymond1, Alain Amblard1
1réanimation néonatale et pédiatrique, Hopital pour enfants Trousseau, Paris, France
Correspondence: Pierre-Louis Leger - leger.pierrelouis@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S54
Introduction The prone positioning (PP) is a strategy widely used in the treatment
of severe forms of acute respiratory distress syndrome (ARDS) in adults. Its early
use significantly reduces mortality (1). However, the studies do not strongly demonstrate
its prognostic impact in pediatric ARDS. The aim of this study was to describe the
prone positioning practices in the French-speaking pediatric intensive care units
(PICU).
Patients and methods This survey was conducted by email questionnaire to pediatric
intensivists belonging to the French Society of Intensive Care Medicine and the French-speaking
Group of Pediatric Intensive Care and Emergency Medicine. It was conducted From February
to May 2016. The survey was addressed to doctors, nurses, physiotherapists practicing
in PICU. It included 29 questions about indications, contraindications, techniques
and medical devices used, and complications.
Results One hundred and three persons answered (69 doctors and 33 nurses) which work
in 28 french hospitals and 1 canadian hospital. Sixty-eight percent of interviewed
persons have more than 5 years experience and 57% of them treat each year more than
10 children ARDS. Only 10% of the PICU have a PP medical protocol. Fifty percent of
interviewed persons frequently use PP for the medical care of ARDS and 30% systematically
use it. Thirty-six percent begin PP at the early phase of ARDS during conventional
ventilation, while 42% before the introduction of unconventional ventilatory strategies
(OHF); only 12% use it after the respiratory failure unless unconventional ventilatory
strategies. Seventy-three percent report that PP is used with prolonged periods (>12 h/day),
22% with short periods (<12 h/day) and 14% with very long periods (>20 h/day). Regarding
the weaning criteria, most of interviewed persons seem to use multiple and combinated
criteria: 51% use hypoxemia severity parameters (PaO2/FiO2, PaO2, SaO2), 39% use the
oxygen level (FiO2) and 38% use the mechanical ventilation parameters (PEEP, P max,
P plate). Finally, despite a low level of scientific evidence in children, 87% of
the persons gave a strong recommendation for PP as standard care in severe pediatric
ARDS. See Fig. 16.
Fig. 16
Criteria used to stop Prone positionin in the French-speaking Pediatric Intensive
Care Units
Discussion The survey confirmed the widely use of PP in pediatric ARDS. However, no
specific protocol is avalaible in most of the PICU. The timing of the PP beginning
can be different according to children, early and prior to use of the conventional
ventilation strategy in most cases. The duration of PP seems more consensual. Most
of the centers use extended periods longer than 12 h/day. These results are close
to Guérin et al. advocating a duration >16 h/day. Finally, the weaning is a great
issue and depends on multiple criteria. In Guerin et al. (2) PP was interrupted if
one of the following criteria were present: PaO2/FiO2 ≥ 150 mmHg, with PEEP of ≤10 cm
of water and a FiO2 of ≤0.6; decreased PaO2/FiO2 than 20%, compared to compared to
the supine position, or the occurrence of complications. No study has validated PP
weaning criteria during pediatric ARDS.
Conclusion The prone positioning is a strategy commonly used in pediatric intensive
care units for the severe pediatric ARDS. The criterias of implementation and timing
are variable, as well as the weaning criterias. More pediatric multicenter randomized
studies will be necessary to confirm the benefits of PP in pediatric ARDS and to define
clear weaning criteria.
Competing interests None.
References
Bloomfield R, Noble DW, Sudlow A. Prone position for acute respiratory failure in
adults. Cochrane Database Syst Rev. 11:CD008095.
Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning
in severe acute respiratory distress syndrome. N Engl J Med. 368(23):2159–68.
S56 Severe opportunistic infections in critically ill allogeneic bone marrow transplantation
recipients
Sarah Morin-Zorman1, Etienne Lengliné2, Claire Pichereau3, Eric Mariotte4, Canet Emmanuel5,
Virginie Lemiale6, Frédéric Pène7, Elie Azoulay6
1SAINT LOUIS, Paris, France; 2Hématologie, Hôpital Saint Louis, Paris, France; 3Réanimation
médicale, Hôpital Saint-Antoine, Paris, France; 4Service de réanimation médicale et
infectieuse, Hôpital Bichat-Claude Bernard-APHP, Paris, France; 5Réanimation médicale,
SAINT LOUIS, Paris, France; 6Réanimation médicale, Hôpital Saint-Louis, Paris, France;
7Réanimation Médicale, Hôpital Cochin, Paris, France
Correspondence: Sarah Morin-Zorman - smorinzorman@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S56
Introduction Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) recipients
have profound defects in every immunity compartments that can lead to severe opportunistic
infections (OI). 20% of HSCT patients require admission to the ICU because of diverse
infectious or non-infectious complications with dismal outcomes. OI specific course
in this population has not been described previously and the management of these infections
may be a concern. The aim of this study was to investigate risk factors, management
and outcomes of IO in HSCT recipients admitted to the ICU.
Patients and methods This was a retrospective (2007–2016) single center study of patients
admitted to ICU after an allogeneic HSCT. Patients provided written informed consent
according to Helsinki declaration. Data regarding the transplant, infections and life
sustaining therapy use were analyzed. OI were considered if present at the time or
during ICU admission.
Results Hundred and ninety-four patients (Pt) were included. Median age was 43 [28;
58] years, 63.2% were males. Reason for transplantation was acute leukemia in 84 (42%)
Pt and the hematological condition was still in complete remission at ICU admission
in 83% of patients. 78 (41%) and 53 (28%) had received a myeloablative conditioning
regimen and anti-thymoglobulin serum respectively. 40% had acute graft versus host
disease over grade 2 at ICU admission. OI was documented in 38 patients (20%). An
invasive fungal infection (IFI) was found in 19 Pt owing to 3 mucormucosis, 1 trichosporon
septicemia and 15 invasive aspergillosis (5 possible, 9 probable and 1 proven according
to EORTC criteria). Serum Galactomannane antigen was positive in 10 (67%). Median
time from transplantation and ICU admission to IFI diagnosis was respectively 86 [18;
529] and −3 [−8; 0] days. Lung was involved in 90% and patients with aspergillosis
were admitted to the ICU for acute respiratory failure in 71% (vs. 33% for others
p = 0.2). They did not required invasive ventilation more frequently (36 vs. 31% p = 0.8).
32 and 10% required vasopressors and renal replacement therapy with no difference
as compared to others. Median ICU length was 3 [2; 6] days. Demographic, stem cell
source, and donor type were not associated with IFI occurrence in this population.
However 15/19 had received a total body irradiation (78 vs. 47% p = 0.01). IFI occurrence
was not associated with ICU or Day 90 mortality (33 vs. 26% p = 0.7 and 53 vs. 41%
p = 0.3 respectively). A viral infection was found in 17 Pt owing to 11 CMV, 1 adenovirus,
1 HSV and 1 VRS infections. Analyses were focused on CMV reactivation. Median time
from transplantation and ICU admission to CMV reactivation was respectively 111 [50;
151] and −23 [−38; −10] days. Reactivation was mainly positive blood PCR but 1 pt
had CMV colitis. A preemptive treatment was started on the same day in median and
lasts 34 [21; 71] days. Patients with CMV reactivation had more frequently multiple
organ failure (50 vs. 22% p = 0.06) and higher ICU admission SOFA score (7 [5; 12]
vs. 6 [3–8] p = 0.05). They trend to have higher admission creatinine serum level
(132 [72; 157] vs. 81 [60; 120] umol/L, p = 0.2) and more frequently required emergency
renal replacement therapy (36 vs. 7% p = 0.01) mechanical ventilation (64 vs. 30%
p = 0.04) and vasopressors (73 vs. 37% p = 0.02). Median ICU length was 4 [2; 11] days
and comparable to others. Demographic, stem cell source, conditioning regimen and
donor type were not associated with CMV occurrence. CMV reactivation was not significantly
associated with ICU or Day 90 mortality (36 vs. 26% p = 0.5 and 60 vs. 41% p = 0.3
respectively).
Conclusion OI was found in 20% of allogeneic HSCT recipients admitted to the ICU.
IFI were mainly responsible for respiratory distress and CMV associated to multiple
organ failure. Non-invasive diagnostic tests were positives in a majority of these
patients. In this cohort, IO treatment was started quickly after the diagnostic and
we did not find an association with mortality. Intensivists should always consider
OI in their diagnostic panel in this specific population.
Competing interests None.
S57 Opportunistic infections in patients with solid tumors: a systematic review
Julien Poujade1, Elie Azoulay2
1Service de réanimation médicale, Hôpital Saint-Louis (AP-HP), Paris, France; 2Réanimation
médicale, Hôpital Saint-Louis, Paris, France
Correspondence: Julien Poujade - julien.poujade236@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S57
Introduction Over the last two decades, targeted therapies in patients with solid
tumors have both increased their length of survival and significantly altered their
immune functions. However, data on opportunistic infections in this setting remain
scarce. In this systematic review, we sought to identify published cases of opportunistic
infections in patients with solid tumors, with a special interest on clinical findings,
trends over time and outcomes.
Materials and methods We performed a search of Medical Subject Headings (MeSH) on
PubMed using the words pneumonia pneumocystis (PCP), invasive aspergillosis (IA),
histoplasma, mucor, geotrichum, cryptococcus, coccidioidomycosis combined with the
MeSH term neoplasms (breast, lung, ovarian, urologic gastrointestinal, digestive system,
abdominal, brain, carcinoid tumor, sarcoma, testicular, seminoma). We identify published
cases of opportunistic infections in non HIV patients with solid tumors between 01/01/1966
and 05/01/2016 included.
Results Regarding Pneumocystis jirovecii pneumonia, 94 cases could be identified.
There were 32 men and 62 women, aged of 57.5 (19–80) years. Underlying tumors were
chiefly brain neoplasms (n = 31, 33%), lung neoplasms (n = 24, 26%) and breast neoplasms
(n = 16, 17%). At the time of Pneumocystis pneumonia onset, 52 patients (55%) had
a history of chemotherapy, 58 (62%) had received long term or high dose steroids,
and 21 (22%) had an history of biotherapy targeting the malignancy. Of note, 18 patients
(19%) had received only chemotherapy, 17 (18%) had received steroids alone, 4 (4%)
everolimus therapy alone and 3 (3%) received none of these treatments. Regarding invasive
aspergillosis 64 cases could be identified. Mean age was 66.7 (37–82) and 46 (72%)
were men. Solid tumors associated with invasive aspergillosis were primarily lung
neoplasms (n = 31, 48%) and brain neoplasms (n = 24, 38%). At aspergillosis onset,
38 (59%) patients had a history of chemotherapy, 29 (45%) were receiving long term
or high dose steroids and 3 (5%) had received targeted therapy. Fourteen (22%) patients
had received only chemotherapy, 2 (3%) only steroids, and 1 (1.5%) had received targeted
therapy alone.
For both infection, there was a trend for a higher number of reported cases throughout
the studied period.
Conclusion This systematic review provides objective data showing that an increased
proportion of patients with solid tumors present with opportunistic infections. We
are convinced that it is a clinically relevant but still neglected problem. Selected
oncologic population may be becoming eligible for antimicrobial prophylaxis against
Pneumocystis or Aspergillus.
Competing interests None.
S58 Invasive aspergillosis in non-immunocompromised patients hospitalized intensive
care unit
Guillaume Trumpff1, Max Guillot2, Thierry Braun2, Ralf Janssen-Langenstein2, Marie-Line
Harlay2, Jean-Etienne Herbrecht2, Quentin Maestraggi3, Baptiste Michard4, Maleka Schenck2,
Francis Schneider2, Vincent Castelain5
1Anesthésie-réanimation, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg,
France; 2Réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg,
France; 3Service de réanimation médicale, Hôpital de Hautepierre du C.H.R.U, Avenue
Molière, Strasbourg, France, Strasbourg, France; 4Service de réanimation médicale,
Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France;
5Hautepierre réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg,
France
Correspondence: Guillaume Trumpff - trumpffguillaume@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S58
Introduction Characteristics and outcomes of adult patients with invasive aspergillosis
in intensive care unit have rarely been described.
Materials and methods We performed a retrospective study on consecutive adult patients
with invasive aspergillosis who were admitted form January 2010 through January 2016
to the intensive care unit of Strasbourg in France. Patients were included only if
they are non-immunocompromised according to the European Organisation for Research
and Treatment of Cancer (EORTC). Invasive aspergillosis was defined as an association
of microbiological evidence, a radiological imaging and a clinical context.
Results Eighteen patients (13 males) were identified during the study period. The
median of IGS II was 60.5 (interquartile range (IRQ), 49.25–78.75). Ninety-four percent
was under mechanical ventilation. Fourteen (78%) patients were suffering from liver
failure. Among liver failure, twelve (86%) were beforehand suffering from cirrhosis.
The median MELD score was 42 (interquartile range (IRQ), 30–53). Sixty-four percent
of aspergillosis were due to Aspergillosis fumigatus. Hundred percent were pulmonary
aspergillosis. Fifty-six percent of aspergillosis were associated with bacterial pneumonia.
The mortality rate at the date of the latest news (an average of 2 years) was seventy-two
percent.
Discussion Invasive aspergillosis is not exceptional in the non-immunocompromised
patient especially in patient developing liver failure. An active research of colonization/infection
with aspergillus in these patients remain to be discussed.
Conclusion Invasive aspergillosis in ICU has a poor prognosis. The liver failure seems
to be the most important risk factor in non-immunocompromised patients according EORCT
criteria.
Competing interests None.
S60 Invasive fungal infection after liver transplantation: diagnostic value of 1,3-beta-d-glucan
(BG)
Noorah Zaid1, Nawel Ait-Ammar2, Christine Bonnal2, Jean-Claude Merle1, Francoise Botterel2,
Eric Levesque1
1Anesthesia and intensive care medicine, CHU Henri Mondor, Créteil, France; 2Unité
de parasitologie-mycologie, département de virologie, bactériologie-hygiène, parasitologie,
hopital henri mondor, Créteil, France
Correspondence: Eric Levesque - eric.levesque@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S60
Introduction Liver transplant recipients have high rate of Invasive Fungal Disease
(IFD) with high morbidity and mortality, in part due to its delayed diagnosis. The
fungal cell wall component (1,3)-beta-d-glucan (BG) is a biomarker for fungal infection
but its utility remains uncertain. This prospective study was designed to review our
experience in IFD and to evaluate the impact of BG in the diagnosis of IFD.
Patients and methods From January 2013 to May 2016, 271 liver transplantation were
performed in our institution. Serum samples were tested for BG (Fungitell; Cape Cod
Inc., USA) least weekly between liver transplantation and their discharge from hospital.
IFD was defined as proposed by the European Organization for research and treatment
of Cancer/mycoses study group.
Results Nineteen patients (7%) were diagnosed with IFD including 13 cases of Candidiasis
infection (CI) in eleven out of 271 patients, 8 invasive pulmonary aspergillosis (including
one who had previously CI) and one case of septic arthritis of the hip caused by Scedosporium
spp. IFD was associated with significantly high mortality (log-rank p = 0.003). The
area under the ROC curves, for BG to predict IFD, was 0.78 (95% CI 0.73–0.83). Using
a cutoff of 139 pg/ml, the most discriminative cut-off point from the ROC curve, The
sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive
Value (NPV) values of BG for overall IFD was 68% (95% CI, 59–77), 79% (95% CI, 76–78),
24% (95% CI, 19–30) and 96% (95% CI, 95–97).
Conclusion Based on its high NPV, BG value appears to be a good biomarker to rule
out the diagnosis of IFD when the value is below 139 pg/ml. A single point BG may
guide the investigation and the decision to start antifungal therapy in patients at
risk for IFD.
Competing interests None.
S61 Monitoring of changes in lung and chest wall mechanics in the supine, lateral
and prone positions during the prone positioning maneuver in ARDS patients
Zakaria Riad1, Mehdi Mezidi1, Hodane Yonis1, Mylène Aublanc,1, Sophie Perinel-Ragey,1,
Floriane Lissonde1, Aurore Louf-Durier,1, Romain Tapponnier1, Jean-Christophe Richard1,
Bruno Louis,2, Claude Guérin1, PLUG working group
1Réanimation médicale, Hôpital de la Croix-Rousse, Lyon, France; 2Inserm, u955, equipe
13, équipe biomécanique cellulaire et respiratoire, Université Paris-Est Créteil -
Faculté de médecine, Créteil, France
Correspondence: Zakaria Riad - zakaria.riad@icloud.com
Annals of Intensive Care 2017, 7(Suppl 1):S60
Introduction Chest wall elastance (Ecw) has been found to increase in prone (PP) as
compared to supine position (SP) in ARDS patients [1]. This makes respiratory system
elastance (Ers) not reflecting lung elastance (El). Little is known about the changes
of Ecw, El and lung resistance (Rl) when moving the patient from the SP to the PP
via the lateral position (LP). The goal of present study was to measure Ecw, El and
Rl in ARDS patients in SP, LP and PP during the proning procedure.
Patients and methods It was a prospective, single-center, controlled study. ARDS patients
intubated, sedated and paralyzed with PaO2/FiO2 ratio < 150 mmHg, PEEP ≥ 5 cmH20 and
an indication of PP were included. Mechanical ventilation was delivered in volume
controlled mode with constant flow inflation and end-inspiratory pause 0.100 s included
into the inspiratory time. Ventilator settings were unaltered during the procedure.
An esophageal balloon catheter (Nutrivent device) was used for esophageal pressure
(Pes) measurement. Pressure at the airway opening (Pao) and airflow were measured
by Fleish 2 pneumotachograph proximal to endotracheal tube and upstream Heat and Moisture
exchanger. Pao, Pes and airflow were continuously measured during 30 min in SP, then
during 1 min in LP and 30 min in PP. The side for the lateralization was that selected
by routine practice (in the opposite side from central venous line). Ers and resistance
of the respiratory system (Rrs) were obtained by fitting flow and Pao signals breath
by breath to the first order equation. Ecw and resistance of the chest wall (Rcw)
were similarly obtained by fitting flow and Pes signals breath by breath to the first
order equation pertaining to the chest wall. El and lung resistance (Rl) were obtained
by subtracting Ers and Rrs from Ecw and Rcw, respectively. Our ethical committee approved
the protocol. Data are shown as median (first and third quartiles). Comparisons between
positions were made by using paired-t-test.
Results Twenty-nine patients, 19 males, of 68 (62–74) years, SAPS 2 45 (34–55) and
SOFA score 7 (3–9) were included 1 (0–2) days after ARDS criteria were met. The ARDS
severity was moderate in 25 cases (86%) and severe in 4 (14%). Tidal volume averaged
5.9 (5.6–6) ml/kg predicted body weight, PEEP 10 (10–10) cmH2O, FiO2 60 (50–70) %,
PaO2/FiO2 122 (108–139) mmHg. The cause of ARDS was pulmonary in 21 cases (72%), extra
pulmonary in 3 (10%) and undetermined in 6 (18%). Lateral positioning was on the right
side in 14 (48.3%) and on the left side in 15 patients (51.7%). The results are shown
in the Table 21.
Table 21
Respiratory mechanics during the proning procedure
SP
LP
PP
Ecw (cmH2O/L)
9.6 (6.5–12.5)
10.5 (6.9–13.3)
11.3 (7.3–13.3)**
El (cmH2O/L)
27.7 (21.7–43.9)
30.8 (23.5–44.5)
31.3 (23.0–47.0)
Rl (cmH2O/L/s)
13.6 (11.2–16.0)
14.2 (12.2–17.5)**
14.7 (13.2–17.0)
** p < 0.01 versus supine
Conclusion During prone positioning in ARDS patients, as compared to SP we observed
a higher RL in LP and an increased Ecw in PP.
Competing interests None.
Reference
Pelosi P, et al. Effects of the prone position on respiratory mechanics and gas exchange
during acute lung injury. Am J Respir Crit Care Med. 1998;157(2):387–93.
S62 Effects of neuromuscular blockers on trans pulmonary pressures in moderate-to-severe
acute respiratory distress syndrome
Christophe Guervilly1, Jean-Marie Forel1, Magali Bisbal2, Samuel Lehingue1, Malika
Mechati3, Jeremy Bourenne4, Gilles Perrin4, Romain Rambaud1, Mélanie Adda1, Sami Hraiech1,
Elisa Marchi1, Antoine Roch1, Marc Gainnier4, Laurent Papazian1
1Réanimation des détresses respiratoires et infections sévères, Hôpital Nord APHM,
Marseille, France; 2Reanimation, Institute Paoli-Calmettes, Marseille, France; 3Réanimation
des détresses respiratoires et infections sévères, Hôpital Nord APHM, Toulon, France;
4Reanimation des urgences et medicale, CHU la Timone 2, Marseille, France
Correspondence: Christophe Guervilly - christophe.guervilly@ap-hm.fr
Annals of Intensive Care 2017, 7(Suppl 1):S62
Introduction Neuromuscular Blocking Agents (NMBA) could exert beneficial effects in
Acute Respiratory Distress Syndrome (ARDS) through properties on respiratory mechanics
and particularly in modifying transpulmonary pressures (PL).
Patients and methods Prospective randomized control study in moderate to severe ARDS
patients within the first 48 h of the onset of ARDS. All patients were monitored by
an esophageal catheter and followed during 48 h. Moderate ARDS patients were randomized
in two groups according to the systematic administration of a 48 h continuous infusion
of cisatracurium besylate or not (control group). The severe ARDS patients group received
a 48 h continuous infusion of cisatracurium besylate. The evolution during the 48 h
of the study of the oxygenation and the respiratory mechanics including inspiratory
and expiratory transpulmonary pressures and driving pressure were assessed and compared.
Delta transpulmonary pressure (∆PL) was defined as inspiratory PL minus expiratory
PL.
Results Thirty patients were included, 24 in the moderate ARDS group and 6 in the
severe ARDS group. NMBA infusion was associated with an improvement in oxygenation
both the moderate and the severe ARDS patients group accompanied by a decrease in
both the plateau pressure and the total positive end expiratory pressure. The mean
inspiratory and expiratory PL were higher in the moderate ARDS patients group receiving
NMBA as compared with the control group (Fig. 17). In contrast, there was no modification
of both the driving pressure and the ∆PL related to NMBA administration.
Fig. 17
Mean pooled values of Pplat, PEEP tot, ∆P, PL insp, PL exp in moderate ARDS, excluding
baseline values, shown as mean and standard deviation
Conclusion NMBA could exert beneficial effects in moderate ARDS patients through higher
observed inspiratory and expiratory transpulmonary pressures.
Competing interests None.
S63 Prone position: impact on intracranial pressure and cerebral perfusion pressure
in ARDS patients with brain injury
Jeremy Bourenne1, Vincent Guerin1, Gilles Perrin2, Lucas Benarous3, Fouad Bouzana1,
Dominique Lambert1, Sami Hraiech4, Laurent Papazian5, Marc Gainnier1
1Service de réanimation des urgences et médicale, Hôpital Timone Adulte, Marseille,
France; 2Réanimation urgence et médicale pr auffray, Hôpital de la Timone, Marseille,
France; 313, Hôpital Timone adulte, marseille, France; 4Réanimation DRIS, Hôpital
Nord APHM, Marseille, France; 5Service de réanimation-détresses respiratoires et infections
sévères, Hôpital Nord, Marseille, France
Correspondence: Jeremy Bourenne - jeremy.bourenne@ap-hm.fr
Annals of Intensive Care 2017, 7(Suppl 1):S63
Introduction Prone position (PP) is a major treatment in management of acute respiratory
distress syndrome (ARDS). The use of PP in patients with severe ARDS associated with
brain injury is at high risk of intracranial hypertension.
The aim of this study is to analyze the effect of PP on intracranial pressure (ICP)
and cerebral perfusion pressure (CPP) in patients with ARDS and acute neurological
condition requiring monitoring of ICP.
Patients and methods It is a retrospective descriptive study including sixteen patients
with acute brain injury (subarachnoid hemorrhage, severe head trauma, and hemorrhagic
stroke) and continuous monitoring of ICP who developed a severe ARDS during ICU stay
from January 2012 to December 2015 and for which PP was performed. 29 PP sessions
were analyzed. Hemodynamic and respiratory parameters, blood oxygenation, PIC and
PPC were studied in supine, before PP and after PP. The study was approved by FICS
ethic comity.
Results A significant increase in PaO2/FiO2 ratio was observed in PP, from 112 ± 34
to 200 ± 84 (p < 0.01). In PP, the ICP was increased 11 ± 1.1–17 ± 1.3 mmHg (p < 0.05)
while the CPP was stable 74 ± 2 versus 76 ± 2 mmHg (NS). Median duration of PP session
was 16 h (12–20). Increasing of ICP during PP required medical treatment in 8 sessions
(27%). PP session was interrupted in 6 sessions (20%). In subgroup of patients who
respond to PP in terms of oxygenation, the increase of ICP was lower than in non-responders
(43 vs 118%) (p < 0.05). CPP was not modified whatever the nature of the response
to PP (76 ± 15–77 ± 11 in non-responders and from 73 ± 10 to 76 ± 10 in responders
(NS)) (Fig. 18).
Fig. 18
Evolution from ICP and CPP during the first PP session, according to the response
Discussion Our study shows an improvement of oxygenation during PP in severe ARDS
patient with acute brain injury. We observe a constant increment of PIC during PP
sessions. The increment of ICP is less in responders to PP.
Significant increased ICP requiring an enhancement in the medical treatment was observed
in 30% of the cases, and lead in most cases to a discontinuation of the session. Our
data underlined the absolute necessity to monitor ICP during PP session in patients
with acute brain injury and ARDS, even if ICP is controlled previously in supine.
Only 3 prospective (1, 2) and one retrospective studies evaluate the effects of PP
on ICP in patients with acute brain injury and acute respiratory failure (ARF). They
results are similar to ours. In all these studies, the severity of ARF was often not
well specified. Roth and al. (2) had included only 10% of ARDS in a population of
patient with ICP not controlled. In others studies, monitoring of ICP during PP was
not systematic.
Despite the retrospective nature of the study and the small number of patients, it
is the only work studying the effects of PP on intracranial pressure in patients with
acute brain injury at risk for intracranial hypertension and severe ARDS according
to the Berlin’s definition.
Conclusion Our work suggest that PP is a quite secure technique for use for the treatment
of severe ARDS even patients at risk of intracranial hypertension with a benefit in
terms of oxygenation without major increase of ICP particularly in PP responders.
Competing interests None.
References
Roth C, Ferbert A, Deinsberger W, Kleffmann J, Kästner S, Godau J, et al. Does prone
positioning increase intracranial pressure? A retrospective analysis of patients with
acute brain injury and acute respiratory failure. Neurocrit Care. 2014;21(2):186–91.
Thelandersson A, Cider A, Nellgård B. Prone position in mechanically ventilated patients
with reduced intracranial compliance. Acta Anaesthesiol Scand. 2006;50(8):937–41.
S64 Bacterial co-infection in influenza-associated ARDS supported by ECMO
Sacha Rozencwajg1, Matthieu Schmidt1, Guillaume Hekimian1, Nicolas Bréchot1, Jean
Louis Trouillet1, Guillaume Lebreton2, Sébastien Besset,1, Guillaume Franchineau1,
Ania Nieszkowska1, Leprince Pascal2, Alain Combes1, Charles-Edouard Luyt1
1Service de réanimation médicale, Groupe Hospitalier Pitié-Salpêtrière, Institut de
Cardiométabolisme et Nutrition, Paris, France; 2Service de chirurgie thoracique et
cardiovasculaire, Groupe Hospitalier Pitié Salpêtrière, Paris, France
Correspondence: Sacha Rozencwajg - sacha.rozencwajg@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S64
Introduction Influenza-associated acute respiratory distress syndrome (ARDS) requiring
extracorporeal membrane oxygenation (ECMO) support is known to have a good prognosis
(1). However, the incidence and impact of co-infection in this setting remain unknown.
Patients and methods We conducted a retrospective, observational analysis of data
prospectively collected from all patients admitted to our medical ICU who received
ECMO support for influenza-associated ARDS between 2009 and 2016. Co-infection was
defined as isolation of a pathogen in the lower respiratory tract at a significant
level or in the blood during the 48 h following hospital admission. When no pathogen
was identified in a patient receiving antibiotics prior to bacteriological sampling,
an independent adjudication committee reviewed all charts to assess if the patient
had a “high probability” or “low probability” for bacterial co-infection, based on
clinical, radiological and biological results available. Results are presented as
median [IQR].
Results Among the 116 patients hospitalized for an influenza-associated infection
in our ICU, 77 had an ARDS requiring support by either veno-venous- (VV, n = 58),
venoarterial (VA, n = 15) or venoarterio-venous- (VAV; n = 4) ECMO. Co-infection occurred
in 39 (51%) patients, Staphylococcus aureus (18 patients [46%]) being the most prevalent
pathogen. Panton-Valentin leucocidin (PVL) was present in 10 (56%) of S. aureus co-infection,
representing 26% of all co-infections. Compared to primary viral pneumonia, co-infected
patients had a lower BMI (26 [24–30] vs 31 [8–38] kg/m2; p < 0.0001), a higher Sequential
Organ Failure Assessment (SOFA) score before ECMO start (16 [14–18] vs 12 [10–16];
p = 0.001), and received less antibiotics before hospital admission (26 vs 51%; p = 0.03).
No differences were observed in age, comorbidities, ARDS management before and after
ECMO, influenza characteristics (genotype, sub-type, neuraminidase inhibitors use,
delay between symptoms onset and hospital or ICU admission), ECMO management (timing
of initiation, VV-, VA or VAV- configuration). Co-infection was associated with increased
ICU mortality (62 vs 29%; OR 3.93; 95% CI [1.51–10.18], p = 0.0059), lower ECMO free
days at day 60 (0 [0–23] vs 23 [0–46]; p = 0.006) and lower mechanical ventilation
free days at 60 days (0 [0–0] vs 6 [0–35]; p = 0.003). Multivariable analysis retained
age >49 years (OR 8.2; 95% CI 2.3–29.9), pre-ECMO SOFA score >14 (OR 6.2; 95% CI 1.9–19.8)
as independent predictors of hospital mortality, but not co-infection (OR 2.5, 95%
CI 0.8–7.9). In a second analysis, patients with proven co-infection and high probability
of co-infection were grouped and compared to patients with no co-infection and low
probability of co-infection; and results were similar. As compared to others co-infected
patients, those co-infected with a PVL-positive S. aureus had same characteristics
and similar mortality rate, but all received a treatment active against PVL production.
Conclusion Co-infection is frequent in patients with influenza-associated ARDS supported
by ECMO, occurring in roughly 50% of the cases. Mortality of patients with co-infection
is higher than those without, but seems mainly due to the severity of the disease.
S. aureus was the most frequently identified pathogen, with a high prevalence of PVL-positive
S. aureus, Infection with a PVL-positive strain was not associated with a poorer outcome
as compared to other co-infections. Whether a treatment active against PVL production
should be given in those patients remains to be determined.
Competing interests None.
S65 Acute respiratory failure (ARF) in patients with systemic rheumatic disease
Maud Loiselle1, Guillaume Dumas2, Guillaume Geri3, Chemam Sarah4, Dangers Laurence5,
Claire Pichereau6, Julien Mayaux7, Maleka Schenck8, Boisramé-Helms Julie8, Thomas
Guillemette9, Claude Guérin10, Sylvie Chevret11, Jean-Daniel Chiche3, Elie Azoulay2
1Réanimation médicale, Hôpital Saint-Louis (AP-HP), Paris, France; 2Réanimation médicale,
Hôpital Saint-Louis, Paris, France; 3Réanimation Médicale, Hôpital Cochin, Paris,
France; 4Réanimation médicale, Hôpital Bichat-Claude Bernard (AP-HP), Paris, France;
5Réanimation médicale, Pitié-Salpêtrière Hospital, Paris, France; 6Réanimation médicale,
Hôpital Saint-Antoine, Paris, France; 7Réanimation médicale, Hôpital Pitié-Salpêtrière,
Paris, France; 8Réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg,
Strasbourg, France; 9Service de réanimation-détresses respiratoires et infections
sévères, Hôpital Nord, Marseille, France; 10Réanimation médicale, Hôpital de la Croix-Rousse,
Lyon, France; 11Service de biostatistique et information médicale, Hôpital Saint-Louis,
Paris, France
Correspondence: Maud Loiselle - maud.loiselle@outlook.fr
Annals of Intensive Care 2017, 7(Suppl 1):S65
Introduction Systemic rheumatic diseases (SRD) are autoimmune diseases that are rare
but cause substantial morbidity and mortality. SRDs chiefly affect the lungs, however,
data on critically ill patients with SRD admitted for ARF are scarce.
Patients and methods Retrospective cohort conducted in 10 French ICUs (2009–2013)
and prospectively completed in the coordinating center until June 2016. Demographic,
clinical and therapeutic data were collected. Predictors of hospital mortality were
identified by multivariable logistic regression.
Results 226 patients totalizing 237 ICU admissions were included (median age 61 [47–71] years,
female gender 62%). SRDs were connective tissue diseases in 63% of cases (Systemic
sclerosis 19.5%, Systemic lupus erythematous 18%) and systemic vasculitis in 31% of
cases. Nearly 5% of patients had antiphospholipid syndrome. Time since SRD onset was
7.5 [2.0–15.8] years with median involvement of two organs [1.0–4.0]. The major comorbidities
were cardiovascular (49%), tobacco exposure (25%), chronic kidney disease (18%) and
neoplasia (15%). Two-thirds of patients were on systemic corticosteroids at admission,
the median dose of 10 (IQR) mg per day. SRD diagnosis was made in the ICU in 11.5%
of patients.
Clinically or microbiologically documented bacterial pneumonia was the leading ARF
etiology (40.9%). In 32% of cases, ARF was related to an opportunistic infection (mainly
Aspergillus (n = 8) and Pneumocystis (n = 7)). Others ARF etiologies included specific
lung involvement (23.2%) and cardiac pulmonary edema (20.7%).
SOFA on day one was 5 [3–9]. Associated organ dysfunctions were mainly hemodynamic
(42%) and renal (45%). Mechanical ventilation was needed in 68% of patients (non invasive
only in 17.3% or invasive in 82.7%), 40% needed vasopressors, and 30% renal replacement
therapy. Systemic corticosteroids were started in 20% of patients and 23% of patients
received pulse steroids. Cyclophosphamide and plasma exchange were required in 10
and 11% of patients, respectively.
Length of ICU stay was 7 [4–14] days. ICU-acquired infection occurs in 25% of cases.
In total, 59 patients (24.9%) died throughout the ICU stay. ARF etiology was not associated
with mortality. By multivariate analysis, shock on admission (OR 6.25 [2.71–14.40],
p < 0.001) and the use of invasive mechanical ventilation (OR 5.06 [1.84–13.94], p = 0.02)
were independently associated with mortality, whereas non-invasive ventilation was
associated with decreased mortality (OR 0.31 [0.12–0.81], p = 0.02). By considering
among the connective tissue diseases, the groups of myositis and scleroderma (n = 61),
these diseases were associated with a trend for a higher mortality (OR 2.08 [0.95–4.55],
p = 0.06).
Conclusion In patients with SRD, ARF is associated with a high case fatality, primarily
when mechanical ventilation is needed. Particular attention must be given to specific
SRD-sub groups for which pulmonary flare may require intensive immunosuppression.
Competing interests None.
S67 Pneumonia during pregnancy and the post partum period: a reappraisal of etiologies
requiring intermediate or intensive care—a retrospective study through the CUBREA
network
Alice Jacquens1, Sebastien Kerever2, Bertrand Guidet3, Philippe Aegerter4, Vincent
Das5, Alain Cariou6, Muriel Fartoukh7, Jan Hayon8, Alain Combes9, Etienne De Montmollin10,
Christian Richard11, Mathieu Desmard12, Bruno Megarbane13, Jean-Pierre Fulgencio7,
Benjamin Zuber14, Benjamin Sztrymf15, Jean-Damien Ricard16, Jonathan Messika17, Cubrea
network
1Réanimation médico-chirurgicale, Hôpital Louis-Mourier - APHP, Colombes, France;
2Département d’anesthésie réanimation, GH St Louis/Lariboisière AP-HP, Paris, France;
3Réanimation Médicale, Hôpital Saint-Antoine, Paris, France; 4Urc, Hospital Ambroise
Paré, Boulogne-Billancourt, France; 5Réanimation polyvalente adulte, Centre Hospitalier
Intercommunal André Grégoire, Montreuil, France; 6Réanimation Médicale, Hôpital Cochin,
Paris, France; 7Réanimation médico-chirurgicale, Hôpital Tenon, Paris, France; 8Réanimation
polyvalente, CHI Poissy-St Germain, Poissy, France; 9Service de Réanimation Médicale,
Groupe Hospitalier Pitié Salpêtrière, Paris, France; 10Réanimation, C.H. Général Saint
Denis hôpital Delafontaine, Saint-Denis, France; 11Réanimation médicale, CHU de Bicêtre,
Le Kremlin Bicêtre, France; 12Réanimation polyvalente, Centre Hospitalier Sud Francilien,
Boulevard Jean Jaurès, Corbeil-Essonnes, France, Corbeil-Essonnes, France; 13Service
de Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; 14Intensive
care unit, Hospital Center De Versailles, Le Chesnay, France; 15Réanimation polyvalente,
Hôpital Antoine Béclère, Clamart, France; 16Service de Réanimation Médico-Chirurgicale,
CHU Louis Mourier, Colombes, France; 17Service de réanimation médico-chirurgicale,
CHU Louis Mourier, Colombes, Colombes, France
Correspondence: Jonathan Messika - jonathan.messika@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S67
Introduction Infections are among the main causes of non-obstetric morbidity and mortality
during pregnancy and the postpartum period, and the second causes of intensive care
unit (ICU) admissions for non-obstetric reasons. Among those, pneumonia is of particular
interest, as pregnancy impairs the ventilatory function, and blunts the immune response.
In addition, pneumonia might increase fetal morbi-mortality. We, therefore, sought
to investigate the epidemiology of community-acquired pneumonia (CAP) occurring during
pregnancy or postpartum (until 6 weeks postpartum) requiring ICU or intermediate care
unit admission.
Patients and methods We conducted a retrospective multicenter observational study
in 41 Paris and suburban area ICUs participating in the CUBREA database (January 2005–December
2014). Women were identified through the ICD-10 database with an obstetric code (O00–O99
or Z35–Z39) and an acute respiratory failure (J96) or pneumonia code (J10–J22). Charts
were reviewed. The primary outcome was to determine the rate of CAP diagnoses within
this population admitted for acute respiratory failure. The secondary outcomes were
to compare CAP and non-CAP women, regarding comorbid conditions, ICU course, therapies
and fetal outcome; and finally to describe the etiologies of CAP episodes.
Results Our search retrieved 367 women pregnant or during the postpartum period. Seventy-one
of those (22.5%) had a CAP, and had been admitted in the intermediate (11; 15.5%)
or intensive (60; 84.5%) care units. CAP women had a median age of 32 years [28–37]
(vs. 32 [27–36] for non-CAP), and a median SAPSII score of 21 [13–29] (vs. 23 [16–41]
for non-CAP). Thirty-four harbored at least one comorbid condition (47.9 vs. 36.9%;
p = 0.10), and they were more frequently active smokers (14.7 vs. 7%; p = 0.044) than
non-CAP women. Fifty-one CAP women were admitted during prepartum (71.8 vs. 36.21%
for non-CAP; p < 0.0001), 7 in intermediate care unit, and 44 in ICU, at 31 weeks
[26–33] of gestational age, while 20 (4 in intermediate care unit, and 16 in ICU)
were admitted during the postpartum period (28.2 vs. 63.8% for non-CAP). Thirty (42.3
vs. 54.3% for non-CAP; p = 0.08) underwent mechanical ventilation, 12 (16.9 vs. 11.5%
for non-CAP; p = 0.23) non-invasive ventilation and 7 (9.9 vs. 2.9% for non-CAP; p = 0.001)
high-flow nasal cannula oxygen therapy. Compared to non-CAP, CAP women had longer
duration of mechanical ventilation (7 days [4–13] vs. 2 [1–5]; p < 0.0001). Acute
respiratory distress syndrome occurred in 20 CAP women (28.2 vs. 3.7% for non-CAP;
p < 0.0001), and 6 required extra-corporeal membrane oxygenation (8.4 vs. 4.5% for
non-CAP; p = 0.23). Preterm extraction occurred for maternal reasons in 15 CAP women
(21.1 vs. 7.8% for non-CAP; p = 0.004), and more frequently by cesarean section (84.2
vs. 53% for non-CAP; p = 0.0003). Fetal survival did not differ significantly, as
live births occurred in 85 vs. 77.4% for non-CAP (p = 0.39). Length of ICU and hospital
stays were significantly longer in CAP compared to non-CAP women (respectively 4 [2–8]
vs. 3 [1–5] days; p = 0.001), and 12 [7–22] vs. 9 [4–15] days; p = 0.001). ICU and
hospital mortality were null for CAP versus 5.8 and 6.6% for non-CAP (respectively
p = 0.045 and p = 0.027). Regarding CAP microbial etiologies, no causative pathogen
was found in 25 CAP subjects (39.7%); Influenza was identified alone in 18 (25.7%),
Streptococcus pneumoniae in 6 (8.6%), Haemophilus sp. in 3 (4.3%), methicilin-resistant
Staphylococcus aureus in 2 (2.3%) and methicillin-susceptible S. aureus in one (1.4%).
Finally, another respiratory virus was diagnosed in 3 patients (4.3%).
Discussion In this series, CAP was the cause of nearly a quarter of pregnancy or postpartum
respiratory failure requiring intermediate or intensive care unit admission. Despite
a longer ICU and hospital stay, no woman died. As in the non-pregnant population,
the absence of any causative pathogen is frequent. Influenza was the most frequent
pathogen identified.
Conclusion Pneumonia during pregnancy and postpartum requiring intermediate or intensive
care unit has important maternal and fetal implications. As such, a rigorous multidisciplinary
approach is warranted.
Competing interests None.
S68 Postoperative morbidity of duodeno pancreatectomy in surgical intensive care unit
M. T. Slaoui1, M. A. Bouhouri, A. Soufi, K. Khaleq, D. Hamoudi, A. Nsiri, R. Harrar
1Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco
Correspondence: Mohamed Taoufik Slaoui - dr.t.slaoui@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S68
Introduction The pancreaticoduodenectomy (PD) is major surgery in visceral surgery.
This technique performed for the first time in 1935 by Whipple has seen much progress
and development over the years that have enabled a significant reduction in mortality,
while the morbidity remains high. The aim of this study was to analyze postoperative
morbidity pancreaticoduodenectomies.
Patients and methods We retrospectively studied 34 cases of cephalic duodenopancreatectomy
at the department of surgical emergencies resuscitation (wing 33) spanning 6 years,
between January 2010 and December 2015.
Results The average age of patients was 58.2 years with 43% of females and 57% of
males, the frequence of pancreatic resections was 5 years.
The indications of cephalic duodenopancreatectomy were: tumors of pancreatic head
(65%), Ampulla Vater (23%), duodenum tumors (12%).
The restoration of continuity after cephalic duodenopancreatectomy was realized with
a rate of 41% for pancreaticogastrostomy and 59% for pancreaticojejunostomy.
The average hospital stay was 11, 7 days, with extreme lengths of 6–27 days.
The postoperative course was marked by the occurrence of 8 deaths (24%), the morbidity
rate was 29, 25% after PJ and 28% after PG; the most frequent complications were the
pancreatic fistula (40%), the postoperative peritonitis (40%), the digestive bleeding
(20%), the gastroparesis (20%).
Conclusion Advances in the overall care of patients by surgical teams, anesthesiologists
and intensivists, the DPC mortality is currently low in experienced centers. The multidisciplinary,
involving surgeons, radiologists and especially intensive care, to manage more effectively
the complications of this surgery remains burdened with high morbidity.
Competing interests None.
S69 Severe acute pancreatitis in ICU: management and outcomes of infected pancreatic
necrosis
Charlotte Garret1, Matthieu Peron2, Emmanuel Coron2, Cédric Bretonnière1, Jean Reignier1,
Christophe Guitton1
1Réanimation médicale, CHU Hôtel-Dieu Nantes, Nantes, France; 2Hépato-gastroentérologie,
CHU Hôtel-Dieu Nantes, Nantes, France
Correspondence: Charlotte Garret - charlottegarret83@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S69
Introduction Severe Acute Pancreatitis (SAP) is a common but potentially lethal pathology
due to the multiplicity and severity of complications that can occur at all stages
of evolution. In the last decade, mini-invasive interventional treatments of infected
pancreatic necrosis (IPN) have been developed. The aim of the present study was to
assess the management and outcomes of SAP patients, as well as to identify the role
of IPN.
Materials and methods This was a retrospective study of prospectively collected data
from all consecutive patients admitted in Intensive Care Unit (ICU) in a single French
center (Hospital of Nantes) from 2012 to 2015. Using logistic regression, we evaluated
the association between IPN and patients characteristics at baseline and the outcomes.
Results In total, 148 patients were included in this study. Overall mortality was
17% and was significantly associated in multivariate analysis with BMI, Computed Tomography
Severity Index (CTSI) and the need for life sustaining support. 16 patients (11%)
died during the early phase ≤8 days. During the late phase of the onset of SAP (>8 days),
IPN was present in 62 patients, all requiring an intervention (i.e. radiologic, endoscopic,
and surgical). In contrast, 70 patients with no suspicion or confirmed IPN were managed
conservatively. The flow chart of the study and details from mortality during the
early and the late phase are details Fig. 19. Complications such as haemorrhage, perforation
of visceral organ, ischemia of enteric tube or colon and portosplenomesenteric venous
thrombosis (PSMVT) occurred more frequently in the IPN group. The late phase mortality
and hospitalisation length of stay were significantly higher in the IPN group (14.3
vs 3.6%, p = 0.01 and 65.5 vs 15 days, p < 0.001, respectively). In multivariate analysis,
factors associated with IPN were PSMVT (OR 6.0 [2.42–14.90], p < 0.001), and life
sustaining support (OR 5.72 [1.06–30.9], p = 0.04).
Fig. 19
Flow chart of the study and details from mortality during the early phase and details
from mortality of the two groups: infected pancreatic necrosis (IPN) and non-IPN patients
during the late phase of the onset of severe acute pancreatitis
Discussion This retrospective cohort reports an overall mortality slightly lower than
previously reported. This may be related to the development of novel life support
techniques and mini-invasive interventional treatments of IPN. The outcomes in term
of late phase mortality, length of stay and complications (i.e. haemorrhage, perforation
of visceral organ and mesenteric ischemia) are all strongly associated with IPN. Therefore,
to determine predictive factors of IPN may help identify patients with a high morbidity
and mortality. In multivariate analysis, organ failure during the first week and PSMVT
were strongly associated with IPN. The radiological findings in term of PSMVT could
be important to assess the degree of severity of patients with AP. Further prospective
studies are needed to confirm the association between these factors and IPN.
Conclusion Our study is the first to focus on mortality and outcomes of IPN in real
life since the development of mini-invasive interventional treatments. 43% of patients
admitted with severe SAP in ICU developed IPN and required intervention. IPN was managed
with different drainage and necrosectomy’s modalities. The late phase mortality, length
of stays and complications such as PSMVT were all significantly higher in the IPN
group.
Competing interests None.
S70 Severe acute pancreatitis in intensive care unit
M. A. Bouhouri1, M. T. Slaoui1, A. Soufi, K. Khaleq, D. Hamoudi, A. Nsiri, R. Harrar
1Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco
Correspondence: Mohamed Taoufik Slaoui - dr.t.slaoui@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S70
Introduction The acute pancreatitis appears as a pathology that we can define with
difficulty because of its clinical presentation or prognosis.
Patients and methods In our study, we analysed 102 cases of acute necrotic and hemorrhagic
acute pancreatitis, hospitalized at the department of resuscitation of the surgical
emergencies (P33) of the UHC Ibn Rochd Casablanca during the period (2009–2015).
The purpose of this study is to do a descriptive analysis of the epidemiologic, clinic,
radiological, therapeutic and evolutive data of the acute necrotic pancreatitits,
we included in our study 102 patients with epidemiologic, clinic, radiologic, biologic
criteria of acute necrotic pancreatitits diagnosis whatever is the biliary or alcoholic
etiology.
The valuation gravity of the pancreatitis has been based on:
Ranson bioclinical score >3/APACHE II >8;
Visceral failure.
Spreading of the necrosis.
Results The analysis of the results shows that: About the epidemiologic aspect: mean
age (52 year old), the biliary etiology predominates (81%).
About the clinical aspect: pain (95%) vomiting (77%), stop of the transit (18%), the
visceral distresses are: the shock (34%), respiratory distress (40%), and neurological
distress (28%).
About the radiological aspect: pleural effusion (42%), abdominal echography: vesicular
lithiasis (60%), dilated principal biliary duct (13%), abdominal computerized tomography:
stage E (49%).
About the biological aspect: hyperglycemia (80%), hyper-amylasemia (68%).
The indexes of gravity that have been appreciated in this study are: Ranson score
>3 (58%), Imrie score >3 (66%), IGS score ≥6 (47%), OSF score ≥1 (70%).
The treatment of the ANHP has been symptomatic in particular and the evolution has
been characterized by mortality about 38%, the cause was particularly infectious.
The prognostic factors predetermined in this study are:
Female type (p = 0.0004).
Hemodynamic distress (p = 0.00005).
Respiratory distress (p = 0.0000001).
Scores of gravity:
Ranson >3 (p = 0.0000001).
Imrie >3 (p = 0.02).
OSF ≥ 1 (p = 00001).
Infection (p = 0.0000001).
Duration of the hospitalization (p = 0.02).
Rate of C-reagent protein (p = 0.001).
Conclusion In conclusion, the mortality is still high in the ANHP, considerable effort
of search is necessary to prevent the infectious complications of mortality.
Competing interests None.
S71 Predicting 90-day mortality following liver transplantation in patients with Acute-On-Chronic
Liver Failure: a decision-tree model from the French national liver transplantation
system, the OPTIMATCH study, 2008–2014
Eric Levesque1, Etienne Audureau2, Winters Audrey3, Duvoux Christophe4, Jacquelinet
Christian5, Azoulay Daniel6, Feray Cyrille4, Optimatch group
1Anesthesia and intensive care medicine, CHU Henri Mondor, Créteil, France; 2Service
de santé publique, ap-hp hôpital henri mondor; ea7376 cepia, université paris est
crétei, ap-hp hôpital henri mondor, Créteil, France; 3Upres ea 2415 département de
biostatistiques, Université de Montpellier, Montpellier, France; 4Service d’hépatologie,
Hôpital Henri Mondor, Créteil, France; 5Aence de la biomédecine, Agence de la biomédecine,
Saint-Denis, France; 6Service de chirurgie digestive et transplantation hépatique,
Hôpital Henri Mondor, Créteil, France
Correspondence: Eric Levesque - eric.levesque@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S71
Introduction Cirrhotic patients undergoing an initial liver transplantation (LT) have
a 1-year survival exceeding 85%. Some cirrhotic patients present organ failures at
the time of LT defining Acute-On-Chronic Liver Failure (ACLF). The aim of this study
was to build a decision-tree algorithm for predicting 90-day mortality in transplanted
patients, by assessing the independent prognostic contribution of ACLF.
Patients and methods All patients transplanted between 2008 and 2014 (N = 4789) were
included as part of the OPTIMATCH study, yielding 4010 patients with complete data
for the present analysis. Data collected comprised clinical and biological features
at the time of LT for recipients and their donors, assessing ACLF status according
to ACLF/CANONIC criteria to categorize patients. A survival Classification and Regression
Analysis (CART) algorithm was applied to build the prognostic model for 90-day mortality.
Results 1657 patients (41%) met the CANONIC criteria of ACLF with at least one organ
failure (1: 20.3%; 2: 12.6%; 3 and more: 8.4%). Overall 90-day mortality rate was
7.6%, with corresponding rates of 5.4, 7.2, 10.2 and 20.1% in patients with 0, 1,
2, 3 and more organ failures, respectively. Decision-tree modelling identified 12
subgroups further classified in 4 increasing risk classes (Fig. 20), highlighting
the prognostic importance of respiratory failure and acute renal failure at the time
of LT, as well as complex interactions between donor and recipient features.
Fig. 20
Decision tree freom CART survival analysis (a) and corresponding Kaplan–Meier curves
(b)
Discussion
Conclusion Ventilator support and/or acute renal failure at the time of LT are major
predictors of mortality but complex recipients/donors relationships may moderate these
associations, as demonstrated by our CART analysis.
Competing interests None.
S72 Morbidity and mortality of gastrectomy for cancer in surgical ICU
Chaigar Mohammed Cheikh1, Wissal Aissaoui1, Kawtar Rghioui1, Wafae Haddad1, Rachid
Cherkab1, Houcine Barrou1
1Anesthésie réanimation, Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Chaigar Mohammed Cheikh - chaigarmed@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S72
Introduction Evaluation of morbidity and mortality in ICU is crucial to determine
risk factors and improve clinical outcome. The aim of our study was to identify risk
factors of postoperative morbidity and mortality of gastrectomy for cancer.
Patients and methods We conducted a retrospective monocentric study in surgical ICU
of UH Ibn Rochd of Casablanca. Were included all patients admitted for gastrectomy
for cancer between January 2014 and December 2015. Clinical, radiological and biological
data was collected. Patients were categorized into 2 groups: Group A including patients
who developed postoperative complications and Group B including patients who didn’t.
The qualitative data were expressed as absolute value and percentage. Quantitative
data were expressed as mean. Categorical variables were compared by a Chi2 test or
Fischer test. Comparing the quantitative variables was performed by a Student’s t
test. Odds ratios were calculated with 95% confidence interval and a difference was
considered significant if p < 0.05. Multivariate analysis was performed by a test
logistic regression. Statistical analysis was performed using the Epi-Info software
3.5.4.
Results Sixty patients were enrolled. The sex-ratio was 1.7. The mean age was 59.8 ± 11.7 years.
The mean ASA score was 2 (± 0.7). Eight patients (13.3%) had a medical history of
diabetes. Nineteen patients (31.7%) had cardiovascular diseases (high blood pressure,
arythmia, heart failure). Seven patients (11.7%) had at least one family history of
gastrointestinal cancer in a related. The postoperative body mass index (BMI) was
23.2 ± 3.2 kg/m2. The mean albumin level was 31 +/9.3 g/l. Twenty-two patients (35%)
suffered from malnutrition and had received preoperative nutritional rehabilitation.
The most frequently reported tumor location was the gastric antrum (40%). Five patients
(8.3%) had a pan-gastric extension. Preoperative chemotherapy was performed in 18.3%
of patients. Total gastrectomy was performed in 28 patients (46.7%). Twenty-three
had partial gastrectomy (2/3), and 9 subtotal gastrectomy (4/5). Enlarged gastrectomy
was performed in 3 patients (5%). The mean operative time was 244.3 ± 58 min. Per-operative
transfusion was required in 14 patients (23.3%). The average length of stay in ICU
was 8.2 ± 5 days. Postoperative mortality was 6.7%. In our series, 13 patients (21.7%)
had at least one postoperative complication: An anastomotic fistula diagnosed in 7
patients (11.7%), 12 patients (11.3%) had postoperative peritonitis and 6 patients
had ventilator associated pneumonia. Reoperation was necessary for 13 patients (21.7%),
it was performed after 7.2 days (2–18 days). In univariate analysis, risk factors
for postoperative morbidity after gastrectomy was hypoalbuminemia (p = 0.0145), anemia
(p = 0.0001), BMI (p = 0.001) and malnutrition (p = 0.007). Age, sex, neoadjuvant
chemotherapy, extended lymphadenectomy, splenectomy or pancreatosplenectomy, total
gastrectomy and operative time were not significantly associated with higher postoperative
morbidity. In multivariate analysis, malnutrition (p = 0.01) and BMI (p = 0.001) were
significantly associated with the occurrence of postoperative complications.
Conclusion The results of our study are similar to those reported in medical literature.
Preoperative evaluation and nutritional rehabilitation are crucial to improve patient’s
outcome and reduce morbidity and mortality after gastrectomy for cancer.
Competing interests None.
S73 Assessment of the management of acute mesenteric ischemia in intensive care unit
M. T. Slaoui1, M. A. Bouhouri, A. Soufi, K. Khaleq, D. Hamoudi, A. Nsiri, R. Harrar
1Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco
Correspondence: Mohamed Taoufik Slaoui - dr.t.slaoui@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S73
Introduction The mesenteric ischemia is a condition relatively rarely. It is marked
by high mortality. Mortality is primarily related to the land on which ischemia occurs
and especially the time taken to diagnose. This delay is due to the low specificity
of clinical signs and the absence of diagnostic laboratory test. The mesenteric ischemia
remains a diagnostic and therapeutic challenge.
Patients and methods Twenty cases of acute mesenteric ischemia have been collected
at the surgical resuscitation (resuscitation 33) at the hospital center IBN ROCHD
of Casablanca from January 2010 to December 2015.
Results The mean age of our patients is 50 year old. It is about a disease that the
incidence increases these last years, particularly because of the waxing number of
old patients and/or suffers from advanced cardiovascular diseases.
The cardiovascular risk factor has been present in 35% of our patients.
The abdominal pain has been present in all the patients. It is a sudden, intensive
pain localized the most often at the level of the epigastria, becomes diffuse in few
hours or even few days. Other clinical signs have been described as the bilious vomiting
that becomes fecaloid after few days. The digestive hemorrhages as the moelena and
the hematemeses. A stop of the matter and the gazes was noticed in 25% of our patients.
The absence of specificity of the clinical signs forced the realization of complementary
examinations.
The scanner becomes the reference imaging. It permits a differential diagnosis, the
search of direct signs of vascular obstruction and the emphasis of intestinal pain.
Four etiologies are noticed: The arterial occlusion by emboli (40%), the arterial
thrombosis (20%), the venous thrombosis (25%) and the “non occlusive” form (15%).
The strategy of management of the acute mesenteric ischemia is multidisciplinary,
based on the equips of radiology, vascular surgery and/or visceral surgery and resuscitation.
The treatment consists in measures of general resuscitation, the techniques of endoluminal
vascular disobstruction and techniques of surgical revascularization.
In spite of the improvements in the diagnosis and the therapeutic procedure of the
IMA, the disease still know a rate of mortality between 60 and 97% according the studies.
In our study, we noticed 8 cases of death (40%), 9 cases of good recovery (45%), 3
cases are unknown evolution (15%).
Conclusion It is a vital emergency that the evolution still knows great mortality.
It is very important to remind the acute mesenteric ischemia in the case of any acute
abdominal symptom in order to anticipate about the natural evolution and to act in
a reversible stage of the ischemia.
Competing interests None.
S74 Emergency digestive surgery in critically ill patients under Extracorporeal Membrane
Oxygenation: a cohort study
Anna Carteaux-Taeib1, Romain Deransy2, Renato Lupinacci1, Gilles Manceau3, Florence
Jeune3, Alexandre Demoule4, Christophe Tresallet1, Alain Combes5, Nicolas Bréchot5
1Chirurgie digestive, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; 2Ranimation
chirurgicale polyvalente, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; 3Chirurgie
digestive et hépato-bilaire, Groupe Hospitalier Pitié-Salpêtrière, Paris, France;
4Service de pneumologie et réanimation médicale, Groupe Hospitalier Pitié-Salpêtrière,
Paris, France; 5Service de réanimation médicale, Groupe Hospitalier Pitié-Salpêtrière,
Institut de Cardiométabolisme et Nutrition, Paris, France
Correspondence: Nicolas Bréchot - nicolas.brechot@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S74
Introduction Extracorporeal Membrane Oxygenation (ECMO) is responsible for hemostatic
disorders, increasing the risk of bleeding during invasive procedures. Particularly,
outcome of patients undergoing digestive surgery while on ECMO has been poorly reported
to date. This study aimed to describe the outcome of critically ill ECMO patients
undergoing emergent digestive surgery, in comparison to a population of non-ECMO patients
operated in the same unit.
Materials and methods Retrospective single-center study.
Results Data are expressed as % or median (IQR).
Between 2006 and 2014, 35 patients with ECMO and 42 patients without ECMO underwent
emergency digestive surgery. The main indications were intestinal ischemia (43% ECMO
vs. 41% non-ECMO, ns) and cholecystectomy (23 vs. 26%, ns). Patients on ECMO were
younger [59 (43–64) vs. 64 (54–74) years; p = 0.02] but had a higher preoperative
SAPS II score [79 (70–90) vs. 71 (44–83); p = 0.03]. There were significantly more
reinterventions for bleeding in the ECMO group (20 vs. 2%, p = 0.02) and a greater
need for blood transfusion within 72 h after surgery (13 packed red blood cells (6–22)
vs. 3 (0–5); p < 0.0001). In multivariate analysis, ECMO remained strongly associated
with the occurrence of bleeding (OR 5.6; CI [0.2–15.4]; p = 0.001). ICU mortality
was significantly higher in patients under ECMO (69 vs. 33%; p = 0.003) but perioperative
mortality remains comparable between groups (14 vs. 12%, ns). These results were confirmed
in a sensitivity analysis in 36 ECMO and non-ECMO patients matched on the pre-operative
SAPS-II score, age, and type of digestive surgery.
Conclusion In critically ill patients undergoing emergent digestive surgery, ECMO
is associated with an increased risk of bleeding but not with perioperative mortality.
Competing interests None.
S75 Burnout risk factors in emergency: multicentric investigation
Sahar Habacha1, Ines Fathallah1, Aymen Zoubli1, Rafaa Aloui1, Nadia Kouraichi1
1Intensive care unit, regional hospital of Ben Arous, Tunis, Tunisia
Correspondence: Ines Fathallah - ines822004@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S75
Introduction Emergency Departments staff are frequently exposed to many complex stressful
situations and consequently burnout syndrome. Our study aimed to describe epidemiological
particularities and determine the risk factors of burnout syndrome in different categories
of emergency.
Patients and methods We studied five academics and four regional hospitals. The level
of burnout was assessed using the “Maslach Burn Out Inventory” score and the degree
of depression with Major Depression Inventory (MDI) test.
Results One hundred and forty-three correctly completed questionnaires were collected.
The mean age of study population was 32 ± 7 years. Sex-ratio was at 0.63. Fifty-one
per cent of the care staff were married. Physicians represented 40% and paramedical
60%. The general frequency of Burnout syndrome was 85% (n = 127). Low level Burnout
was present in 32%, moderate level in 45% and high level in 23%. The depression frequency
was 52%.
A statistically significant correlation was found between burnout and depression firstly
(p = 0.006) and between burnout and lack of equipment (p = 0.04). Their relative risk
was 4.7 [1.5, 15] and 9.14 [2.2, 37.6] respectively).
Main risk factors associated with high level burnout are detailed in Table 22.
Table 22
Factors associated with high level burnout
Factors
High level bunout (N = 29)
No high level burnout (N = 114)
P
RR
95% CI
Conflictual situations
29 (100%)
85 (74%)
0.19
–
–
Civil state: married
21 (72%)
55 (48%)
0.036
2.245
[1.067, 4.724]
Working in Academic hospital
20 (68%)
44 (38%)
0.06
9.708
[1.326, 5.530]
Medical staff
8 (27%)
51 (44%)
0.8
–
–
Heavy workload
21 (72%)
114 (100%)
0.4
–
–
Empathy regard to patients
9 (31%)
72 (63%)
0.14
–
–
Conclusion Burnout syndrome frequency in our emergency departments is alarming. Helping
to resolve social and psychological problems and improving work conditions may help
to decrease it.
Competing interests None.
S76 Let us resuscitate our waste
Emilie Jouet1, Julie Badin, Brice Fermier, Marc Feller, Mathieu Serie
141, C.H. de Blois, Blois, France
Correspondence: Emilie Jouet - emjouet@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S76
Introduction The healthcare activity is recognized as a major polluting activity.
In France, it generates 800,000 tons of waste cremated each year, and represents 12%
of the tertiary energy consumptions. In the United States, it generates 7000 tons
of waste per day and 7% of total CO2 emissions in 2007 were attributed to him. Ultimately,
such waste production is associated with adverse environmental and health effects.
Nevertheless, near half of the hospital waste would be recyclable, particularly in
our intensive care units (ICU) [1]. Furthermore, sustainable development solutions
generate profits.
The aim of this study is to make an overview of waste produced in a ICU and offer
solutions to conserve natural resources and reduce the carbon footprint bound to the
healthcare activity.
Materials and methods Experimental study, single-center, concerning a period of 6 months
in an ICU—high surveillance unit compound of 16 beds. We have identified all waste
generated. Our packaging were given to the recycling company in connection with the
hospital. Then we have studied the impact of the implementation of sustainable development
solutions.
Results Firstly, we have studied the non-recycled waste and the quantity produced
over a period of 1 month. Approximately 8 kg of waste is produced per patient per
day with 45% of infectious waste and 55% of general waste. These results were linked
with a bad distribution of garbage bags in the rooms (130 L of infectious waste versus
50 L of general waste).
Secondly, we have improved our way to sort and consume and we have created recycling
dies without compromising patient safety. All these measures have not increased workload.
Changing bags in the rooms (20 L of infectious waste and 2 bags of 50 L of general
waste) allowed to reach the normal goals of 2 sectors with a net benefit estimated
at 4500 euros per year.
The medical broken glass containing drugs was thrown into plastic containers of 5 L
for infectious waste to prevent the risk of cuts. By creating a specific die intended
to the general waste, we could quantify the production of this glass to 10 kg per
week and to spare the use and the incineration of 350 containers of 5 L per year (global
economy of 1000 euros).
Plastic packaging represented an important proportion of the cremated waste. We have
created 3 sectors of recycling including the polypropylene (80–200 kg per month),
the polyethylene colorless and colored polyethylene. This plastic is sold to be recycled
without additional cost for the hospital.
The linerboards was cremated. We have created a recycling die (50 kg per month). This
sector was subsequently extended to the entire hospital structure, particularly the
pharmacy that produces 12 containers of 400 L per month. They are now sold without
additional cost.
Many unnecessary plastic waste is generated daily. We have removed using mild soap
plastic bottles of 30 ml by using the same mild soap in pump of 500 ml (economy of
1000 euros). The use of 100 L plastic bags for the transitional deposit of linen has
been deleted (economy of 450 euros).
Concerning the paper: 100% of the impressions were made in simplex. Printers were
parametrized on both sides by default allowing the economy of 60 reams per year (30,000
sheets), several thousand liters of water and the reduction of CO2 emissions.
Discussion Recycling is only one component of the sustainable development in health.
Other avenues that could be considered to improve ICU sustainability would include
examining water use (for linen), electricity use (reducing non-essential use at night…).
Beyond these actions, we need to encourage our suppliers to turn to sustainable and
recyclable packages to reduce the use of polluting and depletable fossil fuels such
as oil. But also to develop with them circular economies where waste is returned to
them to be reused.
Conclusion We must ask the question also resuscitate our tons of waste. Our ICU produce
large quantities of waste (over 2 tons per year per bed). However, a significant proportion,
especially plastic, is recyclable with a significant environmental and financial benefit.
Waste management also requires an optimal and rational use of supplies because “the
best waste is that which is not produced” and that excess is not a guarantee of quality.
As already said St Exupéry in 1939: “We do not inherit the Earth from our parents,
we borrow it from our children.” So do not expect tomorrow to reduce major adverse
ecological impact paradoxically generated by a great profession whose ultimate goal
is to cure people.
Competing interests None.
Reference
McGain F, Story D, Hendel S. An audit of intensive care unit recyclable waste. Anesthésia.
2009;64:1299–302.
S77 Point of care ultrasonography: is there a place for pocket size ultrasonography
devices?
Gabriel Preda1, Vincent Dubée1, Naïke Bigé1, Jeremie Joffre2, Jean-Luc Baudel1, Hafid
Ait-Oufella1, Eric Maury1
1Réanimation médicale, Hôpital Saint-Antoine, Paris, France; 2 Service de reanimation
médicale, Hôpital Saint-Antoine, Paris, France
Correspondence: Eric Maury - ejhmaury@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S77
Introduction Point of care ultrasonography (US) is more are more used in Intensive
Care Unit. It should be performed to answer questions with a dichotomous response
(yes or no or I don’t know). Whereas hand held US (HHUS) devices are well fitted to
this practice, the place of new available pocket size US (PSUS) devices has still
to be delineated. The aim of the present study was to compare quality of portable
and pocket size US devices and to assess the agreement between the two modalities.
Patients and methods During a 8-month period every cardiac, pulmonary or abdominal
point of care US exam deemed to be performed between 08.30 am and 07.00 PM with a
HHUS device was eligible. Vascular exam were excluded. Every US exam was performed
twice, with our regular HHUS device (MTurbo®, Sonosite, Bothwell, MA, USA) and with
a PSUS (Vscan®; GEHealthcare, Wauwatosa, WI, USA) equipped with a phased-array probe
1—5 MHz and 1.7—3.8 MHz respectively. HHUS and PSUS were performed at random by intensivists
skilled in general ultrasonography and mastering at least a basic level of echocardiography.
Exam duration as soon as US device was working, imaging quality assessed using a semi
quantitative scale (0 nothing is seen to 4 excellent) were recorded. Several items
were assessed: left ventricular ejection fraction (normal, moderately or severely
depressed), right ventricular dilation (RV < 0.6LV, RV = LV, RV > LV), IVC variation
(present or not), Pleural effusion (present or not, centesis feasible), B-lines (less
than 3 or coalescent), lung condensation (present or not), diphragmatic excursion
ascites (present or not, centesis feasible), kidney visualization (yes or no), obstructive
uropathy (present or not), intrabiliary duct dilation (present or not). Demographic
and descriptive data are expressed as mean ± 1 SD or median IC25%–75%. Procedure duration
ultrasonographic were compared using the Student t test. Answers to the questions
were yes, no, or do not know. Agreement between the answers to clinical questions
was assessed using the Kappa Cohen coefficient.
Results During the study period, 71 US exams were performed in 38 patients (71 years
[51–82], 28 male, SAPSII:45 (30–55), height 172 cm [168–177], weight 74 kgs [65–90],
50% of them receiving mechanical ventilation). Duration of exams were shorter with
(PSUS (181 ± 97 vs 225 ± 146, p = .006). Global imaging quality was better with HHUS
(2.95 ± 0.87 vs 2.73 ± 0.84, p = .004) and was better for cardiac, abdominal and lung
exams even difference did not reach significancy. Simultaneous visualisation of both
ventricles on an apical view was more frequently impaired with PSUS (27 vs 4.5%, p = 0.04).
Among the 690 items assessed by both US devices, inability to answer to a question
was more frequently observed with PSUS than HHUS (6.7 vs 4.2%, p = 0.05).
Agreement between the two devices for some of the items assessed are depicted in the
Table 23.
Table 23
Agreement between HHUS and PSUS for some of the items tested
Question
Case
Discrepant results
K coefficient
Pleural effusion (38)
19
5
0.71 [0.56–0.87]
B-lines (38)
29
5
0.69 [0.55–0.83]
Lung consolidation (38)
12
3
0.71 [0.52–0.90)
Obstructive uropathy (25)
3
0
1
LVEF (23)
7
3
0.7 [0.51–0.89]
VD (23)
1
3
0.61 [0.42–0.79]
Conclusion Despite a weaker imaging quality and greater unconclusive exam rate, this
study suggests that pocket size US device is an acceptable alternative to hand held
US device for basic point of care ultrasonography.
Competing interests None.
S78 Six-months outcome of patients aged 80 and over following admission to an intensive
care unit
Jérôme Pillot1, William Marie1, Chloé Gisbert-Mora1, Camille Vinclair1, Pierre Lesbordes1,
Pascal Mathieu1, Fabienne De Brabant1, Emmanuel Muller1, Marie-Aline Robaux1
1Réanimation polyvalente - usc, Centre Hospitalier de la Côte Basque, Bayonne, France
Correspondence: Jérôme Pillot - jeromewilliam.pillot@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S78
Introduction There is a growing interest in long-term outcomes of patients aged 80
and over. Survival rate ranges from 20 to 30% 1 to 2 years after intensive care unit
(ICU) admission according to different publications. A better knowledge of patient’s
short-term prognosis and the inherent risks of ICU care impeding recovery would provide
intensivists with management guidelines for ICU admissions and procedures for clinical
practices. Physicians could adapt medical care to outcomes which could be expected
rather than limiting to age. This study aims to analyse 6-month mortality in patients
aged 80 and over following admission to an ICU, to investigate withholding/withdrawing
(Wh/Wd) life sustaining treatment decisions and to identify predictors of 6-month
mortality.
Patients and methods We conducted a retrospective, observational, cohort study including
all elderly patients (≥80 years) admitted from 1st January 2012 to 31st December 2013
in a medical-surgical ICU in a French district general hospital.
Results 109 patients (13%) who were at least 80 years old were selected for the study
out of the 814 patients admitted to the ICU during the study. 76 (70%) had medical
conditions and 29 (27%) required unscheduled surgery. The mean SAPS II score was 57 ± 21
and the mean APACHE II score was 19 ± 8. During the ICU stay, 85 (78%) required mechanical
ventilation, 74 (68%) catecholamines, 32 (30%) blood transfusions, 22 (20%) needed
additional renal support and 15 (14%) neuromuscular blockade. More than 80% needed
antibiotics.
Six-month mortality was 58% (63/109), with no significative difference between age,
sex or reasons for admission. Two-thirds (41/63) of deaths occurred in ICU with a
mean length of ICU stay of 9 ± 9 days. ICU-mortality of our study population was significatively
higher than ICU-mortality of the 705 younger patients (<80 years) admitted during
the same period (38 vs 22%, OR 2.1, 95% CI [1.4–3.2], p = 0.001). This was particularly
significant for male mortality (41 vs 20%, OR 2.8, 95% CI [1.7–4.8], p < 0.0001),
but not female (32 vs 26%, p = 0.453). Two-thirds of patients were alive 6-month after
their ICU visit, although 19% were to die during their hospital stay. Less than 6%
of patients followed up with a specific geriatric care after discharge the ICU.
The SAPS II score, the APACHE II score, severe sepsis and Wh/Wd decisions were independently
associated with 6-month mortality (SAPS II ≥ 60, OR 3, CI95% [1.1–8.5], p = 0.034;
APACHE II ≥19, OR 3, CI95% [1.1–8], p = 0.029; severe sepsis, OR 6.2, CI95% [1.1–33],
p = 0.034; Wh/Wd decisions, OR 14.7, CI95% [4.5–47.8], p < 0.0001). 75% (31/41) of
patients died in ICU were identified for Wh/Wd treatment, this represented 63% of
6-month deaths. More than 88% (40/45) of patients who had Wh/Wd decisions during ICU
stay died within 6 months. In contrast, 89% of survivors had no Wh/Wd treatment during
their ICU stay.
Conclusion This study confirms that physicians should not reject ICU admission simply
on the basis of 80 years old or over. Initial clinical severity measured by usual
prognostic scores, severe sepsis, as well as withholding/withdrawing decisions made
during the ICU stay, are independent risk factors of 6-month mortality. Six-month
survival in these patients is far from negligible. Future research on patient’s prognosis
after an ICU stay should clearly concentrate on the existence of a comprehensive geriatric
system of care and on Wh/Wd treatment decisions. Special attention should be paid
to the Wh/Wd decision-making process so as to ensure that patient’s death is not the
result of a self-fulfilling prophecy.
Competing interests None.
S79 Intensive Care Unit (ICU) non-readmission decisions: a survey of practices
Mikhael Giabicani1, Antoine Marchalot1, Stéphanie Gelinotte1, Pierre Louis Declercq1,
Jean-Pierre Eraldi1, François Bougerol1, Nicolas Meunier-Beillard2, Hervé Devilliers3,
Jean-Pierre Quenot4, Jean-Philippe Rigaud1
1Intensive care, Dieppe General Hospital, Dieppe, France; 2Umr 7366 cnrs, University
of Burgundy, Dijon, France; 3Internal medicine, Chu Dijon, Dijon, France; 4 Intensive
care, Chu Dijon, Dijon, France
Correspondence: Mikhael Giabicani - mikhael.giabicani@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S79
Introduction In-ICU admission of critically ill patients depends partly on benefits
expected. Then, some patients are not admitted in ICU because of a high risk of mortality
and/or a poor expected quality of life after ICU hospitalization. While ICU readmissions
increase morbidity and mortality, decisions of “non-readmissions” are taken for patients
who had underwent very difficult ICU hospitalizations. But «non-admission» and «non-readmission»
decisions lead to limit initiation of life-sustaining therapy for (potential) life-threatening
patients. Then, these are decisions to forgo life-sustaining treatment as defined
by the French law enacted in April 2005 (the so-called Leonetti’s law). The aim of
this study is to evaluate practices concerning ICU «non-readmission» decisions.
Materials and methods We performed a survey among French intensive care physicians
by electronic questionnaire between December 2015 and January 2016 to evaluate «non-readmission»
practices. The questionnaire consisted of 27 items relating to various aspects of
the decision process. We also recorded responders’ socio-demographic data (age, sex,
length of practice, type of ICU in which they practiced). Qualitative variables were
expressed in percentages and were compared according socio-demographic data using
the Chi-2 test or Fisher exact test.
Results Among 653 physicians contacted, 165 (25.3%) completed the questionnaire. Responders
were mostly male (sex ratio 3:1), aged between 35 and 50 years and were experienced
for years in intensive care. «Non-readmission» decisions are mainly taken at the end
of ICU hospitalization (87%) following a collegial discussion (89%). However, patients,
relatives and/or family, external consultant or general practitioner are marginally
involved in the decision process (respectively 10, 34, 14 and 29% cases). If 73% of
the relatives are informed of the «non-readmission» decision, less than a third of
patients receive this information. Once decision made, the latter is notified in the
patient’s medical record in 93% cases. However, 96% of responders consider having
the right not into account this decision as appropriate. In addition, 92% of doctors
consider clearly a difference between readmission’s request for a new acute episode
and the same request for a worsening of a chronic disease. Otherwise, palliative care
program is decided jointly to the «non-readmission» decision in only 41% of cases.
Finally, 91% of responders consider the «non-readmission» decisions as fully parts
of the law of April 2005. Secondary analyzes have not identified any difference according
to socio-demographic groups.
Conclusion Evaluation of «non-readmission» decisions shows a defective process regarding
French legal and ethical aspects. Particularly, patients themselves are insufficiently
involved in discussion and/or informed of decisions about their own health. Moreover,
an external consultant is rarely applied and palliative cares are insufficiently developed
after «non-readmission» decisions. For providing corrective measures, this study lead
to propose a «non-readmission» process by integrating the discussion for a real «patient’s
care project» at the end of the ICU hospitalization. This process would lead to collect
patient’s opinion through advance directives, to ensure a collegial discussion including
an external consultant and to allow reevaluation of global patient’s clinical status
and one or more organ failure(s). Then, «non-readmission» decisions would be integrated
in a therapeutic project which would promote the initiation of a palliative care program
if necessary. The purpose of this process is well to respect patient’s autonomy and
dignity as required by French law and medical ethics.
Competing interests None.
S80 Withholding decision in elderly patients: who share the decision?
Sidonie Hubert,1, Camille Verrière,1, Marc Tran,2, Kelly Tiercelet2, Mélanie Cherin3,
Cédric Bruel2, Francois Philippart2
1Médecine interne, Groupe Hospitalier Paris Saint-Joseph, Paris, France; 2Réanimation,
Groupe Hospitalier Paris Saint-Joseph, Paris, France; 3Réanimation polyvalente adulte,
Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
Correspondence: Francois Philippart - fphilippart@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S80
Introduction The proportion of elderly patients is steadily increasing. Due to the
growth of this part of the population who suffer from multiple pathologies, the need
for hospitalization in intensive care increases. According to the simulations, the
proportion of octogenarian patients in ICU will increase reaching the third of ICU
patients. While chronological age is not a significant factor of poor prognosis in
the ICU (1), many factors should be taken into account to evaluate the relevance of
ICU admission in the senior population and withholding such intensification should
be consensually discussed between clinicians and obviously as often as possible with
the patient himself (2).
The aim of the study was to assess the role of stakeholders (ward physicians, intensivists,
family doctor and patient himself) in the decision of withholding ICU admission for
elderly patients in our internal medicine department.
Patients and methods We made a prospective observational monocentric study, including
all the elderly patients (defined as older than 75) admitted in the internal medicine
department from January 2012 to June 2012. The only non-inclusion criterion was patient’s
refusal to participate to the survey.
Collected data involve physiological (cognitive, autonomy, nutritional status), morbidities
(acute and chronic diseases) and social parameters (marital status, relatives). And
evaluation of quality of life by the patient himself using an analog visual scale
was also obtained.
Internal medicine physicians were asked to report any ICU withholds decision for their
patients. In absence of notification, every physician was questioned again the day
of the concerned patient’s discharge.
Results One hundred ninety-one patients were included between January and June 2012.
The average age of the study population was 85.7 ± 6.01 years. A decision of therapeutic
intensity limitations was made for 96 patients (50.2%). Lack of decision concerning
potential ICU transfer was noted for 7 patients (3.6% of cases).
In 60.4% (58 of 96 patients) of cases withholding ICU decision was taken by the attending
physician, alone. Family physicians was involved in limitation decision in only 77
(40.3%) of cases. During the period of the study, ICU physician were involved in only
3 decisions about potential intensification of therapeutic interventions in patients.
Concerning patient for whom a therapeutic limitation was taken, 46% did not want to
take an active part in decision affecting their potential intensity of care. On the
other hand, patient’s opinion was not sought in 30.5% of cases.
Factors associated with an ICU withholding decision were the presence of advanced
cognitive impairment (26% of limitation decisions), dependency (Katz scale ≤4; 22.9%),
high comorbidities and age (86.9 vs 82.8 years; p = 0.002).
Discussion The absence information regarding refusal decision actually made by intensivist
can be considered as a weakness of the study. Nevertheless, systematic prospective
information of limitation decisions before potential ICU proposal of critical patients
show the weak involvement of intensivist about intensification decisions in our hospital.
Conclusion ICU withholding is relatively frequent in internal medicine department,
notably due to the importance of elderly and comorbid admitted patients. Despite medical
societies and law recommendations, lonesome limitation decision remains surprisingly
frequent. Patients’ participation in this reflection is made difficult both because
their desire not to be involved and due to the lack of offered opportunities by clinicians.
Competing interests None.
References
Montuclard L, Garrouste-Orgeas M, Timsit JF, Misset B, De Jonghe B, Carlet J. Outcome,
functional autonomy, and quality of life of elderly patients with a long-term intensive
care unit stay. Crit Care Med. 2000;28(10):3389–95.
Philippart F, Garrouste-Orgeas M. Le refus d’admission en réanimation, première limitation
des thérapeutiques actives. In: Enjeux ethiques en réanimation. Berlin: Springler;
2010.
S81 ICU nurses’ perception of end-of-life decision making: a French multicenter survey
Fanny Ardisson1, Nancy Kentish-Barnes2, Gwenaëlle Jacq,3, Christine Lebert4, Akli
Chermak5, Alexandre Lautrette6, Matthieu Legrand7, Frédéric Pène8, Nicolas de Prost9,
François Vincent10, Amélie Seguin11, Alexis Soummer12, Vincent Peigne13, Guillaume
Thiery14, Alice Cottereau15, Julien Mayaux16, Elie Azoulay17, Emmanuel Canet17
1Hôpital Saint-Louis (AP-HP), Paris, France; 2Réanimation médicale, Assistance Publique
Hôpitaux de Paris, Hôpital Saint Louis, Paris, France; 3Réanimation, C.H. de Versailles,
Le Chesnay, France; 4Réanimation, Centre Hospitalier Départemental - site de La Roche-sur-Yon,
La Roche-sur-Yon, France; 5Réanimation polyvalente, CH sud Essonne, Paris, France;
6Réanimation médicale, CHU Gabriel-Montpied, Clermont-Ferrand, France; 7Anesthésie
réanimation et traitement chirurgical des grands brûlés, APHP - Hôpital Saint-Louis,
Lariboisière, Fernand-Widal, Paris, France; 8Réanimation Médicale, Hôpital Cochin,
Paris, France; 9Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 10Réanimation
polyvalente, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil,
France; 11Réanimation médicale, Centre Hospitalier Universitaire de Caen, Caen, France;
12Réanimation, Hospital Foch, Suresnes, France; 13Réanimation, Hôpital d’Instruction
des Armées Percy, Clamart, France; 14Réanimation - Grands Brulés, CHU Pointe à Pitre
- Abymes, POINTE A PITRE, France; 15 Réanimation polyvalente adulte, Centre Hospitalier
Intercommunal André Grégoire, Montreuil, France; 16 Réanimation médicale, Hôpital
Pitié-Salpêtrière, Paris, France; 17 Réanimation médicale, Hôpital Saint-Louis, Paris,
France
Correspondence: fanny.ardisson@gmail.com (Fanny Ardisson)
Annals of Intensive Care 2017, 7(Suppl 1):S81
Introduction The French law and recent expert opinions have emphasized the need for
a multidisciplinary approach in decisions to forgo life sustaining therapies for the
critically ill. We sought to assess how ICU nurses actually rank their involvement
and perceive this process.
Materials and methods We conducted a cross sectional survey using a web-based questionnaire
between June and September 2016.
Results Of the 38 ICUs invited to participate, 22 (58%) agreed. A total of 541 ICU
participants completed the survey of whom 73% were nurses and 26% assistant nurses.
Median age was 31 (Inter Quartile Range 27–38) years and 84% were female. Median work
experience was 7 (4–12) years and time in the ICU was 5 (3–8) years. Eighty-five percent
of the participants have been involved at least once in a multidisciplinary end-of-life
discussion. Less than half of the participants reported a good (4%) or partial (44%)
knowledge of the current end-of-life legal framework.
The decision to start a discussion about Withdraw Life-Sustaining Therapy (WLST) was
initiated by a senior intensivist in 83% of the cases, by a nurse in 5% and an assistant
nurse in 0.6%. This decision was approved by 97% of the participants. The decision-making
process was considered to be initiated at the right time for 49% of the participants,
too late for 48%, and too early for 3%. The discussion occurred mostly in the afternoon
(38%) or during the medical staff (22%), in a dedicated place in 63% of the cases.
A median of 7 (5–10) health-care professionals attended the WLST discussion.
Half the respondents reported being reluctant to talk during the discussions and 11%
never expressed their own opinion. Indeed, although the length of the discussion was
30 (15–45) minutes, participants estimated to talk during only 3 (1–5) minutes. The
following reasons were mentioned by the participants to explain these facts: having
cared for the patient for too short time (62%), lack of medical knowledge (35%), decision
of WLST already taken by the medical staff (31%), their opinion not really taken into
account (19%), reluctant to talk during meetings in general (18%), consider that the
discussion is limited to a medical expertise (15%), limited professional experience
(14%), and fear to express a different opinion (12%).
Nevertheless, 84% of the participants were partially (76%) or totally (8%) satisfied
by the way the decision making process was conducted, 81% considered that collegiality
was applied, and 93% agreed with the final decisions.
Conclusion ICU nurses rank favorably multidisciplinary WLST discussions. Nevertheless
their involvement in the discussion remains limited. Beyond factors related to work
organization and professional experience, efforts should be made to recognize their
role and value, and to encourage them to share their own opinions with the other members
of the ICU team.
Competing interests None.
S82 Determinants and prognosis of elevation of high-sensitivity cardiac troponin T
in patients hospitalized with vasodilatatory shock
Marie Caujolle1, Jérôme Allyn1, Dorothée Valance1, Caroline Brulliard1, Olivier Martinet1,
Julien Jabot1, Thomas Gallas1, David Vandroux1, Nicolas Allou1
1Réanimation polyvalente, CHU La Réunion, Saint-Denis, France
Correspondence: Marie Caujolle - caujollemarie@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S82
Introduction The aim of this study was to assess determinants and the prognostic value
of high-sensitivity cardiac Troponin T (hsTnT) elevation in intensive care unit (ICU)
patients with vasodilatatory shock (VS).
Materials and methods A prospective observational cohort study conducted in an ICU.
Patients hospitalized for VS were consecutively included between October 2014 and
December 2015. This observational study was approved by the Ethics Committee of Félix
Guyon University Hospital (R14008). Clinical, laboratory, electrocardiography and
echocardiography data were collected within 24 h of admission. Established criteria
for the diagnosis of VS were as follows: (1) vasopressors required despite adequate
fluid loading to achieve a mean blood pressure >65 mmHg; (2) absence of elevated left-ventricular
filling pressures at transthoracic echocardiography; (3) signs of impaired organ perfusion
and (4) absence of positive inotropes.
Values of hs-cTnT with exponential distribution were log10 transformed for linear
analyses. Univariate (t-test and Pearson correlation test) and multivariate analysis
were used to examine correlations of variables with log10(hs − cTnT). Predictive factors
of in-hospital mortality in bivariate analysis with P < 0.05 were entered into a multivariate
logistic regression analysis using backward selection with P < 0.05. Results are expressed
as median [25th–75th percentiles], mean ± standard deviation or number (%) as appropriate.
Results During the study period 206 patients were hospitalized in ICU for VS (71.8%
with septic shock) with a mean simplified acute physiology score 2 of 58 ± 17. Among
them 185 (89.8%) had hsTnT > 14 pg/mL and the median peak of hsTnT was 55.1 [24.5–136]
pg/mL.
Combining all variables following multivariate analysis, high body mass index (t = 2.52,
P = 0.01), low left ventricular systolic function (t = −2.73, p = 0.007), high white
blood cell count (t = 3.72, P = 0.0001), low creatinine clearance (t = −2.84, P = 0.0005),
high lactate level (t = 2.62, P = 0.01) and ST-segment depression (t = 3.98, P = 0.0001)
best correlated with elevated log10 transformed hsTnT concentration. Left ventricular
diastolic dysfunction defined by the presence of a lateral E′ maximal velocity <10 cm/s
did not significantly correlate with log10 (hsTnT) (T = 1.41, P = 0.16).
Seventy-seven patients (37.4%) died in-hospital. Following univariate analysis peak
of hsTnT was higher in non-survivors (67.4 [32.5–167] pgmL) than in survivors (50.1
[20.9–121.3], P = 0.027). After multivariate analysis, peak of hsTnT was not associated
with a significant reduction of in hospital mortality (aOR 0.99 [95% CI 0.93–1.02]).
Factors associated with a significant reduction of in hospital mortality were higher
age (P = 0.002), higher lactate level (P = 0.004), chronic obstructive pulmonary disease
(P = 0.04), diabetes mellitus (P = 0.03), immunodepression (P = 0.05) and respiratory
failure (P = 0.02).
Conclusion In patients hospitalized for VS high body mass index, low left ventricular
systolic function, high white blood cell count, low creatinine clearance, high lactate
level and ST-segment depression are the variables correlating significantly with high-sensitivity
troponin-T concentrations. Peak of hsTnT was not significantly associated with in-hospital
mortality in this setting.
Competing interests None.
S83 Free plasmatic mitochondrial DNA-receptor for advanced glycation end-products:
a new signaling pathway of critical illness-induced endothelial dysfunction
Arthur Durand1, Rémi Nevière2, Florian Delguste2, Eric Boulanger,2, Raphaël Favory3,
Sebastien Preau4
1Nord, Hôpital Roger Salengro, Lille, France; 2Inserm u995 equipe 4, Université Lille
2, Lille, France; 3Pôle de réanimation, hôpital salengro, Centre Hospitalier Régional
Universitaire de Lille, Lille, France; 4Réanimation médicale, Centre Hospitalier Régional
Universitaire de Lille, Lille, France
Correspondence: Arthur Durand - durand.arthur@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S83
Introduction Mitochondria are evolutionary endosymbionts that are derived from ancestral
aerobic bacteria and so might bear and release bacterial molecular motifs supporting
the role of mitochondria in danger signal regulations. Free circulating mitochondrial
DNA (mtDNA) is elevated in a wild range of critical illness observed in intensive
care units, and is associated with bad outcomes and mortality. The mtDNA is a molecular
pattern that belongs to mitochondrial damage associated molecular patterns (mtDAMPs),
and can interact with pattern recognition receptors (PRR) to induce self defense reaction.
Free mtDNA activates inflammatory signaling pathways through Toll-like endosomal receptor
9 (TLR9) interactions. Nevertheless, new evidence advocates a role of the receptor
for advanced glycation end-products (RAGE) in mtDNA signaling. Experimental data suggest
a role of mtDNA-PRR interaction in systemic inflammation and organ dysfunctions as
septic acute kidney injury or pulmonary inflammation. Impact of free circulating mtDNA
on endothelial cell is not known.
The main purpose of this study was to test whether mtDAMPs and mtDNA can induce endothelial
dysfunction. We also evaluated the role of mtDNA-RAGE axis in mtDAMPs induced endothelial
dysfunction.
Materials and methods Mitochondria were isolated from livers of wild type C57B6 mice.
Isolated mitochondria were sonicated on ice to obtain mtDAMP preparations. Semi quantitative
evaluation of mtDAMP content was tested by qPCR, with specific markers of mtDNA (cytochrome
B (cytb), NADPH oxidase (ND4)). Intraperitoneal injection of 1 mg of mtDAMPs was used
as experimental model in wild type and RAGE KO mice, as previously described [1].
The mtDAMPs were also administrated after ex vivo DNAse preparation. Endothelial function
was assessed with a Mulvany-Halpern style myograph, 4 h after mtDAMP administrations
on aorta (conductive vessel) and on 2d division of mesenteric artery (resistive vessel).
Endothelial-dependent relaxation was studied by cumulative expositions of the vessels
to acetylcholine (1.10-10–1.10-5 M). Endothelial-independent relaxation was studied
by sodium nitroprussiate exposition.
Results The mtDAMPs preparation contains a high quantity of mtDNA with a 1/cycle threshold
(Ct) ratio of 0.062 for cytb expression. Intraperitoneal administrations of mtDAMPs
induced a decrease of endothelial-dependent relaxation mainly on conductive vessel
(p = 0.0079, n = 5 per group) and to a lesser extent on resistive vessel (p = 0.22,
n = 5 per group). RAGE-KO mice were protected from mtDAMPs-induced aorta dysfunction
(p = 0.53, n = 5 per group). The ex vivo exposition of mtDAMPs to a DNAse preparation
decreased mtDNA content in mtDAMPs solution with a 1/Ct ratio of 0.038 for cytb expression.
Eventually, the pretreatment of mtDAMPs with a DNAse preparation prevented the mtDAMPs-induced
aorta dysfunction (p = 0.85, n = 5).
Discussion More than prognostic markers, mtDAMPs particularly mtDNA seems implicated
in endothelial dysfunction in critically ill patient. New evidence suggest RAGE interaction
in endosomal TLR9 pro-inflammatory and pro-oxidant response to mtDNA [2]. Also in
sepsis, physiological clearance of circulating DNA might be impaired, this results
comfort the possibility of therapeutic regulation of free circulating mtDNA to prevent
septic organ dysfunction related to mtDAMPs accumulations.
Conclusion Exogenous mtDAMPs can induce endothelial dysfunction in mice. The mtDNA-RAGE
axis is a key component of the signaling pathway involved in this dysfunction.
Competing interests None.
References
Zhang Q, Raoof M, Chen Y, Sumi Y, Sursal T, Junger W, et al. Circulating mitochondrial
DAMPs cause inflammatory responses to injury. Nature. 2010;464:104–7.
Sirois CM, Jin T, Miller AL, Bertheloot D, Nakamura H, Horvath GL, et al. RAGE is
a nucleic acid receptor that promotes inflammatory responses to DNA. J. Exp. Med.
2013;210:2447–63.
S84 Prediction of fluid responsiveness using carbon dioxide gap
Najla Tilouch1, Oussama Jaoued1, Ben Sik Ali Habiba1, Houda Mater1, Rim Gharbi1, Mohamed
Fekih Hassen1, Souheil Elatrous1
1Réanimation Médicale, EPS Taher Sfar Mahdia, Mahdia, Tunisia
Correspondence: Mohamed Fekih Hassen - mohamed.fekihhassen@rns.tn
Annals of Intensive Care 2017, 7(Suppl 1):S84
Introduction The use of dynamic parameters to assess fluid responsiveness was supported
by cyclic changes in stroke volume induced by mechanical ventilation. However, these
parameters have several limits. Venous to arterial carbon dioxide difference inversely
related to cardiac index. Consequently, fluid administration would be beneficial if
carbon dioxide gap increases.
Objective To investigate whether carbon dioxide gap predicts fluid responsiveness
in patients with acute circulatory failure.
Patients and methods We conducted a prospective study in the medical intensive care
unit of Hospital Taher Sfar at Mahdia, between March 2013 and April 2016. Patients
with circulatory failure and who required mechanical ventilation were included. We
measured the variation of cardiac index between baseline and after volume expansion
of 500 ml of saline fluid. The PiCCO2 was used to measure cardiac index. Response
to fluid challenge was defined as a 15% increase in cardiac index. Before and after
fluid administration, we recorded carbon dioxide difference and hemodynamic parameters.
Results Among 68 included patients, 33 (49%) were responders. The causes of acute
circulatory failure were septic shock (n = 45), cardiogenic shock (n = 11), and Hypovolemia
(n = 12). Carbone dioxide gap was significantly higher in responders group (8 ± 7
vs 4 ± 4 mmHg, p = 0.019). The area under the ROC curve for carbon dioxide gap was
0. 68 (95% CI 0.55–0.80). The best cutoff value was 6 mmHg (Sensibility = 46%, specificity = 80%,
positive predictive value = 52% and negative predictive value = 60%). The area under
the ROC curve for delta carbon dioxide was 0.54 (95% CI 0.4–0.68).
Conclusion In this study, baseline carbon dioxide gap was not universal indicator
to predict the fluid responsiveness in patient with circulatory failure.
Competing interests None.
S85 Incidence and prognostic impact of new onset supraventricular arrhythmia in patient
with septic shock
Walid Sellami1, Zied Hajjej1, Soumaya Ben Yedder1, Walid Samoud1, Iheb Labbene1, Mustapha
Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospital of Tunis,
Tunisia, Tunis, Tunisia
Correspondence: Walid Sellami - drsellamiwalid@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S85
Introduction Supraventricular arrhythmia (SVA) is commun in intensive care unit (ICU).
Its incidence seems to be higher in patients with sepstic shock. Sepsis-associated
myocardial dysfunction promote the occurrence of SVA by constituting an arrythmogenic
substrate or under the effect of inotropic drugs.
The aim of this study is to assess the incidence and prognostic impact of SVA in patients
with septic shock.
Patients and methods We retrospectively studied all patients with new onset SVA suffering
from septic shock in non cardiac surgical ICU. Myocardial dysfunction was evaluated
by transthoracic echography (TTE) after an adequate cardiac resuscitation using intravenous
fluids expansion and adjunctive vasoactive agents. SVA was detected by the electrocardiogram
scope. During the study period clinical and biologic characteristics, hemodynamic
tolerance (vasopressors doses, arterial pressure changes), current treatment (such
as corticoid), duration of mechanical ventilation, duration of vasopressor requirement
and hospital mortality were collected.
Results Sixty patients were included in the study. The SVA occurred in 28 patients,
with an incidence of 46%. The median time to onset was 2 days. Cardioversion was performed
for 15 patients with an effectiveness of 80%. Clinical and biological characteristics
were similar between the groups with and without SVA: SAPS 2 and SOFA score at the
beginning of septic shock, the existence of ARDS and cardiac biomarkers (NT-proBNP,
troponin). However, renal failure and the use of corticoid in septic shock were more
frequent in the group with SVA. The maximum doses of vasopressor agent were not significantly
different between the groups with or without SVA. Myocardial dysfunction in sepsis
defined by the left ventricle ejection fraction (LVEF) less than 45% (or the need
for inotropic drug for LVEF > 45%) was not associated with the occurrence of SVA (+SVA
group: n = 8; −SVA group: n = 6; p: 0.57). SVA was poorly-tolerated, observed by a
significant decrease in mean arterial pressure and a significant increase in norepinephrine
doses within 1 h of the start of SVA. The occurrence of SVA was associated with longer
duration of use of vasopressor agent and a longer duration stay in ICU (+SVA group:
21 days, −SVA group: 14 days; p = 0.03). There was no difference in duration of mechanical
ventilation and hospital mortality between the two groups.
Conclusion The occurrence of SVA is common in septic shock, poorly tolerated hemodynamically
and associated with longer duration stay in the ICU and vasopressor need. Sepsis myocardial
dysfunction isn’t necessarily associated to the occurrence of SVA.
Competing interests None.
S86 Long term hemodynamic effects of prone position in ARDS patients
Ruste Martin1, Laurent Bitker1, Hodane Yonis1, Mylène Aublanc,1, Aurore Louf-Durier,1,
Floriane Lissonde1, Sophie Perinel-Ragey1, Claude Guérin1, Jean-Christophe Richard1
1Réanimation médicale, Hôpital de la Croix-Rousse, Lyon, France
Correspondence: Jean-Christophe Richard - j-christophe.richard@chu-lyon.fr
Annals of Intensive Care 2017, 7(Suppl 1):S86
Introduction A short term beneficial effect of prone position on cardiac index has
been shown in 50% of 18 ARDS patients, and was related to an increase in cardiac preload
in preload responsive patients (1). The aim of this study was to evaluate the long
term hemodynamic response to prone position in a larger series of ARDS patients.
Patients and methods Single center retrospective observational study performed on
ARDS patients hospitalized in a medical ICU between July 2012 and March 2016. Patients
included were adults fulfilling the Berlin definition for ARDS, undergoing at least
one prone position session, under hemodynamic monitoring by the Picco® device, with
availability of hemodynamic measurements performed before (T1), at the end (T2), and
after the prone position session (T3). Prone position sessions were excluded if they
were performed >7 days after ARDS onset. The following variables were recorded: demographic,
SAPSII, ARDS severity and risk factor, SOFA score and cumulative fluid balance at
PP onset, delay between ARDS session and PP session, hemodynamic, arterial blood gas,
ventilatory settings, plateau pressure, catecholamine dose and additional treatments.
Statistical analyses were performed using prone position session as statistical unit
and mixed models taking into account both multiple prone position sessions by patient
and multiple measurements during a prone position session. p < 0.05 was chosen for
statistical significance. Data are expressed as mean ± standard deviation.
Results 85 patients fulfilled the inclusion criteria over the study period, totalizing
149 prone position sessions (2 ± 1 sessions per patient). Patients’ age was 65 ± 11
y, 67% were male, 75% fulfilled the criteria for severe ARDS, and SAPSII at ICU admission
was 64 ± 17. ARDS risk factors were pneumonia in 63 (74%), aspiration pneumonia in
26 (31%), and sepsis in 7 (8%) patients. Duration of prone position sessions was 16 ± 3 h.
Hemodynamic measurements were performed in PP 13 ± 3 h after PP session onset. At
session onset, SOFA score was 15 ± 4, and cumulated fluid balance was 2.5 ± 7.1 L.
Vasopressor were used in 87%, inhaled nitric oxide in 22%, and neuromuscular blocking
agents in 91% of the sessions. Hemodynamic and respiratory parameters before, during
and after the prone position sessions are reported in Table 24.
Table 24
Hemodynamic and respiratory measurements at T1, T2 and T3
Before PP (T1)
End of PP (T2)
After PP (T3)
Cardiac index (L min−1 m−2)
3.4 ± 1.2
3.4 ± 1.0
3.2 ± 1.0†,‡
Extravascular lung water (mL kg−1 PBW)
13.9 ± 4.7
13.5 ± 4.5
13.1 ± 4.0†
Pulmonary vascular permeability index
2.6 ± 1.1
2.3 ± 0.8†
2.4 ± 0.8†
Global end-diastolic volume (mL m−2)
729 ± 204
757 ± 203†,*
723 ± 208
dPmax (mmHg s−1)
1207 ± 496
1177 ± 478
1132 ± 458
Global ejection fraction (%)
21 ± 7
21 ± 7
20 ± 7
Cardiac function index (min−1)
4.9 ± 1.5
4.7 ± 1.5
4.6 ± 1.6†
Vasopressor dose (µg kg−1 min−1)
0.94 ± 1.53
0.90 ± 1.82†
0.97 ± 1.94†
Dobutamine dose (µg kg−1 min−1)
3 ± 5
3 ± 6
3 ± 6
Lactates (mmol L−1)
3.7 ± 3.3
3.3 ± 2.9†
3.2 ± 2.9†
PEEP (cmH2O)
9 ± 3
8 ± 2†
9 ± 3†
Plateau pressure (cmH2O)
22 ± 4
21 ± 4†
21 ± 4†
VT (ml kg−1 PBW)
6 ± 1
6 ± 1
6 ± 1
PaO2/FiO2 (mmHg)
110 ± 25
176 ± 58†,*
150 ± 56†
†p < 0.05 versus before PP; ‡ p < 0.05 versus end of PP; * p < 0.05 versus after PP
Cardiac index increased by at least 15%, decreased by at least 15% or remained stable
in 35 (24%), 36 (34%), and 78 (52%) of the sessions, respectively. As compared to
both other groups, PP sessions with significant increase in cardiac index had the
following significant differences at T1 by univariate analysis: lower cardiac index,
lower global end-diastolic volume, lower cardiac function index, and lower vasopressor
dose. Multivariate analysis is under investigation.
Conclusion Prone position is associated with an increase in global end-diastolic volume,
reversible after return in supine position that may explain the positive effect of
PP on cardiac index observed in ¼ of the PP sessions.
Competing interests None.
Reference
Jozwiak M. Beneficial hemodynamic effects of prone positioning in patients with acute
respiratory distress syndrome. Am J Respir Crit Care Med 2013;188:1428–33.
S87 Is the shape of the inferior vena cava a good tool to assess fluid responsiveness?
A pilot study
Hélène Cochet1, Jean Pierre Ponthus1, Virginie Amilien1, Martial Tchir1, Elise Barsam1,
Mohsen Ayoub1, Jean Francois Georger1
1Réanimation polyvalente - surveillance continue, Ctre Hospitalier Intercommunal de
Villeneuve Saint Georges, Lucie et Raymond AUBRAC, Villeneuve-Saint-Georges, France
Correspondence: Hélène Cochet - herrpotok@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S87
Introduction Make sure that our patient have a good circulatory condition is a daily
challenge for the intensivist. One of the therapeutics is fluid and one of his purpose
is to increase venous return and then cardiac output. In order to examine that, There
are several tools as the transthoracic echocardiogram wich allows the visualisation
and the study of the respiratory variability from the inferior vena cava (IVC). Unfortunately
there are some situations where the IVC visualisation is difficult (obesity, gut surgery,
emphysema). The IVC is easily seen by a transhepatic ultrasound in her retrohepatic
section. We make the hypothesis that the shape of the IVC could be predictive of fluid
responsiveness.
Patients and methods We have performed fluid challenge in patients under mechanical
ventilation. The need for fluid therapy is the intensivist in charge decision. We
performed a echocardiogram and we take two measures of the ICV: major axis and minor
axis, the ICV is measured avec the sus hepatic vena. A elastometry index (EI) is determined
which is the ratio of minor axis to minor axis. The fluid challenge is 250 ml of isotonic
saline then we perform a new echocardiogram. A Tag is written on the patient to take
the same ultrasound slice. We retain one increase of 15% of the cardiac index (IC)
as a success of the filling. We exclude the presenting patients A right cardiac insufficiency,
an arrhythmia and/or a HTAP. The statistical analysis is realized with the software
R.
Results Between August, 2015 and January, 2016 we included 49 patients. The average
age is of 59 years (24–81), IGS2 of 48 (20–84), Ejectionnal Fraction of 48% 35–75)
and the S wave tricuspid is 14 (9–21). The causes of the filling were an oliguria
(31%), a low blood pressure (20%), a low cardiac output (30%), a hyperlactatémia (9%)
and an other cause in 10% of the cases. We find a positive correlation between the
EI and the increase of the IC, also for the area of the VCI and the respiratory variations
of the VCI (p0.05) the other variables are not predictive (BP, E/e’, E/A). The data
are summarized in the picture 1. ROC curves has been established (Table 25; Fig. 21).
Table 25
Relevant parameters
R
IC
Value
EI
0.64
0.38–0.77
0.83 (0.69–093)
ICV Area
0.21
0.15–0.89
12 (9–17)
ICV respiratory variation (%)
0.61
0.34–0.85
12 (8–17)
ACS (IC95)
Se/Sp
Threshold
Courbes ROC
EI
0.81 (0.67–0.91)
85.7–75
0.85
ICV Area
0.70 (0.55–0.83
90–45
16.37
ICV respiratory variation
(%)
0.79 (0.65–0.87)
80–77
16
Fig. 21
See text for description
Conclusion It is an alternative and simple technique once acquired. The limits are
essentially established by technical conditions such as the necessity of being very
perpendicular at the risk of falsifying the EI. For now it is just a static index
but an ovoïd vena cava (EI: 0.85) may be predicative of fluid responsiveness. The
strangely big size of the VCI can be attributed to a deformation of the in-depth image
because of the probe but this should not modify in theory the report of EI. It is
a question in the future of testing this parameter at the spontaneous breathing patient,
study his variability with respiration and strengthening its external validity.
Competing interests None.
S88 Quality of reporting of fluid responsiveness evaluation studies: a five year systematic
review
Izaute Guillame1, Matthias Jacquet-Lagrèze1, Jean-Luc Fellahi1
1Anesthésie réanimation, Hopital Louis Pradel, Bron, France
Correspondence: Matthias Jacquet-Lagrèze - matthias.jl@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S88
Introduction The Standards for the Reporting of Diagnostic Accuracy Studies (STARD)
statement was developed in 2003 to improve the quality of reporting of diagnosis studies
(1). STARD is a list of 25 essential items, it was updated in 2015 (2). Fluid responsiveness
evaluation is a cornerstone of hemodynamic management of patient with circulatory
failure. Numerous studies have evaluated tools for assessing fluid responsiveness.
The purpose of this work was to evaluate the quality of reporting of studies assessing
fluid responsiveness, using the STARD criteria.
Materials and methods We used MEDLINE via PubMed to search all publication of studies
assessing the ability to predict or diagnose fluid responsiveness in a perioperative
or circulatory failure context between the 1st of January 2004 and the 1st of January
2014. We have presented herein the last 5 years (2010–2014). Paediatric studies, publication
with no abstract available or in another language than English, review, meta-analysis,
and journals with impact factor less than 2 were excluded. We have checked these studies
for all the 25 STARD criteria. The rating methodology of each item was discussed and
double checked (GI and MJL). The 2003 and 2015 STARD quality score (SQS) was the integer
of the present item. Univariate and multivariate analysis were conducted to find out
if some characteristic of the studies were linked with a better SQS. Following items
were studied: year of publication, positive or negative study, location of study,
expert team, funding source, conflict of interest, the use of a new device, instruction
to the author including STARD statement, impact factor of the journal. Every covariate
associated with a p-value lower than 0.20 in the univariate analysis were used in
the multivariate analysis. Statistical analysis was performed with R software. All
the test were two-sided, p < 0.05 was considered statistically significant.
Results After a double screening (GI, MJL) of 430 articles (2010–2014), 97 were selected,
then 46 were excluded because of an IF < 2. Fifty-one studies were selected and reviewed.
The mean 2003 overall quality score was 11.85 on a scale of 0–25, whereas the mean
2015 overall quality score was 15.34 on a scale of 0–30. The 2003 SQS remained stable
between 2010 and 2014 (p = 0.173). Correlation between 2003 and 2015 SQS was good
(r = 0.83; p < 0.001). Some items are insufficiently reported, especially: participant
sampling (adequately reported in 19.6% of studies), executing and reading the tests
(11.7%), blindness (11.8%) and, the description of test reproducibility (19.1%). Some
items are better reported: technical specifications and/or references to tests (65.1%),
methods for calculating or comparing (90.2%), clinical and demographic characteristics
(82.3%), diagnostic accuracy (90.2%). Only 16% of the journals studied required authors
to use STARD. A high Impact factor and the year of the study were the items associated
with a better SQS the presence of a conflict of interest was associated with a lower
SQS in univariate analysis. A higher impact factor (> 5), was the only independent
factors statistically significantly (p = 0.037) associated with higher SQS in a multivariate
regression model.
Discussion Our study showed that the SQS were very low. Assessment of a study depends
on quality of reporting. Blindness and participant sampling are the cornerstone to
evaluate such bias as spectrum, verification, review and selection bias of a study,
and were unfortunately scarcely reported compared to existing data in diagnosis accuracy
reporting. One of the limitation is the 5 years sample of the study. We have planned
to continue the analysis for a 10-year review starting just after the 2003 STARD publication.
Conclusion Our study showed that several items remain poorly reported. We recommend
systematic use of STARD criteria in the elaboration and reporting of future studies
that evaluates the preload dependence.
Competing interests None.
References
Bossuyt PM. STARD 2015: an updated list of essential items for reporting diagnostic
accuracy studies. BMJ. 2015;351:h5527.
Bossuyt PM. Towards complete and accurate reporting of studies of diagnostic accuracy:
The STARD initiative. Ann Intern Med. 2003;138(1):40–4.
S89 Neurological impairment in cirrhotic patients admitted to ICU: hepatic versus
drug-induced encephalopathy
Julie Assaraf1, Simona Tripon2, Maxime Mallet3, Marika Rudler4, Julien Mayaux5, Dominique
Thabut6, Nicolas Weiss7
1Unité de soins intensifs d’hépatogastroentérologie, Pitié-Salpêtrière Hospital, Paris,
France; 2Unité de soins intensifs d’hépatogastroentérologie, Hôpital Pitié-Salpêtrière,
Paris, France; 3Unité de Soins Intensifs. Service d’Hépato-gastro-entérologie du Pr
Poynard, CHU Pitié Salpétrière, Paris, France; 4Hepatology and gastroenterology, Pitié-Salpêtrière
Hospital, Paris, France; 5Réanimation médicale, Hôpital Pitié-Salpêtrière, Paris,
France; 6Brain Liver Pitié-Salpêtrière Study Group (BLIPS), Hôpital Pitié-Salpêtrière,
Paris, France; 7Unité de réanimation neurologique, Hôpital Pitié-Salpêtrière, Paris,
France
Correspondence: Julie Assaraf - julie.assaraf@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S89
Introduction Neurological impairment, i.e. encephalopathy, is commonly observed in
patients with decompensated cirrhosis and/or portosystemic shunts admitted in ICU.
Often ascribed to high plasmatic levels of ammonia, encephalopathy could also be induced
by drugs or infection, due to altered blood–brain barrier (BBB) permeability. This
latter setting is often underdiagnosed and encephalopathy related to hyperammonemia
(so called hepatic encephalopathy-HE) being pointed out as the culpit of all neurological
symptoms in cirrhotic patients. Quinolones and betalactamins were recently found in
the cerebrospinal fluid of HE patients and it has been shown that the expression of
efflux pumps, responsible for drugs passing through the BBB, was altered in animal
models of HE. The purpose of this study was to assess the incidence of neurological
impairment, i.e. encephalopathy, in cirrhotic patients hospitalized in ICU and to
analyse its promoting factors, especially ammonia levels, infection and drug intake.
Patients and methods Between February 2015 and September 2016, all cirrhotic patients
admitted in ICU were prospectively included. We collected patient’s clinical and biological
parameters, especially ammonia levels, all the ongoing treatments, and seeked for
the presence of evolutive infection defined as an infection considered as clinically
relevant. Cirrhotic patients having encephalopathy and ammonia levels above 75 μmol/L
were considered as having HE. We performed univariate and multivariate analysis to
estimate the association between ammonia level, infection or drugs intake and the
presence of encephalopathy.
Results 202 cirrhotic patients were included, they were 58 ± 11 years-old, 71% were
men. Etiology of cirrhosis was as followed: alcohol 110 (54%), virus 27 (13%), NASH
19 (10%), mixed 30 (15%), others 16 (8%). 122 patients (60%) displayed neurological
impairment, i.e. encephalopathy at admission, 84 (42%) had ammonia levels above 75 μmol/L,
80 (40%) had evolutive infection and the following drugs were found: furosemide, hydrochlorothiazide,
betablockers, lactulose, rifaximine, betalactamins, proton pump inhibitors (PPIs),
quinolones, benzodiazepines, morphine derivatives, insulin, anti-epileptic drugs,
corticosteroids and immunosuppressants. In univariate analysis, patients with encephalopathy
had significantly higher Child and MELD scores, higher ammonia, bilirubin and leukocytes
levels, more evolutive infections, and received more frequently PPIs, lactulose and
quinolones as compared to those who had no encephalopathy. Patients with encephalopathy
took also more frequently an association of agonist of efflux pumps (e.g. PPIs, betalactamins
or quinolones) (p = 0.0005). In the group of patients displaying low ammonia levels
(less than 75 μmol/L), encephalopathy was significantly increased in patients having
infection (p < 0.0001), taking quinolones (p = 0.0086), PPIs (p = 0.0196), and betalactamins
(p = 0.0438) whereas ursodeoxycholic acid treatment had a protective effect (p = 0.0299).
Multivariate analysis showed that high ammonia levels (p < 0.0001), presence of infection
(p < 0.0001), and taking quinolones (p = 0.0403) were independently associated with
the presence of encephalopathy.
Conclusion These results highlight the involvement of drugs in the physiopathology
of neurological impairment in cirrhotic patients. Several drugs that were implicated
can modify the activity of efflux pumps expressed on the BBB. Besides HE, cirrhotic
patients are susceptible to develop drugs-induced encephalopathy regardless of ammonia
level, underlying the necessity to carefully assess every treatment indication, given
their potential neurotoxicity.
Competing interests None.
S90 Functional outcome of prolonged hypoglycemic encephalopathy
Guilaume Barbara1, Bruno Megarbane2, Laurent Argaud3, Guillaume Louis4, Nicolas Lerolle5,
Francis Schneider6, Stéphane Gaudry7, Nicolas Barbarot8, Angéline Jamet,9, Hervé Outin10,
Sébastien Gibot1, Pierre-Edouard Bollaert1
1Réanimation médicale, hôpital central, C.H.U. de Nancy, Nancy, France; 2Service de
Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; 3Réanimation
Médicale, Hospices Civils de Lyon - Groupement Hospitalier Edouard Herriot, Lyon,
France; 4Réanimation polyvalente, Hôpital de Mercy, Ars Laquenexy, France; 5Réanimation
médicale, Centre Hospitalier Universitaire d’Angers, Angers, France; 6Réanimation
médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg, France; 7Service
de réanimation médico-chirurgicale, CHU Louis Mourier, Colombes, Colombes, France;
8Service de réanimation polyvalente, Centre hospitalier, Saint Brieuc, France; 9Réanimation
médicale, CHU de Poitiers, Poitiers, France; 10Service de Réanimation Médico-Chirurgicale,
CHI de Poissy/Saint-Germain-en-Laye - Site Poissy, Poissy, France
Correspondence: Pierre-Edouard Bollaert - pe.bollaert@chu-nancy.fr
Annals of Intensive Care 2017, 7(Suppl 1):S90
Introduction Little is known about the causes, clinical course and long-term outcome
of prolonged hypoglycemic encephalopathy. We investigated functional long-term prognosis
and identify prognosis factors of patients admitted in an Intensive Care Unit (ICU)
with prolonged neurological manifestations related to obvious hypoglycemia.
Patients and methods This was a retrospective study conducted in patients hospitalized
from July 1, 2004, to July 1, 2014, in 9 polyvalent intensive care units in French
university and general hospitals. Participants were adults admitted to the ICU with
a Glasgow Coma Score <8 due to hypoglycemia <0.5 g/l and persistent consciousness
disorders after normalizing blood glucose levels. Patients with possible other causes
of consciousness disorders, previous cognitive disorders, hypothermia <35 °C or circulatory
arrest within 24 h after ICU admission, were excluded. Follow-up phone call was used
to determine the functional outcome using modified Rankin Scale at 1-year minimum
(mRS) with mRS 0–3 defining good and mRS 4–6 poor outcomes.
Results Forty-nine patients were included. Median age was 55 years. Causes of hypoglycemia
were various, mainly including insulin or oral antidiabetic drugs abuse (65%) and
neuroendocrine carcinoma (16%). Twenty (41%) patients died in the ICU, and a total
of thirty-one (63%) patients had a poor outcome at 1-year follow-up. Twenty-two (45%)
patients underwent therapeutic limitation, primarily due to no hope expected for improvement
(86%). Among survivors with poor outcome at ICU discharge (n = 15), one died 10 months
later and six improved their outcome at 1-year follow-up with a median decrease in
mRS of −2 [IQR −2.5 to −1.75], including five patients who finally reached the good
outcome group. Among the patients with good outcome on ICU discharge, one died, seven
further improved their outcome at 1 year with a median decrease in mRS of −2 [IQR
−2.0 to −1.0], whereas one patient deteriorated while remaining in the good outcome
group (from mRS 1–2). On multivariate analysis, only low mRS prior to ICU admission
(OR 2.6; 95% CI = 1.1–6.3; P = .03) and normal brain imaging (OR 7.1; 95% CI 1.1–44;
P = .03) were significantly predictive of outcome. All patients (n = 15) who stayed
hypoglycemic 480 min or more evolved poorly.
Conclusion Poor outcome was observed in about 60% of this population of prolonged
hypoglycemic encephalopathy. Some patients can recover satisfactorily over time though
we did not identify any robust factor of good outcome.
Competing interests None.
Reference
Witsch J, Neugebauer H, Flechsenhar J, Jüttler E. Hypoglycemic encephalopathy: a case
series and literature review on outcome determination. J Neurol. 2012;259(10):2172–81.
S91 Cerebrospinal fluid characteristics during status epilepticus: a descriptive and
prognostic study
Mathilde Holleville1, Stéphane Legriel1, Anne Laure Chateauneuf1, Sébastien Cavelot1,
Gwenaëlle Jacq,1, Jean-Denis Moyer1, Jean Pierre Bedos1, Fabrice Bruneel1
1Réanimation médico-chirurgicale, C.H. de Versailles, Le Chesnay, France
Correspondence: Mathilde Holleville - mathildeholleville@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S91
Introduction The lumbar puncture is an important tool of the etiologic investigations
during status epilepticus. Scarce data are available regarding cerebrospinal fluid
pleocytosis directly induced by seizures. We aimed to describe the cerebrospinal fluid
characteristics of the patients admitted to the intensive care unit for status epilepticus,
and to report the clinical, biological and radiological data of these patients. Furthermore,
to determine whether status epilepticus per se increases the cerebrospinal fluid pleocytosis,
we specifically studied cerebrospinal fluid parameters after status epilepticus in
adult patients after exclusion of the cases of status epilepticus induced by acute
infection or neoplastic disease of the central nervous system.
Patients and methods This monocentric retrospective study (2005–2012) included patients
of more than 18 years old admitted to the intensive care unit for status epilepticus
and who had a lumbar puncture. Status epilepticus was defined by a single seizure
lasting more than 5 min or multiple seizures without neurological recovery in between.
A cerebrospinal fluid pleocytosis was defined by a cerebrospinal fluid cell count
of more than 4/mm3. We analyzed demographic, medical, biological data and outcomes
at 3 months and 1 year. The groups were compared using univariate and multivariate
analysis. Cerebrospinal fluid pleocytosis was considered directly linked to seizures
when etiologic investigations identified causes of status epilepticus which were not
known to induce cerebrospinal fluid pleocytosis.
Results Among 191 patients admitted to the intensive care unit for status epilepticus,
124 (65%) had a lumbar puncture and were included. Eight of them had a cerebrospinal
fluid pleocytosis of infectious or neoplastic origin. Among the 116 remaining patients,
97 (84% = group B2) had normal cerebrospinal fluid parameters, and 19 (16% = group
B1) had a cerebrospinal fluid pleocytosis considered as directly linked to seizures,
with a median [Q1–Q3] cerebrospinal fluid cell count of 8/mm3 [7–20]. No other cerebrospinal
fluid parameters changes were observed in the two groups, unless a slight increase
in the cerebrospinal fluid lactate (mmol/l), but without significant difference between
the two groups (3.1 [2.7–3.4] group B1 vs 2.9 [2.5–3.5] group B2). In the multivariate
analysis, only myoclonic status epilepticus (OR 55.1; CI 95% 6.02–1103.88; p = 0.001)
and leukocytosis at the admission (OR 1.1 per 103/mm3 increment; CI95% 1.01–1.21;
p = 0.01) were associated to pleocytosis directly linked to status epilepticus. The
intensive care unit mortality was significantly increased in patients with pleocytosis
directly linked to status epilepticus (5 (26%) vs 7 (7%), p = 0.02), but hospital
mortality was not significantly different between the 2 groups.
Discussion Overall, we reported a higher rate of lumbar puncture than those reporting
in others studies concerning status epilepticus. Furthermore the rate of 16% of pleocytosis
directly linked to status epilepticus is slightly higher than in most studies. Unfortunately
we didn’t realize a second lumbar puncture to assess the pleocytosis normalization
during the days following the first lumbar puncture. The pathophysiological hypothesis
of this phenomenon may be that prolonged/repeated seizures during status epilepticus
would induce a blood–brain barrier dysfunction thereby favoring a cerebrospinal pleocytosis.
Conclusion In our study, 16% of status epilepticus without infectious or neoplastic
origin had a cerebrospinal pleocytosis directly linked to status epilepticus. This
pleocytosis was significantly associated with myoclonic seizures and blood leukocytosis.
These data may help to interpretation of cerebrospinal fluid pleocytosis during status
epilepticus.
Competing interests None.
References
Chatzikonstantinou A, Ebert AD, Hennerici MG. Cerebrospinal fluid findings after epileptic
seizures. Epileptic Disord. 2015;17(4):453–9.
Tumani H, Jobs C, Brettschneider J, Hoppner AC, Kerling F, Fauser S. Effect of epileptic
seizures on the cerebrospinal fluid—a systematic retrospective analysis. Epilepsy
Res. 2015;114:23–31.
S92 Synek score and NSE to predict poor neurological outcome after cerebral anoxia
and therapeutic hypothermia
Dimitri Titeca Beauport1, Magalie Joris1, Philippe Merle2, Loay Kontar1, Antoine Riviere1,
Bertand De Cagny1, Thierry Soupison1, Michel Slama1, Julien Maizel1
1Réanimation médicale, Centre Hospitalier Universitaire, Amiens, France; 2Explorations
fonctionelles du système nerveux adulte, Centre Hospitalier Universitaire, Amiens,
France
Correspondence: Dimitri Titeca Beauport - titeca.dimitri@chu-amiens.fr
Annals of Intensive Care 2017, 7(Suppl 1):S92
Introduction Neurological prognostication from cardiac arrest survivor is a current
concern. EEG patterns and NSE dosage are two important prognostic factors. NSE threshold
for prediction of poor outcome appear controversial, in part, because of variability
in dosage timing and measurement techniques. Synek Score is routinely used in our
center to classify comatose patients in post cardiac arrest. The aim of this study
was to assess the prognostic value of NSE and Synek classification to predict poor
neurological outcome.
Materials and methods We conducted a retrospective monocentric study in our medical
intensive care unit between November 01, 2013 and August 31, 2016. All patient having
at least one EEG and H48-72 NSE dosage available were included. Patients dead from
post cardiac arrest shock, stroke, moribund, spontaneous awaking, or missing data
were excluded. Electroencephalograms were prospectively classified by electrophysiologist
according to the Synek score and NSE were performed within H48-72 post cardiac arrest.
Results Among 162 cardiac arrest survivors, 70 were retrospectively analyzed. All
patients received sedation with midazolam and sufentanil and mild therapeutic hypothermia
for 24 h. Forty-eight were classified as poor outcome (CPC ≥ 3) and 22 as good outcome
(CPC 1–2). Serum NSE levels above 46 µg/l was associated with a poor neurological
outcome with sensitivity of 75%, specificity of 100% and AUROC at 0.95. The Synek
score ≥3 was also strongly associated with poor neurological outcome with sensitivity
of 91.5%, specificity of 90.9% and AUROC at 0.95.
Conclusion In the limits of this study, Synek score ≥3 on first EEG and H48-72 NSE > 46 µg/l
are two strong predictor of poor neurologic outcome. The prognostic value of the association
of the NSE and the Synek score to predict a poor neurological outcome remain to be
determined.
Competing interests None.
S93 Influence of PbtO2 with severe TBI patients outcome at 6 months
Aurelie Laine1, De Sa Natalie2
1Nord, C.H. Régional Universitaire de Lille (CHRU de Lille), Lille, France; 2Nord,
C.H. de Valenciennes, Valenciennes, France
Correspondence: Aurelie Laine - aurelie-laine@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S93
Introduction Traumatic Brain Injury (TBI) is a major public health problem. It is
the leading cause of death and disability in young subjects. One of the principles
of the TBI management is prevention of secondary cerebral insults including maintaining
perfusion and cerebral oxygenation, control of intracranial pressure (ICP). An increase
in ICP above 20 mmHg is associated with poor outcome. Cerebral hypoxia can occur with
normal level of ICP and cerebral perfusion pressure (CPP).Monitoring of regional partial
pressure of brain tissue oxygen (PbtO2) is a safe and reliable method for measuring
cerebral oxygenation.
Patients and methods A retrospective single-center observational study was conducted
between January 2012 and December 2013, aimed to study the influence of PbtO2 with
severe TBI patients outcome at 6 months through Glasgow Outcome Scale (GOS). The hourly
values of ICP, PbtO2 and CPP were recovered on daily monitoring sheets. We compared
two groups according to their GOS. During the study period, 66 patients underwent
a monitoring ICP and PbtO2.
Results The mean age was 33.7 ± 14.1 years. 78.8% were men. The initial Glasgow score
was 6.6 ± 3.7. The mean Simplified Acute Physiology Score (SAPS II) was 43.4 ± 11.2
and Injury Severity Score (ISS) 30.5 ± 9.7. At 6 months, 7 patients had died (GOS1).
Forty patients had a good outcome: GOS 4–5 (Group 1). Sixteen patients had poor outcome:
GOS 2–3 (Group 2). In Group 2, there are significantly more PbtO2 hourly values below
10 mmHg at Day0 (5.5 ± 6.4 vs 2.3 ± 3, 2 in Group 1, p = 0.025); and more PbtO2 hourly
values greater than 20 mmHg at Day0 (8.4 ± 7.0 vs 4.8 ± 4.9, p = 0.045).
Conclusion PbtO2 less than 10 mmHg or greater than 20 mmHg at Day0 is associated with
poor outcome at 6 months in the severe TBI. The PbtO2 allows a more individual approach
of monitored TBI.
Competing interests None.
References
Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of
Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton
SL, Chestnut RM, et al. Guidelines for the management of severe traumatic brain injury.
VI. Indications for intracranial pressure monitoring. J Neurotrauma. 2007;24(Suppl
1):S37–44.
Stiefel MF, Spiotta A, Gracias VH, Garuffe AM, Guillamondegui O, Maloney-Wilensky
E, et al. Reduced mortality rate in patients with severe traumatic brain injury treated
with brain tissue oxygen monitoring. J Neurosurg. 2005;103(5):805–11.
S95 Organ procurement and kidney transplantation under Maastricht 3 condition (M3):
update on 1 year of activity
Mathieu Cornuault1, Jérome Libot1, Jean Reignier2, Karim Asehnoune3, Bertrand Rozec4,
Jacques Dantal5, Michel Videcoq1
1Coordination prélèvements organes, CHU Hôtel-Dieu Nantes, Nantes, France; 2Réanimation,
Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon, France;
3Réanimation chirurgicale, C.H.U. Hôtel Dieu, Nantes, France; 4Réanimation CTCV Transplantation
thoracique, CHU de Nantes - Hôpital Nord Laennec, Saint-Herblain, France; 5Néphrologie-transplantation
rénale, CHU Hôtel-Dieu Nantes, Nantes, France
Correspondence: Mathieu Cornuault - mathieu.cornuault@chu-nantes.fr
Annals of Intensive Care 2017, 7(Suppl 1):S95
Introduction Organ donation in patients after a decision to withdraw life-supportive
therapies (WLST) (Maastricht 3 condition: M3) have been performed in our hospital
since May 2015. We report here main characteristics of donors, data on M3 procedure
and results on renal transplant recipients.
Patients and methods All potential donors were included in a survey from May 2015
to June 2016, according to the French national M3 protocol defined by the French Organ
Procurement Agency (Agence de la Biomédecine:ABM) [1].The demographical, clinical
and biological characteristics of the donors, the different deadlines and times of
the protocol and data of renal transplantation were collected and analyzed.
Results 28 patients had inclusion criteria. Patients were admitted in intensive care
unit for cardiac arrest (68%), strokes (14%), traumatic brain injury (14%), ARDS (4%).
Of them, 15 procedures (54%) were stopped (6 refusals of organ donation, 4 medical
contra-indications discovered with additional exams, 1 failure of vessel cannulation,
4 deaths more than 3 h after extubation). 28 kidneys were harvested and 26 transplantations
performed (1 renal cancer discovered during procurement surgery).The characteristics
of the donors, deadlines of the protocol and transplant recipients are reported in
the Table 26.
Table 26
Characteristics of the donors, deadlines of the protocol and transplant recipients
Characteristics of potential donors (n = 28)
Age in years, mean [range]
47.9 [21–59]
Sexe, male (%)
24 (86%)
Serum creatinine, mean (μmol/L) [range]
68.96 [31–154]
CrCl by Cockroft-Gault, mean (ml/mn) [range]
139.27 [53–255]
Length of stay in ICU, mean (day) [range]
7.85 [2–23]
Deadlines of the protocol (n = 13)
Time from extubation to death, mean (min) [range]
37.2 [7–160]
Warm ischemia time, mean ‘min) [range]
36.8 [21–51]
Duration of vessel cannulation, mean (min) [range]
27.2 [12–45]
Duration of normothermic regional perfusion, mean (min) [range]
171.2 [94–222]
Duration of cold storage, mean (min)
591
Characteristics of transplant recipients (n = 26)
Age in years, mean [range]
56.4 [35–71]
Sexe, male, n (%)
16 (61.5%)
Length of stay in transplant unit, mean (day) [range]
12.8 [6–41]
Duration before creatinine <250 μmol/L after transplantation, mean (day) [range]
7.8 [1–34]
Serum creatinine (μmol/L) at the hospital discharge, mean [range]
157.5 [52–276]
Delayed Graft Function, n (%)
4 (15.3%)
Conclusion The French programm Maastricht 3 offered a new possibility of organ donation
in our hospital. Thanks to these donors, the number of renal grafts increases and
the preliminary results on transplant recipients are encouraging in line with the
preliminary report of the ABM. Nevertheless, it is necessary to follow the transplant
recipients and extend the procedure to new centres.
Competing interests None.
Reference
Conditions à respecter pour réaliser des prélèvements d’organes sur les donneurs décédés
après arrêt circulatoire de la catégorie III de Maastricht dans un établissement de
santé. Agence de la biomédecine. Version n°6 mai 2016 [consulté le 26/08/2016]. http://www.agence-biomedecine.fr/IMG/pdf/v6_guide_procedures_ddac_miii_052016.pdf.
S96 Is chronic obstructive pulmonary disease a risk factor for microaspiration in
intubated critically-ill patients?
Thècle Degroote1, Emmanuelle Jaillette1, Farid Zerimech2, Balduyck Malika2, Saad Nseir1
1Centre de réanimation, Centre Hospitalier Régional Universitaire de Lille, Lille,
France; 2Laboratoire de biochimie et biologie moléculaire, Centre Hospitalier Régional
Universitaire de Lille, Lille, France
Correspondence: Thècle Degroote - thecle.degroote@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S96
Introduction Microaspiration of gastric and oropharyngeal contaminated secretions
occurs frequently in intubated critically-ill patients, and plays a major role in
the pathogenesis of ventilator-associated pneumonia (VAP). At basic state, patients
with chronic obstructive pulmonary disease (COPD) have an increased risk of microaspiration
(due to gastro-esophageal reflux disease, pharyngo-laryngeal dysfunction…), this risk
may even be more important under mechanical ventilation. The main purpose of this
study is to determine if COPD is a risk factor for global abundant microaspiration
(GAM) in intubated critically-ill patients.
Materials and methods We gathered data about two prospective multicentric randomized
trials focused on microaspiration in intubated patients. Data about COPD were retrospectively
collected in order to complete previous data. Microaspiration of gastric and oropharyngeal
secretions was respectively determined by quantitative measurements of pepsin and
salivary amylase in all tracheal aspirates during the first 48 h after intubation.
GAM was defined as the presence at significant level of pepsin (>200 ng/ml) and/or
salivary amylase (>1685 UI/L) in at least 30% of the tracheal aspirates. In order
to find GAM independent risk factors, we realized an univariate and multivariate analysis
of the variables collected.
Results Out of 448 patients included in the studies, 415 were analyzed among which
95 patients with COPD. 360 patients (87%) had GAM. Neither COPD diagnosis, nor spirometric
severity nor specific therapeutics were associated with GAM. Risk factors for GAM
in univariate analysis were the age, diabetes, low score in Glasgow Coma Scale (GCS),
and no recourse to paralytic agents or vasopressors. After multivariate analysis,
age was identified as independant risk factor for GAM (OR [IC 95%] = 1.03 [1.01–1.05],
p < 0.001); whereas high score in GCS (OR [IC 95%] = 0.93 [0.86–0.99], p = 0.03) and
use of paralytic agents (OR [IC95%] = 0.46 [0.23–0.90], p = 0.02) were associated
with less occurrence in GAM. GAM was not associated with any increase of length of
mechanical ventilation, length of ICU stay, VAP incidence or surmortailty.
Discussion In this study, we found some relevant risk factors for microaspiration
(age, low score at GCS) consistent with literature on the subject. Patients with paralytic
agents had less GAM which may be due to higher PEEP, higher cuff pressure and less
enteral nutrition because of the severity of the underlying diseases.
Conclusion This study did not show any increased risk of microaspiration in intubated
COPD patients, whatever stage of COPD.
Competing interests None.
S97 Microscopic examination and quantitative culture of protected brush specimen in
suspected episodes of ventilator acquired pneumonia: effect of prior antimicrobial
treatment
Jean-François Llitjos1, Marlène Amara2, Guillaume Lacave3, Jean Pierre Bedos3, Béatrice
Pangon2
1Réanimation Médicale, Hôpital Cochin, Paris, France; 278150, Hospital Center De Versailles,
Le Chesnay, France; 3Réanimation médico-chirurgicale, Centre Hospitalier de Versailles,
Le Chesnay, France
Correspondence: Jean-François Llitjos - jllitjos@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S97
Introduction Protected specimen brush (PSB) is considered to be one of the standard
methods for the diagnosis of ventilator-associated pneumonia (VAP). To our knowledge,
there is no study assessing effect of prior antibiotherapy on direct examination,
bacteriological culture and concordance of direct microscopy and culture.
Patients and methods All consecutive episodes of suspected VAP were retrospectively
evaluated between January 2014 and December 2014 in a 20-bed intensive care unit.
Patient’s characteristics and preexisting conditions were abstracted from the medical
charts. After assessment of VAP probability using the clinical pulmonary infection
score (CPIS), PSB were performed in patients with a CPIS of 6 or more. Based on antibiotic
treatment in patients when bacteriological specimens were obtained, two groups were
defined: no antibiotic group and antibiotic treatment started before PSB group. Two
independent bacteriologists retrospectively reviewed direct examination and culture
of PSB to assess bacteriological concordance, defined as non-concordant when direct
examination and culture were different, concordant when direct examination and culture
were similar and partially concordant when either direct examination or culture were
comparable but with other microorganisms lacking in one or the other method.
Results During this 12-months period, among 73 mechanically ventilated patients, 116
episodes of suspected VAP with PSB were evaluated. We found 60% of PSB (n = 70) performed
without antibiotic treatment and 40% of PSB (n = 46) performed under antibiotherapy.
We found no significant differences in patient’s demographics, characteristics, and
severity between both groups. Patients received antibiotics for the following reasons:
aspiration pneumonia (n = 12), peritonitis (n = 8), VAP (n = 7), community-acquired
pneumonia (n = 4), septic shock of unknown origin (n = 4), pyelonephritis (n = 3),
meningitis (n = 2), acute pancreatitis (n = 2) and others (n = 4). The median duration
of mechanical ventilation in the antibiotic receiving group and in the group without
antibiotics was 7.5 days (IQR; 5–12 days) and 9 days (IQR: 5–22), respectively. When
PSB was performed under antibiotic treatment, direct examination was positive in 26%
(n = 12), culture was positive in 28% (n = 13) and those methods were concordant,
non concordant and partially concordant in 93% (n = 43), 4% (n = 2) and 3% (n = 1),
respectively. On the other hand, when PSB was performed without antibiotics, direct
examination was positive in 65% (n = 46), culture was positive in 62% (n = 43) and
those methods were concordant, non concordant and partially concordant in 71% (n = 50),
18% (n = 12) and 11% (n = 8), respectively. In univariate analysis, we found a significantly
higher proportion of negative direct examination and negative culture in the antibiotic
group (p > 0.001). Moreover, these methods were significantly more frequently concordant
(p = 0.01), with a higher rate of both negative microscopic exam and culture when
compared to the no antibiotic group (76%, n = 33 vs 38%, n = 18). Surprisingly, among
the 13 patients previously treated with antibiotics with positive culture, 38% (n = 5)
of the microorganisms showed antibiotics sensitivity.
Discussion Whether prior antibiotic treatment may induce false negative of false positive
treatment is a well-recognized phenomenon, the precise effect of antibiotics on direct
examination and quantitative culture is not well assessed in VAP. Moreover, despite
recent development of clinico-radiological score, diagnosis of VAP remains difficult,
with no gold-standard. Therefore, bacteriological guided therapy is of particular
importance. We found PSB realization under antibiotic treatment is associated with
a lower rate of positive direct examination and culture and suggest performing these
bacteriological samples without antibiotherapy. Some authors have suggested lowering
the diagnostic threshold point of this bacteriological technique in order to preserve
its accuracy. However, we can postulate that microorganisms responsible of superinfection
in mechanically ventilated patients treated with antibiotics may be resistant and
therefore the PSB could be positive.
Conclusion In patients with a high pre-test probability of ventilator-acquired pneumonia,
recent introduction of antibiotics significantly reduced the diagnostic accuracy of
protected brush specimen by reducing rates of positive direct examination and culture.
Further studies should evaluate if antibiotic discontinuation may revert this effect.
Competing interests None.
S98 Implementation and impact assessment of a “ventilator-bundle” at the university
clinics of Kinshasa: before and after study
José Mavinga1, Joseph Nsiala Makunza2, M E Mafuta3, Yves Yanga1, Amisi Eric1, Jp Ilunga1,
Ma Kilembe1
1Anesthesia and Reanimation, Cliniques universitaires de kinshasa, Kinshasa, Democratic
Republic of the Congo; 2Anesthésie-Réanimation, Hôpital Privé d’Athis-Mons - Site
Caron, Athis-Mons, France; 3Scool of public health, Université de Kinshasa, Batiment
administratif, Kinshasa, Democratic Republic of the Congo
Correspondence: José Mavinga - joicemav@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S98
Introduction In 2005, an international consensus conference took stock of the various
measures to be implemented for the prevention of ventilator acquired pneumonia (VAP)
[1]. These measures are often gathered in groups of 3 or 5 under the term of “ventilator-bundle.”
The effectiveness of these “bundles” was poorly evaluated in African environment.
Objective To establish a VAP prevention program and assess its impact on morbidity
and mortality of patients under mechanical ventilation in our service.
Patients and methods Prospective, mono centric, quasi-experimental before-after study.
It took place in the intensive care unit of the University Clinics of Kinshasa in
the Democratic Republic of Congo (DRC). This service is equipped with 8 beds and a
respirator for two beds. The observational period (phase1) was carried out from February
1st to December 31st, 2014 and the intervention period (phase2) from February 15st,
2015 to February 15st, 2016. All consecutive patients intubated and mechanically ventilated
for more than 48 h were included. Five preventive measures were held: hand hygiene,
the elevation of the head of the bed at 30°–45°, the daily lifting of sedation, oral
decontamination with chlorhexidine and control cuff pressure of the endotracheal tube.
Compliance with this bundle was assessed by direct observation without the knowledge
of caregivers. The diagnosis of “VAP” was held before a clinically modified sore (m
CPIS) >6. The main outcomes were the incidence of VAP and mortality. The protocol
for this study was approved by the Ethics Committee of the School of Public Health
of the University of Kinshasa, under the approval number: ESP/EC/015/2015.
We have had non conflict of interest in this study.
Results We included 44 patients in the phase1 and 58 patients in the phase2. Baseline
characteristics of patients were similar in both groups. Compliance with all the measures
has been improved between the two period from 0 to 32.75%. The incidence density decreased
from 33.74 to 18.05 VAP per 1000 ventilator days between observational and interventional
period, but the all-cause mortality was almost equal in the 2 groups (88.6 vs. 86%).
Discussion With the implementation of our bundle, observance of the team were improved
in the second group, compared to the first and the incidence density decreased from
33.74 to 18.05 VAP per 1000 ventilator days between both period. This result is consistent
with the littérature. Sure enough, many studies show the same effect of VAP prevention
with a decrease of nearly 50% of the incidence density of VAP, after implementation
of a «ventilator –bundle [2].
Conclusion The implementation of a “ventilator bundle,” has significantly reduced
the incidence of VAP in our service. In the contrary, our study failed to demonstrate
a reduction in mortality.
Competing interests None.
References
American Thoracic Society, Infectious Diseases Society of America. Guidelines for
the management of adults with hospital acquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med. 2005;171:388.
Morris AC, Hay AW, Swann DG and all. Reducing ventilator-associated pneumonia in intensive
care: impact of implementing a care bundle. Crit Care Med. 2011;39(10):2218–24.
S99 Histone deacetylases inhibition reverses sepsis-induced susceptibility to Pseudomonas
aeruginosa pneumonia
Fanny Alby-Laurent1, Julie Toubiana1, Christophe Rousseau1, Hamid Merdji1, Jean-François
Llitjos1, Jean-Paul Mira2, Frédéric Pène2, Jean-Daniel Chiche2
1U1016, 22 rue méchain, 75014, paris, Institut National de la Santé et de la Recherche
Médicale, Paris, France; 2Réanimation Médicale, Hôpital Cochin, Paris, France
Correspondence: Jean-Daniel Chiche - jean-daniel.chiche@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S99
Introduction With an increasing incidence and high mortality rates, sepsis is a public
health issue. There is growing evidence that sepsis induces long lasting alterations
of transcriptional programs through epigenetic mechanisms that may lead to protracted
inflammation, organ failure, sepsis-induced immune suppression (SIIS), secondary infections
and death. We hypothesized that epigenetic changes contribute to the pathophysiology
of SIIS. To test this hypothesis, we studied the effects of histone deacetylases (HDAC)
inhibition with trichostatin A (TSA) in a double-hit murine model of SIIS and secondary
pneumonia.
Materials and methods C57BL/6 mice were treated with TSA (2 mg/kg ip) or saline serum
(CTL) 30 min before induction of sepsis by cecal ligation and puncture (CLP). Surviving
mice underwent intratracheal instillation of 1.5 × 106 CFU of Pseudomonas aeruginosa
8 days after CLP. We evaluated the effect of TSA on survival and cellular responses
to the primary and secondary infections. Cellular responses in the blood, spleen and
BAL were assessed by flow cytometry after CLP (Days 1, 3 & 8) and after pneumonia
(4 & 12 h). We also studied lymphocyte apoptosis and dendritic cells (DC) expression
of CD40, CD86, and MHCII. Bacterial clearance was assessed in the BAL and in the blood
4 and 12 h after pneumonia. Continuous variables represented as mean ± SD were compared
using Student t test. Kaplan–Meier curves were compared by the log rank test. P < 0.05
indicated statistically significant differences.
Results Whereas treatment with TSA did not change survival after CLP, TSA improved
survival after tracheal instillation of P. aeruginosa (P = 0.009, Fig. 22).
Fig. 22
See text for description
TSA-treated mice had significantly higher absolute DC, T and B-lymphocytes counts
with reduced lymphocyte apoptosis after CLP. Four hours after secondary pneumonia,
TSA-treated mice had significantly higher DC counts and improved bacterial clearance
in the BAL, with reduced systemic dissemination of P. aeruginosa.
Conclusion HDAC inhibition with TSA improves survival in our murine model of secondary
pneumonia, improves bacterial clearance and attenuate cellular features of SIIS. These
results suggest that sepsis-induced epigenetic changes contribute to the advent of
SIIS. Comprehensive characterization of epigenetic changes associated with SIIS might
allow us to identify new therapeutic targets to reprogram immune cells in sepsis and
avoid SIIS.
Competing interests None.
S100 Nosocomial infections in intensive burn care unit
Amel Mokline1, Achraf Laajili1, Helmi Amri1, Imene Rahmani1, Nidhal Mensi1, Lazheri
Gharsallah1, Sofiene Tlaili1, Bahija Gasri1, Rym Hammouda1, Amen Allah Messadi1
1Burn care department, Trauma and burn center, Tunis, Tunisia
Correspondence: Amel Mokline - dr.amelmokline@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S100
Introduction Nosocomial infections (NI) are common in burn patients due to the loss
of the first line of defense against microbial invasion, immunocompromising effects
of burn injury, and invasive diagnostic and therapeutic procedures. The objective
of this study was to identify the incidence of nosocomial infection (NI), the pathogens
and their antibacterial patterns, and prognosis of these burn patients.
Patients and methods A retrospective study was conducted in a 20 bed intensive burn
care unit during 6 months. Patients were eligible for the study, if they met the following
criteria: total burn surface area (TBSA) > 10%, length of ICU stay ≥48 h, and infected
in accordance with the criteria of the National Nosocomial Infections Surveillance
(NNIS) and the criteria of the SFETB [1–2]. In this study, NIs were classified into
four main groups: pneumonias, bloodstream infections (BSI), catheter related infections
(CRI), and urinary tract infections (UTI). For included patients, skin levy, blood
cultures, urine and sputum cultures were drawn during fever or clinical features of
sepsis.
Results During the 6-month study period, 190 patients were admitted to the ICU, 47
patients were included (24.7%). 32 were male and 15 female. The mean age was 41 ± 19 yr.
The mean TBSA was 41 ± 24%. 63% were admitted from another hospital. Burn injuries
were due to domestic accidents in 53% and self immolation in 25%. The mean length
of ICU stay was 16 ± 14 days. 47 patients acquired 58 NIs (36.2% BSI, 20.5% pneumonia,
10.3% CRI and 10.3% UTI. There was no bacteriological documentation of NI in 22.5%
of cases. NIs occured 4 days post burns. The most three isolated pathogens were: Acinetobacter
spp. (31%), P. aeruginosa (22.5%) and extended spectrum beta-lactamase-producing Enterobacteriaceae
(17%). The most frequently administered antibiotics were polymyxin/carbapenem/teicoplanin
combination (21%), polymyxin/carbapenem combination (15%) and carbapenem/tigecycline
combination (15%). In our study, mortality rate was 50%.
Conclusion Nosocomial infection occured in 24.7% of cases in burn patients, caused
by Acinetobacter spp, P. aeruginosa and Enterobacteriaceae BLSE. So, eradication of
infection in burn patients require effective surveillance and infection control in
order to reduce mortality rates, length of hospitalization and associated costs.
Competing interests None.
References
National Nosocomial Infections Surveillance System. National Nosocomial Infections
Surveillance (NNIS) System Report, data summary from January 1992-June 2002, issued
August 2002. Am J Infect Control. 2002;30:458–75.
Critères d’infection chez les brulés. SFETB-2006.
S101 Predictors of treatment failure for patients with pneumonia caused by Staphylococcus
aureus methicillin-sensitive in a intensive care unit: a retrospective study
Pierre-Antoine Allain1, Nathallie Gault2, Catherine Paugam-Burtz1, Arnaud Foucrier1
1Anesthesiology and critical care, Hospital Center University Beaujon (AP-HP), Clichy,
France; 2Unité d’épidémiologie et recherche clinique, Hospital Center University Beaujon
(AP-HP), Clichy, France
Correspondence: Arnaud Foucrier - arnaud.foucrier@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S101
Introduction Infection of the lower respiratory tract is the most common cause of
infection in intensive care unit (ICU) (1). Although the attributable mortality of
ventilator associated pneumonia remains debated, the recurrence of these infections
is always associated with a significant morbidity (2). Staphylococcus aureus methicillin-sensitive
(SAMS) is one of the most frequently germs involved in ICU pneumonia especially in
trauma patients. The aim of the study was to establish the risk factors associated
with microbiological treatment failure of pneumonia, caused by SAMS.
Materials and methods we retrospectively identified 185 patients who developed a first
episode of ventilator associated pneumonia caused by SAMS during a 6 years-period
(2009–2014). The primary end point was the microbiological treatment failure defined
as a second episode of pneumonia caused by SAMS corresponding to either a persistent
or a recurrence of the pneumonia (Fig. 23). The primary aim of the study was to identify
factors associated with a treatment failure, the secondary objective was to identify
factors associated with the occurrence of second episode (i.e. persistent, recurrence,
superinfection and/or relapse of pneumonia caused by any bacteria) during or after
treatment of the first episode caused by SAMS. Definition of outcomes was based after
analysis of current concepts available in the literature. Factors associated with
primary and secondary objectives in univariate analysis (p-value < 0.20), or clinically
relevant ones, were entered in a multivariate logistic regression. The final selection
was performed using the stepwise selection based on the Akaike criterion.
Fig. 23
See text for description
Results Fifty-nine patients (33.3%) developed a second episode of pneumonia and among
them, 30 (16.6%) were considered as a microbiological failure. In a multivariate analysis,
the association of oropharyngeal flora (FOP) with the SAMS (OR, 3.86; 95% CI, 1.33–11.11;
p = 0.011) and the need of emergency surgery (OR, 5.26; 95% CI, 1.39–35.2; p = 0.035)
were predictive of a microbiological failure. Empirical antibiotic therapy with amoxicillin-clavulanic
acid (OR, 2.28; 95% CI, 1.15–4.51; p = 0.017) and performing emergency surgery (OR,
3.60; 95% CI, 1.34–9.65; p = .011) were predictors of a second episode of pneumonia
caused by any bacteria.
Conclusion In this retrospective, monocentric study, the co presence of orophryngeal
flora and the need of emergency surgery were associated with microbiological failure
of pneumonia caused by SAMS in ICU.
Competing interests None.
References
Vincent J-L. International study of the prevalence and outcomes of infection in intensive
care units. JAMA. 2009;302(21):2323–9.
Cavalcanti M. A. Risk and prognostic factors of ventilator-associated pneumonia in
trauma patients. Crit Care Med. 2006;34(4):1067–72.
S102 Ventilator-associated pneumonia: never enough, never give up!
Sahar Habacha1, Bassem Chatbri1, Aymen M’rad1, Youssef Blel1, Nozha Brahmi1, Yousra
Bourbiaa2, Lamia Thabet2
1Departement of intensive care and toxicology, Centre d’Assistance Médicale Urgente,
Tunis, Tunisia; 2Biology departement, Trauma Center, Ben Arous, Tunisia
Correspondence: Sahar Habacha - sahar.habacha@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S102
Introduction Ventilator-associated pneumonia is a major iatrogenic problem since it
is a cause of hospital morbidity, mortality and increase of health care costs. It
has been studied many times, but data’s revision is always necessary. Our study aimed
to describe epidemiology of ventilator-associated pneumonia and identify local causative
pathogens.
Materials and methods We carried out a prospective study in an intensive care unit.
Were included patients intubated for more than 48 h, from April 2015 to May 2016,
and presenting signs of ventilator-associated pneumonia (fever, abundant and purulent
secretion, increase of FiO2 greater than 0.2, signs on chest-X ray) with positive
culture of endotracheal aspirate. Were excluded patients with germ colonization.
Results A total of 268 patients were ventilated for more than 48 h. Among them thirty-four
patients aged of 39 ± 18.5 years presented 54 episodes of ventilator-associated pneumonia
(that is 1.58 ± 0.85 episodes per patient). The mean SOFA score was 5.2 ± 1.8. The
main reasons of mechanical ventilation were loss of consciousness secondary to poisoning
(20%), respiratory distress (20%) and status epilepticus (12%). The mean duration
of stay was 62.5 days with extremes at 7 and 180 days. The average time between hospitalization
and suspicion of ventilator-associated pneumonia was 5.9 ± 2.7 days. The average value
of the Clinical Pulmonary Infection Score at suspicion was 5 ± 1.26. The average time
between recurrences was 16.8 days with extremes at 4 and 39 days. The culture of endotracheal
aspirate identified two pathogens in 11%. It reveled Acinetobacter baumanii in 35%
in which 63% were imipenem resistant, Pseudomonas aeroginosa in 33%, Klebsielle pneumoniae
in 22%, Staphylococcus aureus methicillin resistant in 7%. Extended spectrum β-lactamases
bacteria were found in 10% and carbapenemases producers in 12%. Empirical antibiotherapy
was always association of imipenem and colistin. It was necessary to adapt it to antibiograms
in 33/54.
Ventilator-associated pneumonia was complicated by septic shock in 28% and acute respiratory
distress syndrome in 24%. Patients evolved to healing in 63% of episodes (n = 34),
to superinfection in 26% (n = 14) and to death in 9% (n = 5). Pseudomonas aeruginosa
was the most frequent germ in superinfection (7/14), Acinétobacter baumanii was the
most pathogen associated to death (3/5).
Conclusion Ventilator-associated pneumonia is an iatrogenic disease that threatens
lives. It’s in part avoidable. Preventive measures have to be implemented to reduce
its frequency, consequences and costs.
Competing interests None.
S103 Comparative performance of different automated weaning modes: a network meta-analysis
Arthur Neuschwander1, Looten Vincent2, Chhor Vibol1, Yavchitz Amelie1, Matthieu Resche-Rigon2,
Jean Mantz1, Romain Pirracchio1
1Anesthésie réanimation, Hôpital Européen Georges-Pompidou (AP-HP), Paris, France;
2Biostatistiques, Hôpital Saint-Louis (AP-HP), Paris, France
Correspondence: Arthur Neuschwander - arthur.neuschwander@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S103
Introduction Mechanical ventilation (MV) weaning is a crucial step in critically ill
patients. MV duration is associated with an increased risk of ventilator associated
events, even though its specific impact on mortality has never been clearly demonstrated
(1). Automated closed loop systems might help the weaning process. A recently published
meta-analysis has reported a reduction in MV duration when using an automated weaning
mode as compared to non-automated mode (2). However, the different automated modes
have not been compared to each other. The objective of this network meta-analysis
was to compare the performance of the three major automated weaning modes, i.e. the
Automode°, the Smartcare° and the Adaptative Support Ventilation (ASV°) for MV weaning
in critically ill and post-operative adult patients.
Materials and methods We included all randomised control trials that compared automated
closed loop weaning applications either to another automated application or standard
care, including weaning according to a written weaning protocol or nurse driven protocols.
The three modes of automated modes included in the study were ASV°, Smartcare° and
Automode°. The primary outcome was the duration of MV weaning, defined as the time
between randomization and a successful extubation. We also planned subgroup analyses
in the ICU and the post-operative populations. The quality of the studies was assessed
independently by two blinded investigators, using the evaluation recommended by the
Cochrane Collaboration. A network Bayesian meta-analysis using random effect models
and based on aggregate data from the included studies was performed using the gemtc
package (R project, Vienna). This trial was declared in PROSPERO in August 2015 (CRD42015024742).
Results
Search of databased identified 776 articles; 233 were screened for eligibility after
removal of duplicates. Abstract analysis led to the exclusion of 191 articles with
a final full text analysis of 42 randomised control trials. Ultimately, 15 trials
were included in the analysis, representing 1424 ventilated patients. Nine studies
included patients in the post-operative period while six were conducted in ICU. The
automated mode was ASV° (A) in 9 studies, Smartcare° (C) in 4 studies and Automode°
(B) in 2 studies. All studies reported the duration of MV weaning as defined in our
protocol. In all studies, the control group was standard care with a weaning process
driven either by nurses or physicians. In 12 studies (75%) a written weaning protocol
was used in the control group. All ICU studies used sedation protocols based on sedation
scores, none of them including systematic daily sedation interruption. Each one of
the automated application was associated with a significant reduction in the duration
of MV as compared to the control. When comparing all different modes using the network
meta-analysis framework, ASV° appeared to be the best automated mode when it pertains
to reducing the duration of mechanical ventilation weaning (Fig. 24). Subgroup analysis
showed similar results in the post-operative and the ICU populations.
Fig. 24
Bayesian NMA with random effect
Conclusion Compared to standard weaning practice, the 3 major automated weaning modes
significantly reduced the duration of MV weaning in critically ill and post-operative
adult patients. ASV° was associated with the most significant effect when compared
to the two other automated modes (Smartcare°, Automode°). Further physiological respiratory
studies would help to understand the underlying mechanisms accounting for the superiority
of ASV.
Competing interests None.
References
McConville JF, Kress JP. Weaning patients from the ventilator. N Engl J Med. 2012;367(23):2233–9.
Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus
non-automated weaning for reducing the duration of mechanical ventilation for critically
ill adults and children: a cochrane systematic review and meta-analysis. Crit Care
Lond Engl. 2015;19:48.
S104 Impact of proportional assisted ventilation on dyspnea and asynchrony in mechanically
ventilated patients
Côme Bureau1, Maxens Decavèle1, Sébastien Campion2, Roukia Ainsouya2, Marie-Cécile
Niérat2, Julien Mayaux3, Hélène Prodanovic3, Mathieu Raux4, Thomas Similowski1, Alexandre
Demoule1
1Réanimation médicale, inserm umr_s 1158 neurophysiologie respiratoire expérimentale
et clinique, Pitié-Salpêtrière Hospital, Paris, France; 2Inserm umr_s 1158 “neurophysiologie
respiratoire expérimentale et clinique”, Pitié-Salpêtrière Hospital, Paris, France;
3Unité de réanimation et de surveillance continue, service de pneumologie et réanimation
médicale, Pitié-Salpêtrière Hospital, Paris, France; 4Département d’anesthésie-réanimation
et urm_s 1158, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
Correspondence: Côme Bureau - come.bureau@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S104
Introduction During mechanical ventilation, mismatch between respiratory muscles activity
and the assistance delivered by the ventilator results in dyspnea and asynchrony and
is commonly observed in intensive care unit (ICU) patients. Proportional Assisted
Ventilation (PAV) is a ventilatory mode that adjusts the level of ventilator assistance
to the activity of respiratory muscles estimated by an algorithm. To date, PAV has
been mostly studied in patients without severe dyspnea or asynchrony. We hypothesized
that, compared to pressure support ventilation (PSV), PAV will prevent severe dyspnea
or asynchrony.
Patients and methods Were included ICU mechanically ventilated patient exhibiting
severe dyspnea or asynchrony with PSV. Three conditions were successively studied:
1) PSV on inclusion (Baseline), 2) PSV after optimisation of ventilator settings in
order to minimize dyspnoea and asynchrony (Optimisation), and 3) PAV. Ten-minutes
recording were performed with each condition. The intensity of dyspnea was assessed
by the Visual Analogic State (VAS, only in patients able to communicate) and by the
Intensive Care Respiratory Distress Operating Scale (IC-RDOS) for all the patients.
The electrical activity (EMG) of extradiaphragmatic inspiratory muscles was measured.
The prevalence of asynchrony was quantified by the visual inspection of the airway
flow and pressure traces.
Results 34 patients were included, 74% male, aged 66 [58–78] years, SAPS2 57 [39–66],
mechanically ventilated for 6 [4–9] days. The tidal volume (Tv) was higher in the
Optimisation and PAV than in the Basal condition (Table 27). The respiratory rate(RR)
was lower with PAV than in the other conditions. The dyspnea-VAS was lower with Optimisation
and PAV than with the Basal conditions. The IC-RDOS was lower with PAV than with the
two other conditions. The asynchrony index was lower with PAV than with the two other
conditions. Parasternal EMG activity was lower with PAV and Optimisation (Fig. 25).
Table 27
Breathing pattern, dyspnea score and prevalence of asynchrony according to condition
Variables
Basal
Optimisation
PAV
p
RR (min−1)
27 [22–32]
24 [20–30] *
21 [17–28] *,§
<0.0001
Tidal volume (ml)
489 [373–624]
532 [446–726]*
629 [452–733]*
<0.0001
VAS for Dyspnea. (mm)
62 [28–76]
37 [20–55] *
31 [14–45] *
<0.001
IC-RDOS
4.6 [4.1–6.5]
4.3 [2.3–4.8]
4.2 [2.4–4.7] *
0.002
Asynchrony index (%)
0.68 [0–2.28]
0.6 [0.31–1.4]
0 [0–0.55] *,§
0.005
* p < 0. 05 compared to basal condition; § p < 0. 05 compared to optimisation condition
Fig. 25
Electromyographic of activity parasternal muscles. *p < 0. 05 compared to basal condition
Conclusion In ICU patients receiving mechanical ventilation with PSV and exhibiting
severe dyspnea or asynchrony, the optimisation of ventilator settings with PSV and
the PAV mode decrease in the simiar way the severity of dyspnea and the prevalence
of patient-ventilator asynchrony.
Competing interests None.
S105 Validation of ultrasound to assess diaphragm function in mechanically ventilated
patients
Alexandre Demoule1, Bruno-Pierre Dubé1, Julien Mayaux1, Suela Demiri1, Thomas Similowski1,
Martin Dres1
1Service de pneumologie et réanimation médicale, Hôpital Pitié-Salpêtrière, Paris,
France
Correspondence: Alexandre Demoule - alexandre.demoule@aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S105
Introduction In intensive care unit (ICU) patients, diaphragm dysfunction is associated
with adverse clinical outcomes. Ultrasound measurements of diaphragm thickness (Tdi),
excursion (EXdi) and thickening fraction (TFdi) have been proposed as estimators of
diaphragm function, but have never been compared to phrenic nerve stimulation.
Our aim was to describe the relationship between Tdi, EXdi, TFdi and diaphragm function
evaluated using the change in endotracheal pressure after phrenic nerve stimulation
(Ptr,stim), and to compare their prognostic value.
Patients and methods Ptr,stim and ultrasound variables were measured in mechanically
ventilated (MV) patients <24 h after intubation (“initiation of MV”, under assist-control
ventilation, ACV) and at the time of switch to pressure-support ventilation (“switch
to PSV”). Diaphragm dysfunction was defined as Ptr,stim <11 cmH2O.
Results 112 patients were included. At initiation of MV, Ptr,stim was not correlated
to Tdi (rho = −0·13, p = 0·28), EXdi (rho = 0·10, p = 0·66) or TFdi (rho = −0·03,
p = 0·80). At switch to PSV, TFdi and EXdi were correlated to Ptr,stim, (rho = 0·87,
p < 0.001 and 0·45, p = 0·001, respectively), but Tdi was not (rho = −0·09, p = 0·45).
At switch to PSV, a TFdi <29% could reliably identify diaphragm dysfunction (sensitivity
and specificity of 85 and 88%, respectively), but Tdi and EXdi could not. This value
was associated with increased duration of ICU stay and MV, and mortality.
Conclusion Under ACV, neither Tdi, EXdi nor TFdi were related to Ptr,stim. Under PSV,
TFdi was strongly correlated to diaphragm strength and, when decreased, was associated
with poorer outcome.
Competing interests Alexandre Demoule has signed research contracts with Covidien,
Maquet and Philips; he has also received personal fees from Covidien and MSD.
S107 End-tidal carbon dioxide during spontaneous breathing trial to predict extubation
failure: a single center prospective observational study
Faten May1, Keyvan Razazi1, François Bagate1, Guillaume Carteaux1, Nicolas de Prost1,
Armand Mekontso Dessap1
1Réanimation médicale, Hôpital Henri Mondor, Créteil, France
Correspondence: Faten May - m_faten2001@yahoo.fr
Annals of Intensive Care 2017, 7(Suppl 1):S107
Introduction In spite of recent research and progress in weaning protocols, extubation
failure still occurs in 10–20% of patients and is associated with poor outcomes, with
a mortality rate of 25–50%. Many risk factors for planned extubation failure have
been suggested, including hypercapnia at end of spontaneous breathing trial (SBT).
However, performing arterial blood gases at the end of SBT is not routinely recommended
whereas EtCO2 may be routinely monitored during a low pressure support SBT. The aim
of this prospective observational study was to determine the clinical usefulness of
EtCO2 to predict extubation failure.
Patients and methods We recorded clinical data and EtCO2 during a successful 1 h low
level pressure support SBT (at the beginning, after 5 min and at the end of the trial).
Patients ventilated through tracheostomy and unplanned extubations were excluded.
Extubation failure was defined as death or the need for reintubation within 72 h (1)
after extubation; this delay was prolonged to 7 days (2) in case of noninvasive ventilation
after extubation, which was systematic in older patients or those with cardiorespiratory
disease, as per our weaning protocol. Multivariable logistic regression analysis was
performed to identify independent variables associated with extubation failure.
Results One hundred and fifteen ventilated patients were enrolled in our study from
July 2015 to June 2016. The median age of these patients was 63 [52–75] years, their
median Simplified Acute Physiology Score (SAPS) II was 48 [38–61] points and 42.5%
(n = 49) were female. Seventeen (15%) patients had chronic obstructive pulmonary disease.
Reintubation rate was 15% (n = 18). EtCO2 at the end of SBT was similar between patients
with failed and successful extubation: 38 [29–41] vs. 35 [30–40] mmHg, p = 0.9. EtCO2
at other time points as well as its changes during the SBT were also similar between
groups. The three variables predicting extubation failure in the multivariable logistic
regression model were a past medical history of cirrhosis, acute respiratory distress
syndrome before weaning and lower minute ventilation at the end of SBT.
Conclusion EtCO2 during a successful SBT seems useless to predict outcome of extubation.
Competing interests None.
References
Girault C, Bubenheim M, Abroug F, Diehl JL, Elatrous S, Beuret P, et al. Noninvasive
ventilation and weaning in patients with chronic hypercapnic respiratory failure:
a randomized multicenter trial. Am J Respir Crit Care Med. 2011;184(6):672–9.
Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguia C, et al.
Risk factors for extubation failure in patients following a successful spontaneous
breathing trial. Chest. 2006;130(6):1664–71.
S109 A multicenter prospective observational study of 1514 extubation procedures in
26 intensive care units: the FREE-REA study
Samir Jaber1, Hervé Quintard2, Audrey De Jong1, for the FREE-REA study group
1DAR B, Hôpital Saint Eloi, Montpellier, France; 2Réanimation polyvalente, Hôpital
Saint-Roch, Nice, France
Correspondence: Audrey De Jong - audreydejong@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S109
Introduction Airway management in intensive care unit (ICU) patients is challenging
[1]. “Airway failure”, defined as the inability to breathe without endotracheal tube,
differs from “weaning failure”, defined as the inability to breathe without an invasive
mechanical ventilation. However, most of the studies assessing predictive factors
of extubation failure did not separate airway from weaning failure. We aimed to describe
incidence of extubation failure in critically ill patients, separating for the first
time airway from weaning failure, in a prospective multicenter observational study.
Patients and methods A prospective, observational, multicenter study was conducted
in 26 French ICUs. All adult patients consecutively extubated in ICU were included.
An ethics committee approved the study design (code UF: 9242, register: 2013-A01402-43).
The study was registered on clinicaltrials.gov (identifier no.NCT 02450669). Clinical
parameters were prospectively assessed before, during and after extubation procedure.
Extubation failure was defined as the need to reintubate less than 48 h after extubation.
Extubation failure could be due to airway failure, weaning failure or mixed airway
and weaning failure.
Results From December 2013 to May 2015, 1514 intubation-procedures were studied in
1465 patients from 26 centers. 49 patients (3.2%) were intubated twice. The median
number of intubation-procedures included by center was 27 (11–72). The flow chart
of the study is shown in Fig. 26. Incidence of extubation failure was 10.4% (157 of
1514 intubation-procedures). Incidence of airway failure, weaning failure and mixed
failure were respectively 4.6% (70 of 1514), 5.2% (78 of 1514) and 0.6% (9 of 1514).
Fig. 26
Flow chart of the FREE-REA study
Conclusion Extubation failure at 48 h occurred in 10.4% of the 1514 extubation procedures
recorded, 44% due to airway failure, 50% to weaning failure and 6% to mixed airway
and weaning failure. Specific risk factors will be determined using this multicenter
database.
Competing interests None.
Reference
De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, Allaouchiche B,
Paugam-Burtz C, Constantin JM, Lefrant JY, et al. Early identification of patients
at risk for difficult intubation in the intensive care unit: development and validation
of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 2013;187(8):832–39.
S110 Efficiency and safety of total plasma exchange in critically ill cirrhotic patients
with acute on chronic liver failure admitted to the ICU
Ilias Kounis1, Faouzi Saliba1, Stephane André1, Marc Boudon,1, Philippe Ichai1, Aline
Younes1, Lionel Nakad1, Audrey Coilly1, Teresa Antonini1, Rodolphe Sobesky1, Eleonora
De Martin1, Didier Samuel1
1Centre hépato-billiaire, APHP Hôpital Paul-Brousse, Villejuif, France
Correspondence: Faouzi Saliba - faouzi.saliba@pbr.aphp.fr
Annals of Intensive Care 2017, 7(Suppl 1):S110
Introduction Acute on chronic liver failure (ACLF) have been recently defined by an
acute decompensation of a chronic liver disease associated to organ failure and a
high mortality rate. Few authors reported on the use of total plasma exchange (TPE)
in patients with the current definition of ACLF. The aim of this pilot study was to
evaluate the efficiency and safety of TPE in critically ill cirrhotic patients admitted
with ACLF in the ICU.
Patients and methods A prospective cohort of cirrhotic patients admitted to the ICU
between February 2015 and February 2016. TPE was performed using a plasma filter (TPE2000,
Hospal®) on a CVVHDF machine (Prismaflex®, Baxter®) connected to the patient with
a femoral double lumen 13F catheter. The plasma volume exchanged per session was 1.3–1.5
of the total plasma volume. Ratio and type of fluid replacement were 50% with 5% albumin
solution followed by 50% with fresh frozen plasma. Clinical and biological parameters,
and the following scores MELD, SOFA, CLIF-SOFA, CLIF-OF and Child Pugh were evaluated
prior, after TPE session and 7 days distant of treatment.
Results Seven male patients with a mean age of 50.6 ± 7.7 years comprised the study
and had a total of 20 TPE sessions. The etiology of cirrhosis was alcoholic (n = 6)
or post-HCV (n = 1). The reasons of ACLF were acute alcoholic hepatitis (n = 2), variceal
bleeding (n = 2) and sepsis (n = 3). Prior to TPE, the mean scores of SOFA, CLIF-SOFA,
CLIF-OF, MELD and Child-Pugh were respectively 9.4, 12, 11.7, 37.6 and C12.5. Mean
total bilirubin prior and after TPE sessions was reduced from 392.3 ± 117.8 µmol/l
to 244.9 ± 93.2 µmol/l (reduction of 37.5%; p = 3.81E−6); at day 7, mean total bilirubin
was still lower at 333 ± 132 µmol/l (p = 0.1). Mean INR prior and after TPE improved
from 5.54 ± 3.38 to 2.32 ± 0.80 (reduction of INR of 58.1%, p = 4.76E−5) and at day
7 of treatment at 4 ± 1.64 (reduction of 43%, p = 0.125). Mean GGT levels reduced
by 28.5% (p = 0.01). Mean platelet counts (50.8 ± 19.5 G/L) reduced by 10.2% (p = NS).
The probability of survival at 10, 28 and 90 days was 42.8, 28.6 and 14.3%. One patient
was transplanted and still alive. Tolerance during sessions was good similar to CVVHDF.
Two side effects related to the femoral catheter were observed (bacteremia and hemorrhagic
shock post catheter ablation).
Conclusion This preliminary study of TPE in ACLF showed a marked reduction of liver
enzymes and improvement in coagulation parameters with a relative good safety. A specific
caution should be undertaken regarding catheter related complications. TPE worth to
be evaluated in large trials in ACLF’ patients, with a liver transplant project, and
a lesser degree of organ failure.
Competing interests None.
S111 Management of enteral feeding during extubation in the intensive care unit: a
multi-center retrospective study in 11 French intensive care units
Mickael Landais1, Noemie Hubert2, Mai-Anh Nay3, Johann Auchabie4, Bruno Giraudeau5,
Reignier Jean6, Arnaud W Thille7, Stephan Ehrmann8
1Service de réanimation médicale, CHU Hôtel-Dieu Nantes, Nantes, France; 2Réanimation,
C.H.U de Caen, Caen, France; 3Réanimation médicale polyvalente, Hôpital de La Source,
CHR Orléans, Orléans, France; 4Réanimation médicale, Centre Hospitalier Universitaire
d’Angers, Angers, France; 5Unité de biostatistiques, Hôpital Bretonneau, Tours, France;
6Réanimation médicale, CHU Hôtel-Dieu Nantes, Nantes, France; 7Réanimation Médicale,
CHU de Poitiers, Poitiers, France; 8Réanimation polyvalente, CHRU Hôpitaux de Tours,
Tours, France
Correspondence: Mickael Landais - mickaelandais@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S111
Introduction Extubation is a key moment for the patient on his way to recovery. Extubation
failure concerns 10–20% of ICU patients and is closely linked to nosocomial pneumonia.
The practice concerning enteral feeding interruption at time of extubation has not
been investigated. Fasting before extubation may prevent aspiration and development
of nosocomial pneumonia. Thus, fasting and gastric content suctioning before extubation
may be reasonably considered as a mean to reduce this burden. Fasting before extubation
may prevent aspiration and development of nosocomial pneumonia. Thus, fasting and
gastric content suctioning before extubation may be reasonably considered as a mean
to reduce this burden. However, fasting, as recommended before elective general anesthesia
is likely to be ineffective in the setting of extubation in the ICU, due to patients’
gastroparesis and prolonged gastric stasis. Beyond the potentially unnecessary burden
in terms of paramedical workload, fasting may have some side effects such as caloric
deficit, hypoglycemia, or delayed extubation. Given the current lack of objective
data concerning the clinical practice of feeding/fasting and gastric tube suctioning
before extubation in the ICU, we undertook this descriptive study to assess current
practice.
Materials and methods We conducted a retrospective, multicenter study in eleven intensive
care units in the west of France over a 1 month timespan. All patients extubated were
included and data about enteral feeding during the peri-extubation period as well
as extubation failure and nosocomial that pneumonia occured within 7 days were recorded.
Data observed in the eleven participating centers were completed with a short email
survey concerning declarative practice performed among 43 intensive care units.
Results During the study period, 162 patients were included. Overall, 25 patients
(15%) failed extubation and needed reintubation within the 7 days following planned
extubation. Pneumonia was significantly more frequent reintubated patients than the
other (36 vs. 4%, p < 0.01). Hundred patients (62%) received enteral feeding at the
time of extubation. Compared to patients who did not receive enteral feeding, those
patients had a higher disease severity (SAPSII score 50, [41; 63] vs. 45 [35; 52],
p < 0.01; longer duration of mechanical ventilation 7 [4; 13] vs. 1.5 [1; 3] days,
p < 0.01). Accordingly, those patients had a higher rate of extubation failure (21
vs. 7%, p = 0.01) and pneumonia (13 vs. 3%, p = 0.05). Among the 100 patients receiving
enteral feeding, fasting was implemented before extubation for 64 patients (64%).
Median fasting duration before extubation was 6 h [2; 13]. Despite a higher severity
of disease of patients undergoing fasting before extubation (SAPS II of 50 [42; 66]
vs. 48 [31; 60], p = 0.05). The rate of extubation failure was similar between the
fasting patients and the others: 15 of 64 patients (23%) versus 6 of 36 (17%) of the
patient (p = 0.60). Similarly, the incidence of pneumonia was not different between
groups (n = 9 (14%) vs. n = 4 (11%), p = 0.76). After extubation, the fasting patients
experienced a longer delay until feeding resumption as compared to non-fasting patients
(21 h [6; 42] vs. 8 [5; 22]), but this difference did not reach statistical significance.
Overall gastric content suctioning before extubation was not commonly performed; before
extubation: 30% of the fasting patients and 26% of the non fasting patients.
Among the 11 participating centers, while some centers imposed a fasting period before
extubation to all their patients, some did it infrequently. However, no center never
imposed fasting, illustrating between and within center heterogeneity.
This heterogeneity was confirmed on the larger scale declarative email survey (88%
response rate amont 43 units) which showed that only 44% of the units had a written
standardized operational procedure for extubation. Survey respondents reported to
practice fasting before extubation “Always”, “Frequently” and “Never or Rarely” in
respectively 71, 21 and 8% of cases.
Conclusion Both practices, fasting as well as pursued nutrition until extubation are
commonly performed in ICUs, with little standardization of practice. Safety seems
equivalent, as no clinically significant difference in terms of reintubation rate
and pneumonia were observed. Thus, the equipoise condition appears met to undertake
a trial evaluating feeding strategies in the peri-extubation period.
Competing interests None.
References
Smith I, Kranke P, Murat I, Smith A, O’Sullivan G, Søreide E, Spies C, in’t Veld B;
European Society of Anaesthesiology. Perioperative fasting in adults and children:
guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28:556–69.
Thille AW, Richard JC, Brochard L. The decision to extubate in the intensive care
unit. Am J Respir Crit Care Med. 2013;187:1294–1302.
S112 More than half the patients receiving non-invasive ventilation are fasting
Nicolas Terzi1, Michaël Darmon2, Jean Reignier3, Stephane Ruckly4, Maïté Garrouste-Orgeas5,
Elisabeth Gratia1, Alexandre Lautrette6, Elie Azoulay7, Bruno Mourvillier8, Laurent
Argaud9, Laurent Papazian10, Marc Gainnier11, Dany Goldgran-Toledano12, Samir Jamali13,
Anne Sylvie Dumenil14, Carole Schwebel15, Jean-François Timsit16, OUTCOMEREA study
group
1Service de réanimation médicale, Clinique de Réanimation Médicale, Grenoble, France;
2Réanimation Médicale, CHU Saint-Etienne - Hôpital Nord, Saint-Étienne, France; 3Réanimation
médicale, CHU Hôtel-Dieu Nantes, Nantes, France; 4Reanimation, Hôpital Bichat-Claude
Bernard (AP-HP), Paris, France; 5Réanimation, Fondation Hopital Saint Joseph, Paris,
France; 6Réanimation médicale, CHU Gabriel-Montpied, Clermont-Ferrand, France; 7Réanimation
médicale, Hôpital Saint-Louis, Paris, France; 8Réanimation Médicale et Infectieuse,
GH Bichat Claude Bernard, Paris, France; 9Réanimation Médicale, Hospices Civils de
Lyon - Groupement Hospitalier Edouard Herriot, Lyon, France; 10Service de réanimation-détresses
respiratoires et infections sévères, Hôpital Nord, Marseille, France; 11Réanimation
des urgences médicales, Hôpital de la Timone, Marseille, France; 12Réanimation polyvalente,
Centre Hospitalier Général, Gonesse, France; 13Réanimation médicale, Centre Hospitalier
Sud Essonne, Dourdan, France; 14Réanimation chirurgicale, Hôpital Antoine Béclère,
Clamart, France; 15Réanimation médicale, C.H.U. Grenoble, Grenoble, France; 16Réanimation
médicale et infectieuse, Hôpital Bichat-Claude Bernard, Paris, France
Correspondence: Nicolas Terzi - terzinicolas@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S112
Introduction Noninvasive ventilation (NIV) has become a cornerstone for the supportive
therapy of acute respiratory failure (ARF). Survival benefits in chronic obstructive
pulmonary disease (COPD) and cardiac patients have been demonstrated. Although ARF
and COPD patients are at risk of malnutrition that adversely affects patient outcomes,
few data are available regarding the management of nutritional support in non-invasively
ventilated patients. We sought to describe nutritional management in patients receiving
NIV as the first line therapy for ARF. Secondary objectives were to assess the impact
of early nutrition use on the need for invasive mechanical ventilation, occurrence
of ICU-acquired pneumonia, length of stay, and death.
Patients and methods We conducted an observational study from the multicenter French
database fed by 20 French ICUs. Our institutional review board approved this study.
Adult medical patients admitted to the ICU and receiving NIV for more than 2 days
were included. Exclusion criteria were patients admitted after surgery, readmitted
in ICU, patients with neuromuscular disease and treatment-limitation decisions on
admission. Four groups of patients were defined according to nutrition received during
the first 2 days of NIV: (1) No nutrition; (2) Enteral nutrition: patients who received
enteral nutrition with or without parenteral nutrition; (3) Parenteral nutrition only
(3) Oral nutrition only.
The impact of nutrition on day-28 mortality was assessed through the use of a Cox
model adjusted on clinically relevant covariates. The impact of nutrition on other
secondary end-point i.e. ICU-acquired pneumonia occurrence, need for invasive mechanical
ventilation were assessed using a Fine & Gray models. Patients were censored after
28 days of follow-up. Choice among collinear variables was performed considering clinical
relevance, rate of missing variables and reproducibility of definitions. Results were
given as hazard ratio (HR) for Cox models and subdistribution hazard ratios (sHR)
and 95% confidence intervals (CI). The impact on duration of stay was estimated by
a multivariate Poisson regression. P values less than 0.05 were considered as significant.
Statistical analysis was performed using SAS 9.4 (Cary, NC).
Results During the study period, 16,734 patients were included in the database and
1075 met inclusion criteria. Among them, 622 received no nutrition; 28 received enteral
nutrition, 74 received parenteral nutrition only, and 351 received oral nutrition
only. Overall, 86 patients developed ICU-acquired pneumonia (8%), 158 required invasive
mechanical ventilation (14.7%) and 161 died before day-28 (15%). Median length of
stay was 6 days [4; 9].
After adjustment for confounders, type of nutrition support was associated with an
increase day-28 mortality (P = 0.02). Compared to oral nutrition, enteral nutrition
was associated with an increase day-28 mortality [sHR 2.91, 95% CI 1.44–5.89; P = 0.003]
whereas parenteral nutrition and no nutrition did not influence this outcome. The
type of nutrition was not associated with the occurrence of ICU-acquired pneumonia
(P = 0.18). However, patients who received enteral nutrition experienced more frequently
ICU-acquired pneumonia [sHR = 3.00, 95% CI 1.08–8.37; P = 0.036] as compared to oral
nutrition patients. Ventilator free days within the 28 days were negatively associated
with the type of nutrition (P < 0.0001). Compared to oral nutrition, parenteral and
enteral nutrition were negatively associated with ventilator free days within the
28 days [RR per day = 1.48, 95% CI 1.22–1.78; P < 0.0001 and RR per day = 1.77, 95%
CI 1.37–2.30; P < 0.0001]. Delta PaCO2 measured between the first 2 days was not associated
with any type of nutrition.
Conclusion More than half the patients receiving NIV were fasting within the first
two NIV days. Oral nutrition was prescribed for one-third of them and was well tolerated.
Lack of feeding or underfeeding had no impact on mortality and ventilator free days
within the 28 days. However, enteral nutrition was associated with an increased occurrence
of ICU-aquired pneumonia and a higher mortality rate.
Competing interests None.
S113 Nutritional support in patients receiving temporary extracorporeal life support:
a retrospective cohort study
Arthur Bailly1, Laurent Brisard1, Philippe Bizouarn1, Thierry Lepoivre1, Johanna Nicolet1,
Jean Christophe Rigal1, Jean Christian Roussel2, Bertrand Rozec1
1Réanimation ctcv transplantation thoracique, CHU de Nantes - Hôpital Nord Laennec,
Saint-Herblain, France; 2Chirurgie ctcv transplantation thoracique, CHU de Nantes
- Hôpital Nord Laennec, Saint-Herblain, France
Correspondence: Laurent Brisard - laurent.brisard@chu-nantes.fr
Annals of Intensive Care 2017, 7(Suppl 1):S113
Introduction The optimal nutritional intake in patients receiving temporary extracorporeal
life support (ECLS), including extracorporeal membrane oxygenation (ECMO) venovenous
(VV) or venoarterial (VA), remains controversial. Enteral nutrition (EN) is suspect
to increase risk of gastrointestinal (GI) intolerance and intestinal ischemia. So,
total parenteral nutrition (TPN) is often preferred. The purpose of this study is
to describe the nutrition practices for critically ill patients receiving ECLS and
identify opportunities for improving nutrition therapy in this population.
Patients and methods Retrospective analysis of patients requiring ECMO-VA or ECMO-VV
between 2010 and 2014 in the cardiac surgery intensive care unit of the University
Hospital of Nantes. Nutritional support was daily monitored with parenteral intake
(glucose, lipid and propofol, protein and albumin, parenteral nutrition) and enteral
nutrition until ECLS weaning. Two groups were compared during ECLS period: no enteral
nutrition delivered (none or TPN) (ANEC, n = 73) and at least once enteral nutrition
delivered (NEC, n = 50) including EN alone and supplemental parenteral nutrition (SPN).
Primary outcome was incidence of GI intolerance and risk factors. Secondary outcomes
were nutritional adequacy (calculated as overall of calories and protein delivered
divided by the theoretical amount requirements: 20 kcal/kg/d and 1.2 g/kg/d) and clinical
outcome. Data are reported as median (25th and 75th percentiles) or number (%), and
analyzed with student’s t test for continuous variables and χ2 test for categorical
variables. P < 0.05 was considered as significant.
Results 123 patients were enrolled [age 49 years (38–59), IGS-II 51 (35–67), IMC 24
(22–29)], represented 1009 nutrition days [ANEC = 428 (42), NEC = 581 (58)] with duration
of 7 days (5–10) [ANEC = 6 (5–8), NEC = 9 (6–13); P < 0.001] including 96 ECMO-VA
and 27 ECMO-VV. None nutrition support and TPN were respectively received on 42% (n = 428)
and 32% (n = 321) of patient days (NEC = 105, SPN = 155). Patients received median
intake of 1188 kcal (751–1784) [NEC = 1458 kcal (952–2016), ANEC = 990 kcal (605–1389);
P = 0.001]. The median ratio of prescribed/required calories per day was 83% (50–127)
[NEC = 105% (61–144), ANEC = 70% (42–101); P = 0.001]. Evolution of daily energy balance
is reported in Fig. 27. Digestive intolerance was reported in 27 patients (54%) including
gastric residual volume considered high for physician in 15 cases (30%). Motility
agents were used in 18 patients(36%). No serious GI complications or clinical signs
of mesenteric ischemia were reported. Risk factors for GI intolerance were low weight
[66 kg (56–75) vs. 80 kg (68.5–86); P = 0.034] and long duration of circulatory support
[8 days (5–9.5) vs. 11 days (6.5–14.5); P = 0.018]. Clinical outcome was similar between
the groups (NEC vs. ANEC; ECMO-VA vs. ECMO-VV).
Fig. 27
Daily proportion of target energy delivered on first 8 days
Discussion TPN was preferably used in this specific cohort of critically ill patients.
Although, the number of patients receiving no nutrition was high, caloric debt during
temporary ECLS was low in comparison with previous results [1]. Overnutrition was
frequent in the NEC group and would justify implementation of nutrition protocol.
Incidence of GI intolerance remains frequent and could justify systematic used of
motility agents with introduction of EN.
Conclusion Enteral nutrition in patients treated with temporary extracorporeal life
support is feasible and may be improve with systematic motility agents and implementation
of nutritional protocol.
Competing interests None.
Reference
Ferrie, et al. Intensive Care Med 2013;39:1989–94.
S114 Refeeding hypophosphoremia in a medical critical care unit: 3-month observational
study
Gioia Gastaldi1, Cherifa Cheurfa2, Julien Abily1, Steven Grange1, Dorothée Carpentier1,
Christophe Girault1, Gaetan Beduneau1, Thomas Lescot3, Fabienne Tamion1
1Réanimation médicale, Centre Hospitalier Universitaire Rouen, Rouen, France; 2Anesthésie
réanimation, Centre Hospitalier Universitaire Rouen, Rouen, France; 3Réanimation chirurgicale
digestive, Hôpital Saint-Antoine, Paris, France
Correspondence: Gioia Gastaldi - gioia.gastaldi@chu-rouen.fr
Annals of Intensive Care 2017, 7(Suppl 1):S114
Introduction Refeeding syndrome (RS) is a potentially lethal condition that remains
underdiagnosed. It is characterized by severe electrolyte and fluid shifts associated
with metabolic abnormalities in malnourished patients undergoing refeeding orally,
enterally, or parenterally. Clinical criteria have been proposed for determination
of its risk and reported in the National Institute for Clinical Excellence (NICE)
Clinical Guidelines. Hypophosphoremia (hP) is a prominent feature of the RS and seems
to be the earliest abnormality. Phosphorus is a vital component of nucleic acids,
enzyme systems, and various metabolic pathways.
Objective To determine the incidence of refeeding hypophosphoremia (RH) < 0.9 mmol/L,
and severe RH < 0.6 mmol/L in a medical critical care unit.
Patients and methods Monocentric, retrospective and observational study with patients
from FRench-speAking icu Nutritional Survey study FRANS. Critically ill adults (more
than 18 yo) were enrolled if they were hospitalized for more than 3 days during a
3-month period and had an artificial nutritional support. Refeeding hypophosphoremia
is defined by the occurrence of hypophosphoremia after refeeding. We studied the incidence
of HR, risk factors, and prognosis.
Results 34 patients were enrolled between 03/01/2015 and 05/31/2015. RH appears in
73.5% and severe RH < 0.6 mmol/L in 35.3% (Fig. 28). There is no correlation between
RS risk factors and RH in our study. Logistic regression did not permit to identify
neither risk factor nor prognostic modification. There is a lack in phosphoremia measuring
(27.6%), and overfeeding during the first 3 days occurs in 29.4%.
Fig. 28
Incidence of hypophosphoremia at admission, the first day, and refeeding hypophosphoremia
Discussion We define that an hypophosphoremia appearing after refeeding is a refeeding
hypophosphoremia, and we do not consider others etiologies, such as mechanical ventilation,
alkalosis, sepsis, alcoholism, malabsorptive states, poor intake, some medication.
Our cohort is too small to find some possible correlations with risk factors or prognosis.
Conclusion Refeeding hypophosphoremia is common in our population. Hypophosphoremia
is not an independent predictor of ICU or in-hospital mortality in critically ill
patients. The knowledge of the SRI requires the follow-up of the phosphoremia during
nutrition after critical illness in particular in the undernourished patients.
Competing interests None.
References
Marik PE. Refeeding hypophosphatemia in critically ill patients in an intensive care
unit. A prospective study. Arch Surg 1996;131:1043–1047.
Crook MA. Refeeding syndrome: problems with definition and management. Nutrition 2014;30:1448–55.
S115 Impact of the cumulated proteins and energy deficits on ICU patient’s outcome
Isaline Page1, Stéphanie Warnier1, Monique Nys1, Anne-Françoise Rousseau1, Pierre
Damas1
1Intensive care, CHU Sart-Tilman, Liège, Belgium
Correspondence: Pierre Damas - pdamas@chu.ulg.ac.be
Annals of Intensive Care 2017, 7(Suppl 1):S115
Introduction To determine the possible relationship between 10 days cumulated proteins
(10 days CPD) and energy deficits (10 days CED) observed in ventilated patients and
ICU length of stay, duration of ventilator support, incidence of infections and 28 days
mortality.
Patients and methods Mixed medical or surgical ventilated for at least 2 days adult
patients from 5 ICUs from CHU Liège Belgium were enrolled into the study. They were
fed by enteral route with a target of 25 kcal and 1.25 g of proteins by corrected
kg of bodyweight and by day. If 50% of the target was not reached on day seven, parenteral
nutrition was added with the same target. CED and CPD were calculated for 10 days,
taking into account all the sources of nutrition, and was defined as the difference
between the amount of energy or protein intake and the target.
Results From 10/12/2014 till 30/5/2015, 99 patients were followed. Data from 62 patients
could be cumulated on the first 10 days. There were 45 males, mean BMI was 26.9 ± 6.3;
SAPS II score on day 1 was 51.3 ± 15.8, SOFA score at day 1 was 9.1 ± 3.5. They were
ventilated for a median of 18 days (IQR 13–26), median ICU length of stay was 27 days
(IQR 19–35). Mean SOFA max calculated for the first 10 days was 12.1 ± 4.2 and the
28 day mortality was 32.3%. On day 5, only 42% reached the target of 25 kcal/kg and
27% the target of 1.25 g of protein/kg. Mean 10 days CED was −5555.2 ± 4639.9 kcal
and mean 10 days CPD was −350.8 ± 252.3 g. There was a significant negative relationship
between both deficits and the SOFA max (p = 0.0064 for CED and p = 0.0053 for CPD).
However, there were no correlations between any of the deficits and ICU length of
stay, duration of mechanical ventilation, occurrence of infections and 28 days mortality.
Discussion Saps II level, SOFA max level, ICU length of stay, all these parameters
emphasize the high severity of this cohort of patients. It could indeed been thought
that it is in this group of critically ill patients that the impact of nutrition could
be easily demonstrated. Clear relationships between SOFAmax on day 10 and the 10 days
CED and CPD could be seen. However, both the deficit and the level of organ dysfunctions
could be cause or consequence. Unlike previous studies, usually performed in less
severely ill patients, we did not find any relationship between CED or CPD and patient’s
outcome.
Conclusion Contrary to some recent studies, we found no relationship between CED and
CPE and outcome of patients. Future studies are needed.
Competing interests None.
S116 Cardiopulmonary bypass induces lymphopenia and decreases lymphocyte proliferation
ability: IL-10 and PD-L1 as potential therapeutic targets to reduce postoperative
infection
Fabrice Uhel1, Mathieu Lesouhaitier1, Murielle Grégoire2, Baptiste Gaudriot3, Arnaud
Gacouin1, Yves Le Tulzo1, Erwan Flecher4, Karin Tarte5, Jean-Marc Tadié1
1Réanimation médicale, Centre Hospitalier Universitaire de Rennes, Rennes, France;
2Biosit and inserm u917, faculte de medecine, université rennes 1, Centre Hospitalier
Universitaire de Rennes, Rennes, France; 3Anesthésie-réanimation, Centre Hospitalier
Universitaire de Rennes, Rennes, France; 4Service de chirurgie thoracique, cardiaque
et vasculaire, Centre Hospitalier Universitaire, Rennes, France; 5Biosit and inserm
u917, faculte de medecine, universite rennes 1, Centre Hospitalier Universitaire de
Rennes, Rennes, France
Correspondence: Jean-Marc Tadié - jeanmarc.tadie@chu-rennes.fr
Annals of Intensive Care 2017, 7(Suppl 1):S116
Introduction Cardiac surgery with cardiopulmonary bypass (CPB) is associated with
a generalized inflammatory response with concomitant immune paresis which predisposes
to the development of postoperative infections and sepsis (1). Lymphocytes are essential
agents of innate and adaptive immune responses during infections or inflammation processes.
Lymphopenia has been associated with immune dysfunction during septic shock, and it
has been shown that low absolute lymphocyte count was predictive of postoperative
sepsis (2). Furthermore, impaired lymphocyte function probably occurs after CPB. Thus,
we investigated mechanisms involved in postoperative lymphopenia and impaired lymphocyte
function after CPB. The aims of this study were: 1) To describe a potential relationship
between lymphopenia and occurrence of postoperative infections. 2) To demonstrate
that CPB induces lymphocytes apoptosis. 3) To demonstrate that CPB impaired lymphocyte
function (ability to proliferate). 4) To demonstrate that IL-10, PD-L1 (programmed
cell death 1 ligand 1) and Indoleamine 2,3-dioxygenase (IDO) could be interesting
targets to restore lymphocyte ability to proliferate after CPB.
Patients and methods Blood cell counts with differentials obtained within the first
postoperative week were analyzed in 828 patients undergoing cardiac surgery in 2015.
Postoperative lymphopenia was defined as a lymphocyte count <1.3 × 109 cells L−1.
Postoperative infections were defined following CDC criteria.
Study procedures: The following analysis were performed before (T0) and 24 h after
(T1) cardiac surgery with CPB: Lymphocyte apoptosis; T-cell proliferation ability
following polyclonal stimulation; HLA-DR and PD-L1 expression on monocytes; plasma
IDO activity and IL-10 levels; and the ability of lymphocytes to undergo a clonal
proliferation when stimulated using specific inhibitors of IL-10 and IDO.
The study was approved by our local ethics committee. Patients were informed of the
observational nature of the study and gave their consent.
Results
Early lymphopenia after CPB was associated with the occurrence of postoperative infection:
Postoperative infections occured with a median delay of 6 days. Patients who developed
postoperative infections had a significantly lower lymphocyte count at Day 4, Day
5 and Day 6 than patients without postoperative infections.
CPB induced lymphocyte apoptosis and decreased T-cell proliferation ability.
CPB during cardiac surgery decreased mHLA-DR expression.
CPB increased IDO activity, PD-L1 expression and IL-10 plasma levels.
IL-10 or PD-L1 inhibition of inhibition could restore ability of lymphocytes to proliferate,
although IDO inhibitors did not show any effect.
Conclusion We provided new evidences that CPB induces immunosuppression. We also demonstrated
that IL-10 and PD-L1 could be interesting targets to restore ability of lymphocytes
to proliferate. As maintaining MV during CPB decreased plasmatic levels of IL-10,
our study brings new evidences that ventilator strategies could be of interest to
decrease postoperative infections.
Competing interests None.
References
Gaudriot B, Uhel F, Gregoire M, Gacouin A, Biedermann S, Roisne A, et al. Immune dysfunction
after cardiac surgery with cardiopulmonary bypass: beneficial effects of maintaining
mechanical ventilation. Shock. 2015;44(3):228–33.
Edwards MR, Sultan P, del Arroyo AG, Whittle J, Karmali SN, Moonesinghe SR, et al.
Metabolic dysfunction in lymphocytes promotes postoperative morbidity. Clin Sci. 2015;129(5):423–37.
S117 Influence of neutropenia on mortality of critically ill cancer patients: results
of a systematic review on individual data
Quentin Georges1, Elie Azoulay2, Djamel Mokart3, M Soares4, Kyeongman Jeon5, Sandra
Oeyen6, Chin Kook Rhee7, Pascale Gruber8, Marlies Ostermann9, Quentin Hill10, Peter
Depuydt11, Christelle Ferra12, Alice Muller13, Virginie Lemiale2, Bourmaud Aurelie14,
Michaël Darmon1
1Réanimation médicale, CHU Saint-Etienne - Hôpital Nord, Saint-Étienne, France; 2Réanimation
médicale, Hôpital Saint-Louis, Paris, France; 3Réanimation, Institut Paoli-Calmettes,
Marseille, France; 4Post-graduation program, D’Or Institute for Research and Education,
Rio de Janeiro, Brazil; 5Department of critical care medicine and division of pulmonary
and critical care medicine, Sungkyunkwan University, Seoul, Republic of Korea; 6Department
of intensive care, Ghent University hospital, Gent, Belgium; 7Division of pulmonary,
allergy and critical care medicine, Seoul St. Mary’s Hospital, Seoul, Republic of
Korea; 8Intensive care, anaesthesia, and surgery, The Royal Marsden Hospital, London,
United Kingdom; 9Nephrology and intensive care, St Thomas’ Hospital, London, United
Kingdom; 10Hematology, Leeds Teaching Hospital, Leeds, United Kingdom; 11Department
of intensive care, Ghent University Hospital, Ghent, Belgium; 12Hematology, Catalan
Institute of Oncology, Barcelona, Spain; 13Department of critical care medicine and
pulmonary medicine, hOSPITAL DE CLINICAS DE PORTO ALEGRE, Porto Alegre, Brazil; 14Département
de santé publique, Institut de Cancérologie de la Loire Lucien Neuwirth, Saint-Priest-en-Jarez,
France
Correspondence: Michaël Darmon - michael.darmon@chu-st-etienne.fr
Annals of Intensive Care 2017, 7(Suppl 1):S117
Introduction The prognostic impact of neutropenia in critically-ill cancer patients
remains controversial. Hence, several studies in critically ill cancer patients failed
to demonstrate the impact of neutropenia on outcome [1]. This lack of statistical
association might however, reflect a lack of statistical power.
A previous meta-analysis of aggregated data suggested 11% (95% CI 9–14%) raw increase
in mortality in neutropenic patients. The available data were, however insufficient
to allow adjustment with confounders [2].
The aim of this study was to assess the influence of neutropenia on mortality of critically
ill cancer patients using individual data obtained from studies identified by our
systematic review. Secondary objectives were to assess the influence of neutropenia
on mortality of critically ill patients while taking into account underlying malignancy,
use of G-CSF or changes related to period of admission.
Patients and methods This systematic review and meta-analysis was performed according
to the PRISMA statements. Public-domain databases including PubMed and the Cochrane
database were searched by using predefined keywords. The research was restricted to
articles published in English and studies focusing on critically ill adult patients
from May 2005 to May 2015.
The methods and objectives of this systematic review were reported in the PROSPERO
database (CRD42015026347).
Selected manuscripts’ authors were then contacted to obtained part of their dataset.
Mortality was defined as either hospital or day-28 mortality.
This preliminary analysis reports results from the whole dataset before and after
adjustment using logistic regression. Period of admission and use of G-CSF were then
assessed and were a pre-planned analysis.
Results Our initial search yielded 1528 citations and 131 studies were retained for
further analysis. Overall, 9 studies were excluded for redundancy with other included
studies, 5 as containing only neutropenic patients, and two as containing only palliative
patients. Finally 30 datasets (26%) containing sufficient data to allow comparison
were obtained from authors.
Overall, 7356 patients were included in this study, including 1666 patients with neutropenia
at ICU admission. Median age was of 60 years (IQR 49–69). Median SAPSII score at ICU
admission was 42 (IQR 28–57). Respectively 4101 and 3255 patients had underlying haematological
malignancy and solid tumours, and 438 patients underwent allogeneic stem cell transplantation.
Mechanical ventilation, vasopressors, and renal replacement therapy were required
in respectively 50.7% (n = 3729), 41.1% (n = 3024) and 16.1% (n = 1174) of the included
patients.
Mortality was of 47.4% in the overall population (n = 3483) and was higher in neutropenic
patients (60.3 vs. 43.6% in non-neutropenic patients; P < 0.001). Neutropenia was
independently associated with poor outcome when adjusted for underlying malignancy,
allogeneic stem cell transplantation and severity as assessed by organ support (OR
1.45; 95% CI 1.27–1.65).
Mortality decreased progressively over time in both non-neutropenic (from 54 to 44%;
P < 0.0001) and in neutropenic patients (from 72 to 57%; P < 0.0001). When adjusted
for confounders, admission during a more recent period was independently associated
with favourable outcome and did not change the final model.
Conclusion This preliminary analysis suggests a meaningful survival in neutropenic
critically ill cancer patients despite an independent association between neutropenia
and mortality.
Additional analyses are on-going in order to adjust for study weight, heterogeneity
across studies, assess the influence of neutropenia duration or G-CSF use, and confirm
the influence of neutropenia in a predefined subgroup of patients.
Competing interests None.
References
Azoulay, et al. Blood Rev. 2015.
Bouteloup, et al. Oncotarget. 2016.
S118 Cytokinic profiles kinetic in response to Candida bloodstream infections
Christopher Niles1, Fabien Herbert2, Sylviane Pied2, Séverine Loridant,3, Nadine François3,
Anne Bignon4, Boualem Sendid5, Julien Poissy1
1Pôle de réanimation, hôpital salengro, C.H.R.U. - Lille, Avenue Oscar Lambret, Lille,
France, Lille, France; 2Centre d’infection et d’immunité de lille equipe 4 - basic
and clinical immunity of parasitic di, Institut Pasteur de Lille, Rue du Professeur
Calmette, Lille, France, Lille, France; 3Centre de biologie et pathologie génétique,
laboratoire de mycologie et parasitologie, Centre Hospitalier Régional Universitaire
de Lille, Lille, France; 4Service de réanimation chirurgicale, hôpital huriez, Centre
Hospitalier Régional Universitaire de Lille, Lille, France; 5Inserm u995-2, Universite
Lille 2 - Droit et Santé, Lille, France
Correspondence: Julien Poissy - julien_poissy@hotmail.fr
Annals of Intensive Care 2017, 7(Suppl 1):S118
Introduction
Candida bloodstream infections (CBI) are frequent and increasing in hospitalized patients,
especially in intensive care units. Considering the results of some experimental in
vitro and animal studies, it seems that yeasts belonging to Candida genus are able,
so as to survive, to modulate the immune response of the host by guiding T cells polarization
to Th2 profile. Th1 and Th17 cytokines are known to be involved in host defense against
CBI. However, these data are mainly experimental or collected after candidemia. The
aim of this study is to precise kinetic of cytokines network during human CBI.
Patients and methods This was an ancillary study of an institutional project dedicated
to pathophysiology of candidiasis. We have included 32 patients with candidemia and
54 controls (27 matched hospitalized controls and 27 healthy subjects). The sera of
cases were gathered before (almost 5 days before), during and after the isolation
of yeasts from blood culture, defined as day 0 (D0). Quantitative analysis of 28 cytokines
by Luminex® technology and of (1,3)-β-d-glucans by Fungitell® test were performed
on 132 samples. The amplitude of Th profile response was expressed by summing the
amount of the most relevant cytokines for Th1, Th2 and Th17 profiles, in pg/mL. For
each patient, the highest level of response was considered as 100%. Results are expressed
for the population by means of the results. We then performed univariate analysis
(Fischer exact test for qualitative variables, Mann–Whitney and Wilcoxon test for
quantitative variables, Spearman for correlation; GraphPad Prism V6 software) and
a multidimensional analysis by principal component analysis (PCA; IgorPro software).
Results Patients with candidemia exhibited an increase in pro-inflammatory cytokines
(IFNγ, TNFα and IL-12), in comparison with the anti-inflammatory cytokines (IL-4 and
IL-10) before D0 (p = 0.034) in univariate analysis. The ratio between mean values
reverses at D2 and D3 (p = 0.02) and the increase of Th2 response level from D0 to
D4 is correlated to the decrease of Th1 response (r = −0.885; p = 0.033) in univariate
analysis and PCA. A pro-inflammatory response (Th1) is associated with a reduced mortality
(RR = 0.58 [0.34; 0.98]) and with a lower β-D-glucans levels (p < 0.0001).
Discussion We describe here a dynamic cytokine profiles in response to candidemia.
Pro-inflammatory response predominates before D0 and reverses after. This is contradictory
to the postulate that an anti-inflammatory background could predispose to invasive
candidiasis in ICU patients and exhibiting a “Post-infectious immune suppression conditions”.
But the relative deficiency in Th1 response compared to simultaneous anti-inflammatory
cytokines secretion observed after CBI is in accordance with experimental data, suggesting
the modulation of the immune response by Candida. The link between cytokinic profile
and mortality can also raise the hypothesis of an influence by genetic factors on
the regulation and direction of the immune response and so, the existence of a high-risk
population.
Conclusion These data suggest a relation between Candida and the orientation of the
immune response towards a pattern deleterious for the infected host. This could allow
to determine the most relevant cytokines varying during CBI. They could be used as
biomarkers to identify the patients who could benefit from an early treatment in a
preemptive targeted therapeutic strategy. These data will be paralleled to genetic
background and to circulating Candida derived molecules to precise the relative part
of the host and the pathogen in this complex interaction.
Competing interests None.
S120 Neutrophil-to-lymphocyte ratio as an independent predictor of mortality in critically
ill cirrhotic patients
Mikhael Giabicani1, Caroline Lemaitre1, Emmanuel Weiss2, Steven Grange1, Dorothée
Carpentier1, Gaetan Beduneau1, Christophe Girault1, Catherine Paugam-Burtz2, Fabienne
Tamion1
1Intensive care, Hospital Center University Rouen, Rouen, France; 2Anesthesiology
and critical care, Hospital Center university Beaujon (AP-HP), Clichy, France
Correspondence: Mikhael Giabicani - mikhael.giabicani@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S120
Introduction Prognosis of cirrhotic patients hospitalized in intensive care unit (ICU)
remains poor. Many studies suggested a negative impact of systemic inflammation on
organ failure and outcome in cirrhosis(1). In ICUs, cirrhotic patients are widely
admitted and revalued after receiving optimal treatments for 3 days. However, little
is known about how manage these patients after day 3 according to their prognosis.
The blood neutrophil-to-lymphocyte ratio (NLR) as a novel inflammation index biomarker
has been reported to be a predictor of clinical outcomes in various malignancies and
in unselected critically ill patients(2). NLR has also been identified as a predictor
of mortality in patients with stable liver cirrhosis. To our knowledge, the ability
of NLR to predict outcome in critically ill cirrhotic patients has never been studied.
The aim of this study was to evaluate the usefulness of inflammatory marker such as
NLR for diagnosis of infection and predicting the outcome in hospitalized critically
ill cirrhotic patients.
Patients and methods We performed a retrospective monocentric study including consecutively
cirrhotic patients hospitalized in a medical ICU from 2010 to 2014. For each patient,
clinical and biological data at admission and day 3 were collected. NLR at admission
(“NLRD0”), at day 3 (“NLRD3”) and the variation of NLR between admission and D3 (“delta
NLR”) were calculated. Statistical analysis used appropriate non parametric tests
and Cox regression for survival analysis. The ability of the variables to discriminate
survivors from non-survivors was determined using ROC curves. Results are expressed
as median (IQR).
Results During the study period, 149 cirrhotic patients were admitted in ICU. The
etiologies of liver cirrhosis were alcoholic in 87% of cases with severe score: median
Child-Pugh score = 9 [7–11], median MELD score = 25 [18.3–30.8]. Main reasons for
ICU admission were sepsis (40.9%), gastrointestinal bleeding (23.5%) and renal failure
(19.5%). NLRD0 was higher for patients hospitalized for septic shock (p < 0.001).
Patients were followed up for 23 days [5.5–289.5]. 90 (59.6%) patients died including
57 (37.7%) deaths in ICU and 18 (12.1%) deaths after ICU discharge during the same
hospitalization. NLR decreased for survivors between D0 and D3 (−4.5 [−9.8 to 0.0])
whereas it increased for non-survivors (+1.2 [−3.1 to +10.1]). In univariate analysis,
for predicting survival, higher values of NLRD3, delta NLR, MELD score at admission,
SOFA score at admission and at day 3 and delta SOFAD0-D3 were significant factors.
Predictors of death in multivariate analysis are shown in Fig. 29. Area under delta
NLR ROC curve was 0.72 (CI = 0.61–0.83).
Fig. 29
Multivariate analysis of factors associated with mortality
Conclusion The blood NLR is a novel inflammation index that has been shown to independently
predict poor clinical outcomes. We have demonstrated that delta NLR is an independent
predictor of mortality in critically ill cirrhotic patients. Delta NLR could help
to identify cirrhotic patients at risk of unfavorable outcome.
Competing interests None.
References
Salciccioli JD, et al. The association between the neutrophil-to-lymphocyte ratio
and mortality in critical illness: an observational cohort study. Crit Care. 2015;19:13.
Gandoura S, et al. Gene- and exon-expression profiling reveals an extensive LPS-induced
response in immune cells in patients with cirrhosis. J Hepatol. 2013;58(5):936–48.
S121 Serum procalcitonin is a good diagnostic marker of bacterial infection in patients
with hematologic malignancies in the Intensive Care Unit
Celine Dupre1, Saad Nseir2, Anne-Sophie Moreau1
1Centre de réanimation, C.H. Régional Universitaire de Lille (CHRU de Lille), Lille,
France; 2Centre de Réanimation, Centre Hospitalier Régional Universitaire de Lille,
Lille, France
Correspondence: Celine Dupre - duprecece@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S121
Introduction Diagnosis of infection in immunocompromised patients can be difficult.
However, diagnosing infection is very important, particularly in critically ill. This
study aims to evaluate the benefit of procalcitonin (PCT) blood level as a diagnostic
marker for bacterial infection in patients with hematological malignancies admitted
to the Intensive Care Unit (ICU).
Patients and methods This retrospective single-center study included all consecutive
patients with acute myeloid leukemia or high grade lymphoid malignancy admitted to
the ICU. Patients were sorted into three subgroups, according to clinical and microbiological
data: «Infectious disease», «no infectious disease» and «Unknown». Initial serum PCT
and when available at day 3 and day 5 were recorded. Receiver Operating Characteristic
(ROC) curve, sensitivity and specificity were calculated. Serum PCT was considered
as decreasing when the decrease was ≥25% at day 3 and/or ≥50% at day 5. Mortality
rates in the ICU and at day-90 were also studied.
Results Fifty-four patients were included in the study. At diagnosis, PCT levels were
significantly different between the “Infection disease” group and the “No infection
disease” group (p = 0.002). There was no difference between the “Infection disease”
group and the “Unknown” group (p = 0.052). For the diagnosis of bacterial infection,
best initial serum PCT threshold was 0.65 ng per milliliter. For that threshold, sensitivity
was 94.6% and specificity was 78.6%. PCT area under the ROC curve was 0.93 [CI 95% = 0.855–1].
Youden’s J statistic was 0.73. PCT levels weren’t different between groups according
to the presence of neutropenia or in case of inaugural disease. There was a significant
difference in PCT values between groups according to the SOFA score (p = 0.027), but
not the SAPS2 score. Mortality rate in the ICU and at day-90 were significantly lower
for the patients with decreasing PCT (p < 0.001 and p < 0.001, respectively). When
comparing serum PCT and CRP predictive values, PCT was significantly a better marker
of bacterial infection (Fig. 30).
Fig. 30
ROC Curve of initial blood level of PCT and CRP as markers of bacterial infection
Discussion We found that serum PCT, with a threshold of 0.66 ng/mL, is a reliable
marker of bacterial infection disease in patients with aggressive hematological malignancy
admitted to the ICU. Our study confirms the results of a previous study in unselected
immunocompromised patients admitted to the ICU, showing a 100% sensitivity, a 63%
specificity and an area under ROC curve of 0.851 [0.78–0.92] for a threshold of 0.5 ng/mL
(1).
The main limitations of our study are its retrospective design and the small number
of included patients.
Conclusion PCT is a reliable marker of bacterial infection in patients with hematological
malignancies admitted to the ICU. PCT kinetic seems to be an interesting prognostic
marker in this population.
Competing interests None.
Reference
Bele N, Darmon M, Coquet I, Feugeas J-P, Legriel S, Adaoui N, Schlemmer B, Azoulay
É. Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients.
BMC Infect Dis. 2011;11:224.
S122 Could Endocan plasmatic level predict the nature of pathogenic microorganisms
in sepsis?
Aymen Zayene1, Lucie Portier2, Nathalie De Freitas Caires2, Philippe Lassalle3
159, C.H. Régional Universitaire de Lille (CHRU de Lille), Lille, France; 2Inserm
u1019 e13, Institute Pasteur De Lille, Lille, France; 359, LUNGINNOV, Lille, France
Correspondence: Aymen Zayene - aymen.z@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):S122
Introduction Endocan is a proteogycan secreted by pulmonary and renal endothelial
cells (Lassalle et al.). Its synthesis is increased in sepsis and is regulated by
Lipopolysaccharide (LPS) and cytokines.
Toll Like Receptors (TLRs) are receptors of innate immunity and recognize diverse
exogenous and endogenous patterns.
In this study, we have compared the effect of 2 TLRs agonists on regulation of secretion
and expression of Endocan by Human Umbilical Veinous Endothelial Cells (HUVECs).
Materials and methods The stimulation of HUVECs was performed by 2 TLRs agonists:
LPS and PolyInossinic Polycytidylic acid (Poly (I:C)).
The secretion of Endocan was evaluated by Enzyme Linked Immuno Sorbant Assay (ELISA)
in the supernatant of stimulated HUVECs.
Real Time Polymerase Chain Reaction (qPCR) study compared the expression of Endocan
in the two groups.
Results The secretion of Endocan by HUVECs is upregulated by LPS and poly (I:C).
Kinetics of secretion of Endocan was faster with LPS than Poly (I:C).
q PCR study confirmed that Endocan is overexpressed in HUVECs stimulated with LPS
than Poly (I:C).
Discussion TLR 4 is involved in the recognition of LPS (Kawai et al.), a component
of the outer membrane of Gram Negative Bacteria, respiratory syncytial virus fusion
proteins, Steptococcus pneumoniae pneumolysin.
TLR 3 was originally identified as recognizing a synthetic analog of double stranded
Ribonucleic Acid (dsRNA), poly(I:c) which mimics viral infections.
In this study, we have found that kinetics of secretion and expression of Endocan
is faster with HUVECs stimlated by TLR 4 agonist than TLR 3 agonist.
This results could suggest that Endocan may be not only a marker of septic shock but
could be also a specific marker to recognize the nature of pathogenic microorganisms
in septic shock.
Furthermore, other studies with more TLR agonists could be useful to confirm these
results.
Conclusion Studying the effects of diverse TLRs agonists could make the plasmatic
dosage of Endocan more specific and helpful to recognize the nature of pathogenic
microorganisms in septic shock.
Competing interests None.
References
Kawai T, Akira S. The role of pattern-recognition receptors in innate immunity: update
on Toll-like receptors. Nat Immunol. 2010;21(8):373–82.
Lassalle P, Molet S, Janin A. ESM-1 is a novel human endothelial cell specific molecule
expressed in lung and regulated by cytokines. J Biol Chem. 1996;271(34):20458–64.
Physiotherapists abstracts
Oral communications
O79 Lung ultrasound: help to the diagnostic and the monitoring of response to physiotherapy.
A case report of pneumonia
Aymeric Le Neindre1, Pascal Selot1, Daniel Ferreiro,1, Maria Bonarek,1, Stépahen Henriot,1,
Julie Rodriguez,1
1Physiotherapy, Hôpital Forcilles - Fondation Cognacq-Jay, Férolles-Attilly, France
Correspondence: Aymeric Le Neindre - aymeric.leneindre@gmail.com
Annals of Intensive Care 2017, 7(Suppl 1):O79
Introduction Lung ultrasound is widely used in intensive care, ermergency and pneumology
medicine, for assessing acute respiratory pathologies. It is noninvasive, radiation
free and rapidly available at the patient’s bedside and provides an excellent accuracy.
So, lung ultrasound may be an interesting tool for the physiotherapist as it allows
to assess with more accuracy the patient improving the chest physiotherapy indication
and monitoring (1).
As far as we are aware, no study has evaluated the impact of lung ultrasound on clinical-decision
making by physiotherapists in the use of chest physiotherapy.
This case report highlights the lung ultrasound interest in chest physiotherapy in
patient with lung consolidation.
Patients and methods This was a case report written following the recommendations
of the CARE guideline (2).
The case was a 68-years-old female patient, non intubated, hospitalized in a respiratory
ICU. She was hypoxemic (PaO2 = 59 mmHg and SaO2 = 89%), with dyspnoea at rest and
an increasing radiological opacity at the right lung base. Hypoxemia was the indication
for physiotherapist referral.
At the clinical examination, the physiotherapist’s findings were: decreased mobility,
dullness and abolished vesicular sound at the base of right hemithorax.
This clinical examination and chest x-rays analysis allowed the physiotherapist to
propose several clinical hypotheses: pleural effusion, obstructive atelectasis or
pneumonia.
The chest physiotherapy treatment differs according to the type of lung deficiencies.
For example, the physiotherapist must to refer the patient to the medical staff in
case of pleural effusion or may implement hyperinflation technique in case of obstructive
atelectasis. Determining the nature of lung deficiencies is essential to provide the
more suitable therapeutic strategy. So, the physiotherapist decided to perform a lung
ultrasound examination to retain the more likely hypothesis.
Results Ultrasound examination performed by the physiotherapist highlighted the presence
of a lung consolidation at the infero-lateral and posterior parts of the right lung
with a pneumonia pattern: presence of tissue-like sign, shred sign, dynamic air bronchogram
and fluid bronchogram.
The medical staff implemented antibiotic treatment. The ultrasound findings guided
the physiotherapist to choose chest physiotherapy technique improving the alveolar
recruitment: nearly prone position (left side down) and continuous positive airway
pressure during 45 min.
The patient response to the treatment was monitored by ultrasound and showed a decrease
of the lung consolidation size and apparition of B lines, meaning a gain of lung aeration.
These findings were associated with SpO2 improvement but without decrease of dyspnoea.
Discussion Lung ultrasound allowed the physiotherapist to precise the nature of the
radiological lung opacity. As it is more accurate than clinical examination or chest
x-ray, this suggests a more suitable choice of chest physiotherapy techniques than
conventional clinical decision-making process.
Ultrasound findings suggested a positive response to the chest physiotherapy treatment.
The apparition of re-aeration signs (B lines, decreased consolidation size) showed
a short-term efficacy of the chest physiotherapy treatment. This allowed the physiotherapist
to continue the treatment during 1 week and obtain a substantial clinical improvement.
Conclusion The use of lung ultrasound in the clinical decision-making process may
help the physiotherapist to choose with more accuracy the therapeutic strategy. Moreover,
it allows to monitor the treatment in real-time and assess the patient’s response.
The use of this tool may allow the physiotherapist to determine the optimal indications
for chest physiotherapy and thus avoid unnecessary or inappropriate treatments.
Competing interests None.
References
Le Neindre A, Mongodi S, Philippart F, Bouhemad B. Thoracic ultrasound: potential
new tool for physiotherapists in respiratory management. A narrative review. J Crit
Care. 2016;31(1):101–9.
Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. The CARE guidelines: consensus-based
clinical case reporting guideline development. J Med Case Rep. 2013;7(223):1–6.
O80 Chronic critical illness: a prospective observational study in Florence, Italy
Mara Taddei1, Mauro Di Bari2
1Department of healthy profession, intensive care unit, division of cardiology, Careggi
University Hospital, Firenze, Italy; 2Division of geriatric cardiology and medicine,
research unit of medicine of ageing, Careggi University Hospital, Firenze, Italy
Correspondence: Mara Taddei - marataddei@libero.it
Annals of Intensive Care 2017, 7(Suppl 1):O80
Introduction Chronic Critical Illness (CCI) syndrome is a new condition affecting
an increasing number of patients, who survived an acute critical illness but have
persistent severe organ dysfunction, requiring prolonged specialized care. CCI is
a iatrogenic process, reflecting the efficacy of modern life support technologies(1),
and encompasses multiple organ failure, need for prolonged mechanical ventilation
(MV), organ support, and palsy due to polineuromyopathy. The transition from acute
to CCI is gradual: definitions are based on duration of MV, with cut-offs of 7, 14
or 21 consecutive days of MV for ≥6 h/day. CCI patients may come from either medical
or surgical ICU; their health status fluctuates between improvements and deteriorations
implying recurrent transitions between different levels of care (1).The risk of death
is reported to be as high as 50%. Despite a relatively young age (65 years on average),
functional status of CCI patients discharged is seriously impaired, thus CCI patients
require long-term rehabilitation.
AIM: To estimate the frequency of CCI Syndrome in Careggi, a large academic, tertiary
care hospital; to describe the clinical course of CCI patients through discharge,
and their functional status at discharge.
Patients and methods Administrative data on admission, transfer, death and discharge
of all CCI patients, consecutively admitted in one of the 56 ICU beds at Careggi Hospital
from January 1 to December 31, 2014, were collected. CCI was defined with the cut
off of ≥21 days of ICU stay, representing the index event (IE) without contribution
of previous or subsequent hospitalization in other hospitals. Reasons for admission
were grouped into the 4 broad categories of medical causes, surgery, major trauma
and cardio-respiratory arrest. Patients discharged were evaluated in daily living,
cognitive status, and mobility using Barthel Index.
Results We identified 123 subjects who developed CCI (71 males; age 61.7 ± 1.5 years,
mean ± SEM); 36 of them came from an external ICU, 87 began their CCI course within
Careggi hospital (60 from the Emergency Room, 27 from a regular ward). Average duration
of the IE was 36.1 ± 2.1 days. These sample developed accumulative length of ICU stay
of 4440 days, corresponding to a 22% ICU bed occupation over the theoretical total
of 20,440. When days of sub-intensive care and regular ward were separately added,
5500 days of highly specialized care and 6266 days of total acute hospital stay were
reached. Surgical patients had longer hospitalizations (p = 0.009).CCI patients confirmed
to be highly erratic: a total of 302 transitions across different services were recorded
in the 123 patients, with a maximum of 9 in 6 of them. Mean age was comparable between
the 27 patients who died (22%) and the remaining 95 who were discharged alive (66.9 ± 2.5
vs. 60.3 ± 1.7 years; p = 0.058).Fourteen subjects continued their ICU stay out of
hospital. Only 6, whose age was lower (37.7 ± 3.7 years), were discharged home; half
of the participants (n = 68, 55.2%) were admitted to a residential rehabilitation
facility. Younger subjects scored better in the domains of self care (p = 0.018) and
cognitive status (p = 0.008) but not in the domain of mobility, including walking
ability: 45 patients required maximal assistance in performing activities of daily
living and transfers, other 12 required medium/maximal assistance, with no statistical
difference between DG group.
Conclusion CCI is a relevant clinical condition that need to be assessed and possibly
prevented, as it causes severe morbidity, long-term functional impairment and exceeding
healthcare costs.
Competing interests None.
Reference
MacIntyre NR, Fan E, et al. Journal Conference on Chronic Critical Illness. Resp.
Care 2012;57(6).
O81 Physical therapy during the early course of sepsis is safe and preserves skeletal
muscle mass
Cheryl Hickmann1, Diego Castanares-Zapatero1, Louise Deldicque2, Peter Van Den Bergh3,
Gilles Caty4, Jean Roeseler1, Marc Francaux2, Pierre-François Laterre1
1Intensive care unit, Cliniques universitaires Saint-Luc, Université catholique de
Louvain, Bruxelles, Belgium; 2Institute of neuroscience, Université catholique de
Louvain, Louvain-la-Neuve, Belgium; 3Neuromuscular reference centrer, Cliniques universitaires
Saint-Luc, Université catholique de Louvain, Brussels, Belgium; 4Department of physical
medicine and rehabilitation, Cliniques universitaires Saint-Luc, Université catholique
de Louvain, Brussels, Belgium
Correspondence: Cheryl Hickmann - cheryl.hickmann@uclouvain.be
Annals of Intensive Care 2017, 7(Suppl 1):O81
Introduction Critical illness together with immobilization have deleterious effects
on patients outcome, especially in the presence of sepsis. Increased muscle catabolism
and membrane inexcitability reduce muscular mass and impair function within the first
days after sepsis onset (1). Early mobilization could potentially limit muscle wasting
and functional impairment in this population. The purpose of this study was to test
whether exercise during the early phase of sepsis is safe and beneficial and to which
extent it can limit skeletal muscle protein catabolism and preserve function.
Patients and methods Adult patients admitted with the diagnosis of severe sepsis were
included and randomly allocated to two groups; 1) Control group (Ctrl-G): manual passive/active
manual mobilization twice a day or 2) Experimental group (Exp-G): additional two times
30 min of passive/active cycling exercise. Both groups benefited from a reduced sedation,
adjusted nutritional intake and bed to chair transfer as soon as possible.
Skeletal muscle biopsy and electrophysiological testing were realized at day-1 and
day-7. Muscle histology, biochemical and molecular analyses of anabolic/catabolic
and inflammatory signalling pathways were performed. A group of four healthy subjects
was used to obtain non pathological values.
Hemodynamic parameters and patients perception were collected during each session.
Results Twenty-one patients were included, however 3 died before the second muscle
biopsy. Ten patients in Ctrl-G and nine in Exp-G were finally analysed. Muscle fibre
cross sectional area (µm2) was significantly preserved by exercise (relative changes
were Ctrl-G: −45 ± 41% vs Exp-G:12 ± 19%, p = 0.001). Markers of catabolic systems
were highly increased during sepsis compared to healthy subjects and reduced in both
groups 7 days after admission. However the reduction in mRNA (relative change) tended
to be more important in Exp-G: MURF-1 (Ctrl-G: −31 ± 67% vs Exp-G: −63 ± 45%, p = 0.15),
MAFbx (Ctrl-G: −7 ± 138% vs Exp-G: −56 ± 37%, p = 0.23), LC3b (Ctrl-G: 5 ± 47% vs
Exp-G: −21 ± 18%, p = 0.18) and Bnip3 (Ctrl-G: 27 ± 198% vs Exp-G: −59 ± 23%, p = 0.02).
Anabolic and inflammatory markers were not affected by exercise.
Electrophysiological testing, including direct muscular stimulation, was abnormal
on Day-1 in 10 of 13 evaluated patients. Since only a limited number of patients could
be reassessed a second time, comparison between groups was not possible.
In general, all activities were well tolerated by patients with no adverse events.
Conclusion Early mobilization during the first week of the sepsis onset was safe and
preserved muscle fibre cross sectional area.
Competing interests None.
Reference
Kress JP, Jesse BH. ICU-Acquired weakness and recovery from critical illness. N Engl
J Med. 2014;(370):1626–35.
O82 Where should we place the stethoscope’s chestpiece to hear the noise of the primary
bronchi?
Frédéric Duprez1, Bastien Dupuis2, Grégory Cuvelier2, Thierry Bonus1, Sandra Ollieuz1,
Sharam Machayeckhi1, Gregory Reychler3
1Icu, C.H. Epicura, Hornu, Belgium; 2Laboratoire de l’effort et du mouvement, Condorcet,
Tournai, Belgium; 3Service de pneumologie, Cliniques Universitaires Saint Luc, Bruxelles,
Belgium
Correspondence: Frédéric Duprez - dtamedical@hotmail.com
Annals of Intensive Care 2017, 7(Suppl 1):O82
Introduction The pulmonary auscultation is used by respiratory therapist (RT) to evaluate
the efficiency of a treatment. Listen to the noises coming from the primary bronchi
(PB) is important because it is the place where secretions can be accumulated. Therefore,
it is crucial to know exactly where to place the stethoscope’s chestpiece on the chest.
Few studies have analyzed the chest area where the PB were located. Our hypothesis
is that PB are localized on a line that joins axillary fossa (Bi-Axillary line: BAL).
The aim of our study is to evaluate the probability to find the primary bronchi by
analysis of chest radiography.
Patients and methods A retrospective study was performed by analysis of chest X-Ray
using the software: TM reception®, which allows precise measures to the tenth of millimeter.
All the X-Rays were made on confined to bed patients hospitalized within intensive
care unit, internal medicine and abdominal surgery rooms.
The following measures (in mm) were made between:
Lowered perpendicular (LP) of:
Bi-Axillary Line (BAL) and the sternal carina (SC)
BAL’s and the position of right and left PB
Middle of the body-sternum (BS) and the perpendicular middle of right and left PB.
Hyoid bone and the SC
The exclusion criteria were: BMI < 18.5 kg/m2 and BMI > 30 kg/m2, scoliosis, minor
patient, lack of visibility of one of the axillary fossa, lack of visibility of PB,
clavicular asymmetry, kyphosis, lack of symmetry in the shot, atelectasis and pneumothorax.
Statistics: Normality test: KS. Mean values are expressed with their SD and 95% CI.
Results
Discussion In this study, we performed analysis of chest x-Rays of bedridden patients
and we demonstrated that it is possible to localize easily, on either side of the
BS, the right and left PB at ± 25 mm distance (LP) above a line joining axillary fossa.
This study constitutes a new tool for the RT who, by using stethoscope with a chestpiece
of 10 cm2 surface area, will be able to listen to noise coming from PB.
Conclusion The data presented herein (Fig. 31) show that right and left PB are located
at a mean distance of 25 (±5) mm and 27 (±6) mm above the BAL, on both sides of the
BS. The BAL represents thus an easy and precise mode to detect right and left PB by
bedridden. Finally, the distance between the hyoid bone and the SC is about 12 cm.
As the PB are located after the bifurcation, this information constitutes another
useful way for the localization the right and left PB by bedridden patient.
Fig. 31
50 X-Rays (Men = 26, women = 24) have been analyzed. Normality test passed. LP lower
perpendicular, BAL bi-axillary line
Competing interests None.
O83 Study of efficacy on ICU acquired weakness of early standing with the assistance
of a tilt table in critically ill patients
Celine Sarfati1, Alex Moore1, Paula Mendialdua1, Emilie Rodet1, Catherine Pilorge2,
Francois Stephan2, Saida Rezaiguia-Delclaux2
1Physiotherapy department, Surgical Center Marie Lannelongue, Le Plessis-Robinson,
France; 2Réanimation adulte, Surgical Center Marie Lannelongue, Le Plessis-Robinson,
France
Correspondence: Celine Sarfati - celine.sarfati@yahoo.com
Annals of Intensive Care 2017, 7(Suppl 1):O83
Introduction Critically ill patients frequently develop muscle weakness, which is
associated with prolonged intensive care unit and hospital stay (1). This randomized
controlled trial (Clinical Trials NCT02047617) was designed to investigate whether
a daily training session using a tilt table, started early in stable critically ill
patients with an expected prolonged ICU stay, could improve strength at ICU and hospital
discharge compared to a standard physiotherapy program.
Patients and methods The study protocol was approved by an ethics committee and informed
consent was obtained from all patients. Patients admitted in adult ICU of Marie Lannelongue
hospital, France, who were mechanically ventilated for at least 3 days were included.
Exclusion criteria were cerebral or spinal injury, pelvic or lower limb fracture.
Patients were assessed each day for temporary contraindications for mobilization out
of bed (RASS score <−2 or >1; hemodynamic instability; a continuous intravenous dose
of epinephrine/norepinephrine >2 mg/h; continuous renal replacement; ECMO). Interventions
for patients assigned to the standard physiotherapy group (Std) included sitting in
armchair for at least 2 h per day. In addition to the standard physiotherapy mobilization
protocol, patients assigned to the Tilt table physiotherapy group (Tilt) were positioned
on a tilt table for 1 h per day. The primary outcome was the muscles strength evaluated
using the Medical Research Council (MRC) score (range 0 = no muscle contraction, to
5 = normal strength), scoring 3 muscle groups in each limb, at ICU and hospital discharge,
compared to MRC score evaluated in ICU before the implementation of the physiotherapy
program. Secondary outcome variables included ICU and hospital length of stay.
Results The flow chart of the study, conducted between October 2013 and October 2014,
is presented in the Fig. 32.
Fig. 32
See text for description
Both groups (Std vs Tilt) are comparable for age (63 ± 16 vs 60 ± 15, p = 0.37), gender
(21 Females vs 26 F and 52 Males vs 46 M, p = 0.34) and the SAPSII (43 ± 13 vs 42 ± 12,
p = 0.65). No significant difference was observed in terms of MRC score or in terms
of pts with or without weakness (MRC > 48) at ICU or hospital discharge. However,
the number of pts with weakness was significantly higher in the group before Tilt
mobilization, suggesting a more rapid improvement in the tilt group. The ICU and hospital
lengths of stay were not different between groups.
Discussion The prevalence of muscle weakness in our population is high before mobilization
(90.6%, 95% CI 85.2–95.6), is still 48.6% at ICU discharge but represents only ~ 1%
at hospital discharge. This low hospital discharge prevalence is probably related
to the early and intense physiotherapy in both groups, which may explain our inability
to demonstrate superiority of the addition of tilt table positioning, although a faster
recovery is suggested.
Conclusion Training sessions using a tilt table, in addition to early and intense
physiotherapy did not improve muscle strength evaluated using MRC score in surgical
ICU patients with muscle weakness.
Competing interests None.
Reference
Am J Respir Crit Care Med. 2007;175:480–9.
O84 Aerosol delivery using two nebulizers through high flow nasal cannula: a randomized
cross-over SPECT-CT study
Jonathan Dugernier1, Michel Hesse2, Thibaud Jumetz1, Emilie Bialais1, Jean Roeseler1,
Virginie Depoortere2, Jean Bernard Michotte3, Xavier Wittebole1, Pierre-François Laterre1,
François Jamar4, Gregory Reychler5
1Sevice des soins intensifs, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium;
2 Médecine nucléaire, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium; 3Respiratory,
Haute École de Santé Vaud, Lausanne, Switzerland; 4Service de médecine nucléaire,
Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium; 5Service de pneumologie,
Cliniques Universitaires Saint Luc, Bruxelles, Belgium
Correspondence: Jonathan Dugernier - jonathan.dugernier@uclouvain.be
Annals of Intensive Care 2017, 7(Suppl 1):O84
Introduction Patients with high flow nasal cannula may benefit from combined aerosol
therapy. Clinical efficacy depends on pulmonary deposition which is related to the
type of nebulizer. All new nebulizers or delivery methods require rigorous evaluation.
The aim of this study was to compare lung deposition between two nebulizers (jet nebulizer
vs vibrating-mesh nebulizer) through high flow nasal cannula in healthy subjects.
Patients and methods Aerosol delivery of diethylenetriaminepentaacetic acid labelled
with technetium-99m (99mTc-DTPA, 4 mCi/4 mL) to the lungs using a vibrating-mesh nebulizer
(Aerogen Solo®, Aerogen Ltd., Galway, Ireland) and a constant-output jet nebulizer
(Opti-Mist Plus Nebulizer®, ConvaTec, Bridgewater, NJ) through high flow nasal cannula
(Optiflow®, Fisher & Paykel, New Zealand) was compared in 6 healthy subjects. Flow
rate was set at 30 L/min through the heated humidified circuit. Pulmonary and extrapulmonary
deposition were measured by single photon emission computed tomography combined with
a low dose CT-scan (SPECT-CT) and by planar scintigraphy.
Results Lung deposition was only 3.3 ± 1.3 and 1.2 ± 0.8% of the nominal dose with
the vibrating-mesh nebulizer and the jet nebulizer, respectively (p < 0.05). Dose
lost in the high flow circuit, humidification chamber and nasal cannula was higher
with the vibrating-mesh nebulizer as compared to the jet nebulizer (75.2 ± 8.2 vs
45.0 ± 6.2% of the nominal dose, p = 0.001). Expressed as percentage of emitted dose,
lung deposition was similar with both nebulizers.
Conclusion This study demonstrated that aerosol delivery through HFNC is poor in the
specific conditions of the study despite the higher efficiency of the vibrating-mesh
nebulizer as compared to the jet nebulizer. Placing the nebulizer on the HFNC circuit
at 30 L/min induces high aerosol loss on the circuit and the oropharynx.
Competing interests J. Dugernier: unrestricted grant by Aerogen Ltd. (Galway, Ireland).