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M E E T I N G A B S T R AC T S
Conclusion Our study shows for the first time an assessment of the changes in aged sepsis is still unclear. The purpose of this study was to
prevalence of polymorphisms of TLR4 Asp299Gly and Thr399Ile con- clarify the immunological changes in sepsis of aged patients.
sidering its cosegregation in healthy individuals and septic patients. Methods Forty-four septic patients and 48 gender-matched healthy
And that septic patients who develop respiratory dysfunction have volunteers were prospectively enrolled in the study, which included
more presence and genotypes 399Selv 299Selv/399Selv and less the the following investigations: (1) The SOFA score and clinical outcome
presence of genotype 299Het/399Het, featuring a protective effect of were compared between adult sepsis (<65 years of age) and older adult
the polymorphism Thr399Ile. sepsis (≥65 years of age). (2) Blood samples were collected from septic
References and control volunteers. Separated peripheral blood mononuclear cells
1. Lorenz E, Mira JP, Cornish KL, Arbour NC, Schwartz DA: A novel were stained with CD4, CD8, programmed death-1 (PD-1), CD28, and
polymorphism in the toll-like receptor 2 gene and its potential association CD62L antibodies and analyzed by flow cytometry, and serum was used
with staphylococcal infection. Infect Immun 2000, 68:6398-6401. to measure cytokine concentrations by using multiplex bead assay.
2. Janeway CA, Jr, Medzhitov R: Introduction: the role of innate immunity in Values were compared among four groups: normal adult (<65 years of
the adaptive immune response. Semin Immunol 1998, 10:349-350. age), normal older adult (≥65 years of age), adult sepsis (<65 years of
age), and older adult sepsis (≥65 years of age) groups.
Results (1) No differences in SOFA scores were observed between
P4 adult sepsis (n = 19, 39 years) and older adult sepsis (n = 25, 78 years),
Modelling immune responses in sepsis but 3-month survival in older adult sepsis was significantly decreased
R Grealy1, M White2, M O’Dwyer2, P Stordeur3, DG Doherty1, R McManus1, compared with that in adult sepsis (36% vs. 4%, P <0.05). (2) Population
T Ryan2 of CD8+ T cells in normal older adults was significantly less than that
1
Trinity College Dublin, Ireland; 2St James’s Hospital, Dublin, Ireland; 3Hopital in normal adults (1.5×105 vs. 5.7×104/ml, P <0.01), and percentage
d’Erasme, Bruxelles, Belgium of PD-1+CD8+ T cells in the older adult sepsis group was significantly
Critical Care 2012, 16(Suppl 1):P4 (doi: 10.1186/cc10611) greater than that in the normal older adult group (40% vs. 29%,
P <0.01). Population of CD4+, CD62L+CD4+, and CD28+CD4+ T cells in the
Introduction The onset and evolution of the sepsis syndrome in older adult sepsis group was significantly less than that in the normal
humans is modulated by an underlying immune suppressive state [1,2]. older adult group (n = 26, 80 years) (1.8×105 vs. 5.9 ×104/ml, 1.6×105 vs.
Signalling between immune effector cells plays an important part in 5.4×104/ml, and 1.6×105 vs. 4.4×104/ml, respectively; P <0.01); however,
this response. The objective of this study was to investigate peripheral these values did not differ between the adult sepsis and normal adult
blood cytokine gene expression patterns and serum protein analysis (n = 22, 39 years) groups. Serum IL-12 level in older adult sepsis was
in an attempt to model immune responses in patients with sepsis of increased when compared with that in the other three groups (P <0.01).
varying severity. We hypothesised that such immunologic profiling Conclusion Poor prognosis in older adult sepsis may be related to both
could be of use in modelling and prediction of outcomes in sepsis in preexisting decrease of CD8+ T cells with aging and loss of CD4+ T cells
addition to the evaluation of future novel sepsis therapies. with sepsis.
Methods A prospective observational study in a mixed medical/
surgical ICU and general wards of a large academic teaching hospital
was undertaken. Eighty ICU patients with a diagnosis of severe sepsis, P6
50 patients with mild sepsis (bacteraemia not requiring ICU admission) Homeostatic pulmonary microenvironment is responsible for
and 20 healthy controls were recruited. Gene expression analysis by alveolar macrophages resistance to endotoxin tolerance
qPCR for INFγ, TNFα, IL-2, IL-7, IL-10, IL-23, IL-27 on peripheral blood F Philippart1, C Fitting2, B Misset1, J Cavaillon2
1
mononuclear cells (PBMCs) and serum protein analysis for IL-6 was Groupe Hospitalier Paris Saint Joseph, Paris, France; 2Institut Pasteur de Paris,
performed. Multivariate analysis was used to construct a model of gene Paris, France
expression based on cytokine copy numbers alone and in combination Critical Care 2012, 16(Suppl 1):P6 (doi: 10.1186/cc10613)
with serum IL-6 levels.
Results Sepsis was characterised by decreased IL-2, IL-7, IL-23, INFγ Introduction Endotoxin tolerance (ET) is a modification of immune
and greater TNFα, IL-10 and IL-27 gene expression levels compared response to a second challenge with lipopolysaccharide (LPS), which
to controls. Severe sepsis differed from mild sepsis by a decreased results in a decreased production of proinflammatory cytokines, and
INFγ and increased IL-10 gene expression (P <0.0001). A composite is considered partly responsible for the susceptibility to infectious
cytokine gene expression score differentiated controls from mild sepsis processes in hospitalized patients [1]. We previously observed an
and mild sepsis from severe sepsis (P <0.0001). A model combining absence of ET of alveolar macrophages (AM) to LPS in an ex vivo
these cytokine gene expression levels and serum IL-6 protein levels murine model of endotoxin tolerance [2]. We hypothesized that this
distinguished sepsis from severe sepsis with an ROC value of 0.89. singularity could be mediated by granulocyte–macrophage colony-
Conclusion Accurate modelling of patient response to infection is stimulating factor (GM-CSF) (known to be predominantly produced
possible using peripheral blood mononuclear cell gene expression by type II pneumocytes) and interferon-gamma (INFγ), two cytokines
and serum protein analysis. Molecular biological techniques provide known to prevent the occurrence of ET [3]. The objectives were to
a robust method of such profiling. This approach may be used to confirm the absence of tolerance of AM to LPS and to assess the
evaluate novel sepsis therapies. respective roles of GM-CSF and INFγ in this phenomenon and the
References cellular origin of INFγ.
1. O’Dwyer et al.: The occurrence of severe sepsis and septic shock are related Methods We used different wild-type mice strains (BALB/c,
to distinct patterns of cytokine gene expression. Shock 2006, 26:544-550. C57BL/6,129SV), and KO mice lacking different leukocytes subset
2. O’Dwyer et al.: The human response to infection is associated with distinct rag2–/–, rag2gc–/–, cd3e–/–, μ–/–, il-15–/– and Ja18–/–. We used an ex vivo
patterns of interleukin 23 and interleukin 27 expression. Intensive Care Med model consisting of intravenous injection of LPS 20 hours prior to an in
2008, 34:683-691. vitro stimulation of AM, peritoneal macrophages and monocytes with
LPS. We pretreated the wild-type mice with anti-cytokines antibodies,
and KO mice with B cells and NK cells adoptive transfer.
P5 Results We confirmed the absence of AM tolerance to endotoxin in all
Decreased peripheral CD4+/CD8+ lymphocytes and poor prognosis the strain of wild-type mice. Inhibiting either GM-CSF or INFγ in vivo
in aged sepsis at homeostasis led to a decrease in TNF production by AM during
S Inoue, K Utsunomiya-Suzuki, S Morita, T Yamagiwa, S Inokuchi the in vitro stimulation by LPS, suggesting the involvement of these
Tokai University, Kanagawa, Japan cytokines in the prevention of tolerance within the lungs. The fact that
Critical Care 2012, 16(Suppl 1):P5 (doi: 10.1186/cc10612) AM from rag2–/–, rag2gc–/–, μ–/– could be tolerated, the fact that adoptive
transfer of B lymphocytes in these deficient mice restores the wild-type
Introduction Aging is a significant factor and is associated with a response, and the presence of INFγ mRNA in the lungs at homeostasis
poor prognosis in sepsis; however, the mechanism of immunological in wild-type mice and before and after adoptive B-lymphocyte transfer
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P7
In vivo natural killer and natural killer T-cell depletion affects
mortality in a murine pneumococcal pneumonia sepsis model
E Christaki1, E Diza1, SM Opal2, A Pistiki3, DI Droggiti3, DP Carrer3,
M Georgitsi3, N Malisiovas1, P Nikolaidis1, EJ Giamarellos-Bourboulis3
1
Aristotle University of Thessaloniki, Greece; 2Memorial Hospital of RI, Alpert
Figure 2 (abstract P7). Kaplan–Meier survival curve of groups B and C.
School of Medicine of Brown University, Providence, RI, USA; 3University of
Athens, Medical School, Athens, Greece
Critical Care 2012, 16(Suppl 1):P7 (doi: 10.1186/cc10614)
Conclusion Our study has shown that NK cells appear to contribute
Introduction Apart from macrophages and neutrophils, natural killer to mortality in pneumococcal pneumonia. More research is needed to
(NK) and natural killer T (NKT) cells have been found to play a role in explore their role in host response to bacterial infection and sepsis.
the early stages of bacterial infection. In this study, we investigated
the role of NK and NKT cells in host defense against Streptococcus
pneumoniae, using a murine pneumococcal pneumonia sepsis model.
Our hypothesis was that NK and NKT cells play an immune-regulatory
role during sepsis and thus in vivo depletion of those cell populations P8
may affect mortality. Mobilization of hematopoietic and nonhematopoietic stem cell
Methods We used four groups of C57BL/6 mice (A, B, C and D, n = 10 subpopulations in sepsis: a preliminary report.
mice/group). Animals were infected intratracheally with 50 μl of T Skirecki1, U Zielińska-Borkowska1, M Złotorowicz1, M Złotorowicz1,
S. pneumoniae suspension (106 cfu). Twenty-four hours prior to bacterial J Kawiak2, G Hoser1
1
inoculation, Group A received 50 μl of anti-asialoGM1 rabbit polyclonal Medical Center of Postgraduate Education, Warsaw, Poland; 2Polish Academy
antibody (Wako Chemicals GmbH, Neuss, Germany) intravenously (i.v.) of Science, Warsaw, Poland
to achieve in vivo NK cell inactivation; in Group B, NKT cell depletion Critical Care 2012, 16(Suppl 1):P8 (doi: 10.1186/cc10615)
was performed by targeting the CD1d receptor using 2 mg/kg of the
monoclonal antibody anti-CD1d, clone 1B1 (BD Pharmingen, San Introduction Sepsis and septic shock lead to the multiorgan damage
Diego, CA, USA) i.v.; Group C (control) received an equivalent amount by extensive release of inflammatory mediators. Regenerative
of isotype antibody control (nonspecific Ig). Group D received sham mechanisms include such regimens as stem cells which differentiate
intratracheal installation of normal saline. Animals were observed daily towards specific tissues. Also, in the course of the systemic inflammation
for 7 days and deaths were recorded. The survival analysis was plotted the disruption of various regulatory axes occurs, including chemokines
using the Kaplan–Meier method and differences in survival between (VEGF, HGF) and complement proteins (C5a,C3a). Among other
groups were compared with the log-rank test. functions these axes maintain stem cell circulation and recruitment
Results We found that in vivo NK cell depletion improved survival after [1]. The aim of the study was to evaluate circulating stem cells in the
pneumococcal pneumonia and sepsis in the group of mice that received peripheral blood of septic patients.
the anti-asialoGM1 antibody when compared with animals that Methods Blood samples were obtained from five patients with sepsis
received nonspecific IgG antibody (P = 0.041) (Figure 1). Nevertheless, or septic shock on the second day after diagnosis. Blood from five
when NKT cell depletion was attempted, survival worsened compared healthy volunteers served as control. Samples were stained with the
to the control group; however, that difference did not reach statistical panel of antibodies against: CD45, lineage markers (Lin), CD34, CD133,
significance (P = 0.08) (Figure 2). VEGFR2 and isotypic controls. Cells were analyzed by flow cytometry
and the total cell count per milliliter was calculated.
Results On the basis of cell surface phenotype the following stem
cell subpopulations were distinguished: hematopoietic stem cells
(HSCs) CD34+CD133+CD45+Lin–, endothelial progenitor cells (EPCs)
CD34+CD133+VEGFR2+; and primitive nonhematopoietic stem cells.
In the blood of septic patients we found: HSCs (5/5), median level
96/ml; EPCs (5/5), median 48/ml; and nonhematopoietic stem cells
(4/5), median 48/ml. Whereas in the control group the results were as
follow: HSCs (5/5), median level 644/ml; EPCs (5/5), median 70/ml; and
nonhematopoietic stem cells (0/5). Two of five patients died of septic
shock. A trend to lower number of HSCs in nonsurvivors was observed.
Conclusion Stem cells can be identified phenotypically in the blood
of septic patients and healthy volunteers. However, the circulating
primitive nonhematopoietic stem cells could not be detected under
physiological conditions. Furthermore, we suggest that stem cells
analysis may have serve as prognostic tool in the future.
Acknowledgements Supported by EU Structural Funds, ‘Innovative
Methods of Stem Cells Applications in Medicine’, Innovative Economy
Operational Programme, POIG 01.02-00-109/09.
Figure 1 (abstract P7). Kaplan–Meier survival curve of groups A and C. Reference
1. Ratajczak MZ, et al.: Leukemia 2010, 24:1667-1675.
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P9
Blunted IL-17 responses early after advent of multiple injuries
M Paraschos1, M Patrani1, A Pistiki2, J Van der Meer3, M Netea3,
E Giamarellos-Bourboulis2, K Mandragos1
1
Korgialeneion Benakeion Hospital, Athens, Greece; 2University of Athens,
Medical School, Athens, Greece; 3UMC St Radboud, Nijmegen, the Netherlands
Critical Care 2012, 16(Suppl 1):P9 (doi: 10.1186/cc10616)
References Results In season 2010/11 only six patients with a confirmed A/H1N1
1. Vanhorebeek I, et al.: Lancet 2005, 365:53-59. infection required admission to intensive care (47% of all patients with
2. Vanhorebeek I, et al.: Kidney Int 2009, 76:512-520. a confirmed A/H1N1 infection admitted to our hospital). All patients
3. Van den Berghe G, et al.: N Engl J Med 2001, 345:1359-1367. required ventilation. Median APACHE II score was 18.2. Median ICU stay
was 18.5 days. Median number of ventilator days was 14. No patient
died, both 28-day and 3-month mortality was 0%. Total leukocyte
P12 count was without substantial differences, but there was a prominent
Modulation of mediators derived from whole blood or monocytic lymphopenia at the time of admission (0.05 to 0.22% of total leukocyte
cells stimulated with lipopolysaccharide reduces endothelial cell count) as has been described in similar studies. All lymphocyte
activation populations were decreased but a most prominent decrease was in
A Schildberger, T Stoifl, D Falkenhagen, V Weber CD4 (T-helpers) and CD8 (T-suppressors), CD19 (B-lymphocytes) and
Danube University Krems, Austria NK cells were less decreased. Comparison of the admission sample and
Critical Care 2012, 16(Suppl 1):P12 (doi: 10.1186/cc10619) the second sample taken 21 days after admission: both CD4 and CD8
were most decreased at admission, immunoregulatory index had a
Introduction Modulation of inflammatory mediators with specific or shift to positive values in the admission sample.
selective adsorbents may represent a promising supportive therapy Conclusion Our small sample of intensive care patients with a
for septic patients. The aims of this study were to modulate mediator confirmed A/H1N1 infection supports the scarce published data about
concentrations from lipopolysaccharide (LPS)-stimulated whole blood the early immunological profile of these patients. All our patients had
or monocytic THP-1 cells with specific or selective adsorbents and to a prominent lymphopenia with a most significant decrease in CD4 and
compare the influence on endothelial cell activation. CD8 cells. Due to the number of patients in the season 2010/11 and
Methods Whole blood or THP-1 cells (1×106 cells per ml medium the survival of all patients we could not analyse the relation of survival
containing 10% human plasma) [1] were stimulated with 10 ng/ml LPS and the change in time of immunological profile in this unique and
from Escherichia coli for 4 hours. Mediator modulation was performed probably already extinct group of patients.
with either a specific adsorbent for TNFα which was based on sepharose Acknowledgements Our study was supported by a grant from
particles functionalized with anti-TNFα antibodies, or with a selective Scientific Board of Regional Hospital Liberec.
albumin-coated polystyrene divinylbenzene copolymer (PS-DVB) References
[2]. Human umbilical vein endothelial cell (HUVEC) activation was 1. Shapovalov KG, et al.: Immunological and bacteriological monitoring of
monitored for 15 hours by measuring secretion of IL-6 and IL-8, as well patients with pneumonia and influenza A/H1N1 infection. Zh Mikrobiol
as surface expression of the adhesion molecules ICAM-1 and E-selectin. Epidemiol Immunobiol 2011, 1:79-82.
Results Conditioned media derived from whole blood (CMB) or THP- 2. Kim JE, et al.: CD4+/CD8+ T lymphocytes imbalance in children with severe
1 cells (CMT) both contained approximately 1,300 pg/ml TNFα which 2009 pandemic influenzaA/H1N1 pneumonia. Korean J Pediatr 2011,
is known to be an important stimulator for HUVEC [1,2]. However, 54:207-211.
CMB led to a significantly higher HUVEC activation as compared to
CMT, as indicated by increased secretion of IL-6 and IL-8 (IL-6: 52,000
vs. 2,000 pg/ml; IL-8: 295,000 vs. 43,000 pg/ml), as well as significantly P14
increased E-selectin surface expression (50 vs. 12 mean fluorescence Time of course CD64, a leukocyte activation marker, during
intensity for CMP and CMT, respectively). Adsorption of inflammatory extracorporeal circulation
mediators from the conditioned medium of whole blood or THP-1 cells S Djebara, P Biston, F Emmanuel, A Daper, M Joris, P Cauchie,
either with the specific TNFα adsorbent or with the selective PS-DVB M Piagnerelli
beads resulted in decreased endothelial cell activation, as shown by CHU Charleroi, Belgium
statistically significant reduction of IL-6 and IL-8 secretion from HUVEC, Critical Care 2012, 16(Suppl 1):P14 (doi: 10.1186/cc10621)
as well as statistically significant reduction of surface expression
of the adhesion molecules ICAM-1 and E-selectin. The reduction of Introduction CD64 is a high-affinity leukocyte receptor for the Fc
HUVEC activation was more pronounced when applying the selective portion of IgG [1]. As CD64 expression on neutrophil cells (PMNs) is
adsorbent showing that the modulation of more than one cytokine is upregulated specifically after bacterial stimulation, it could be used
more effective than removing TNFα alone. to discriminate inflammatory states from bacterial infections [1-3]. The
Conclusion Inflammatory mediator modulation with specific or objective was a comparison of the time course of CD64 expression
selective adsorbents reduces endothelial cell activation and thus may on PMN cells between patients undergoing cardiac surgery with
support the development of new therapies for sepsis. extracorporeal circulation (ECC) with septic patients.
References Methods Prospective study realized in the ICU of CHU Charleroi (Belgium).
1. Schildberger et al.: Innate Immun 2010, 16:278-287. Thirty-nine patients scheduled for a cardiac surgery with ECC (coronary,
2. Schildberger et al.: Blood Purif 2011, 32:286-295. valvular or mixed surgery) (ECC group) and 11 patients with severe sepsis
or septic shock (septic group) were included. The CD64 expression on
PMNs was quantified by the hematologic Cell Dyn Sapphire method
P13 (Abotte US) before T0, at ICU admission (T1) and postoperatively on day
A/H1N1 infection: immunological parameters in ICU patients 1 (T2) and day 5 (T3) for the ECC group and on days 0, 1 and 5 for the
I Zykova, P Sedlák, T Zajíc, A Vitouš, F Stejskal septic group. Values are expressed as median (25th to 75th) percentiles
Regional Hospital Liberec, Czech Republic Results Fifty patients were included among which 39 in the ECC
Critical Care 2012, 16(Suppl 1):P13 (doi: 10.1186/cc10620) group (nine valvular, 20 coronary artery bypass grafting and 10 mixed
surgery). As expected, the inflammatory parameters were significantly
Introduction The outbreak of influenza A/H1N1 2009 had influenced increased in septic patients compared to the ECC group except on day
ICUs all over the world. In the season 2009/10 we admitted to intensive
care 13 patients with A/H1N1 infection in our regional hospital. In Table 1 (abstract P14)
the next season 2010/11 another outbreak of A/H1N1 infection was ECC Sepsis P value
predicted. We decided to study the immunological profiles of these
patients and its development in time. T0 0.8 (0.6 to 1.08) 3.24 (1.9 to 7.8) <0.001
Methods We conducted a prospective study on patients admitted to our
T1 0.9 (0.6 to 1.14)† Not available
hospital with A/H1N1 infection in the season 2010/11. The diagnosis was
confirmed by RT-PCT from nasopharyngeal smear or bronchoalveolar T2 1.3 (0.77 to 1.8)*,** 4.4 (2.63 to 6.7)* <0.001
lavage in all patients. Immunological parameters (leukocyte count,
T3 1.1 (0.74 to 1.4)‡ 1.3 (0.74 to 1.4) 0.16
lymphocyte count, CD19, CD4, CD8, immunoregulatory index, NK cells)
were analysed on admission and 3 weeks after admission. † ‡
*P <0.05 T2 vs. T3, **T2 vs. T0, T2 vs. T1, T3 vs. T0. ANOVA tests.
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5 (for example, CRP: 0.2 (0.1 to 0.6) vs. 12.5 (5.7 to 26.9) mg/dl; WBC 6.5 changes in metabolism and the metabolic interaction between tissues
(5.2 to 8.7) vs. 19.5 (12 to 20.5) 103/mm3; for respectively ECC and septic and red blood cells are not well understood. The objective of this study
group at T0, P <0.001). The CD64 expression increased significantly in was to assess changes in intermediary metabolism during the onset
both groups but index values were lower in the ECC compared to the of an animal model of sepsis by determining glycolytic, TCA and PPP
septic group except on T3 (Table 1). metabolites, amino acids and ATP levels in heart, liver and red blood
Conclusion ECC modifies the inflammatory parameters, including cells.
the expression of the CD64 on PMNs but this one presents the best Methods C57BL/6 mice (30 to 35 g) were injected intraperitoneally
specificity to diagnose an infection. Thus, CD64 expression could be with lipopolysaccharide (LPS, 40 mg/kg) to induce endotoxemia.
proposed as a promising marker in the early diagnosis of the infection. Six hours post LPS, C13-pyruvate (a key intermediate metabolite) was
References administered subcutaneously for fluxome analysis of intermediate
1. Ioan-Fascinay A, et al.: Immunity 2002, 16:391-402. metabolites. At 20, 40 and 60 minutes, heart, liver and red blood cells
2. Nuutila J, et al.: J Immunol Methods 2007, 328:189-200. were collected and stored at –80°C. Labeled metabolites were measured
3. Qureshi SS, et al.: Clin Exp Immunol 2001, 125:258-265. using capillary electrophoresis–mass spectrometry, quantified by
calculating the AUC/t0–60 and expressed relative to control. Heart
P15 function was monitored by echocardiography.
Oral neutrophil quantitation in patients undergoing elective Results Red blood cells preferentially metabolized pyruvate (ninefold
cardiopulmonary bypass increase) compared to heart (1.2-fold increase) or liver (–2.1-fold
ME Wilcox1, P Perez2, C DosSantos3, M Glogauer1, E Charbonney3, decrease), and were a net lactate source (2.1-fold increase). Glycolytic
A Duggal2, S Sutherland2, G Rubenfeld2 intermediates increased in the heart, but decreased in red blood cells,
1
University of Toronto, Canada; 2Sunnybrook Health Sciences Centre, Toronto, while TCA intermediates decreased in the heart and amino acids
Canada; 3St Michael’s Hospital, Toronto, Canada increased in the liver. Under the hypoglycemic conditions of the animal
Critical Care 2012, 16(Suppl 1):P15 (doi: 10.1186/cc10622) model, red blood cells were found to accumulate glycerol-3-phosphate
(red cell glycerol flux remained normal) and 2,3BPG following C13-
Introduction Recent research suggests that the oral cavity may provide pyruvate injection. ATP was stable in the heart, but decreased in
an early opportunity to monitor the innate immune system; an oral rinse the liver and red blood cells. Echocardiography revealed a transient
assay was found to be a reliable predictor of bone marrow engraftment recovery of left ventricular function that correlated with shifts in red
and neutrophil recovery in patients undergoing bone marrow blood cell metabolism.
transplantation [1]. Multiorgan failure may be mediated by neutrophil Conclusion Metabolic investigation of different septic tissues revealed
extravasation and aggregation [2] in highly inflammatory states, such shifts in metabolism between organs, suggesting that sepsis induces
as cardiopulmonary bypass (CPB). The objective of this novel pilot study complex metabolic shifts in response to changing nutrient availability
was to determine whether the kinetics of oral neutrophil recovery post- and cell function; moreover, enhancing red blood cell metabolism
CPB surgery reflect systemic immune activation. may be beneficial to depressed organ function during the onset of
Methods Samples [3] from four-quadrant mucosal swabs and oral cavity endotoxemia.
rinses were obtained from 41 patients undergoing on-CPB elective Acknowledgements Supported by the Ministry of Education, Culture,
cardiac surgery preoperatively (t–1) and postoperatively upon arrival to Sports, Science and Technology, Japan, Global COE Program.
the CVICU (t0), at 12 to 18 hours (t1), and on day 3 (t2). Oral neutrophil
counts (/ml) were determined by hemacytometry and validated by an
electronic cell counter. Concurrent blood samples were collected for P17
measurement of IFNα, interleukins (IL-1β, IL-6, IL-8 and IL-10), chemokine AMP-activated protein kinase controls liposaccharide-induced
C-C motif ligand 4 (CCL-4) and Th1 and Th2 cytokines using a 10-plex hyperpermeability
human cytokine mediator panel. Continuous variables were summarized D Castanares-Zapatero1, M Overtus2, D Communi3, M Horckmans3,
with means (standard deviation). Preoperative and postoperative oral L Bertrand2, C Oury4, C Lecut4, P Laterre1, S De man2, C Sommereyns2,
neutrophil counts were compared using paired t tests. S Horman2, C Beauloye2
1
Results Patients were 65 (10.6) years old; 78% male; 51% had significant Université catholique de Louvain, Cliniques universitaires Saint Luc,
co-morbidities (25% diabetes); 54% took a statin; APACHE II score was Brussels, Belgium; 2Université catholique de Louvain, Institut de Recherche
22 (4.4); and multiorgan dysfunction score (MODS) was highest on Expérimentale et Clinique, Brussels, Belgium; 3Université libre de Bruxelles,
hospital day 1 (6.2; 2.2). Mean delta oral neutrophil count by oral swab Institut de Recherche Interdisciplinaire en Biologie humaine et moléculaire,
(between t–1 and t0) was 1.7×106 (2.0×106). A significant difference was Brussels, Belgium; 4Université de Liège, Groupe Interdisciplinaire de
seen in the absolute neutrophil counts (oral swab) between t–1 (1.7×106 Génoprotéomique Appliquée, Liège, Belgium
(1.3×106)) and t0 (3.4×106 (2.7×106); P <0.001), but not between t–1 and Critical Care 2012, 16(Suppl 1):P17 (doi: 10.1186/cc10624)
t1 (2.0×106 (1.7×106); P = 0.14) or t2 (6.6×105 (1.1×106); P = 0.14). Similar
results were obtained by oral cavity rinse. Introduction Organ dysfunction determines the severity of sepsis and
Conclusion An oral swab assay has the potential to provide rapid, risk- is correlated to mortality. Endothelial increased permeability contri-
free, and early data on neutrophil activation and chemotactic defects in butes to the development of organ failure. AMP-activated protein
response to CPB, obviating the need for invasive sampling. This method kinase (AMPK) has been shown to modulate cytoskeleton and could
could provide a new perspective on the systemic inflammatory mediate endothelial permeability. Our hypothesis is that AMPK controls
response in surgery, traumatic injury, burns, and sepsis. sepsis-induced hyperpermeability in the heart and is involved in septic
References cardiomyopathy.
1. Cheretakis C, et al.: Bone Marrow Transplant 2005, 36:227-232. Methods Sepsis was induced by intraperitoneal injection of
2. Fung YL, et al.: J Crit Care 2008, 23:542-549. liposaccharide, 10 mg/kg (LPS). Alpha-1 AMPK knockout mice (α1KO)
3. Wright DG, et al.: Blood 1986, 67:1023-1030. were compared with wild-type. Vascular permeability was characterized
by Evans blue extravasation. Inflammatory cytokine mRNA expression
P16 was determined by qPCR analysis. Left ventricular mass was assessed
C13-pyruvate administration revealed differential metabolism by echocardiography. In addition, to emphasize the beneficial role of
between heart, liver and red blood cells and improved heart AMPK on heart vascular permeability, AMPK activator (acadesine) was
function during endotoxemia administered to C57Bl6 mice before LPS injection. The ANOVA test with
RM Bateman Bonferroni’s post hoc test and the log-rank test were used. P <0.05 was
Keio University, Tokyo, Japan considered as significant.
Critical Care 2012, 16(Suppl 1):P16 (doi: 10.1186/cc10623) Results Increased cardiac vascular permeability was observed in the
LPS group in comparison to untreated animals (2.5% vs. 16%; P <0.05).
Introduction The systemic inflammatory response to bacterial infection, The α1KO mice exhibited an increase vascular permeability after LPS
or sepsis, results in a hypermetabolic state; yet, systemic metabolic injection in comparison to wild-type mice (41.5% vs. 16%; P <0.05).
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α1KO animals had a significant mortality increase after LPS injection tremendous financial costs. Recently, the primary metabolite of
(70% vs. 10%; P <0.05). LPS markedly induced the production of sevoflurane, hexafluoro-2-propanol (HFIP), has been found to exert
proinflammatory cytokines (TNFα, IL-1β, IL-6) that were significantly immunomodulatory properties attenuating inflammatory response
higher in the α1KO animals. More importantly, LPS treatment leads to to lipopolysaccharides (LPS) in vitro [1]. We investigated whether HFIP
an increased left ventricular mass in the α1KO mice within 24 hours, attenuates plasma and tissue inflammatory mediator expression in a
suggesting the onset of edema. Finally LPS-induced vascular rat model of endotoxic shock.
hyperpermeability was greatly reduced after AMPK activation by Methods Thirty-two male Wistar rats were anesthetized, tracheoto-
acadesine (13.2% vs. 40%; P <0.05). mized, and mechanically ventilated. The animals were randomly
Conclusion AMPK importantly regulates cardiac vascular permeability assigned to one of the following groups: (I) LPS group (n = 8), which
and could control the sepsis-induced cardiomyopathy. AMPK could received intravenous Escherichia coli endotoxin (1 mg/kg); (II) LPS/
represent a new pharmacological target of sepsis. HFIP group (n = 8), which was treated identically to the LPS group with
Reference the additional administration of HFIP (67 μg/kg over 30 minutes) after
1. Gustot T: Curr Opin Crit Care 2011, 17:153-159. LPS injection. Control groups received Ringer’s lactate instead of LPS.
General anesthesia was maintained with propofol. All animals received
additional 30 ml/kg Ringer’s lactate after injection of LPS over a time
P18 period of 1 hour. Arterial blood gases were measured every hour.
Reduced expression of PPAR-β/δ limits the potential beneficial Animals were euthanized 6 hours after endotoxin injection. The
effects of GW0742 during septic shock in atherosclerotic swine concentrations of monocyte chemoattractant protein-1, key player in
H Bracht1, F Simon1, J Matallo1, M Gröger1, O McCook1, A Seifritz1, the recruitment of monocytes during endotoxemia, was analyzed in
M Georgieff1, E Calzia1, P Radermacher1, A Kapoor2, C Thiemermann2 bronchoalveolar lavage fluid and in plasma. Linear regression was used
1
University Clinic Ulm, Germany; 2William Harvey Research Institute, London, UK to evaluate influence of HFIP on inflammatory mediator expression.
Critical Care 2012, 16(Suppl 1):P18 (doi: 10.1186/cc10625) Results Plasma MCP-1 protein levels assessed 6 hours after LPS injection
were increased by +5,192 ng/ml compared to baseline (R2 = 0.661,
Introduction The PPAR-β/δ agonist GW0742 was shown to attenuate P <0.001). This increase in MCP-1 protein was attenuated by –48% in
cardiac dysfunction in murine septic shock [1] and renal ischemia/ the LPS/HFIP group (+2,706 ng/ml to baseline, R2 = 0.661; P = 0.004).
reperfusion injury in diabetic rats [2]. Since these data originate from Similar results were found in BALF, in which HFIP decreased the LPS-
unresuscitated models, we investigated the effects of GW0742 during induced raise in MCP-1 protein concentration by –62% (difference of
long-term, resuscitated porcine septic shock. In order to assess the role 54 ng/ml, P = 0.034). LPS-stimulated animals had a +12% higher mean
of pre-existing cardiovascular morbidity we used animals with familial arterial blood pressure after 6 hours when treated with HFIP (78 mmHg
hypercholesteremia (11.1 (7.4; 12.3) vs. 1.4 (1.3; 1.5) mmol/l in a healthy vs. 67 mmHg, R2 = 0.684, P = 0.035). No significant differences in lactate
strain; P <0.001) and consecutive, diet-induced ubiquitous atherosclerosis levels were observed. HFIP attenuated base deficit in LPS-stimulated
resulting in coronary artery disease [3], reduced glomerular filtration rate animals by 1 mmol/l (R2 = 0.522, P = 0.034).
(76 (60; 83) vs. 103 (79; 120) ml/minute in healthy swine; P = 0.004) and Conclusion Hexafluoro-2-propanol attenuated LPS-induced inflamma-
presence of chronic histological kidney injury. tory mediator secretion, the decrease in mean arterial blood pressure,
Methods Anesthetized and instrumented animals randomly received and base deficit. These results suggest that hexafluoro-2-propanol
vehicle (n = 9) or GW0742 (n = 10; 0.03 mg/kg) at 6, 12, 18 hours after may partly inhibit inflammatory response, hypotension and the
induction of fecal peritonitis [4]. Hydroxyethyl starch and noradrenaline development of metabolic acidosis during endotoxic shock.
were infused to maintain normotensive, hyperdynamic hemodynamics. Reference
Creatinine clearance was measured from 0 to 12 hours and from 12 to 1. Urner et al.: Am J Respir Cell Mol Biol 2011, 45:617-624.
24 hours of sepsis, respectively. Data are median (quartiles).
Results GW0742 did not affect the noradrenaline infusion rate required
to achieve target hemodynamics (0.57 (0.30; 3.83) vs. 0.56 (0.41; 0.91)
μg/kg/minute; P = 0.775) nor the fall in creatinine clearance (GW0742:
from 129 (114; 140) to 78 (55; 95) ml/minute, P = 0.002; vehicle: from P20
130 (91; 142) to 41(31; 84) ml/minute, P = 0.004; P = 0.967 and P = 0.191 Effects of noradrenaline and lipopolysaccharide exposure on
between groups). Immune histochemistry analysis of kidney biopsies mitochondrial respiration in alveolar macrophages
in sham-operated swine showed markedly reduced tissue expression M Gröger, M Widman, J Matallo, P Radermacher, M Georgieff
of the PPAR-β/δ receptor in atherosclerotic swine (281 (277; 404) vs. 57 University of Ulm, Germany
(53; 77)×103 densitometric units in healthy swine; P = 0.008). Critical Care 2012, 16(Suppl 1):P20 (doi: 10.1186/cc10627)
Conclusion Even early post-treatment with the PPAR-β/δ agonist
GW0742 did not beneficially influence acute kidney injury during long- Introduction Mitochondrial respiratory capacity of immune cells seems
term, resuscitated fecal peritonitis-induced septic shock in swine with to be impaired in septic patients [1]. On the other hand, the effects of
pre-existing impairment of kidney function and histological damage. catecholamines on mitochondrial function are still controversial [2] and
The lacking beneficial effect of GW0742 was most likely due to the may confound the genuine mitochondrial response to the septic event.
reduced expression of the PPAR-β/δ receptor. In order to test if catecholamine therapy may influence the impairment
Acknowledgements Supported by the Else-Kröner-Fresenius-Stiftung. of mitochondrial function in immune cells during sepsis, we measured
References mitochondrial respiration in cultured murine alveolar macrophages
1. Kapoor et al.: Am J Respir Crit Care Med 2010, 182:1506-1515. (AMJ2-C11) after 24 hours of incubation with noradrenaline and
2. Collino et al.: Free Radic Biol Med 2011, 50:345-353. lipopolysaccharide (LPS).
3. Thim D: Med Bull 2010, 57:B4161. Methods Three states of mitochondrial respiratory activity were
4. Simon F, et al.: Crit Care 2009, 13:R113. quantified in terms of O2-flux (JO2) in intact cells at 37°C by means of
an O2K (Oroboros® Instruments Corp., Innsbruck, Austria) according
to a previously published protocol [3] yielding routine respiration (R)
P19 as the standard respiratory level of the cells without any intervention,
Effects of hexafluoro-2-propanol on inflammatory and proton leak compensation (L) after blocking ATP synthesis by 2.5 μM
hemodynamic responses in a rat model of endotoxic shock oligomycine, and maximum capacity of the electron transport system
M Urner, IK Herrmann, M Hasler, C Booy, B Beck-Schimmer (E) after uncoupling by 1 μM FCCP. The cells were studied after five
University Hospital Zurich, Institute of Anesthesiology, Zurich, Switzerland different exposure conditions: control (C), 15 μmol/ml noradrenaline
Critical Care 2012, 16(Suppl 1):P19 (doi: 10.1186/cc10626) (high NoA), 5 nmol/ml noradrenaline (medium NoA), LPS, and LPS +
high NoA. All data are presented in pmol/(s*million cells) as medians
Introduction Sepsis with multiple organ failure remains a leading and 25 to 75% quartiles. Statistical significance was tested by means of
cause of hospital morbidity and mortality on ICUs imparting the Kruskal–Wallis one-way ANOVA followed by Dunn’s method.
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Results After exposure with high but not with medium NoA we P22
observed a statistically significant decrease in maximum mitochondrial Adrenomedullin blockade improves catecholamine responsiveness
respiratory capacity (E-state, C 133 (118; 148) vs. high NoA 111 (106; and kidney function in resuscitated murine septic shock
113), and medium NoA 129 (123; 140), P <0.05 C vs. high NoA). Both K Wagner1, U Wachter1, J Vogt1, S Weber1, M Groeger1, O McCook1,
LPS and LPS + high NoA did not affect E-state respiration (LPS: 152 M Georgieff1, A Bergmann2, H Luettgen2, E Calzia1, P Radermacher1,
(136; 179), and LPS + NoA 129 (125; 137)), but increased routine (R) F Wagner1
1
respiration when compared to control (C 45 (40; 55) vs. LPS 66 (51; 72) University Medical School Ulm, Germany; 2AdrenoMed AG, Henningsdorf,
and LPS + NoA 65 (55; 68), P <0.05; high NoA 41 (37; 47), and medium Germany
NoA 52 (51; 57), NS). Critical Care 2012, 16(Suppl 1):P22 (doi: 10.1186/cc10629)
Conclusion High but not moderate doses of noradrenaline reduced
mitochondrial respiration in alveolar macrophages in vitro. Surprisingly, Introduction The effects of adrenomedullin in circulatory shock states
LPS increased routine respiration regardless of simultaneous are controversially discussed: while its exogenous supplementation
noradrenaline exposure. improved organ function and survival [1] in experimental models due
References to maintenance of hyperdynamic hemodynamics [2] in otherwise
1. Japiassú AM, et al.: Crit Care Med 2011, 39:1056-1063. hypodynamic conditions, high blood levels were associated with
2. Porta F, et al.: Inflammation 2009, 32:315-321. increased mortality in patients with septic shock [3], most likely as a
3. Renner K, et al.: Biochim Biophys Acta 2003, 1642:115-123. result of excessive vasodilatation [4] and/or impaired systolic heart
function [5].
Methods Immediately after cecal ligation and puncture to induce
peritonitis, mice randomly received vehicle (n = 11) or the adreno-
medullin antibody HAM1101 (n = 9; 2 μg/g to achieve antibody
concentrations >4 ng/ml). Fifteen hours later animals were anesthetized,
P21 mechanically ventilated and instrumented for a consecutive 6-hour
Effects of the anti-diabetic imeglimin in hyperglycemic mice with observation period. Colloid fluid resuscitation and continuous i.v.
septic shock noradrenaline were titrated to maintain normotensive (mean blood
F Wagner1, J Vogt1, U Wachter1, S Weber1, B Stahl1, M Groeger1, O McCook1, pressure >60 mmHg) and hyperdynamic hemodynamics. Creatinine
M Georgieff1, P Fouqueray2, T Kuhn2, E Calzia1, P Radermacher1, blood levels and clearance were assessed as surrogate for glomerular
E Fontaine3, K Wagner1 filtration [6,7]. All data are median (quartiles).
1
University Medical School Ulm, Anesthesia, Ulm, Germany, 2Poxel, Lyon, Results Adrenomedullin antagonism decreased the noradrenaline
France, 3Université Joseph Fourier, LBFA, Grenoble, France requirements needed to achieve target hemodynamics (0.009 (0.009;
Critical Care 2012, 16(Suppl 1):P21 (doi: 10.1186/cc10628) 0.012) vs. 0.02 (0.015; 0.044) μg/g/hour, P <0.001), increased total
diuresis (2.6 (2.3; 3.9) vs. 0.6 (0.5; 2.7) ml, P = 0.028) resulting in improved
Introduction Shock-related hyperglycemia impairs mitochondrial fluid balance (0.18 (0.14; 0.2) vs. 0.26 (0.19; 0.27), P = 0.011) and kidney
function and integrity [1], ultimately leading to apoptosis and function (creatinine levels at the end of the experiment: 1.3 (1.2; 1.5) vs.
organ failure [1,2]. Imeglimin is a new anti-diabetic drug with anti- 2.0 (1.5; 2.9) μg/ml, P = 0.006; creatinine clearance: 400 (316; 509) vs.
hyperglycemic and anti-apoptotic properties [3]. Therefore we 197 (110; 301) μl/minute, P = 0.006).
investigated its effects in hyperglycemic mice with septic shock. Conclusion In resuscitated murine septic shock, early modulation
Methods Immediately after cecal ligation and puncture, mice of excess adrenomedullin activity via antibody HAM1101 improves
randomly received s.c. vehicle (n = 9) or imeglimin (n = 10; 100 μg/g). cardiovascular catecholamine responsiveness, ultimately associated
Fifteen hours later animals were anesthetized, mechanically ventilated with attenuation of acute kidney injury.
and instrumented for a consecutive 6-hour observation period. After Acknowledgements Supported by an unrestricted grant from
a second imeglimin bolus, colloid fluid resuscitation and continuous AdrenoMed AG.
i.v. noradrenaline were titrated to maintain normotensive and References
hyperdynamic hemodynamics. Then 2 mg/g/hour glucose was infused 1. Wu R, et al.: Mol Med 2009, 15:28-33.
to induce hyperglycemia. Glucose oxidation and gluconeogenesis 2. Ertmer C, et al.: Br J Anaesth 2007, 99:830-836.
were derived from blood 13C6-glucose and mixed expiratory 13CO2/12CO2 3. Guignant C, et al.: Intensive Care Med 2009, 35:1859-1867.
isotope enrichment during continuous isotope infusion. Liver mito- 4. Mazzocchi G, et al.: Life Sci 2000, 66:1445-1450.
chondrial activity was assessed using high-resolution respirometry 5. Hyvelin JM, et al.: J Card Surg 2002, 17:328-335.
[4,5], Bax, HO-1 and NF-κB expression by immunoblotting and EMSA. 6. Wagner F, et al.: Shock 2011, 35:396-402.
All data are median (quartiles). 7. Wagner F, et al.: J Trauma 2011. [Epub ahead of print]
Results Imeglimin decreased blood glucose levels (165 (153; 180) vs.
192 (184; 221) mg/dl, P = 0.007) by increasing whole body glucose
oxidation (55 (52; 57) vs. 51 (49; 55)% of infused isotope, P = 0.085), which
coincided with partial restoration of gluconeogenesis (0.38 (0.34; 0.41)
vs. 0.31 (0.27; 0.33) mg/g/hour, P = 0.032), liver mitochondrial activity P23
(oxidative phosphorylation (136 (134; 160) vs. 116 (97; 122) pmol O2/ Activated protein C, severe sepsis and 28-day mortality
second/mg tissue, P = 0.003); maximal oxidative capacity (166 (154; M De La Torre-Prados, A García-de la Torre, M Nieto-González,
174) vs. 147 (130; 159) pmol O2/second/mg tissue, P = 0.064). Imeglimin I Lucena-González, R Escobar-Conesa, A García-Alcántara,
increased liver HO-1, reduced liver Bax expression and attenuated NF- A Enguix-Armada
κB activation (all P <0.001). Hospital Virgen de la Victoria, Málaga, Spain
Conclusion Imeglimin improved whole body glucose utilization and Critical Care 2012, 16(Suppl 1):P23 (doi: 10.1186/cc10630)
gluconeogenesis, a well-established marker of liver metabolic capacity
[4,5], and attenuated organ injury, at least in part due to inhibition of Introduction Protein C (PC) deficiency is prevalent in severe sepsis,
the mitochondrial apoptosis pathway. studies showing that more than 80% of patients with severe sepsis
Acknowledgements In memoriam of Xavier Leverve who initiated this have a baseline PC level below the lower limit of normal [1,2]. The aim
project; supported by an unrestricted grant from Poxel. of the study was to relate the anticoagulation activity evaluated by PC,
References with clinical parameters and 28-day mortality.
1. Vanhorebeek I, et al.: Crit Care Med 2009, 37:1355-1364. Methods A cohort study of 150 patients >18 years with severe sepsis
2. Devos P, et al.: Curr Opin Clin Nutr Metab Care 2006, 9:131-139. according to the Surviving Sepsis Campaign, in an ICU of a university
3. Fouqueray, et al.: J Diabetes Metab 2011, 2:4. hospital. Demographic, clinical parameters and coagulation markers
4. Albuszies G, et al.: Intensive Care Med 2007, 33:1094-1101. during the first 24 hours were studied. PC activity was analysed using
5. Baumgart K, et al.: Crit Care Med 2010, 38:588-595. a haemostasis laboratory analyser (BCS® XP; Siemens). Descriptive and
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comparative statistical analysis was performed using SPSS version 15.0 P25
(SPSS Inc., Chicago, IL, USA). Role of mannose-binding lectin on pneumococcal infections
Results We analyzed 150 consecutive episodes of severe sepsis J Solé Violán1, I García-Laorden1, F Rodríguez de Castro1, A Payeras2,
(16%) or septic shock (84%) admitted to the ICU. The median age was J Ferrer Agüero1, M Briones3, L Borderías4, J Aspa5, J Blanquer3, O Rajas5,
64 years old (interquartile range, 48.7 to 71); male: 60%. The beginning M García-Bello1, J Noda1, J Rello6, C Rodríguez Gallego1
1
of severe sepsis took place in the emergency area in 46% of cases. Hospital Dr Negrín, Las Palmas de Gran Canaria, Spain; 2Hospital Son Llatzer,
The main sources of infection were respiratory tract 38% and intra- Palma de Mallorca, Spain; 3Hospital Clínico y Universitario, Valencia, Spain;
4
abdomen 45%; 70.7% had medical pathology. The 28-day mortality Hospital San Jorge, Huesca, Spain; 5Hospital de La Princesa, Madrid, Spain;
6
was 22.7%. The profile of death patients were men (64.7%, n = 22), Hospital Universitario Vall d´Hebró, Barcelona, Spain
with significantly higher average age (63 vs. 57 years; P = 0.049), as Critical Care 2012, 16(Suppl 1):P25 (doi: 10.1186/cc10632)
well as clinical severity scores, APACHE II (29.8 vs. 24.1; P <0.001) and
SOFA (12.1 vs. 8.9; P <0.001) and major dysfunction organs (4.6 vs. 3.6; Introduction The role of mannose-binding lectin (MBL) deficiency
P <0,001); we observed significantly major consumption of PC (55.2 vs. (MBL2 XA/O + O/O genotypes) in host defences remains controversial.
70.1, P = 0.011). Lower levels of PC were found in surgery septic shock The surfactant proteins (SP)-A1, SP-A2 and SP-D, and other collectins
patients, neurological focus or catheter-related infection and Gram- whose genes are located near MBL2, are part of the first-line lung
negative pathogens from blood cultures. The ROC analysis showed defence against infection. We analyzed the role of MBL on susceptibility
superior risk prediction of SOFA score for 28-day mortality, AUC 0.81 to pneumococcal infection and the existence of linkage disequilibrium
(95% CI: 0.73 to 0.88, sensitivity: 73.5%; specificity: 76.7%, P = 0.001), (LD) among the four genes.
that improves by combining with PC, AUC 0.83 (95% CI: 0.75 to 0.90, Methods We studied 348 patients with pneumococcal community-
sensitivity: 77%; specificity: 83%, P = 0.001). acquired pneumonia (P-CAP) and 1,591 controls. A meta-analysis of
Conclusion This cohort study showed an improvement in the survival MBL2 genotypes in susceptibility to P-CAP and to invasive pneumo-
in septic patients under a lower consumption of PC. Low levels of PC are coccal disease (IPD) was also performed. The extent of LD of MBL2 with
associated with more severity in Sepsis, dysfunction organ and poor SFTPA1, SFTPA2 and SFTPD was analyzed.
outcome. Results MBL2 genotypes did not associate with either P-CAP or
References bacteraemic P-CAP in the case–control study. The MBL-deficient O/O
1. Brunkhorst F, et al.: Protein C concentrations correlate with organ genotype was significantly associated with higher risk of IPD in a meta-
dysfunction and predict outcome independent of the presence of sepsis. analysis, whereas the other MBL-deficient genotype (XA/O) showed
Anesthesiology 2007, 107:15-23. a trend towards a protective role. We evidenced the existence of LD
2. Yan SB, et al.: Low levels of protein C are associated with poor outcome in between MBL2 and SPs genes.
severe sepsis. Chest 2001, 120:915-922. Conclusion The data do not support a role of MBL deficiency on
susceptibility to P-CAP or to IPD. LD among MBL2 and SP genes must
be considered in studies on the role of MBL in infectious diseases.
P24 P26
Soluble usokinase plasminogen activator receptor as a useful Role of serum biomarkers in the diagnosis of infection in patients
biomarker to define advent of sepsis in patients with multiple undergoing extracorporeal membrane oxygenation
injuries M Pieri1, T Greco1, AM Scandroglio1, M De Bonis1, G Maj1, L Fumagalli2,
M Patrani1, M Paraschos1, M Georgitsi2, E Giamarellos-Bourboulis2, A Zangrillo1, F Pappalardo1
K Mandragos1 1
Istituto Scientifico San Raffaele, Milan, Italy; 2Istituto Scientifico San Raffaele
1
Korgialeneion Benakeion Hospital, Athens, Greece; 2University of Athens, Turro, Milan, Italy
Medical School, Athens, Greece Critical Care 2012, 16(Suppl 1):P26 (doi: 10.1186/cc10633)
Critical Care 2012, 16(Suppl 1):P24 (doi: 10.1186/cc10631)
Introduction Although rates and causal organisms of infections occurring
Introduction Soluble usokinase plasminogen activator receptor in patients on extracorporeal membrane oxygenation (ECMO) have already
(suPAR) has been considered a useful biomarker to define prognosis in been described [1], diagnosis of infection itself is challenging in clinical
patients with sepsis [1]. The present study aimed to define the kinetics practice. In addition, a significant heterogeneity in infection surveillance
of suPAR during the physical course of patients with multiple injuries. practice patterns among ELSO centers has recently been reported [2]. The
Methods A total of 62 patients were enrolled. All patients were aim of the study was to analyze the role of C-reactive protein (CRP) and
bearing: multiple injuries necessitating ICU admission with an injury procalcitonin (PCT) in the diagnosis of bacterial and fungal infection in
severity score (ISS) more than 8; and systemic inflammatory response critically ill patients requiring ECMO, and to assess the difference between
syndrome. Patients with infections upon ICU admission were excluded venovenous (VV) and venoarterial (VA) ECMO setting.
from the study. Peripheral venous blood was sampled within the first Methods A case–control study on 27 patients. We analyzed serum
24 hours after ICU admission. Blood sampling was repeated within the values of PCT and CRP according to the presence of infection.
first 24 hours upon advent of sepsis. suPAR was measured in serum by Results Forty-eight percent of patients had infection. Gram-negative
an enzyme immnunoassay. bacteria were the predominant pathogens (54%), and Candida was
Results Mean ISS of patients was 14.6. Median suPAR upon ICU the most frequent isolated microorganism overall (15%). PCT had an
admission was 3.74 ng/ml (range: 1.57 to 16.77 ng/ml). No correlation AUC of 0.681 (P = 0.0062), for the diagnosis of infection in patients on
was found between ISS and suPAR. Sepsis was presented in 27 patients. VA ECMO, but failed to discriminate infection in the VV ECMO group
Median suPAR upon sepsis diagnosis was 7.05 ng/ml (range: 2.18 to (P = 0.14). The AUC of CRP was 0.707 (P ≤0.001) in all ECMO patients. In
32.51 ng/ml) (P <0.0001 compared with ICU admission). This change patients receiving VA ECMO, PCT had good accuracy with 1.89 ng/ml
corresponded to median increase of 57.81%. as the cut-off (SE = 87.8%, SP = 50%) and CRP as well with 97.70 mg/l
Conclusion The presented findings show that measurement of serum as the cut-off (SE = 85.3%, SP = 41.6%). PCT and CRP tests in parallel
suPAR may help diagnosis of sepsis presenting in patients with multiple had SE = 87.2%, and SP = 25.9%. Four variables were identified as
injuries. statistically significant predictors of infection: PCT and CRP tests in
Reference parallel (OR = 1.184; P = 0.0008), age (OR = 0.980; P ≤0.001), presence
1. Savva A, et al.: J Infect 2011, 63:344-350. of infection before ECMO implantation (OR = 1.782; P ≤0.001), and the
duration of ECMO support (OR = 1.056; P ≤0.001).
Conclusion Both traditional and emerging inflammatory biomarkers
can help in the diagnosis of infection in patients receiving ECMO.
Indeed, we demonstrated for the first time that PCT is a reliable
infection marker in patients undergoing VA ECMO. We suggest routine
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concomitant PCT and CRP assay with definite cut-off values as a new 12th day. C-reactive protein (CRP) and PCT were measured daily. We
test to identify infection in patients undergoing VA ECMO. compared infected and noninfected patients.
References Results A total of 50 patients were included during a 12-month
1. Bizzarro MJ, et al.: Pediatr Crit Care Med 2011, 12:277-281. period (age 70.5 ± 9.4 years, 50% male). The 21 patients (42%) that
2. Kao LS, et al.: ASAIO J 2011, 57:231-238. subsequently developed infection (16 surgical wound infections) had
age, Charlson comorbidity score, primary diagnosis, surgical procedure,
intestinal preparation and antibiotic prophylaxis similar to those who
P27 had an uneventful recovery. Infection was less frequent in men (28%
Correlation of VAP diagnosis with parameters of critically ill patients vs. 72%, P = 0.042). Moreover PCT and CRP before surgery were equally
in a general ICU low in patients with or without postoperative infection (0.10 ± 0.06 vs.
DK Matthaiou, A Ioannidis, G Gounti, D Lathyris, A Vathis, S Vasiliagkou, 0.07 ± 0.04 ng/ml; 1.81 ± 2.83 vs. 0.72 ± 1.12 mg/dl, respectively). After
K Kontopoulou, K Mandraveli, E Antoniadou surgery, both PCT and CRP increased markedly: PCT increased around
‘G. Gennimatas’ General Hospital, Thessaloniki, Greece 10× the basal level and peaked at 24 to 48 hours; CRP increased more
Critical Care 2012, 16(Suppl 1):P27 (doi: 10.1186/cc10634) than 15× and peaked at 48 hours. Infection was diagnosed a median
of 7 days after surgery. The CRP time-course from the day of surgery
Introduction We aimed to describe various parameters of critically ill onwards was significantly different in infected and noninfected patients
patients who developed VAP and correlate them with its outcome. (P = 0.001). In opposition, the PCT time-course was almost parallel in
Methods Twenty-three VAP cases out of 338 ICU patients were studied both groups (P = 0.866). To assess the diagnostic performance of each
retrospectively. Data regarding age, sex, etiology, scores (APACHE II, biomarker, we performed multiple comparisons between infected and
SOFA, CPIS), CRP, miniBAL cultures, comorbidities, antibiotic exposure, noninfected patients between day 5 and day 9. The CRP concentration
duration of mechanical ventilation, length of ICU and total stay, VAP was significantly different (P < 0.01, Bonferroni correction) on days 6, 7
and patient outcome were recorded. Chi-square and Mann–Whitney U and 8. The area under the ROC curve of CRP of days 6, 7 and 8 were 0.74,
tests were used for statistical analyses. 0.73 and 0.75, respectively. A CRP concentration >5.0 mg/dl at day 6
Results VAP incidence was 23/338 (6.8%). Fourteen of 23(60.9%) was predictive of infection with a sensitivity of 85% and a specificity of
were males, and 9/23(39.1%) were surgical patients. Their age was 62% (positive likelihood ratio 2.2, negative likelihood ratio 0.2).
63.5 ± 16.6 years. APACHE II was 20.5 ± 6.7, initial SOFA was 8.8 ± 3.7, Conclusion After a major elective surgical insult both CRP and PCT
SOFA at VAP was 9.4 ± 3.1, CPIS 2 days before VAP was 4.6 ± 2, CPIS the serum levels increased independently of the presence of infection.
day before VAP was 6 ± 1.2, and CPIS at VAP was 7.6 ± 1.3. Length of The CRP time-course showed to be useful in the early detection of an
stay was 25.5 ± 13.1 days, ICU stay was 24.8 ± 13.4 days, and duration infectious complication whereas PCT was unhelpful.
of mechanical ventilation was 22.5 ± 12.1 days. Previous antibiotic
exposure included: linezolid 10/23 (43.5%), vancomycin 2/23 (8.7%),
antipseudomonadic penicillins 14/23 (60.9%), β-lactams ± β-lactamase P29
inhibitor 7/23 (30.4%), quinolones 14/23 (60.9%), aminoglycosides Procalcitonin as a predictive marker for PCR test and blood culture
6/23 (26.1%), antifungals 4/23 (17.4%), carbapenems 1/23 (4.3%), results in suspected invasive candidemia
tigecycline 3/23 (13%), and colistin 8/23 (34.8%). Antibiotic therapy A Cortegiani, SM Raineri, F Montalto, MT Strano, A Giarratano
after the positive miniBAL was modified according to antibiograms. The University Hospital Policlinico P. Giaccone, Palermo, Italy
isolated microorganisms in miniBAL were A. baumannii 10/23 (43.5%), Critical Care 2012, 16(Suppl 1):P29 (doi: 10.1186/cc10636)
P. aeruginosa 5/23 (21.7%), K. pneumoniae 4/23 (17.4%), Candida spp.
2/23 (8.7%), and other 4/23 (17.4%); one infection was polymicrobial. Introduction Procalcitonin (PTC) seems to have potential to predict
In 20/23 cases (87%) VAP was of late onset (>4 days) (9.7 ± 6.8 days). the result of blood culture (BC) supporting the diagnosis of invasive
VAP was improved in 17/23 cases (73.9%), but 15/23 patients (65.2%) candidemia. Although blood culture is still the gold standard, PCR
died. High overall mortality may be attributed to grave condition. Most assays are able to quickly and reliably detect fungi in blood in suspected
patients were admitted to the ICU hours after they were admitted invasive candidemia. Our aim is to verify the potential of PTC values to
to the hospital. Increased SOFA scores during admission (12 ± 2 vs. predict the result of PCR assay in suspected invasive candidemia.
7.7 ± 3.4, P = 0.009) and on the day of VAP diagnosis (11.5 ± 2.1 vs. Methods We retrospectively analyzed 78 patients with suspected
8.6 ± 3, P = 0.016) were associated with VAP deterioration. Increased invasive candidemia from whom we obtained PCT value, BC and
CPIS on the last 2 days before VAP was also associated with worse VAP PCR assay. All tests have been obtained on the day in which patients
outcomes (6.2 ± 1.7 vs. 4.1 ± 1.8 and 6.8 ± 1.2 vs. 5.7 ± 1.1, P = 0.03 and reached a Candida score ≥4. We calculated PTC mean values according
P = 0.03, respectively). to BC and PCR results and compared data using the Mann–Whitney U
Conclusion Our findings support the prognostic value of SOFA score. test. We performed the ROC analysis to test the diagnostic performance
CPIS values of 6, although not diagnostic, may need increased alertness of PTC with regards to BC and PCR result.
on behalf of the clinician. Results PCR tests and BC were both negative in 48 patients and the
References PTC mean value in this group was 21.5 ng/ml while 19 patients were
1. Vincent JL, et al.: Intensive Care Med 1996, 22:707-710. PCR-positive and BC-positive with a PTC mean value of 2.07 ng/ml. The
2. Papazian L, et al.: Am J Respir Crit Care Med 1995, 152:1982-1991. difference between these PCT mean values was significant (P = 0.0001).
In eight cases BC were negative whereas PCR tests were positive with
the PCT mean level in this group being 1.82 ng/ml. No patient resulted
P28 PCR-negative and BC-positive. According to PCR results only, there
Usefulness of daily monitoring of procalcitonin and C-reactive was a significant difference between PTC mean values in positives and
protein in the early diagnosis of infection after elective colonic negatives (P = 0.0001). The ROC analysis showed that the best PTC cut-
surgery off value for prediction of BC result was 4.57 with AUC of 0.91 (CI 0.83 to
J Rebanda, P Povoa 0.96, sensitivity 99%, specificity 80.39%). Concerning the PCR result, the
Hospital São Francisco Xavier, CHLO, Lisbon, Portugal calculated cut-off was 4.31 with AUC of 0.96 (CI 0.948 to 1, sensitivity
Critical Care 2012, 16(Suppl 1):P28 (doi: 10.1186/cc10635) 96.6%, specificity 97.9%; positive predictive value 94.51%; negative
predictive value 97.83%).
Introduction The diagnosis of infectious complications after elective Conclusion According to our data, PTC seems to be characterized by
colonic surgery is frequently misleading, delaying its resolution. a remarkable diagnostic performance and predictive value for both
Recently several biomarkers, namely procalcitonin (PCT), have been BC and PCR assay in suspected invasive candidemia. PCT could be
described as more specific in infection diagnosis. considered as the first step of the diagnostic process for suspected
Methods We conducted a prospective observational study segregating invasive candidemia in order to spare as much time as possible before
patients submitted to elective colonic surgery. Patients were assessed starting a pre-emptive antifungal therapy. This may lead to less useless
before surgery, and then from the day of surgery until discharge or the therapies in negative patients and quicker and more reliable start of
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treatment in positive patients while waiting for the BC and antibiogram follow-up data including PCT measurement were collected. The SOFA
results. score was calculated daily during the first week of antifungal treatment.
Reference Survivors at discharge from the ICU were compared to nonsurvivors by
1. Charles PE, Castro C, Ruiz-Santana S, et al.: Serum procalcitonin levels in univariate followed by a Cox regression analysis.
critically ill patients colonized with Candida spp: new clues for the early Results Fifty patients were included among whom 28 (56%) died
recognition of invasive candidiasis? Intensive Care Med 2009, 35:2146-2150. in the ICU. Candida albicans was the most common isolated yeast
(58%), regardless of the outcome. Nonsurvivors were elder and had
a greater SAPS II score value on admission than survivors (55.8 ± 21.7
P30 vs. 42.5 ± 14.9 points, P = 0.01). The time elapsed between the ICU
Would procalcitonin measurement aid antimicrobial stewardship in admission and the onset of invasive candidiasis was significantly longer
a UK district general hospital mixed adult critical care population? in the nonsurvivors than in the survivors (8.3 ± 12.8 vs. 1.2 ± 2.8 days,
J Clayton, J White, L Wilson, M Leonard, J Cuniffe P = 0.01). At the onset of candidemia, the nonsurvivors were more
Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK severely ill as assessed through SOFA score calculation (10.4 ± 4.4 vs.
Critical Care 2012, 16(Suppl 1):P30 (doi: 10.1186/cc10637) 7.8 ± 3.9 points, P = 0.04). Antifungal treatment was given within the
first 24 hours following the onset of candidemia in 60% of the whole
Introduction We sought to establish what impact knowledge of patients and was always appropriate, regardless of the survival. During
procalcitonin (PCT) levels could have on antimicrobial prescribing therapy, the SOFA score remained greater in the nonsurvivors than
and stewardship within our 18-bed mixed critical care unit. Assicot in the survivors. In contrast, PCT failed to differentiate the survivors
and colleagues demonstrated that PCT levels are raised during sepsis from the nonsurvivors the day antifungals were started (8.7 ± 13.1
and can correlate with the severity [1]. The PCT level peaks after 6 to vs. 4.5 ± 4.1 ng/ml, P = 0.21), as well as the following days. The SAPS
12 hours and has a half-life of approximately 25 to 36 hours in critically II, the SOFA score and the time elapsed between ICU admission and
ill patients [2], declining with adequate treatment. A recent multicentre candidemia onset were the sole independent predictors of death in our
trial demonstrated reduced duration of antibiotic therapy by using study population.
PCT-guided treatment strategy; however, only 10% of the cohort was Conclusion The late-onset candidemia are more likely to be associated
surgical patients and therefore this finding cannot be extrapolated to a with death than earlier episodes. Unresolved organ failure as assessed
general critical care population [3]. through SOFA score despite effective antifungal treatment was
Methods The question was posed: would knowledge of PCT levels associated with death, while PCT failed to predict the outcome.
have altered real-time clinical management of patients on established References
antimicrobial therapy? Over a 2-month period patients were treated 1. Charles PE, et al.: Intensive Care Med 2006, 32:1577-1583.
in a conventional manner based on clinical findings and standard 2. Charles PE, et al.: Intensive Care Med 2009, 35:2146-2150.
investigations. Plasma samples from days 0 (respective to antimicrobial 3. Martini A, et al.: J Infect 2010, 60:425-430.
therapy) 1, 3, 5 and 7 were analysed for PCT. Nonparametric statistical
analysis of PCT levels was available for a retrospective multidisciplinary
team review of case notes. This was performed within the context of a P32
local service review and the chair of the local ethics committee gave Assessment of the usefulness of presepsin (soluble CD14 subtype)
approval for analysis of plasma samples and case-note review in septic patients
Results Twenty-seven patients were identified. Antimicrobial cessation T Nishida1, H Ishikura1, A Murai1, Y Irie1, R Yuge1, T Kamitani1, S Endo2
1
was deemed possible in seven of these cases at day 5. Nonescalation Fukuoka University Hospital, Fukuoka City, Japan; 2Iwate Medical University,
of treatment was supported in six further cases. In one case treatment Iwate, Japan
had been escalated and PCT supported this decision. This would have Critical Care 2012, 16(Suppl 1):P32 (doi: 10.1186/cc10639)
resulted in 19 fewer days of antibiotic therapy.
Conclusion Our experience suggests the availability of the PCT Introduction Sepsis is a life-threatening condition that is characterized
response between days 0 and 5 would have been a useful adjunct in by a whole-body inflammatory state. The early diagnosis and
monitoring treatment of sepsis on our unit and would have facilitated treatments of sepsis will improve the outcome of the patients. The aims
timely de-escalation and hence exposure to antimicrobial therapy. of this study were to investigate the most useful biomarkers which are
We hypothesise such a reduction could help to prevent antimicrobial serum levels of soluble CD14 subtype (sCD14-ST) named presepsin,
resistance, lead to decreased pharmacy and consumable costs and procalcitonin (PCT), IL-6, and C-reactive protein (CRP) as markers for
reduce the incidence of adverse antimicrobial-related events. early diagnosis of sepsis.
References Methods A single-center, prospective, observational study. Patients
1. Assicot M, et al.: Lancet 1993, 341:515-518. who had one or more systemic inflammatory response syndrome (SIRS)
2. Meisner M, et al.: Intensive Care Med 2000, 26:1193-1200. criteria were included in this study. The blood samples for measuring
3. Bouadma L, et al.: Lancet. 2010, 375:463-474. the markers were collected and the severity of sepsis was evaluated
at the time of admission and every other day for a week. Eighty-four
patients were enrolled for this prospective study from June 2010 to
P31 June 2011.
Procalcitonin has a poor prognosis value in critically ill patients with Results Eighteen were SIRS and 42 were sepsis at the time of
candidemia registration. In the receiver operating characteristics (ROC) analysis,
PE Charles, R Bruyère, H Roche, JP Quenot, S Prin, A Pavon, F Dalle the area under the curve (AUC) to distinguish sepsis was the highest
University Hospital, Dijon, France for presepsin (0.92) followed by IL-6 (0.89), PCT (0.88), and CRP (0.83).
Critical Care 2012, 16(Suppl 1):P31 (doi: 10.1186/cc10638) The ROC analysis showed that at a cut-off value 647 pg/ml, presepsin
may be able to discriminate between patients with and without sepsis
Introduction Candidemia is an infrequent but serious infection in the with a sensitivity and a specificity of 92.9% and 83.3% respectively with
critically ill patients. Although effective antifungal drugs are available, 95% confidence intervals of 0.929 (0.805 to 0.985). And the presepsin
mortality rates remain high so far. Procalcitonin (PCT) repeated values were significantly higher in the patients with the more severe
measurements have proven useful for assessing the prognosis and the septic condition (for example, sepsis, severe sepsis, septic shock). In
antimicrobial treatment responsiveness in the patients with systemic addition, a significant correlation was found between the SOFA scores
bacterial infection. Little is known about it in the setting of candidemia. and the presepsin values (r2 = 0.258; P <0.01). But there was only
The PCT predictive value regarding the outcome of such patients was weak correlation between APACHE II scores and the presepsin values
therefore addressed. (r2 = 0.053).
Methods A retrospective single-centre observational study. All Conclusion In this study, presepsin is the most valuable predictor
patients with ICU-acquired pure candidemia between 2005 and 2011 about sepsis compared with PCT, IL-6, and CRP. Moreover, these results
were included. Baseline characteristics and both clinical and biological suggest that presepsin values can serve as a parameter that closely
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reflects the pathology. So we strongly suggest that presepsin will be who had suspected infection in the emergency room and ICU, but
not only a very useful new biomarker for a diagnosis of the sepsis, but the clinical usefulness of measuring EAA in the diagnosis of sepsis in
also useful for monitoring the severity of the disease in the near future. critically ill patients is not yet clear.
Reference Methods We performed an observational cohort study in critically
1. Endo S, Yaegashi Y, Sato N, et al.: Comparative study of soluble CD14 and ill patients in the ICU of a tertiary care hospital. We investigated the
soluble CD14-subtype in sepsis. Med Postgrad 2006, 44:381-385. correlation between EA levels and blood concentration of endotoxin
measured by the chromogenic limulus amoebocyte lysate (LAL) assay,
causative microorganism identified in laboratory culture, procalcitonin
P33 (PCT), soluble CD14 subtype (named presepsin), IL-6, antithrombin,
Circulating cell-free DNA levels measured by a novel simple protein C, thrombomodulin, lactate, disseminated intravascular
fluorescent assay are predictive for outcome of severe sepsis coagulation scores in both the Japanese Ministry of Health and Welfare
A Douvdevani, A Avriel, M Paryente Wiessman, V Novack, Y Almog and the Japanese Association for Acute Medicine, and severity of illness
Soroka University Medical Center and Ben-Gurion University of the Negev, at ICU admission.
Beer-Sheva, Israel Results We enrolled 49 subjects. There was no significant correlation
Critical Care 2012, 16(Suppl 1):P33 (doi: 10.1186/cc10640) between EA levels and endotoxin concentration measured by LAL
assay. There were no significant difference in the EA levels of the Gram-
Introduction Circulating cell-free DNA (CFD) was found to be a predic- negative infection patients and the others. The diagnostic value of EA
tor of outcome in severe sepsis and septic shock [1]. The standard levels was investigated using ROC curve analysis. For the diagnosis of
CFD assays are work-intensive and not practical for routine clinical sepsis, area under the curve of EA levels, PCT, presepsin, IL-6 and CRP
laboratory use. We have recently developed a new simple, fast and were calculated as 0.76, 0.83, 0.89, 0.88 and 0.72, respectively. Both the
reliable assay for CFD measurement. The aim was to evaluate the EA levels and ICU mortalities of the patients who met the criteria for
association between admission levels of CFD and severe sepsis severe sepsis were significantly higher than those of the patients who
outcome in patients hospitalized in intensive care utilizing the new did not have sepsis (0.44 ± 0.21 vs. 0.22 ± 0.17, P = 0.0004; EA levels,
assay. 33% vs. 5%, P = 0.022; ICU mortalities). There was a positive relationship
Methods Seventy-six patients diagnosed with severe sepsis hospitalized between EA levels and thrombomodulin (r = 0.30, P = 0.049), EA
in the ICU were enrolled in the study. Serum CFD levels were measured levels and lactate (r = 0.31, P = 0.028), and EA levels and SOFA score
upon admission and after 72 hours using the SYBR-Gold rapid direct (r = 0.34, P = 0.02). There was a negative relationship between EA levels
fluorescent assay [2]. Primary outcome was 28-day mortality. Logistic and platelet counts (r = –0.34, P = 0.018), EA levels and antithrombin
regression analysis of CFD quintiles adjusted for baseline comorbidities (r = – 0.41, P = 0.004), and EA levels and protein C (r = –0.38, P = 0.010).
and severity of the disease was utilized. Conclusion EA levels in the patients on ICU admission correlated
Results Out of those diagnosed with severe sepsis, 28 (36.8%) have died with disease severity. Moreover, we strongly suggested that EAA may
either during hospitalization or within 28 days of admission to the ICU. have the potential to assess organ dysfunction with sepsis, especially
Decedents had higher APACHE II score on admission (median 24.5 vs. coagulopathy.
17.5, P = 0.140). Similarly their admission CFD levels were higher than Reference
in survivors (median 3,712 vs. 1,974, P = 0.001). Spearman’s correlation 1. Marshall JC, et al.: J Infect Dis 2004, 190:527-534.
analysis showed significant correlation between APACHE II score and
CFD level on admission (ρ = 0.315, P = 0.007). ROC curve for APACHE
II score and CFD level on admission for prediction of 28-day mortality
showed area under the curve of 0.59, 95% CI 0.44 to 0.74 (P = 0.208), P35
for APACHE II score; and area under the curve of 0.73, 95% CI 0.60 Prognostic value of serum galactomannan in mixed ICU patients:
to 0.86 (P = 0.001), for CFD level on admission. The study group was a retrospective observational study
divided into quintiles by CFD levels of admission. The 28-day mortality S Teering, A Verreth, W Verlinden, J Jacobs, S Pilate, M Peetermans,
rate was 12.5% in the CFD lowest quintile and 60.9% in the highest A Verrijcken, N Van Regenmortel, I De laet, K Schoonheydt, H Dits,
quintile. Logistic regression analysis showed that adjusted for age, M Van De Vyvere, M Malbrain
sex and APACHE II score CFD divided into quintiles was significantly ZNA Stuivenberg, Antwerp, Belgium
associated with death at 28 days, OR = 1.83 per quintile (95% CI 1.12 Critical Care 2012, 16(Suppl 1):P35 (doi: 10.1186/cc10642)
to 2.98, P = 0.015).
Conclusion By using a simple fluorometric assay, we were able to Introduction Little is known about galactomannan (GM) testing in
measure CFD levels in severe septic patients. CFD levels were found mixed ICU patients that are often not neutropenic. The aim of this study
to be an independent predictors for 28-day mortality. We believe that was to look for the incidence and outcome of invasive aspergillosis (IA)
CFD is an objective, reliable and integrative prognostic marker that will in critically ill patients, to validate previous reported GM thresholds and
allow fast evaluation of intensive care patients and predicting mortality. to evaluate the prognostic value of GM.
References Methods A retrospective study of 474 GM samples in 160 patients from
1. Saukkonen K, et al.: Clin Chem 2008, 54:1000-1007. 1 January 2003 to 1 February 2004. GM tests were ordered because of
2. Goldshtein H, et al.: Ann Clin Biochem 2009, 46:488-494. clinical suspicion of IA or on a regular basis in immune compromised
patients. The number of samples per patient was 3 ± 2.6. Similarly to
the EORTC criteria we defined ‘proven IA’ as those patients with positive
tissue specimen, ‘probable IA’ as those with positive cultures, and
P34 ‘possible IA’ as those treated with antifungals (high clinical index of
Clinical usefulness of measuring endotoxin activity on ICU suspicion). The number of positive samples (GM >0.5 ng/ml) was 230
admission (48.5%). Patient characteristics: M/F ratio 1/1, age 64.5 ± 15.9, SAPS
A Murai, H Ishikura, T Nishida, Y Irie, T Kamitani, R Yuge, T Kitamura, 45.5 ± 16.8, APACHE II 19.3 ± 8, SOFA 5.8 ± 3.5, mean days on ventilation
T Umemura 12.9 ± 8.7, mean CRP 10.4 ± 11.2 mg/dl.
Fukuoka University Hospital, Fukuoka City, Japan Results In our study population 5% had proven IA, 5% probable
Critical Care 2012, 16(Suppl 1):P34 (doi: 10.1186/cc10641) IA, 17.5% possible IA and 72.5% had no IA. We could not identify a
GM threshold for IA. The best threshold was GM >1.1 for identifying
Introduction According to the Surviving Sepsis Campaign, diagnosis patients with IA (proven + probable + possible) with a specificity of
of sepsis and infection is urgent, therefore rapid diagnostic tools play 70.7% and negative predictive value of 76.6%. The ICU mortality was
a major role in the management of septic patients. The endotoxin 41.9% and the hospital mortality was 58.1%. Patients who died in the
activity (EA) assay (EAA) is one of those tools based on the ability of ICU had higher APACHE, SAPS and SOFA scores (P <0.0001), and had a
antigen–antibody complexes to prime neutrophils for an augmented significant increase in GM during their stay (0.27 ± 1.26 vs.–0.43 ± 1.7,
respiratory burst response [1]. EAA has been used widely in patients P = 0.004). We observed higher mean GM values in nonsurvivors but
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this was not statistically significant. Patients who died in the hospital admission. Heart rate variability (HRV) is decreased in severe sepsis.
also showed a significant increase in GM during their stay (0.11 ± 1.55 The objective was to determine the ability of a panel of HRV indices
vs. –0.48 ± 1.51, P = 0.017). There was a trend towards higher GM values to identify physiologically stable ED sepsis patients who will develop
in patients treated with piperacillin/tazobactam (n = 34) but this was worsening organ failure. We hypothesized that patients meeting the
not statistically significant. Neutropenic patients (n = 31) showed an outcome of progressive organ failure will have decreased HRV on initial
increase in GM during their stay (0.32 ± 1.3 vs. –0.43 ± 1.7, P = 0.07). presentation.
Patients on total parenteral nutrition (n = 125) had higher maximal Methods We performed a prospective observational study of adult
GM levels (1.55 ± 1.94 vs. 0.88 ± 1.25, P = 0.058). Patients that were ED patients admitted to the hospital for infection and treated with
mechanically ventilated had significantly higher mean (P = 0.038) and i.v. antibiotics. Patients in overt shock (vasopressor requirement or
maximal (P = 0.007) GM levels. The presence of IA was associated with mechanical ventilation) at enrollment or with the inability to provide
100% hospital mortality. written informed consent were excluded. A panel of HRV indices
Conclusion The current GM threshold of 0.5 ng/ml does not allow one was assessed over a 2-hour ED period using CIMVA (continuous
to discriminate between patients with and without IA. A threshold of individualized multiorgan variability analysis) software including
1.1 ng/ml had the best specificity and negative predictive value for IA. standard deviation (SD), LF/HF ratio, Poincare SD, sample entropy,
There seems to be a correlation between GM levels and total parenteral wavelet AUC, detrended fluctuation analysis (DFA), correlation
nutrition due to interference with the ELISA test. dimension, and the Lyapunov exponent. Patients were followed to
assess the occurrence of the primary outcome of increased organ failure
(SOFA score increase greater than 1 point at 24 hours), mechanical
ventilation, vasopressor use, or in-hospital mortality.
P36 Results We enrolled 105 ED sepsis patients. Twenty patients were
Analysis of (13)β-D-glucan as a diagnostic adjunct for invasive removed due to nonsinus cardiac rhythm or poor data quality of the
fungal infections in the ICU setting telemetry signal. Complete HRV assessment was performed on 81
N Yamada, K Shirai, T Doi, K Kumada, M Nakano, S Yoshida, I Toyoda, subjects with 17 patients removed who developed shock in the ED.
S Ogura The primary outcome was met in 44% (28/64) of the cohort. On HRV
Gifu University Hospital, Gifu, Japan assessment, outcome patients had a lower LF/HF ratio (1.47 vs. 3.11,
Critical Care 2012, 16(Suppl 1):P36 (doi: 10.1186/cc10643) P = 0.009) and DFA (0.65 vs. 0.94, P = 0.04) compared with stable
patients with no differences in other HRV indices. The overall mortality
Introduction Since invasive fungal infections are associated with rate was 15%. Compared to stable patients, outcome patients had no
high morbidity and increased mortality in the ICU, early diagnosis difference in age, initial heart rate, systolic blood pressure, or serum
and treatment are essential. This study assesses the performance of lactate with similar initial SOFA scores that were higher at 24 hours (1.0
an assay of serum (13)-D-glucan (BDG) concentration in patients vs. 3.0), a higher ICU transfer rate (62 vs. 20%, P <0.001) and increased
admitted to the ICU. ICU length of stay.
Methods Patients admitted to our advanced critical care center from Conclusion While standard physiologic parameters in the ED were
April 2007 to March 2011 with measurements of BDG were enrolled unable to differentiate sepsis patients who developed increased organ
in this retrospective study. BDG was measured when invasive fungal failure, a decreased LF/HF ratio and DFA, measurements of variability
infection was suspected based on the Japanese guidelines for representing physiologic reserve, was associated with impending
diagnosis and treatment of invasive fungal infections. BDG levels were deterioration. The ability of decreased HRV to predict clinical outcomes
measured using the WAKO method. A BDG level greater than 11 pg/ml in a high-risk yet physiologically identical population at presentation
was considered to be positive. No gray zone was considered. supports the need for continued studies into the predictive role of HRV
Results Of the 872 patients enrolled in this study, there were 580 males assessment in the ED to supplement clinical decision-making in sepsis
and 292 females. The mean age was 60.7 years (range: 48 to 87). The patients.
mortality rate was 16.3%. We make a clinical diagnosis of invasive
fungal infections according to Japanese guidelines for diagnosis and
treatment of invasive fungal infections. The sensitivity of the BDG
assay was 71.9% and the specificity was 91.0%. There were significant P38
differences in sensitivity, specificity, and optimal cut-off points among Severe community-acquired pneumonia: risk factors for in-hospital
patients with different clinical conditions (that is, trauma, burn, mortality
postoperative, and medical conditions).The area under the summary JM Pereira1, JA Paiva1, JP Baptista2, F Froes3, J Gonçalves-Pereira4
1
receiver operating characteristic curve was 0.82, but there were also Centro Hospitalar S. João, Porto, Portugal; 2Hospitais Universidade Coimbra,
differences across clinical categories. Portugal; 3Hospital Pulido Valente – CHLN, Lisbon, Portugal; 4Hospital S.
Conclusion The BDG profile in ICU patients is similar to that of other Francisco Xavier, Lisbon, Portugal
inpatients. It can be useful in clinical practice if implemented in the Critical Care 2012, 16(Suppl 1):P38 (doi: 10.1186/cc10645)
proper setting and interpreted after consideration of the patient’s
clinical status. Introduction Severe community-acquired pneumonia (SCAP) is an
References important cause of hospital mortality. The goal of this study was to
1. Committee for Guideline for Management of Deep-seated Mycoses 2007: identify variables associated with increased risk of in-hospital mortality
Guideline for Management of Deep-seated Mycoses 2007. Tokyo: Kyowa kikaku; at ICU admission.
2007. Methods A prospective, multicentre, observational cohort study of
2. Drosos EK, et al.: β-D-glucan assay for the diagnosis of invasive fungal all patients with SCAP consecutively admitted to 15 Portuguese ICUs
infections: a meta analysis. Clin Infect Dis 2011, 52:750–770. during a 12-month period. Demographic characteristics, co-morbidities,
general severity scores (SAPS II, SAPS3, total SOFA), microbiological data
and initial empirical antibiotherapy were recorded. Logistic regression
analysis was performed to identify predictors of in-hospital mortality.
P37 Results A total of 505 (14%) of the 3,572 enrolled patients had SCAP,
Impaired heart rate variability predicts clinical deterioration and mostly male (66%) with a median age 58 (29 to 82). Median general
progressive organ failure in emergency department sepsis patients severity scores were: SAPS II 44 (21 to 80), SAPS3 65 (41 to 98) and
R Arnold, G Green, A Bravi, S Hollenberg, A Seely total SOFA 8 (3 to 17). Comorbidities were present in 74% of the
Cooper University Hospital, Camden, NJ, USA patients and the most frequent were: diabetes mellitus (22%), chronic
Critical Care 2012, 16(Suppl 1):P37 (doi: 10.1186/cc10644) respiratory failure (18%) and alcoholism (15%). Median Charlson’s
comorbidity index was 4 (0 to 13). At ICU admission, 44% of SCAP
Introduction Emergency department (ED) sepsis patients without patients had septic shock. Thirty-seven per cent of the cases were
overt shock have a high incidence of clinical deterioration after microbiologically documented (St. pneumoniae – 24%; influenza A
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(H1N1) virus – 20%; Enterobacteriaceae – 18%) and 12% had secondary P40
bacteremia. Antibiotics were administered in the first 3 hours after Characteristics of leptospirosis patients admitted to a tropical
hospital admission in 71% of the patients and 76% of them received university hospital during the 2000 to 2010 period
combination therapy. Antibiotherapy was appropriate in 80% with a H Mehdaoui, E Caffiot, R Theodose, R Valentino, D Resiere, C Chabartier,
median duration of 8 days. Median ICU and hospital lengths of stay M Jonas
were 10 and 19 days respectively. Median ICU and hospital mortalities Fort de France University Hospital, Fort De France, Martinique
were 25% and 34% respectively. Variables independently associated Critical Care 2012, 16(Suppl 1):P40 (doi: 10.1186/cc10647)
with hospital mortality were: SAPS II score (OR 1.06; 95% CI 1.037 to
1.086), severe sepsis (OR 3.61; 95% CI 1.334 to 9.791), septic shock (OR Introduction Leptospirosis is an endemic disease in the intertropical
4.25; 95% CI 1.61 to 11.194), inappropriate antibiotherapy (OR 5.06; area. Most of the patients present with mild to moderate clinical forms,
95% CI 1.766 to 14.516) and the use of a macrolide (OR 0.40; 95% CI but leptospirosis may lead to multiple organ failure and death.
0.203 to 0.809). Methods We retrospectively analyzed the characteristics of 113
Conclusion Disease severity evaluated by SAPS II and sepsis staging patients with leptospirosis admitted to our emergency department.
score and inappropriate initial antibiotherapy were independent Results PCR and/or immunological investigations confirmed the
risk factors for in-hospital mortality. The use of a macrolide was diagnosis for 88 patients. We compared the periods before and after
independently associated with a reduced risk of death. PCR diagnosis implementation (2006), and determined the pattern of
the most severe forms. Thirty-two patients were admitted to our ICU.
Eight of the ICU patients died including four with confirmed diagnosis.
Nineteen patients were diagnosed before 2006, and 69 during the
period to 2010. Patients were less frequently admitted to the ICU during
P39 the second period (29% vs. 63%, P = 0.013). ICU patients had a higher
Systemic corticosteroids for community-acquired pneumonia in heart rate (111 ± 28 vs. 93 ± 21, P = 0.001), and had more frequently
adults jaundice (94% vs. 64%, P = 0.002) and oliguria (81% vs. 23%, P <0.001).
RJ Pugh, N Roy Glycemia (8.7 ± 3.3 vs. 7.1 ± 3.4, P = 0.04), creatinin (530 ± 299 vs.
Glan Clwyd Hospital, Rhyl, UK 142 ± 113, P <0.0001), bilirubin (423 ± 251 vs. 69 ± 103, P <0.0001), CRP
Critical Care 2012, 16(Suppl 1):P39 (doi: 10.1186/cc10646) (325 ± 135 vs. 210 ± 127, P <0.0001), and WBCC (21.7 ± 9.5 vs. 9.7 ± 5.3,
P <0.0001) were higher and protidemia (58 ± 15 vs. 68 ± 13, P = 0.002),
Introduction We aimed to evaluate evidence from randomised hematocrit (24 ± 6 vs. 34 ± 6, P <0.0001), and P/F ratio (271 ± 127
controlled trials (RCTs) investigating the effect of systemic vs. 352 ± 84, P = 0.036) were lower in the ICU group. Troponin was
corticosteroids in adults with community-acquired pneumonia increased more frequently in the ICU group (44% vs. 9%, P = 0.0003)
(CAP). Observational data suggest that corticosteroids may decrease and ECG anomalies (78% vs. 52%, P = 0.02) were more frequent. Among
mortality in severe CAP [1], and several large RCTs have been published the 22 early cardiac echographies performed in the ICU, 11 patients
since the recent Cochrane review [2]. had LVEF <50%.
Methods A systematic review of the literature: Cochrane Central Conclusion The use of PCR dramatically improved the diagnosis of mild
Register for Controlled Clinical Trials, MEDLINE, EMBASE and SCOPUS, to moderate forms of leptospirosis and led to an apparent increase its
and reference lists of original studies and reviews. Data were collated incidence. Severe forms were less easy to assess as they occur later and
and analysed using Review Manager v5.1. we should have a more aggressive policy to improve the immunological
Results A total of 254 RCTs were identified. Seven met inclusion diagnosis which was sometimes neglected since the implementation
criteria, totalling 806 patients. Studies varied in methodology, of PCR diagnosis. Severe forms have a more pronounced inflammatory
participants, interventions, and outcome measures. Where meta- syndrome and diffuse organ failure. Aggressive fluid loading as
analysis was possible, data are presented in Table 1 (outcomes: hospital recommended in septic states may have worsened hemodynamic
mortality, 30-day mortality, hospital length of stay, superinfection, and respiratory conditions in the ICU group. This is suggested by the
hyperglycaemia). Excepting hyperglycaemia, effect estimates were hemodilution pattern found in this group. The association of renal,
not statistically significant. Two small studies (n = 46 and n = 30) myocardial and respiratory failures in leptospirosis should lead to a
concentrated on severe CAP (using ATS and BTS criteria); one study careful monitoring of fluid loading and myocardial status.
found a statistically significant reduction in mortality, lengths of stay
and duration of mechanical ventilation in the steroid group, but similar
improvements in the other study, and in a large subgroup of patients
with severe CAP in another study (n = 93) were not found. Significant
reductions in inflammatory markers in the week following initiation of P41
steroid treatment were found in six studies. Prognostic impact of imported and newly-isolated
methicillin-resistant Staphylococcus aureus in the ICU
Table 1 (abstract P39). Meta-analysis of clinical outcomes S Ohshimo, K Ota, T Tamura, Y Kida, J Itai, K Suzuki, K Kanao, Y Torikoshi,
K Koyama, T Otani, T Sadamori, K Une, R Tsumura, Y Iwasaki, N Hirohashi,
Outcome Number of studies Population Effect
K Tanigawa
Hospital mortality 5 537 OR 0.65 Hiroshima University, Hiroshima, Japan
Critical Care 2012, 16(Suppl 1):P41 (doi: 10.1186/cc10648)
30-day mortality 3 562 OR 0.90
Hospital LOS 2 244 MD –1.52 Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is a
leading pathogen of hospital-acquired pneumonia. The difference in
Superinfection 3 563 OR 1.24 outcome between patients with imported and newly-isolated MRSA
Hyperglycaemia 2 517 OR 2.69* in the ICU has not been well investigated. The aim of our study was
to explore the incidence, risk factors and outcome in patients with
LOS, length of stay. *P <0.0001. imported and newly-isolated MRSA.
Methods Patients admitted to the ICU in our university between
Conclusion Systemic corticosteroid administration as adjunctive April 2009 and May 2010 were prospectively studied. Nasal swabs
treatment for CAP does not appear to improve relevant clinical were collected from all patients on admission and subsequently
outcomes, regardless of severity, and is associated with significantly collected weekly during the ICU stay. When patients were intubated,
increased incidence of hyperglycaemia. intratracheal aspirates were concurrently collected. The correlations of
References positive culture of MRSA with clinical variables were analysed.
1. Garcia-Vidal et al.: Eur Respir J 2007, 30:951-956. Results A total of 1,270 consecutive patients were enrolled. Median
2. Chen et al.: Cochrane Database of Systematic Reviews 2011, 3. follow-up period was 404 (187 to 609) days. There were 803 males and
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467 females. Median age was 63 (1 to 97). Of these, imported MRSA P43
was found in 124 (10%) patients, and newly-isolated MRSA in 57 (4%) Predicting methicillin-resistant Staphylococcus aureus in critically ill
patients. The incidence of imported MRSA was associated with the patients with pneumonia presenting to the hospital
comorbidity of cardiovascular disease or malignancy and long hospital AF Shorr1, DE Myers2, DB Huang3, BH Nathanson4, MF Emmons5
1
stay before admission to the ICU, whereas the incidence of newly- Washington Hospital Centre, Washington, DC, USA; 2Pfizer, Inc., Collegeville,
isolated MRSA was associated with the positive culture in intratracheal PA, USA; 3VA NJ Healthcare System, East Orange, NJ, USA; 4OptiStatim, LLC,
aspirates or blood/intravenous catheter, the comorbidity of shock, Longmeadow, MA, USA; 5Cerner LifeSciences, Beverly Hills, CA, USA
pneumonia or trauma, increased number of isolated sites, higher Critical Care 2012, 16(Suppl 1):P43 (doi: 10.1186/cc10650)
APACHE II score, prolonged ICU stay and higher mortality during the ICU
stay. Although no statistical significance was found in total patients, the Introduction Methicillin-resistant Staphylococcus aureus (MRSA)
subset analysis of the male patients demonstrated that the outcome represents an important pathogen in those presenting to the hospital
of newly-isolated patients was significantly poor compared with those with pneumonia and requiring ICU admission. However, empiric
of imported MRSA (P = 0.005). Multivariate analysis revealed that new treatment against MRSA in those admitted to the ICU with severe non-
isolation of MRSA in the ICU (P = 0.03; hazard ratio (HR), 2.62), negative nosocomial pneumonia could lead to overuse of anti-MRSA therapy.
culture of MRSA in nasal swab (P = 0.02; HR, 4.18), ≥2 isolated sites To address this concern, we sought to develop a simple clinical score
(P = 0.01; HR, 4.59) and comorbidity of ARDS (P = 0.002; HR, 4.63) were for identifying ICU patients presenting to the hospital with pneumonia
the independent poor prognostic factors. unlikely to be caused by MRSA.
Conclusion The new isolation of MRSA during the ICU stay was Methods We retrospectively identified patients admitted to the ICU
associated with poor outcome compared with the imported MRSA. with community-acquired pneumonia (CAP) or healthcare-associated
Clinicians should be aware of the high-risk group of MRSA infection. pneumonia (HCAP) between April 2007 and March 2009 at 62 hospitals
Strict hand hygiene plus a careful assessment of the patient, applying in the USA. The diagnosis of pneumonia was based on ICD-9 codes. We
aggressive procedures such as patient isolation, staff cohorting, and only included patients with laboratory evidence of bacterial infection
active surveillance cultures should be indicated. (for example, positive sputum, blood, pleural cultures or urinary
antigen testing). We determined, via logistic regression, variables
independently associated with the presence of MRSA (two-thirds of
cohort) and developed a risk score based on this. We then internally
validated (one-third of cohort) the score.
Results The cohort included 957 patients (mean age 65.8 ± 16.4
P42 years, 50.2% male, 43.7% HCAP). MRSA was identified in 20.1%. The
Necrotizing pneumonia due to methicillin-sensitive Staphylococcus risk score assigned points as follows: 1 point – age <30 or >79 years,
aureus secreting Panton-Valentine leukocidin: a review of case recent immunosuppression other than corticosteroids, shock; 2
reports points – admission from a skilled nursing facility, history of diabetes
L Kreienbuehl1, E Charbonney2, P Eggimann3 without coronary artery disease (CAD) or heart failure without CAD.
1
HUG, Geneva, Switzerland; 2Li Ka Shing Knowledge Institute, St Michael’s The prevalence of MRSA increased with escalating score (P <0.001). We
Hospital, Toronto, Canada; 3CHUV, Lausanne, Switzerland collapsed the score into three strata based on risk for MRSA (score of
Critical Care 2012, 16(Suppl 1):P42 (doi: 10.1186/cc10649) 0 to 1 (low), 2 to 4 (moderate), ≥5 (high)). The respective MRSA rates
by strata equaled 15.2%, 24.7%, and 31.9%, (P <0.001). A score ≤1 as a
Introduction Community-acquired necrotizing pneumonia caused screening test to exclude MRSA performed poorly (sensitivity 58.3%,
by Panton-Valentine leukocidin (PVL)-secreting Staphylococcus aureus specificity of 53.3%).
is a highly lethal infection, which mainly affects healthy children and Conclusion The prevalence of MRSA in patients with CAP or HCAP
young adults [1,2]. This study focuses on necrotizing pneumonia due requiring ICU care was high. A score to assess the risk for MRSA in these
to methicillin-sensitive S. aureus strains, with the purpose to determine patients performed poorly but requires external validation. Given the
factors associated with outcome. high risk of MRSA in this setting along with the limited discriminatory
Methods We performed a systematic review of case reports on power of our risk score, empiric therapy for MRSA in these patients
PVL-secreting MSSA necrotizing pneumonia and analyzed factors seems appropriate.
associated with outcome.
Results A total of 32 patient descriptions were retained for analysis.
Septic shock, influenza-like prodrome and the absence of a previous
skin and soft tissue infection were associated with fatal outcome. P44
In multivariate analysis, influenza-like prodrome (OR 7.44; 95% CI: Predictors of multidrug-resistant Acinetobacter baumannii
1.24 to 44.76; P = 0.028) and absence of previous skin and soft tissue infections: a retrospective analysis in surgical ICU patients
infection (OR 0.09; 95% CI: 0.010 to 0.86; P = 0.036) remained significant A Camkiran, A Kundakci, C Araz, A Pirat, P Zeyneloglu, H Arslan, G Arslan
predictors of death. See Table 1. Baskent University, Ankara, Turkey
Critical Care 2012, 16(Suppl 1):P44 (doi: 10.1186/cc10651)
Table 1 (abstract P42). Univariate analysis of mortality risk factors
Introduction Multidrug-resistant Acinetobacter baumannii (MRAB)
Univariate
is an important cause of hospital-acquired infection and leads to an
Died Survived analysis
increasing morbidity and mortality in ICUs. The aim of this study was
(n = 13) (n = 19) OR (95% CI) P value
to investigate the predictors of MRAB infection in surgical ICU patients.
Flu-like prodrome 9/12 (75%) 4/16 (25%) 9.00 (1.60 to 50.7) 0.020 Methods The charts of the patients who were admitted to the ICU
between January 2008 and August 2010 were reviewed to identify
SSTI 1/13 (8%) 9/19 (47%) 0.09 (0.01 to 0.86) 0.024 patients with MRAB infection. Recorded data were as follows: age,
Septic shock 11/11 7/15 (47%) 26.0 (1.30 to 522) 0.007 sex, medical history, underlying surgical pathology, APACHE II score
on ICU admission, days in hospital before ICU, presence of invasive
Leukocytopenia 9/11 (82%) 8/17 (47%) 5.06 (0.83 to 30.8) 0.115 procedures (intubation, tracheostomy, arterial, central venous lines,
urinary and nasogastric catheters, enteral or parenteral nutrition and
Conclusion Influenza-like prodrome may be predictive of adverse renal replacement therapy), days in the ICU and white blood cell (WBC)
outcome and previous skin and soft tissue infection may be associated count on infection day, infection site, complications (such as organ/
with improved prognosis. system failure), length of stay (LOS) in the ICU and hospital, and final
References outcome.
1. Gillet Y, et al.: Lancet 2002, 359:753-759. Results During the study period 25 patients with MRAB infection were
2. Gillet Y, et al.: Clin Infect Dis 2007, 45:315-321. identified. When compared with their matched control group (n = 25),
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patients with MRAB infection had a significantly higher mean APACHE P46
II score (P <0.001) and more frequently had an open wound (P = 0.002) Improved antibiotic stewardship resulting from a multifaceted
or required mechanical ventilation (P = 0.005), arterial catheterization strategy implemented after an outbreak of multiresistant
(P = 0.006), and central venous catheterization (P = 0.004). Multivariate Acinetobacter baumannii in a university ICU
logistic regression revealed that APACHE II score (OR, 1.19; 95% CI, M Beach, M Cohen, V Grover, J Ho, N Soni, B Azadian, S Singh
1.005 to 1.315; P = 0.043) and open wound (OR, 0.45; 95% CI, 0.003 to Chelsea & Westminster Hospital, London, UK
0.587; P = 0.18) were predictors of MRAB infection in these patients. Critical Care 2012, 16(Suppl 1):P46 (doi: 10.1186/cc10653)
Compared to their controls, patients with MRAB infection had a longer
LOS in the ICU (36.44 ± 30.44 days vs. 7.80 ± 8.13 days, P <0.001) and Introduction A 12-bed ICU experienced an outbreak of multiresistant
hospital (55.12 ± 40.81 days vs. 19.04 ± 13.44 days, P <0.001). In-hospital Acinetobacter baumannii (MRA) from October 2009 to May 2010. A
mortality rates for patients with MRAB infection and their controls were multifaceted strategy involving segregation, enhanced infection
56% and 32%, respectively (P = 0.154). control procedures, and microbiological surveillance was implemented.
Conclusion Our results indicate that higher APACHE II scores and We evaluated its impact on antibiotic stewardship.
presence of an open wound are predictors of MRAB in ICU surgical Methods A retrospective review of patient notes and results using
patients. Patients with MRAB infection tended to have a higher AcuBase® was conducted: 90 consecutive patients before the outbreak
mortality and had a longer LOS in the ICU and hospital than their (January to June 2008) and 91 thereafter (October 2010 to May
controls. 2011). Data included patient profiles, admission criteria, ICU survival,
antimicrobials used, antibiotic days, number of patients on antibiotics,
prescribing cost and the demographic of microbes isolated.
Results Following the outbreak, enhanced infection control measures
were implemented alongside the Matching Michigan protocols. Daily
operational critical care and elective planning meetings and a staff
education programme were undertaken. ICU mortality (31 (14%) vs. 43
P45 (16%)) was unchanged. Microbiological isolates were overall similar, with
Risk factors for bronchial acquisition of resistant Gram-negative a reduction in coagulase-negative Staphylococcus and Klebsiella and an
bacteria in critically ill patients and outcome increase in Enterobacter. The use of cefuroxime (3.2 vs. 2.3 antibiotic days/
I Papakonstantinou1, E Perivolioti1, C Vrettou2, I Baraboutis1, E Magira2, patient) and quinolones (6 vs. 2) decreased. There was a reduction in
E Balioti1, D Panopoulou1, T Pitsolis1, C Routsi2, S Nanas2 average antibiotic days per patient episode (5.1 vs. 4.2) (P = 0.0291) and
1
Evaggelismos Hospital, Athens, Greece; 2National and Kapodistrian University the prescribing cost savings were £13,558 (47%). See Figure 1.
of Athens, Greece
Critical Care 2012, 16(Suppl 1):P45 (doi: 10.1186/cc10652)
are often started in high-risk patients with severe sepsis despite Conclusion The above data show a slight reduction of Candida spp.
the absence of proven disease. According to current guidelines, colonization in septic shock patients treated with IgGAM therapy.
echinocandins are the drugs of choice in this setting. However, the level Further studies are needed to confirm this finding.
of evidence supporting this statement is low. References
Methods A retrospective single-centre observational study including 1. Gonçalves e Silva CR, Melo KE, Leão MV, Ruis R, Jorge AO: Relationship
every patient with highly suspected but unproven IC (that is, Candida between Candida in vaginal and oral mucosae and salivary IgA. Rev Bras
score >3, multifocal Candida sp. colonization, unresolved sepsis Ginecol Obstet 2008, 30:300-305.
despite >2-day broad-spectrum antibiotics, negative blood culture) 2. Bai XD, Liu XH, Tong QY: Intestinal colonization with Candida albicans and
who received at least two doses of one echinocandin between 2008 mucosal immunity. World J Gastroenterol 2004, 10:2124-2126.
and 2011. Patients with proven IC (that is, candidemia) over the same
period were used as controls. These two groups of patients were
compared regarding baseline characteristics and both clinical and P49
biological follow-up data while receiving antifungal therapy. The Predictive and prognostic factors of septic shock of nosocomial
clinical response to antifungal therapy was assessed through the SOFA origin
score daily decrease from day 0 to day 3 in both groups and compared JP Quenot1, A Pavon1, C Binquet1, F Kara2, O Martinet3, F Ganster3,
by repeated-measures ANOVA. Then, independent predictors of death JC Navellou4, V Castelain5, D Barraud6, J Cousson4, JF Poussel7, P Perez8,
in the ICU were determined by Cox regression analysis. K Kuteifan9, A Noirot2
1
Results Fifty-one patients were included (30 with suspected IC and University Hospital Bocage, Dijon, France; 2Centre Hospitalier, Haguenau,
21 with proven IC). At the onset of antifungal therapy, the Candida France; 3Nouvel Hopital Civil, Strasbourg, France; 4University Hospital,
score was greater in the patients with suspected IC than in those with Besancon, France; 5Hopital Hautepierre, Strasbourg, France; 6Hopital Central,
proven infection (3.7 ± 0.7 vs. 3.0 ± 0.8, P = 0.001) since multifocal Nancy, France; 7Regional Hospital, Metz-Thionville, France; 8Hopital Brabois,
colonization was more frequent in the former. In addition, the patients Nancy, France; 9CHG, Mulhouse, France
with suspected but unproven IC looked more seriously ill according to Critical Care 2012, 16(Suppl 1):P49 (doi: 10.1186/cc10656)
the SOFA score (8.3 ± 3.0 vs. 6.6 ± 3.5, P = 0.07). This mainly resulted
from a greater level of hypotension as assessed through the SOFA score Introduction The incidence of septic shock in intensive care in France is
(2.8 ± 1.5 vs. 1.2 ± 1.5 points, P = 0.0006). Obviously, the clinical response around 8 to 10%, with in-hospital mortality ranging from 55 to 60% [1].
to antifungal therapy was significantly more consistent in the patients Mortality increases by 10% when the infection causing septic shock is
with unproven IC than in those with proven infection (P = 0.032). In acquired in-hospital or in the ICU [1]. We aimed to determine predictive
addition, there was a trend toward an improved survival in the former and prognostic factors for septic shock caused by a nosocomial
patients (53 vs. 47%, P = 0.42). The only independent protective factor infection (NI).
was echinocandin therapy duration (HR = 0.84 (95% CI 0.75 to 0.94), Methods Subgroup analysis of a prospective, multicentre, observa-
P = 0.0034). tional study performed between November 2009 and March 2011 in
Conclusion A significant clinical improvement is achieved in patients 14 ICUs from 10 university and community (nonacademic) hospitals
with suspected but not proven IC receiving empirical antifungal in the northeast of France. This study was supported by the Collège
therapy with an echinocandin. In contrast, the patients with proven IC Interrégional des Réanimateurs du Nord-Est. Patients were included
are less responsive to therapy and are more likely to die in the ICU. Our if they were aged >18 years and had septic shock plus at least one
data support the use of an echinocandin as empirical therapy in very criterion of hypoperfusion. Infection was classed as nosocomial if
high-risk patients. acquired in-hospital more than 48 hours after admission. Data control
References and statistical analysis were performed by the CIC-EC of Dijon University
1. Pappas PG, et al.: Clin Infect Dis 2009, 48:503-535. Hospital (INSERM Unit CIE1).
2. Leon C, et al.: Crit Care Med 2009, 37:1624-1633. Results In total, 1,147 patients were included in the cohort, of whom
409 (35.6%) presented a NI (345/409 (84%) acquired in-hospital and
64/409 (16%) acquired in the ICU). The factors significantly associated
P48 with NI (in-hospital or in-ICU) were: immunodepression, a Knaus score
Relationship between polyclonal immunoglobulin therapy and C to D, SAPS II score, and SOFA score. Other variables such as age, sex,
colonization by Candida spp. type of admission and type of infection were not significantly related to
G Serafini, I Cavazzuti, C Venturelli, M Girardis the nosocomial origin of infection. In-hospital mortality for community-
University Hospital, Modena, Italy acquired versus NIs was 40.8% vs. 53.5% respectively (P <0.01), and
Critical Care 2012, 16(Suppl 1):P48 (doi: 10.1186/cc10655) 46.9% vs. 62% respectively at 28 days (P <0.01).
Conclusion Mortality of patients with septic shock of nosocomial origin
Introduction Low IgA levels in blood serum and in saliva have been is particularly high. Scores evaluating gravity of disease are also higher
associated with an increased risk for Candida colonization and infec- in patients with NI versus those with community-acquired infection.
tion [1,2]. In this retrospective cohort study, we aimed to evaluate the This could be explained by delayed presentation or difficulties with
effects of an intravenous immunoglobulin preparation containing management, but also by immunodepression and a poor state of
polyclonal IgG, IgM and IgA (IgGAM) on the prevention of Candida spp. prior health. It is likely that appropriate measures, particularly aimed
colonization in patients with septic shock. at prevention, could help to reduce mortality in patients with septic
Methods In this study we analyzed 69 patients with septic shock and shock caused by NI.
without Candida spp. colonization before shock appearance admitted Reference
to the ICU of a university hospital from January 2008 to November 1. Annane D: Am J Respir Crit Care Med 2003, 168:165.
2011. All of the patients were treated in according to the Surviving
Sepsis Campaign guidelines. In addition to standard therapy, 44 (64%)
patients received IgGAM therapy (Pentaglobin® 38 g/l IgG, 6 g/l IgM, P50
and 6 g/l IgA) within 24 hours from the diagnosis of septic shock at the Catheter-related bloodstream infection: factors affecting incidence
dose of 250 mg/kg/day for 3 days. The colonization by Candida spp. was K Boner1, M McGovern2, J Bourke1, C Walshe3, D Phelan1
1
evaluated by analyzing the results of the microbiological surveillance Mater Misericordiae University Hospital, Dublin, Ireland; 2Harvard University,
cultures (two times per week) of pharyngeal swab, tracheal aspirate, Cambridge, MA, USA; 3Beaumont Hospital, Dublin, Ireland
urine and surgical drains between 48 hours and 21 days after the Critical Care 2012, 16(Suppl 1):P50 (doi: 10.1186/cc10657)
diagnosis of septic shock.
Results In the IgGAM group, 11 patients (25%) developed Candida spp. Introduction Catheter-related bloodstream infection (CRBSI), its
colonization compared to nine patients (36%) of the control group. The associated morbidity, mortality and expense are the most important
Candida colonization index was similar in the two groups: 0.42 ± 0.16 in adverse effect of central venous catheters (CVCs) [1]. The objective of
the IgGAM group and 0.45 in the control group. this study of a population in whom the rate of CRBSI fell significantly
Critical Care 2012, Volume 16 Suppl 1 S18
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over 12 years [2] was to evaluate the influence of both patient and CVC P <0.01); Knaus score C–D (OR 2.16, 95% CI 1.64 to 2.84, P <0.01); SOFA
factors on CRBSI rates in patients receiving total parenteral nutrition score (OR for an increase of 1 point 1.32, 95% CI 1.26 to 1.38, P <0.01);
(TPN) in this time. and infection acquired in the ICU (OR 1.86, 95% CI 1.03 to 3.37, P = 0.03).
Methods Set in a 525-bed university hospital providing acute and Protective factors were surgical admission (OR 0.61, 95% CI 0.41 to
tertiary services. A prospective database was established in 1997, 0.89, P = 0.01) and urinary tract infection (OR 0.55, 95% CI 0.37 to 0.82,
recording data on all patients with CVCs inserted for TPN administration. P <0.01).
This database was examined up to 2009 to ascertain the effects of Conclusion Our findings are coherent with the literature. Multivariate
patient and CVC factors on CRBSI. analysis found nonmodifiable risk factors such as age, but also
Results During the 12-year study period, 2,573 CVCs were inserted into modifiable risk factors that warrant further investigation, such as
1,343 patients and 15,385 CVC days were accumulated. Overall, 13.8% infections acquired in-hospital or in the ICU. Future clinical studies in
of patients developed CRBSI throughout the study. In terms of patient septic shock should take these findings into account when selecting
factors affecting CRBSI rates, CRBSI was increased in patients with patients.
longer duration of TPN administration (where each additional day was Reference
associated with a relative risk ratio of 1.02, P <0.01), increased numbers 1. Annane D: Am J Respir Crit Care Med 2003, 168:165.
of CVCs inserted (where each additional line was associated with a
relative risk ratio of 1.21, P <0.01), and use of lipid formulation of TPN
(58.9 vs. 49% use was associated with a relative risk ratio of 1.56, P <0.01). P52
Overall 8.6% of CVCs inserted became infected. Hospital location of Severe sepsis in the United Sates: a 5-year analysis
CVC insertion was an important risk factor for CRBSI. The most common J Knittel, S Quraishi
site for insertion was the ICU (almost 40% of CVCs); however, compared Massachusetts General Hospital, Boston, MA, USA
to ICU insertion, insertion in the HDU was associated with an increased Critical Care 2012, 16(Suppl 1):P52 (doi: 10.1186/cc10659)
risk of CRBSI (a relative risk ratio of 1.75, P <0.01), as was insertion in the
operating theatre for ward patients (a relative risk ratio of 2.08, P <0.01). Introduction We describe patient-level healthcare data related to
CVC maintenance at ward level was associated with increased CRBSI severe sepsis over a 5-year period (2004 to 2008) in the United States.
rates, with a relative risk ratio of 2.06 (P <0.01). Methods We queried the largest all-payer inpatient care database in
Conclusion CRBSI occurs commonly in TPN populations, but there are the United States to identify cases of hospital admissions between 2004
very limited published data as regards incidence or factors affecting and 2008 with a primary diagnosis of severe sepsis (ICD 9: 995.92). This
incidence in this population. This large study of TPN patients provides retrospective analysis was performed with data from the Healthcare
prospective analysis of both patient and CVC factors influencing the Cost and Utilization Project National Inpatient Sample (NIS) repository.
development of CRBSI for the first time. Data related to length of stay, in-hospital mortality, and hospital
References charge was extracted. The 2004 and 2008 data for these variables
1. O’Grady NP, Alexander M, Dellinger EP, et al.; Healthcare Infection Control were compared and further analyzed by age and sex in SPSS v.19 (IBM
Practices Advisory Committee: Guidelines for the prevention of Corporation, Amonk, NY, USA). Results are reported with ± standard
intravascular catheter-related infections. Infect Control Hosp Epidemiol 2002, error where applicable, and P <0.05 represented statistical significance.
23:759-769. Results Our query of the NIS data revealed a similar number of hospital
2. Walshe CM, Boner K, Bourke J, et al.: Catheter related blood stream infection admissions with a primary diagnosis of severe sepsis in 2004 versus
(CRBSI) in TPN patients. Benefit of an educational programme using 2008. Sex (male vs. female) and age group composition (18 to 44 vs.
multimodal CRBSI expression. Clin Govern Int J 2010, 15:292-301. 45 to 64 vs. 65 to 85 vs. 85+) within these cohorts were similar. No
significant change in overall length of stay or in-hospital mortality rate
was appreciated. However, a significant increase in overall cost was
appreciated ($67,670 ± 5,742 vs. $100,973 ± 10,525; P = 0.006), which
P51 outpaced healthcare-specific and general inflation during this period.
Prognostic factors of septic shock Sex did not influence length of stay or in-hospital mortality rate. Cost
JP Quenot1, A Pavon1, C Binquet2, F Kara3, O Martinet4, F Ganster4, of care was higher for males versus females (2004: $78,361 ± 8,982
JC Navellou5, V Castelain6, D Barraud7, J Cousson3, JF Poussel8, P Perez9, vs. $57,040 ± 5,959; P = 0.048 and 2008: $111,298 ± 13,835 vs.
K Kuteifan3 $90,730 ± 11,380; P <0.001). Age had a significant influence on in-
1
University Hospital Bocage, Dijon, France; 2CIC EC, Dijon, France; 3Centre hospital mortality in 2004 and in 2008, with the highest percentage
Hospitalier, Haguenau, France; 4Nouvel Hopital Civil, Strasbourg, France; of in-hospital deaths in the 85+ category. Age also had a significant
5
University Hospital, Besancon, France; 6Hopital Hautepierre, Strasbourg, influence on cost/day. Whereas in 2004 patients in the 85+ category
France; 7Hopital Central, Nancy, France; 8Regional Hospitalier, Metz-Thionville, represented the age subset with the lowest cost/day, in 2008 this age
France; 9Hopital Brabois, Nancy, France group witnessed a threefold increase in daily costs (P <0.001) and
Critical Care 2012, 16(Suppl 1):P51 (doi: 10.1186/cc10658) represented the highest cost/day subset.
Conclusion Our data suggest that despite significant increases in
Introduction The incidence of septic shock in intensive care (ICU) in healthcare costs attributable to severe sepsis, survival and length of
France is around 8 to 10%, with in-hospital mortality ranging from stay has not improved significantly between 2004 and 2008. Dramatic
55 to 60% [1]. The identification of prognostic factors is essential to increases in cost are particularly notable in males versus females and in
guarantee optimal management. patients who are 85 years old and over. Policies to control healthcare
Methods A prospective, multicentre, observational study was per- costs in the United States should focus on the root causes that lead to
formed between November 2009 and March 2011 in 14 ICUs from 10 such significant increases in cost without appreciable societal returns
university and community (nonacademic) hospitals in the northeast on investment.
of France. This study was supported by the Collège Interrégional
des Réanimateurs du Nord-Est. Patients were included if they were
aged >18 years and had septic shock plus at least one criterion of P53
hypoperfusion. Data control and statistical analysis was performed by District hospital experience of organ support requirements for
the CIC-EC of Dijon University Hospital (INSERM Unit CIE1). Univariate H1N1-associated pneumonia
and multivariate logistic regression analysis was used to identify A Krige, S Chukkambotla
predictors of mortality at 28 days. East Lancashire Hospitals NHS Trust, Blackburn, UK
Results In total, out of 7,833 patients admitted to intensive care during Critical Care 2012, 16(Suppl 1):P53 (doi: 10.1186/cc10660)
the study period, 1,147 (14.6%) had septic shock. Factors significantly
associated with mortality at 28 days by logistic regression were: age Introduction The objective of our study was to describe the disease
>70 (OR 1.98, 95% CI 1.5 to 2.6, P <0.01); transfer (OR 1.42, 95% CI 1.04 pattern, outcomes and organ support required in treating H1N1-
to 1.95, P = 0.02); immunodepression (OR 1.91, 95% CI 1.41 to 2.57, associated pneumonia in a single-centre, district hospital ICU.
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Methods All of the patients with confirmed H1N1 infection admitted to still a large proportion of patients not receiving aspects of the bundle
our ICU during the months of December 2010 and January 2011 were in spite of being in a critical care environment.
studied. The outcome measures were incidence, severity and support Reference
for organ dysfunction, length of stay in ICU and mortality. 1. Dellinger RP, Levy MM, et al.: Surviving Sepsis Campaign: international
Results During the study period 27 patients were admitted. The mean guidelines for management of severe sepsis and septic shock. Intensive
age was 46.6 years (SD 13.6) with 20 (74%) patients being female, of Care Med 2007, 34:17-60.
whom two were pregnant. The mean APACHE scores were similar
between survivors and nonsurvivors, 14.1 and 13.7 respectively. Twenty
patients (74%) required invasive mechanical ventilation with median P55
duration of 9 days (range 2 to 54 days). Advanced techniques like prone Improving early administration of antibiotics: a ‘Plan Do Study Act’
position ventilation and high-frequency oscillatory ventilation were approach
required in 20% and 10% of these patients respectively. Two patients A Revill1, N Wennicke2, J Tipping2, R Matull2
1
were referred for ECMO. Ventilator-associated pneumonia (VAP) Derriford Hospital, Plymouth, UK; 2Taunton Musgrove Park Hospital, Taunton,
ensued in 25% of invasively ventilated patients resulting in an increase UK
in ventilator days (median) from 9 to 19 and ICU stay (median) from 15 Critical Care 2012, 16(Suppl 1):P55 (doi: 10.1186/cc10662)
to 23 days. Four (15%) required advanced cardiovascular support, 14
(52%) developed acute kidney injury (AKI) of which nine (33%) patients Introduction Delayed administration of antibiotics is associated with
required renal replacement therapy. The ICU mortality was 11.1% and an increased mortality in severe sepsis. The Surviving Sepsis Campaign
hospital mortality was 14.8%. The cohort who developed AKI had 21% advocates administering antibiotics to severely septic patients within
mortality. The median ICU stay (range) was 15 days (2 to 68 days). 1 hour. Predicting the patients that will become severely septic is
Conclusion H1N1 pneumonia was associated with significant morbidity difficult, and therefore we have introduced a pathway via a unique care
and mortality requiring advanced multiorgan support in the majority bundle to identify and treat all patients with suspected sepsis, prior to
of patients. Although the incidence of organ dysfunction in our cohort significant organ dysfunction, and maintain a 1-hour target.
mirrored that found in the Swift study [1], in keeping with advances Methods In September 2009, we introduced an audit proforma and
in management of H1N1-associated critical illness the mortality was management tool into the medical admissions unit of our hospital. This
lower in the current study. was accompanied by an extensive education programme of all medical
Reference and nursing staff. The proforma consists of two parts, a recognition and
1. Rowan KM, et al.: The Swine Flu Triage (SwiFT) study: development and intervention section. The process is triggered when the patient satisfies
ongoing refinement of a triage tool to provide regular information to two of the SIRS criteria and has symptoms consistent with an infection.
guide immediate policy and practice for the use of critical care services All six management processes, including antibiotic administration,
during the H1N1 swine influenza pandemic. Health Technol Assess 2010, must then be completed within 1 hour of the trigger time. By using the
14:335-492. ‘Plan Do Study Act’ cycle, we refined the proforma and streamlined the
process and introduced it into emergency department and the surgical
admissions unit. A dedicated multidisciplinary team was assigned to
review and improve performance every 2 weeks by amending the form
P54 and processes.
Compliance with the sepsis resuscitation bundle in patients with Results Over a 24-month period we have a database with 1,571
severe sepsis and septic shock admitted to Scottish ICUs patients. The results demonstrate that the median time to antibiotic
JA Davidson1, K Dunne2 administration is consistently near our target of 1 hour for all septic
1
Victoria Infirmary, Glasgow, UK; 2Forth Valley Royal Hospital, Larbert, UK patients included in this pathway. Through continued refinement and
Critical Care 2012, 16(Suppl 1):P54 (doi: 10.1186/cc10661) staged introduction the proforma and the process has demonstrated
consistency from medical to surgical wards; introduction in new areas
Introduction Severe sepsis is the second leading cause for admission has rapidly improved results. See Figure 1 overleaf.
to critical care and in spite of advanced care remains associated with Conclusion Our pathway has undergone a successful and dynamic
a high mortality. When implemented the sepsis resuscitation bundle development process guided by a multidisciplinary team. Compared
has been associated with a 20% reduction in mortality and is therefore with the usual audit process this has allowed rapid changes and
recommended as standard care for all patients with severe sepsis [1]. improvements to take place and be tested. Further analysis of our
Methods All new admissions to seven west of Scotland ICUs were database is ongoing, determining our impact on length of stay,
screened during a 12-week period for evidence of severe sepsis mortality and intensive care admissions with a matched cohort.
or septic shock. Those meeting the criteria were then assessed for
sepsis bundle compliance. The Institute for Healthcare Improvement
sepsis resuscitation bundle was taken as standard of care. This has a P56
6-hour time frame and includes measurement of serum lactate, blood Source-directed antimicrobials: a shot in the dark?
cultures taken prior to antibiotics, antibiotics administered within L Richardson1, GB McNeill2, S Gupta1
1
3 hours, fluids of 20 ml/kg if hypotensive or hyperlatataemia and use University Hospital Southampton NHS Foundation Trust, Southampton, UK;
2
of early goal-directed therapy in the event of persistent hypotension/ Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
hyperlatataemia in spite of fluid resuscitation. Critical Care 2012, 16(Suppl 1):P56 (doi: 10.1186/cc10663)
Results Of the 652 patients screened, 115 met the definition of
severe sepsis or septic shock (17.6%). We collected full data from 108 Introduction The Surviving Sepsis Campaign advocates giving early
patients, of which 69 patients (63.8%) had severe sepsis and 39 patients empirical antibiotics directed against all likely pathogens [1]. The
(36.1%) had septic shock. Full bundle compliance was 5.6%. Early ICU failure to instigate antimicrobials against a later confirmed pathogen
admission (within 6 hours) was associated with improved compliance impacts negatively on mortality [2]. Many hospitals advise source-
with measured lactate (87.3% vs. 60.4%, P <0.01), and where indicated, directed therapy from the beginning. Our project aims to elicit the
vasopressor use (94.4% vs. 61.3%, P <0.01), CVP measurement (77.5% proportion where the source of sepsis is initially predicted incorrectly
vs. 44.4%, P <0.01), and ScvO2 measurement (25.6% vs. 2.8%, P <0.01). thereby putting patients at risk.
ICU mortality was 12/64 patients (18.8%) with severe sepsis and 18/38 Methods A prospective cohort study was performed in two UK
patients (47.4%) for those with septic shock. Full bundle compliance teaching hospitals of patients presenting with sepsis to critical care
and mortality was not different for those reaching ICU early compared between May 2010 and March 2011. Hospital computer systems and
with those who were admitted after 6 hours. patient notes were used to extract the initial suspected source of sepsis,
Conclusion At present the sepsis resuscitation bundle is not uniformly and later verified with true microbiology data. Overall mortality was
implemented. Although compliance with early goal-directed therapy measured and compared between correctly and incorrectly suspected
and lactate measurement is better in those reaching ICU early, there is source of sepsis patients.
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Results Of the 128 patients, the source of sepsis was wrongly identified We advise that in patients with severe sepsis or septic shock first-line
in 30% (38/128) (Southampton 28% 15/53, Sheffield 31% 23/75 respect- antibiotics should remain broad spectrum with rigorous follow up to
ively) (Figure 1). The most common source was the bowel, which was de-escalate as early as possible.
initially suspected as a respiratory source in most cases. Interestingly, References
the mortality was higher in the correctly identified group (13%, 16/128 1. Dellinger RP, et al.: Surviving Sepsis Campaign: international guidelines for
vs. 5%, 7/128). This probably reflects the severity of illness where the management of severe sepsis and septic shock. Crit Care Med 2008,
diagnosis is sometimes more obvious. 36:296-327.
Conclusion Good antimicrobial governance requires early adminis- 2. Kumar A, et al.: Initiation of inappropriate antimicrobial therapy results in
tration of narrow-spectrum antibiotics as best guess source-directed fivefold reduction of survival in human septic shock. Chest 2009,
therapy from the outset, because de-escalation is often not practical. 136:1237-1248.
Our data reveal that in 30% of cases we incorrectly guess the source.
P57
Relation between temperature in the initial 24 hours in patients
with severe sepsis or septic shock with mortality and length of stay
in the ICU
R Sanga, S Zanotti, C Schorr, B Milcareck, K Hunter, P Dellinger, J Parrilo
Cooper University Hospital, Camden, NJ, USA
Critical Care 2012, 16(Suppl 1):P57 (doi: 10.1186/cc10664)
Figure 1 (abstract P58). Type of antipyretic and physical cooling used on ICU mortality 35% 22%
the study day (n = 311). Hospital mortality 41% 28%
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in patient characteristics and outcomes are reported (Table 1). rapid diagnosis and immediate treatment are necessary to improve the
Baseline characteristics were similar in colonized patients treated with survival of septic patients. However, the presence of bacteremia seems
antifungal therapy compared to those that were untreated. Only a to relate to the severity and mortality of septic shock patients in the
modest difference in the length of stay in the ICU prior to study day (25 ICU.
(14, 40) vs. 21 (8, 43)) and utilization of mechanical ventilatory support Methods The patients clinically suspected with sepsis were tested for
(76% vs. 63%) was noted in the treated compared to the untreated serum procalcitonin level using a procalcitonin kit (BRAHMUS PCT Kit).
patients with Candida colonization (P <0.05). Despite the relatively The PCT test was performed 334 times from March 2008 to August 2010.
similar baseline characteristics and equivalent severity of illness scores, Sixty-three adult patients showed high PCT level (>10 ng/ml). Thirty
treated patients had an increased ICU (35.3 vs. 22.3%) and hospital of 62 (48%) patients showed bacteremia. Sixteen of these bacteremic
(41.0 vs. 27.7%) mortality (P <0.05). patients were Gram-negative bacteremia and 14 patients were Gram-
Conclusion As colonized patients receiving antifungal treatment had positive bacteremia. The hemodynamic parameter, APACHE II score,
significantly higher mortality, our data do not support the routine use SOFA score, serum lactate, some other laboratory data and mortality
of antifungal therapy in ICU patients based solely on colonization. rate were compared between the patients with bacteremia and those
Reference without bacteremia. Statistical analyses were performed by chi-square
1. Vincent JL, et al.: JAMA 2009, 302:2323-2329. test and Mann–Whitney U test.
Results The bacteremic patients with high serum PCT level showed
significant higher APACHE II score, SOFA score and serum lactate
P60 concentration than nonbacteremic patients. The mortality rate of
Pharmacokinetics of micafungin in patients with severe burn bacteremic patients was significantly higher than that of nonbacteremic
injuries patients (66% vs. 28.1%, P <0.01). There were no differences in the
J Sasaki1, S Kishino2, N Aikawa1, S Hori1 severity and the mortality between Gram-negative and Gram-positive
1
Keio University School of Medicine, Tokyo, Japan; 2Meiji Pharmaceutical bacteremia.
University, Tokyo, Japan Conclusion The presence of bacteremia relates to the severity and the
Critical Care 2012, 16(Suppl 1):P60 (doi: 10.1186/cc10667) mortality of septic patients with high serum PCT in the ICU.
from the 17 participant institutions; (7) 3-day nursing visits from the Age and serum creatinine significantly influence the ceftazidime
coordinating hospital to perform advice on care practice; (8) basic life disposition. These covariates must be used to propose the first doses of
support courses, 56 vacancies per hospital, and fundamentals of critical ceftazidime. The required dosage regimens are higher than in other ICU
care support, 30 vacancies; and (9) implementation of a web-based patients and doses between 4 and 16 g/day are proposed.
system to collect ICU and hospital mortality, SAPS3, standardized-
mortality ratio (SMR) and CRBSI after June 2011. We assessed variation
of SMR and CRBSI on time using weighted linear regression, and P67
variation of mortality on time using generalized-estimating equations. Continuous versus intermittent vancomycin in children after cardiac
Results The results are presented in Table 1. surgery with delayed sternal closure
Conclusion A multifaceted intervention program applied to a network P Skrak, L Hlinkova, L Kovacikova
of ICUs in nonacademic public hospitals reduced mortality. National Institute of Cardiovascular Diseases, Bratislava, Slovakia
Critical Care 2012, 16(Suppl 1):P67 (doi: 10.1186/cc10674)
function (NRF). It is generally considered that no adjustment of LZD Table 1 (abstract P69). Steady-state pharmacokinetic parameters of
dosage is needed in subjects undergoing CVVH. In Japan, continuous teicoplanin
venovenous haemodiafiltration (CVVHDF) has preferentially been
Total Free
administered under low flow rate. Investigating the effects of flow
rate on LZD removal during continuous renal replacement therapy is Cmax 20.1 2.6
essential to regulate therapeutic dosages. We aimed to investigate the
pharmacokinetics of LZD in CVVHDF patients in this setting. Cmin 6.7 2.3
Methods LZD (600 mg) was administered intravenously every 12 hours AUC 137.9 28.6
in ICU patients on CVVHDF and NRF patients (creatinine clearance
50 ml/minute). Blood and filtrate samples were collected at 0, 1, 1.5, CL 7.0 33.5
2, 3 and 5 hours after infusion from both groups. The elimination half- Vz 174.1 196.6
life (T–1/2), maximum concentration, concentration time curve (AUC),
volume distribution (Vd), clearance (CL) and sieving coefficient (Sc) were
evaluated. Patient characteristics and CVVHDF parameters including References
the filter type, dialysate and filtration flow rates were recorded. 1. Brink et al.: Int J Antimicrob Agents 2008, 32:455-458.
Results Fourteen CVVHDF patients and nine NRF patients were 2. Mimoz et al.: Intensive Care Med 2006, 32:775-779.
included into the study. CVVHDF was performed using polysulfone
and triacetate membranes. Mean blood, dialysate and filtration flow P70
rates were 79.3 ± 2.7 ml/minute, 8.7 ± 5.1 ml/minute and 5.5 ± 2.5 Pharmacokinetics of inhaled colistin in critically ill patients with
ml/minute, respectively. Sc was 0.86 ± 0.03. T–1/2 data (8.78 ± 3.74 vs. ventilator-associated tracheobronchitis
5.54 ± 3.27 hours, P = 0.05) were significantly longer in the CVVHDF Z Athanassa1, M Fousteri2, S Markantonis2, P Myrianthefs3, E Boutzouka3,
compared with the NRF group, AUC data (247.9 ± 107.8 vs. 136.0 ± 84.9 E Tsigou3, A Tsakris4, G Baltopoulos3
1
g hour/ml, P = 0.02) were significantly higher and CL (2.94 ± 1.38 vs. Hygeia Hospital, Marousi, Greece; 2Faculty of Pharmacy, University of Athens,
5.92 ± 2.97 l/hour, P = 0.004) and Vd (31.0 ± 3.8 vs. 35.8 ± 3.3 l, P = 0.01) Greece; 3Faculty of Nursing, University of Athens, Greece; 4Faculty of Medicine,
data were significantly lower. LZD clearance was not correlated with University of Athens, Greece
the type of membrane used (polysulfone vs. triacetate: 2.8 ± 1.5 vs. Critical Care 2012, 16(Suppl 1):P70 (doi: 10.1186/cc10677)
3.6 ± 1.2 l/hour, P = 0.39).
Conclusion Clearance of LZD in patients undergoing CVVHDF was Introduction Although inhaled colistin is frequently used in ventilator-
significantly lower than in patients with normal renal function. associated pneumonia (VAP), data regarding its pharmacokinetic
Pharmacokinetic data from CVVHDF patients demonstrated that properties are scarce [1-3]. The aim of this study was to describe colistin
flow rates significantly influenced the efficiency of LZD removal. pharmacokinetics in critically ill patients after administration of a single
The maintenance dose of LZD may need to be reduced in patients dose of 1 million units of colistimethate sodium (CMS) via nebulization.
undergoing CVVHDF under reduced flow conditions. Methods Patients with ventilator-associated tracheobronchitis dye
Reference to polymyxin-only susceptible Gram-negative bacteria were included
1. Meyer B, et al.: J Antimicrob Chemother 2005, 56:172-179. in the study; patients receiving intravenous and/or nebulized colistin
were excluded. CMS was administered at a dose of 1 million units every
P69 8 hours for 7 days, via a vibrating-mesh nebulizer. Mini bronchoalveolar
A post-authorisation survey to analyse the perioperative lavage was collected before and at 1, 4 and 8 hours post nebulization,
teicoplanin plasma concentrations in adult patients with chronic while blood samples were collected before and at 0.16, 0.5, 1, 2, 4, and
bone sepsis, who received loading doses of 12 mg/kg 12-hourly for 8 hours post nebulization. Colistin concentrations in epithelial lining
48 hours followed by 12 mg/kg once daily fluid (ELF) and plasma were determined by high-performance liquid
AJ Brink1, G Richards2, C Lautenbach1, N Rapeport1, V Schillack3, J Roberts4, chromatography.
J Lipman4 Results Our study population included five patients (three female) with
1
Milpark Hospital, Johannesburg, South Africa; 2University of Witwatersrand, mean age 60.6 years. Median (range) colistin concentrations in ELF
Johannesburg, South Africa; 3Ampath National Referral Laboratory, Pretoria, were 6.9 (6.2 to 13.9), 3.7 (2.7 to 11.6) and 2.1 (1.2 to 8.7) g/ml at 1, 4,
South Africa; 4University of Queensland, Brisbane, Australia and 8 hours, respectively, after nebulization. Colistin concentrations in
Critical Care 2012, 16(Suppl 1):P69 (doi: 10.1186/cc10676) serum were substantially lower than those observed in ELF with peak
median (range) values 1.56 (1.19 to 2) g/ml. The estimated colistin
Introduction To rapidly achieve teicoplanin trough (Cmin) concentrations mean half-life was 3.4 hours.
≥20 mg/l suggested for sternal sepsis, loading doses higher than 6 mg/ Conclusion Administration of 1 million units of inhaled CMS resulted in
kg 12-hourly might be warranted [1]. high colistin concentrations in the ELF; moreover, concentrations were
Methods Patients (n = 10) with deep-seated Gram-positive infections maintained for up to 8 hours in the majority of patients. This finding
were enrolled perioperatively. During the first 4 days of therapy might support the use of inhaled CMS for the treatment of patients
teicoplanin loading doses of 12 mg/kg 12-hourly were administered for with VAP due to multidrug-resistant Gram-negative bacteria. Moreover,
48 hours and 12 mg/kg once daily thereafter. Surgical debridement was the low serum concentrations and the short half-life suggest that
performed on D3. Samples were collected 15 minutes before and 30 administration of inhaled colistin may be associated with less systemic
minutes and 120 minutes after each teicoplanin administration. Total toxicity.
and unbound teicoplanin levels were determined using HPLC. References
Results All patients had hypoalbuminemia (mean 20.2 g/l). The SS 1. Ratjen F, et al.: J Antimicrob Chemother 2006, 57:306-311.
PK parameters of teicoplanin are described in Table 1. On D3 the 2. Marchand S, et al.: Antimicrob Agents Chemother 2010, 54:3702-3707.
median total and free Cmin were 14.66 (8.93 to 19.66) and 3.09 (0.0 to 3. Lu Q, et al.: Intensive Care Med 2010, 36:1147-1155.
6.4) mg/l, respectively. In a multivariate logistic regression model,
total teicoplanin concentrations (P = 0.174) and serum creatinine P71
concentration (P = 0.034) did not impact significantly on free Efficacy of inhaled tobramycin in severe nosocomial pneumonia
teicoplanin levels whereas, in contrast, albumin concentration did (OR A Kuzovlev1, S Polovnikov2, V Stec2, V Varvarin2
1
0.120, 95% CI 0.078 to 0.161, P <0.001). V.A. Negovsky Scientific Research Institute of General Reanimatology RAMS,
Conclusion The levels achieved on D3 in this study are similar to those Moscow, Russia; 2N.N. Burdenko Main Clinical Military Hospital, Moscow, Russia
achieved by Mimoz and colleagues using the same dosing schedule Critical Care 2012, 16(Suppl 1):P71 (doi: 10.1186/cc10678)
in ICU patients with VAP [2]. Only hypoalbuminemia impacted on the
free levels of teicoplanin in this setting. High teicoplanin loading doses Introduction Nosocomial pneumonia (NP) is one of the most prevalent
of 12 mg/kg 12-hourly should probably be extended beyond 48 hours, complications in ICUs. The efficacy of inhaled antibiotics in treatment
before major elective surgery for chronic bone sepsis. of NP was shown in several research works. The aim of this study was
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to estimate the efficacy of inhaled tobramycin (IT) as an adjunct to BAL (P <0.0001), consistent with ELF dilution by saline lavage. The
systemic antibiotics in the treatment of severe NP. ratio of BMS-derived cytokine to BAL for each patient group did not
Methods Twenty ICU patients with NP were enrolled in the study (all differ significantly. Spearman coefficients (r) for IL-1, IL-6, IL-8, TNFα
male, 49 ± 7.3 years old); primary reason for ICU stay – intraabdominal and G-CSF were 0.38, 0.52, 0.25, 0.38 and 0.40. All correlations were
infections (60%), mediastinitis (10%), others (30%). Diagnosis of NP significant (P <0.01) except for IL-8 (P = 0.05). Both sampling methods
was made according to standard clinical and CPIS criteria. Associa- demonstrated a gradation of cytokine level, with burns and ALI/ARDS
tions of multiresistant Gram-negative bacteria were detected in having significantly higher levels than patients with stable chronic lung
bronchoalveolar lavage (BAL) of all patients. Eighty percent of bacteria disease or healthy controls.
were sensitive to tobramycin. Patients were randomized into two Conclusion The BMS probe was well tolerated and provided cytokine
groups – ‘IT’ (group 1, n = 10) + systemic antibiotics (carbapenems, data comparable to that obtained by BAL in acute and chronic
aminoglycosides, protected penicillins); ‘no IT’ (group 2, n = 10), only respiratory diseases. The BMS probe may have utility as a biomarker
systemic antibiotics, same as in group 1. Groups were comparable in sampling modality in patients where clinicians have concerns over
APACHE II and CPIS scores. IT (Bramitob) was administered 300 mg BID conventional BAL.
via nebulizer. Acknowledgements The BMS probes were provided by Olympus
Results Duration of IT use in group1 was 7.5 ± 2.5 days. There were no (Tokyo, Japan).
statistically reliable differences between groups detected due to the Reference
small number of patients enrolled. But it was clinically detected that 1. Ishizaka A, et al.: Crit Care Med 2001, 29:896-898.
treatment with IT in group1 was associated with a decrease of SIRS
signs and CPIS scores and an increase of oxygenation index in 70% of
patients. Positive dynamics in chest X-ray and computed tomography P73
was detected in two patients of group 1 (20%; no dynamics in group Clinical and epidemiological risk factors for ventilator-associated
2). The titre of microbes in BAL decreased (100%) and their sensitivity pneumonia in a cohort of critically ill patients
to other groups of antibiotics, which they were previously resistant to, G De Pascale, MA Pennisi, V Raggi, E Piervincenzi, V Bernini, A Occhionero,
increased (40%) in group 1 patients after IT administration. Efficacy of P De Santis, A Moccaldo, S Cicconi, R Maviglia, M Tumbarello, M Antonelli
IT in patients with a registered resistance of microbes to tobramycin Sacro Cuore Catholic University, Rome, Italy
can be explained by a high local concentrations of tobramycin in Critical Care 2012, 16(Suppl 1):P73 (doi: 10.1186/cc10680)
lungs. The mortality in groups was similar (40% and 40%) and not
related to a progression of NP. Two patients of group 1 (20%) presented Introduction Ventilator-associated pneumonia (VAP) represents a
with hearing loss and tinnitus which revealed 3 months after the last major infectious complication in the ICU. The aim of this study is to
IT administration. There were no cases of bronchospasm or renal identify risk factors for VAP acquisition.
insufficiency in group 1. Methods All patients admitted to the 18-bed ICU of our university
Conclusion Administration of IT as an adjunct to systemic antibiotics hospital between 1 October 2009 and 31 December 2010 were
is efficient and safe in treatment of severe nosocomial pneumonias enrolled on the day of VAP diagnosis. Controls were selected by our
caused by multiresistant Gram-negative bacteria. Profound randomized computerized database. Statistical analyses were performed using the
clinical trials on IT are required. StataICl l program.
Reference Results Over the study period, among 902 admissions, 100 VAP occurred.
1. Polovnikov SG, Kuzovlev AN, Iliychev AN: Case report of a successful The rate of multidrug resistance (MDR) was 23%. Development of VAP
treatment of severe nosocomial pneumonia with inhaled tobramycin. was associated with a significantly longer duration of ICU stay (24
Pulmonologia 2011, 2:109-112. days (17 to 30) vs. 7 days (5 to 9); P <0.001) and mechanical ventilation
(19 days (13 to 20) vs. 4 days (3 to 6); P <0.001). Overall ICU mortality
was higher in the VAP population (41% vs. 29%; P = 0.09). Comparing
P72 patients affected by VAP with controls (100 matched patients), the
Comparison of a bronchoscopic microsample probe with former group was significantly more likely to be male (P <0.001) and
bronchoalveolar lavage to measure cytokine levels in critically ill to be immunosuppressed (P = 0.004). In addition, VAP development
patients was associated with higher rate of central venous catheter placements
V Grover, LE Christie, P Charles, P Kelleher, P Shah, S Singh (P <0.001), higher mean SOFA score value (P <0.001) and previous
Chelsea and Westminster Hospital, London, UK exposure to antimicrobials (P = 0.004). Successful use of noninvasive
Critical Care 2012, 16(Suppl 1):P72 (doi: 10.1186/cc10679) ventilation, and trauma admission appeared as protective factors
(P <0.001). Table 1 shows independent risk factors associated with VAP
Introduction The use of bronchoalveolar lavage (BAL) to investigate acquisition in multivariate analysis.
inflammatory lung disease in the critically ill may not be tolerated in
hypoxic patients. Furthermore, soluble protein analysis of BAL fluid Table 1 (abstract P73)
suffers from inaccuracies related to saline dilution. The bronchoscopic
P value OR (95% CI)
microsample (BMS) probe allows absolute cytokine levels in epithelial
lining fluid (ELF) to be measured directly without lavage [1]. We NIV success 0.005 0.1(0.01 to 0.4)
compared cytokine levels from ELF obtained by the BMS probe with
those from BAL, to verify its utility in critical illness. SOFA score* 0.01 1.2(1 to 1.3)
Methods We recruited 45 patients into five groups in whom BMS and Male gender <0.001 14(5 to 39.4)
BAL were conducted sequentially: two ventilated with ALI/ARDS, six
with burns inhalational injury (five ventilated), 15 with COPD, 18 with Immunosuppressive status 0.001 4(1.7 to 9.6)
interstitial lung disease and four healthy patients. The BMS probe *Mean value.
was bronchoscopically inserted to the subsegmental level in order to
contact the mucosa for 5 to 7 seconds, collecting approximately 20 μl Conclusion VAP occurrence seems to be associated with increased
ELF [1]. BAL was performed with 150 ml of 0.9% saline, discarding the morbidity and ICU mortality. NIV use, avoiding endotracheal
first 20 ml (bronchiolar fraction). We assayed IL-1, IL-6, IL-8, TNFα and intubation and invasive mechanical ventilation, has appeared to be
G-CSF. Comparisons between paired cytokine ELF concentrations in effective in reducing the rate of VAP episodes, particularly in high-risk
BMS and BAL were analysed using the nonparametric Wilcoxon’s test patients (severe immunosuppressed). The application of behavioural
and Spearman’s correlation coefficient. intervention bundles might represent the suitable preventive measure
Results The critically ill patients were aged 18 to 84 years (APACHE in settings where high rates of MDR pathogens limit the extensive use
II 12 to 21). One patient had ARDS due to urinary tract infection and of pharmacological ones.
another related to pneumonia. No adverse incidents noted were Reference
noted. Overall, cytokine levels were all higher in the BMS group than 1. Vincent JL, et al.: Drugs 2010, 70:1927-1944.
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P74 maintenance standards in the baseline period (Phase 1). The bundle
Use of a ventilator-associated pneumonia (VAP) bundle to decrease was introduced in Phase 2. CRBSI was determined according to US CDC
the VAP rate in Syria diagnostic criteria. The rates of CRBSI before and after the introduction
R Alsadat1, M Mazloum2, A Alshamaa3, A Dakkak4, H Al-Bardan1, M Eltayeb2, of the bundle of interventions were compared.
A Marie2, F Esber1, O Naes3, M Shama5, I Betelmal5, M Kherallah6 Results A total of 619 patients were enrolled in the study. During
1
Al-Mouassat Hospital, Damascus, Syria; 2General Assembly of Damascus the baseline period (Phase 1), 238 patients with 2,456 catheter days
Hospital, Damascus, Syria; 3Al-Bassel Heart Institute, Damascus, Syria; 4Ibn were assessed, 30 patients developed a CRBSI. The CRBSI rate during
Alnafees Hospital, Damascus, Syria; 5World Health Organization, Damascus, this period was 12.2 per 1,000 catheter days. All nurses and principle
Syria; 6King Faisal Specialist Hospital and Research Center, Riyadh, Saudi doctors in the seven ICUs received training on the standard of care
Arabia for catheter maintenance along with the introduction of Q-Syte™ and
Critical Care 2012, 16(Suppl 1):P74 (doi: 10.1186/cc10681) Posiflush™. In Phase 2, following introduction of the interventions,
12 of 381 patients developed a CRBSI. Total catheter days during this
Introduction Implementation of a ventilator-associated pneumonia period were 3,562. The CRBSI rate decreased to 3.4 per 1,000 catheter
(VAP) bundle as a performance improvement project in the critical days. This was significantly lower than during the baseline period
care units for all mechanically ventilated patients aiming to decrease (Wilcoxon nonparametric test, u = 4.36, P = 0.0003). Additional analyses
the VAP rates over the study period at four major teaching hospitals in demonstrated that patients were at higher risk for developing a CRBSI
Damascus. if associated with: a prolonged catheter dwell time, a higher number
Methods CDC criteria were used to define VAP. VAP rates were of insertion attempts, a blood infusion or an increased frequency
calculated based on occurrences per 1,000 ventilator days, VAP rates of catheter connector changes. We also found that the patients who
were monitored on a monthly basis throughout the project period. VAP developed a CRBSI had prolonged hospital stay and significantly added
bundle elements included elevation of the head of the bed to between to the cost of treatment.
30 and 45°, daily sedation vacation, daily assessment of readiness to Conclusion Introduction of Q-Syte™ and Posiflush™ and improved stan-
wean, peptic ulcer disease prophylaxis and deep venous thrombosis dards of practice for catheter maintenance can significantly decrease
prophylaxis if not contraindicated. Each hospital formed a task force CRBSI in the ICU.
with a team leader, one or two physicians and one or two nurses. Reference
Education took place at an initial conference and a follow-up meeting 1. O’Grady NP, Alexander M, Burns LA, et al.: Guidelines for the Prevention of
for the implementation process and frequent staff education session Intravascular Catheter-Related Infections 2011 [www.cdc.gov/hicpac/bsi/
in individual units. Compliance with the VAP bundle was considered bsi-guidelines-2011.html]
based on the implementation of all elements of the bundle. Statistical
Control Chart (SPC) was used to monitor the compliance with the
individual bundle elements as well the bundle as a whole.
Results VAP bundle compliance rates were steadily increasing from 33
to 80% in Hospital 1, from 33 to 86% in Hospital 2 and from 83 to 100% P76
in Hospital 3 during the study period. The VAP bundle was not applied Wash your hands: simple measures save lives
in Hospital 4 and therefore no data were available. This correlated with a S Macedo, GV Bispo, LA Ferreira, TO Cavalcanti, PF Rosa, C Paiva,
decrease in VAP rates from 30 to 6.4 per 1,000 ventilator days in Hospital DR De Melo, LG Rezende
1, from 12 to 4.9 per 1,000 ventilator days in Hospital 3, whereas the VAP São Jose do Avai Hospital, Itaperuna, Brazil
rate failed to decrease in Hospital 2 (despite better compliance) and it Critical Care 2012, 16(Suppl 1):P76 (doi: 10.1186/cc10683)
remained high around 33 per 1,000 ventilator days in Hospital 4 where
the VAP bundle was not implemented or monitored. Introduction Sepsis is a challenge for the intensive therapy unit, being
Conclusion The VAP bundle is known to be an effective way to the principal cause of death during hospitalization.
decrease VAP but has performed differently in different hospitals in Methods We realized a longitudinal and individuated intervention
our study. Prevention of VAP requires concerted efforts on the part of authorized by the HSJA ethics committee applying the campaign
hospital administration, physicians, and ICU personnel. The program ‘Simple Measures Save Lives’ in which 105 educational adhesives
must be evidence-based, maintained, and accepted by ICU personnel. served as a guide for washing hands and flags for high-contaminated
Monitoring and collection of data should be strict and objective. locations. A decontamination routine of monitors, control panels, fans
Continued education and feedback are crucial to maintain a low VAP and infusion bombs was established at each 12 hours; and continued
rate. Other factors of healthcare infection prevention should also be education for the health team was intensified during the intervention.
taken into consideration. Was separated two groups, patient enrollments in periods of 45 days
before and after the intervention, with more than 24 hours of
hospitalization: group A with 18 patients and group B with 15 patients.
Results The hospital infection incidence decreased by 40% and VAP by
P75 39.6%. Urine culture was positive in 33.3% of those patients (n = 5) in
A strategy for prevention and control of catheter-related group A and in 16.7% (n = 1) in group B (a 50.1% decrease). The cultures
bloodstream infection of ICU patients in China (Prevent CRBSI): of catheter tip were positive in 68.8% (n = 22) of catheters in group A,
a prospective, multicenter, controlled study which used 32 catheters in total, and none in group B, which used 13
G Cai, J Yan catheters. The sepsis incidence decreased by 39.6%. Septic shock was
Zhejiang Hospital, Hangzhou, China detected in 16.6% (n = 3) of patients in group A. There was a drop of
Critical Care 2012, 16(Suppl 1):P75 (doi: 10.1186/cc10682) the costs between groups (R4,479.28, 10.5%). The cost of campaign
material was R$50.00.
Introduction Catheter-related bloodstream infection (CRBSI) continues Conclusion This intervention was a simple form to decrease the related
to be a key issue in ICUs despite recent improvements in the clinical number of infections in the neurovascular ICU, having spent irrelevant
technique, standardization of the CVC insertion protocol and hand values when compared with treatment of these clinical tables.
hygiene. The impact of catheter maintenance on CRBSI rates in China References
needs to be further investigated. The objective of study is to evaluate a 1. Zanon F, Caovilla JJ, Michel RS, et al.: Sepsis in the intensive care unit:
bundle of interventions for reducing CRBSI in ICUs. The bundle includes etiologies, prognostic factors and mortality. Rev Bras Terapia Intensiva 2008,
new technology (BD Q-Syte™ and BD Posiflush™) in addition to updated 20:128-134.
standards of practice for catheter maintenance. 2. Silva E, Pedro MA, Sogaya ACB, et al.: Brazilian Sepsis Epidemiological Study.
Methods This is a prospective, multicenter, controlled study. Patients Crit Care 2004, 8:R251-R260.
receiving CVCs in the ICUs were eligible for inclusion. The study was 3. Chesley R: Getting to zero: an emerging policy framework for the
performed in seven general and teaching hospitals from June 2010 elimination of hospital-associated infections. Infect Control Hosp Epidemiol
to June 2011 in China. The clinicians conducted their original catheter 2008, 30:71-73.
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process. To disinfect the ICU environment we have used the original Table 1 (abstract P81). Types of management versus mortality in massive
device, Medisize 99.99®, which releases a synergistic formulation of hemoptysis
hydrogen peroxide with silver ions. The machine launches a dry cloud
Management Total Mortality Percentage
of 0.5 to 2 m particles which penetrates everywhere, without humidity
or corrosive activity. Medical 6 5 83.3
Methods The study has been conducted in the ICU area, just after the
patients have been discharged, before and after the use of the Medisize BI 35 7 20
99.99® device. The overall number of samples taken has been 54 on BAE 19 1 5.2
three different days. The sampling has been taken with Petri contact
plates and incubated at 35°C for 48 hours, counting afterwards the Surgery 30 4 13.3
CFU/plate. Multiple 21 2 9.5
Results We found the annulment of the contamination at all sites
tested after sanitation (Table 1).
CT chest in 65.5% and in 64.4% by fiber optic bronchoscopy (FOB).
Table 1 (abstract P80). CFU of sample sites before and after sanitation However, combined FOB and CT scan could localize bleeding in 87.8%.
See Table 1.
Sample sites Before UFC/cm2 After UFC/cm2
Conclusion All-cause mortality in massive hemoptysis at our center
Mattress 104 <0.5 was 18.8%. Lung cancer, necrotizing pneumonia and bronchiectasis
carried significantly higher mortality. BAE showed low mortality but
Vital parameters monitor 5,000 <0.5 required multiple interventions in nearly two-thirds of cases. Hence,
Wall 2,000 <0.5 surgery remains the intervention of choice in massive hemoptysis at
our setup with acceptable mortality and outcome.
Bed rail <0.5 <0.5
Bed remote control <0.5 <0.5
Ventilator screen 5,000 <0.5 P82
Capnography use in Scottish ICUs
Ventilator chassis 104 <0.5
C Wallace, S Cole, B McGuire
Infusion pump <0.5 <0.5 Ninewells Hospital, Dundee, UK
Critical Care 2012, 16(Suppl 1):P82 (doi: 10.1186/cc10689)
Conclusion The destruction of the bacteria has practically taken place
in all the points tested. The system has resulted to be compatible Introduction Almost 20% of adverse airway events reported to the
with the electronic equipment and a few minutes after the end of Royal College of Anaesthetists 4th National Audit Project (NAP4)
the procedure it is possible to use the area. The catalytic action of the occurred in the ICU [1]. NAP4 commented that the failure to use
silver atoms produces the tyndallisation of the surfaces, increasing capnography probably contributed to 77% of the ICU airway mortality.
the effectiveness of the sanitizer. Eight minutes after the end of the NAP4 subsequently made a number of recommendations pertaining
treatment, 98% of the OH– radicals have been destroyed and 95% of the to capnography use. We designed a survey to describe practice with
dry cloud has been deposited, inhibiting the possibility of regeneration regards to these.
of any resistant microorganism. Methods A survey was sent to an intensivist at each of the 23 adult
ICUs in Scotland.
Results There was a 100% response rate. Nineteen (83%) units used
capnography for all tracheal intubations on the unit, two (9%) in over
P81 three-quarters, one (4%) in under one-half and one (4%) unit reported
Massive hemoptysis in a respiratory ICU: causes, interventions and never using it. For tracheal intubations prior to unit admission, the
outcomes – Indian study corresponding usage was three (13%) always, seven (30%) in over
D Talwar, J Chudiwal, R Jain, S Kumar three-quarters, seven (34%) in over one-half and six (26%) in less than
Metro Center for Respiratory Diseases, Noida, India one-half of all intubations. Continuous capnography monitoring was
Critical Care 2012, 16(Suppl 1):P81 (doi: 10.1186/cc10688) in use on 54% of the intubated patients and 63% of the ventilator-
dependent patients. Twelve (52%) units reported using capnography
Introduction Massive hemoptysis carries high mortality and morbidity, in all the intubated and ventilated patients. Of the units not using
requiring multidisciplinary management. In India, tuberculosis is a continuous capnography routinely, two (18%) had no equipment for
very common cause of severe hemoptysis and is being treated in continuous monitoring.
tuberculosis hospitals where such an approach is not available. We Conclusion UK Intensive Care Society (ICS) guidelines make strong
evaluated the profile of patients admitted with massive hemoptysis in recommendations for the use of capnography in all critically ill patients
a well-equipped Indian tertiary-care respiratory center. during intubation [2]. We show a reassuring compliance with those
Methods Retrospective analysis of 376 patients admitted with guidelines during tracheal intubations performed on ICUs. Compliance
hemoptysis to the respiratory ICU of the Metro Center for Respiratory was much poorer with the guidelines for those intubations performed
Diseases, India was done. We identified 90 patients with massive outside units. An AAGBI safety statement recommended that
hemoptysis (>600 ml in 24 hours) between 2005 and 2011 and the continuous capnography should be used in all patients with intubated
results were analyzed. As per our protocol all patients had active tracheas, regardless of location [3]. This was not echoed in the 2009 ICS
medical management and those suitable for surgery underwent guidelines (although in the light of NAP4, these have been updated to
elective or emergent surgery. Unsuitable candidates underwent support this). Despite the majority of units in Scotland having facilities
bronchial artery embolisation (BAE) or bronchoscopic interventions to monitor patients using capnography, just over one-half were doing
(BI) and if suitable were taken for surgery later. so routinely. Capnography monitoring will surely increase in the advent
Results The mean age of patients was 49.5 ± 16.53 years with 73.33% of NAP4 and because of the change to the ICS guidelines.
(n = 66) being male. Mortality in male patients was significantly higher References
than females (64.7 vs. 35.3%, P = 0.02). The mean length of stay in 1. Cook TM, et al.: Br J Anaesth 2011, 106:617-631 and 632-642.
hospital was 10.44 ± 6.9 days and significantly less (7.06 ± 4.8, P = 0.01) 2. Thomas AN, et al.: Standards for Capnography in Critical Care. London:
in the mortality group. Massive hemoptysis was due to tuberculosis Intensive Care Society Standards and Guidelines; 2009.
(active and old) in 61%, pneumonia in 25.5%, bronchiectasis in 21.1%, 3. The Association of Anaesthetists of Great Britain and Ireland: Safety Statement
aspergillus-releated disease in 11.1%. Lung cancer in 6.6% cases but on Capnography Outside The Operating Theatre. London: AAGBI; 2009 [http://
this carried highest mortality. The bleeding site was identified on www.aagbi.org/sites/default/files/AAGBI%20SAFETY%20STATEMENT_0]
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P83 pressure support ventilation (PSV). This can be reduced with the
Digitalized acoustic monitoring of lung congestion application of an external positive end-expiratory pressure (PEEPe) [1].
S Lev1, L Wolloch2, I Kagan1, M Grienv1, P Singer1 However, an accurate measurement of PEEPi during PSV is challenging
1
Rabin Medical Center, Petah Tikva, Israel; 2Deep Breeze Ltd, Or-Akiva, Israel [2]. The aim of the present study is to investigate if the use of the
Critical Care 2012, 16(Suppl 1):P83 (doi: 10.1186/cc10690) electrical activity of diaphragm (EAdi) may yield the detection of PEEPi
in patients undergoing PSV. We reasoned that if PEEPi was present
Introduction Changes in lung water are known to change breath sound the inspiratory airflow would start after EAdi had reached a given
acoustics [1]. Using two pig models, we observed that continuous value (EAdi-threshold) necessary to generate the muscle pressure
elevation of lung sound amplitude may indicate an increase in total overcoming PEEPi.
lung water content [2]. Here we report three cases of ventilated Methods Ten patients with a clinical suspicion of PEEPi undergoing PSV
patients in whom continuous acoustic monitoring was done during were enrolled. Exclusion criteria were: age <18 years, hemodynamic
extravascular lung water (EVLW) measurements. instability, fever and PaO2/FiO2 <100 mmHg. All patients were tested
Methods We retrospectively analyzed cases in which EVLWi (PiCCO) and during PSV for seven steps of 3 minutes each with increasing PEEPe (2,
other clinical parameters were measured, during continuous acoustic 4, 6, 8, 10, 12, 14 cmH2O). At the end of each step, PEEPi was estimated
monitoring (VRI), using eight small sensors adhered to the anterior with an end-expiratory occlusion maneuver. During the study, we
chest. A transmission factor (TF) was calculated, using the sound transfer continuously recorded airway pressure, flow, volume and EAdi wave-
function between different sensors. The TF changes in correspondence forms for off-line analysis. Data were analysed by linear regression and
to changes in tissue density [1]. The difference in TF was calculated t test. P <0.05 was considered statistically significant.
between recordings when pulmonary edema was observed (>7 ml/kg Results If PEEPi is present, EAdi-threshold is supposed to gradually
threshold accompanied with an increase of 2 ml/kg in the EVLWi) and decrease together with the raise of PEEPe; thus we divided patients
when absent. Statistical analysis was made using a t test. into five responders for whom EAdi-threshold was significantly
Results A total of 336 continuous acoustic recordings in three patients correlated with PEEPe, as opposed to five nonresponders. In the
(acoustic monitoring was applied together with EVLWi measurements) group of responders we observed significant correlations between the
were analyzed (146 recordings when lung edema was present; 190 reduction of PEEPi and the increase of PEEPe (r2 = 0.86, P <0.01), and
with no edema). In all patients, the acoustic profile corresponded between EAdi-threshold and PEEPi at different PEEPe levels (r2 =0.96,
to changes in the clinical picture. In two of the cases, changes in P <0.001). In the same group, respiratory rate (RR) decreased (r2 = 0.76,
acoustic profile were similar to the ones in the EVLWi and other P = 0.01), tidal volume increased (r2 = 0.71, P = 0.02) and the peak of
clinical parameters (Figure 1). In one case, where there was stability in EAdi decreased (r2 = 0.94, P <0.001) at increasing levels of PEEPe. On
lung sound acoustics, EVLWi and other clinical parameters were also the contrary, in the nonresponder group the increase of PEEPe was
stable. Significant differences existed between recordings with edema associated only with an increase of RR (r2 = 0.75, P = 0.01).
(–3.61 ± 0.39) and without edema (–5.71 ± 0.15) (P <0.001). Conclusion In five of 10 patients with clinical suspicion of PEEPi, when
the PEEPe was increased we observed a decrease of EAdi-threshold,
associated with improved respiratory mechanics, suggesting that EAdi-
threshold could be a useful indicator for the presence of PEEPi.
References
1. Mancebo J, et al.: Anesthesiology 2000, 93:81-90.
2. Marini JJ: Am J Respir Crit Care Med 2011, 184:756-762.
P85
Adequate lung sliding identification is not influenced by the level of
academic or ultrasound training
E Piette1, R Daoust1, J Lambert2, A Denault3
1
Hôpital du Sacré-Coeur de Montréal, Canada; 2Université de Montréal,
Canada; 3Institut de Cardiologie de Montréal, Canada
Critical Care 2012, 16(Suppl 1):P85 (doi: 10.1186/cc10692)
students), 70.9% (residents) and 69.0% (attendings) (P = 0.361). medicine (EM) to diagnose pneumothorax as well as to evaluate the
No difference was shown between the subgroups of US training adequacy of endotracheal intubation. Presence of the Lung Pulse
with means of 63.9% (no formation), 70.2% (FAST), 70.9% (FAST + artefact (back and forth pleural motion induced by the heartbeat)
advanced cardiac US), and 74.2% (fellowship) (P = 0.119). Accuracy was as well as the underlying heart may affect correct identification of
significantly better when participants could abstain from answering in LS in the left hemithorax, but this has never been studied. Our main
uncertain cases with means of 67.5% (95% CI: 65.7 to 69.4) in the first objective was to evaluate the rate of correct identification (accuracy) of
group and 73.1% (95% CI: 70.7 to 75.5) in the second (P <0.001). the presence or absence of LS in the right and left hemithorax.
Conclusion Correct LS identification on short lung US sequences is not Methods A total of 280 short lung US sequences (one respiratory
influenced by the level of academic or US training. Accuracy is better cycle), recorded in the operating room, of presence and absence of
when the possibility to abstain oneself from answering is given. LS LS in intubated patients were randomly presented to two groups of
identification using one respiratory US sequences should be used with physicians (in total: two medical students, 42 EM residents and 31 EM
caution to confirm adequacy of endotracheal intubation. attendings). Sequences were divided equally between the right and left
hemithorax. Each participant’s knowledge of the Lung Pulse artefact
was noted. Only the second group was instructed not to answer in case
P86 of uncertainty. A Kolmogorov–Smirnov test showed the rate of correct
Lung ultrasound can differentiate Pneumocystis jiroveci versus other LS identification did not follow a normal distribution. Median rates are
etiologies among critically ill AIDS patients with pneumonia reported with interquartile range (IQR) and compared using a Mann–
A Japiassu, F Bozza Whitney test.
IPEC-FIOCRUZ, Rio de Janeiro, Brazil Results Knowledge of Lung Pulse was higher in the second group
Critical Care 2012, 16(Suppl 1):P86 (doi: 10.1186/cc10693) (55% vs. 21%, P <0.05). Globally, median accuracy of identification of LS
presence or absence was 74.0% (IQR: 48.0 to 90.0) in the first group and
Introduction Lung ultrasound (US) can be applied as a point-of-care 83.7% (IQR: 53.3 to 96.2) in the second (P = 0.006). For the first group,
approach for diagnosis of pneumonia in AIDS patients. We compare median accuracy was 80.0% (IQR: 57.0 to 95.0) in the right hemithorax
US examinations of Pneumocystis jiroveci versus other etiologies of and 67.0% (IQR: 43.0 to 83.0) in the left (P <0.001). For the second group,
pneumonia in critically ill patients. median accuracy was 88.7% (IQR: 63.1 to 96.9) in the right hemithorax
Methods Every HIV/AIDS patients admitted to the ICU with pneumonia and 76.3% (IQR: 42.9 to 90.9) in the left (P <0.001).
was included. The first US examination was performed until 72 hours Conclusion Accuracy of identification of LS presence or absence
after admission. Pneumonia was defined by clinical examination, is higher in the right hemithorax. Our study is the first to report this
laboratorial parameters and chest X-rays. Etiologic agents were defined finding. Presence of the Lung Pulse artefact, as well as the underlying
according to appropriate cultures and serology. US was applied to heart, probably explains the worse accuracy found in the left
four fields (apex, lateral middle third, anterior basal and posterior hemithorax. Caution should be taken in using LS identification as a
basal regions) for each hemithorax, with 2.5 MHz curved transducer. diagnostic tool in the left hemithorax and knowledge of the Lung Pulse
Three pneumonia patterns were defined: interstitial pneumonia, artefact should be emphasized in chest US curriculum.
bronchopneumonia and pneumonia with consolidation. The
presence of B lines, peripheral microabscesses (bronchopneumonia),
consolidations and pleural effusions were compared between the P88
Pneumocystis pneumonia group (PCP) versus other etiologies. Trans-thoracic echo evaluation before and during noninvasive
Results We included 21 patients (age (median) 38 years; male 71%). ventilation
Most (80%) patients were admitted because of acute respiratory L Vetrugno, M Costa, C Centonze, N Langiano, M Rojatti, G Della Rocca
insufficiency by pneumonia. Seventeen (81%) had CD4 cell counts University Hospital of Udine, Italy
lower than 200/mm3. The SAPS 2 score was 47 points and the SOFA Critical Care 2012, 16(Suppl 1):P88 (doi: 10.1186/cc10695)
score on day 1 of admission was 6 points. Hospital mortality was
43%. All radiographic pneumonia images were viewed on lung US Introduction Over the last decade noninvasive ventilation (NIV) gained
examinations. Possible and probable pneumonia by P. jiroveci was the dignity of first-line intervention for acute lung injury (ALI) and acute
diagnosed in six patients; all of these patients presented diffuse thin respiratory distress syndrome (ARDS) in the ICU. Its great interest is
and/or gross B lines on both lungs. Bacterial (n = 7), mycobacterial based on a lower complications rate compared with traditional invasive
(tuberculosis (n = 6) and Mycobacterium kansasii (n = 1)), and fungal ventilation. However, the NIV application, although less invasive, cannot
(Aspergillus sp. (n = 1)) were diagnosed in other patients. Peripheral ignore its hemodynamic effect over the patient. This study evaluates
microabscesses were viewed on one patient with PCP and four patients the NIV effects on the left ventricle in terms of systolic and diastolic
with other etiologies (P = NS); pleural effusions were present on US function through trans-thoracic echocardiography (TTE). We also try to
of seven patients with diverse etiologies (no PCP patient had pleural obtain a preload value index equivalent of flow time corrected (FTc).
effusions; P = 0.06); no pneumothorax was diagnosed in the study. Methods Thirteen patients admitted to our ICU with ALI/ARDS
Consolidation was present in one patient with PCP and 11 patients underwent TTE before and during NIV. NIV was set as a 1 hour cycle with
with bacterial, mycobacterial and fungal pneumonia (P = 0.05). There 5 to 7 cmH2O of PEEP and 5 to 7 cmH2O of pressure support ventilation.
was a high degree of symmetry on lung US examinations of PCP During NIV for a better patient compliance a continuous i.v. infusion of
patients, while there was always differences between the right and left remifentanil was used (range 0.03 to 0.05 μg/kg/minute). At baseline
hemithorax among other etiologic pneumonia (P <0.001). (T0 = before NIV) and after 30 minutes of NIV (T1), the following data
Conclusion We suggest that high-degree symmetric and diffuse B were recorded: respiratory – RR, SaO2%, PaO2, PaCO2, pH, BE, and HCO3–;
lines, without pleural effusions, are compatible with P. jiroveci as the and cardiac – heart rate (HR), arterial blood pressure (systolic, diastolic
etiology of recent diagnosed pneumonia in critically ill AIDS patients. and media), diastolic and systolic volume (EDV, ESV), ejection fraction
(EF), stroke volume (SV), velocity time integral (VTI), FTc, E wave,
deceleration time (Dt), A wave, ventricular flow propagation velocity
P87 (Vp).
Difference in accuracy of lung sliding identification between the Results From T0 to T1 the following changes with Wilcoxon matched pairs
right and left hemithorax test were statistically significant (P <0.05*). PaO2 (94 to 123 mmHg*), SaO2
R Daoust1, E Piette1, J Lambert2, A Denault3 (87 to 97%*) and PaO2/FiO2, RR (37 to 28/minute*). At T0, EF was >55%
1
Hôpital du Sacré-Coeur de Montréal, Canada; 2Université de Montréal, in seven patients and <55% in six patients. In the group with EF <55%
Canada; 3Institut de Cardiologie de Montréal, Canada (T0) the EF increased at T1 (42 to 52%*). Dt significantly increased
Critical Care 2012, 16(Suppl 1):P87 (doi: 10.1186/cc10694) from T0 to T1 (182 to 198 cm/second*). No significant changes were
observed in VTI, E/A ratio, Vp, and E/Vp ratio, from T0 to T1.
Introduction The field of lung ultrasound (US) in critical care is in rapid Conclusion Our study suggests that NIV improves cardiac function in
expansion. Lung sliding (LS) identification has been used in emergency patients with reduced EF, positioning the patients to a more favorable
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point of the Frank Starling curve. In these patients we also showed an Table 1 (abstract P89). Patient data
increase in FTc that seems to be affected by either preload or afterload
Age >300 (n) ALI (n) ARDS (n)
reduction.
(n) (years) LOS (days) LOS (days) LOS (days)
References
1. Antonelli M, Pennisi MA, Montini L: Clinical review: Noninvasive ventilation Male 165 65 ± 8.2 47 8 ± 2.1 65 12 ± 3.4 53 16 ± 4.2
in the clinical setting – experience from the past 10 years. Crit Care 2005,
9:98-103. Female 108 69 ± 7.6 33 7 ± 2.9 43 11 ± 3.7 32 17 ± 3.8
2. Shekerdemian L, Bohn D: Cardiovascular effects of mechanical ventilation.
Arch Dis Child 1999, 80:475-480. Conclusion We concluded that the PaO2/FiO2 ratio was a powerful
indicator for predicting ICU LOS in patients with RI. In addition there
was no need to classify patients according to PaO2/FiO2 to predict
LOS; any decreased ratio meant a longer LOS. However, this study
P89 was weak in power; it had a small sample, did not include comorbid
Listen to PaO2/FiO2 ratios: they tell us about length of stay conditions, did not account for accepted scoring systems, and did not
V Inal, B Comert, L Yamanel include daily ABGA for prediction. On the other hand, these results are
GATA, Ankara, Turkey promising for future observations that ABGA taken in the ED would be
Critical Care 2012, 16(Suppl 1):P89 (doi: 10.1186/cc10696) a supplemental tool for the physician’s approach in the ICU.
Results Data were available for 815 patients (see Figure 1). Increasing P92
OI was associated with increasing mortality (P <0.0001 chi-squared test Do actual tidal volumes differ from prescribed tidal volumes?
for trend). Each step increase in OI was associated with approximately R Kleijn, B Kalkman, N Verburg, H Oudijk, B Van Vondelen, M Luttmer,
a 6% absolute increase in mortality. The OI was also associated with I Slagers, M Ruijters, I Meynaar
increasing Standardised Mortality Ratio (ICNARC model). Reinier de Graaf Groep, Delft, the Netherlands
Conclusion The highest OI occurring in the first 24 hours of ventilation Critical Care 2012, 16(Suppl 1):P92 (doi: 10.1186/cc10699)
is an independent predictor of mortality. Collection of OI data may
allow better prediction of outcome than P/F ratio data alone. Introduction Studies have shown that the selection of incorrect
References tidal volume can cause ventilator-induced lung injury and increased
1. Winter B, et al.: Management of Severe Refractory Hypoxia in Critical Care mortality [1]. This study was done to determine if the actual tidal
in the UK in 2010 Report from UK Expert Group [http://www.ics.ac.uk/ volume (aVt) differs from the prescribed tidal volume (pVt) based on
latest_news/management_of_severe_respiratory_failure_in_critical_care_] predicted body weight (PBW).
2. Britos M, Smoot E, Liu KD, et al.: The value of positive end-expiratory Methods The ICU is a 10-bed intensivist-led unit in a 500-bed teaching
pressure and FiO2 criteria in the definition of the acute respiratory distress hospital. All consecutive patients receiving invasive mechanical
syndrome. Crit Care Med 2011, 39:2025-2030. ventilation in June 2011 were included. Patients with noninvasive
ventilation or with continuous positive airway pressure only were
P91 excluded. The ICU has a mechanical ventilation protocol that prescribes
The Oxygenation Index compared with the P/F ratio in ALI/ARDS tidal volume to be between 6 and 8 ml/kg PBW. A table with prescribed
M Van Haperen1, PH Van der Voort2, RJ Bosman2 tidal volumes based on PBW is available at the bedside throughout the
1
AMC, Amsterdam, the Netherlands; 2Olvg, Amsterdam, the Netherlands ICU. All patients were ventilated with Drager Evita XL ventilators on
Critical Care 2012, 16(Suppl 1):P91 (doi: 10.1186/cc10698) pressure support (ASB) or pressure control mode (BIPAP). During the
study period we compared the aVt with the pVt each day at 0, 6, 10, 14,
Introduction The usual way to describe the severity of pulmonary 18 and 22 hours for all patients.
dysfunction in ventilated ICU patients is by using the PaO2/FiO2 ratio Results Seventeen patients with mean age of 70.2 years (SD 14.1)
(PF). The PF may be adjusted by the ventilator pressure settings in order and median APACHE IV expected mortality of 31% (IQR 14 to 70),
to reduce inspiratory oxygen fraction but the PF does not take the 10 admitted for medical reasons and seven for surgical reasons, and
mean airway pressure (MAP) into account. In contrast, the Oxygenation ventilated for 4 days median (IQR 3 to 6) fulfilled inclusion criteria and
Index (OI) is defined as the reciprocal of PF times MAP: OI = (FiO2×mean were included in the study. Results of tidal volume measurements are
airway pressure) / PaO2. As such, the OI is a better representative of shown in Table 1.
oxygenation dysfunction. The objective was to study the correlation
between and the impact of the MAP on the PF and OI. Table 1 (abstract P92). Tidal volume measurements
Methods We performed a retrospective analysis of 27 consecutive
Total number of aVt measurements 286
mechanically ventilated patients admitted to our ICU with bilateral
interstitial/alveolar lung disease, defined as ALI or ARDS. The data of Number of aVt measurements per patient (IQR) 12 (4 to 20)
these patients were collected during a time period of maximum 30
consecutive days. Demographic data were recorded and the PF, OI aVt <6 ml/kg PBW 25 (9%)
and MAP were assessed daily at 6:00 am during the first 30 days of aVt 6 to 8 ml/kg PBW 156 (58%)
admission. OI >8.1 is usually regarded as ARDS and >5.3 as ALI [1].
Results We included 27 patients, 25 were male, the mean APACHE II aVt 8 to 10 ml/kg PBW 82 (29%)
score was 22, the median length of stay on the ICU 11 days and the ICU aVt >10 ml/kg PBW 23 (8%)
mortality was 11/16 (69%). The mean PF was 165 (SD 83), the mean OI
was 8.2 (SD 5) and the mean MAP was 16 cmH2O (SD 5). The 27 patients Mean aVt per kg PBW (SD) 7.85 (1.23)
resulted in 364 measurements. Of these measurements 158 had OI aVt, actual tidal volume; PBW, predicted body weight.
>8.1, of which 157 had PF <200 and a mean MAP of 19.3 cmH2O. In
one patient PF was >200 while OI was >8.1 with MAP 18 cmH2O. Of the
100 measurements with OI 5.3 to 8.1, 14 had PF 200 to 300 and 85 had Conclusion In this small single-centre study, the mean aVt is between
PF <200. The MAP in these measurements was 17, 64 and 24 cmH2O 6 and 8 ml/kg PBW as prescribed, but only 58% of measured tidal
respectively. Figure 1 shows the nonlinear relation between OI and PF. volumes are indeed between 6 and 8 ml/kg PBW.
Conclusion In patients with ARDS, OI >8.1 is usually in agreement with Reference
PF <200. However, patients with ALI based on OI 5.3 to 8.1 frequently 1. Ventilation with lower tidal volumes as compared with traditional tidal
had PF <200. More studies are needed to determine the optimal level volumes for acute lung injury and the acute respiratory distress syndrome.
of OI for the diagnosis of ALI/ARDS. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000,
Reference 342:1301-1308.
1. Pediatr Crit Care Med 2010, 11:12-17.
P93
Intratracheal administration of siRNA targeting FAS reduces
ischemia–reperfusion-induced lung injury
L Del Sorbo, G Muraca, A Costamagna, G Rotondo, L Laudari, F Civiletti,
E Tonoli, E Martin, V Fanelli, V Ranieri
University of Turin, Italy
Critical Care 2012, 16(Suppl 1):P93 (doi: 10.1186/cc10700)
Methods C57BL/6 male mice were randomized to intratracheally Conclusion Acute lung injury induced by intratracheal hydrochloric
receive a specific sequence of siRNA targeting FAS (siRNA-FAS) or acid instillation requires the function of TNFα receptor I and associates
a scrambled siRNA 48 hours before undergoing 6 hours of cold with activation of downstream proinflammatory signaling pathways
ischemic time (4°C) followed by 2 hours of ex vivo ventilation (peak p44/42 and c-Jun N-Terminal kinase.
inspiratory pressure = 7 cmH2O, PEEP = 2 cmH2O, respiratory rate = 100
breaths/minute, FiO2 = 100%) and reperfusion (4% bovine serum
albumin RPMI medium with 10% fresh blood at 1 ml/minute flow P95
rate) in a predisposed humidified chamber at 37°C. At the end of the Retrieval of patients with severe respiratory failure on venovenous
experiment, lung elastance, assessed through tidal volume, and total extracorporeal membrane oxygenation: an intensivist-led model
protein concentration in the bronchoalveolar lavage (BAL) fluid were A Burrell1, V Pellegrino1, D Pilcher1, S Bernard1, M Kennedy2
1
measured. A separate set of lungs were analysed by western blot before The Alfred Hospital, Melbourne, Australia; 2Adult Retrieval Victoria,
undergoing cold ischemia to assess the expression of FAS protein. Melbourne, Australia
Results The intratracheal administration of siRNA-FAS reduced Critical Care 2012, 16(Suppl 1):P95 (doi: 10.1186/cc10702)
the expression of FAS in the lung by 44% (siRNA-FAS 0.90 ± 0.11 vs.
scrambled siRNA 1.61 ± 0.18 AU). Lung elastance and BAL total protein Introduction Patients with severe respiratory failure may require veno-
concentration were significantly reduced in the siRNA-FAS group as venous extracorporeal membrane oxygenation (vv-ECMO). However,
compared to control in lungs exposed to 6 hours of cold ischemia this treatment is only available in specialized centres. Previous reports
followed by 2 hours of reperfusion. See Table 1. of vv-ECMO cannula insertion and retrieval have included large teams
of surgeons, perfusionists, physicians, retrieval doctors, paramedics
Table 1 (abstract P93) and nurses. We hypothesized that an intensivist-led model for rapid
response to a referring hospital, the insertion of vv-ECMO cannulae and
siRNA-FAS siRNA scrambled
subsequent retrieval would be safe and feasible.
Elastance (cmH2O/ml) 11.34 ± 0.24* 13.75 ± 0.99 Methods The Alfred Hospital ICU is the specialist centre for ECMO
services for the states of Victoria and Tasmania in Australia. The
BAL proteins (μg/ml) 529.1 ± 64.8* 928.5 ± 138.2 intensivists in our ICU are trained to insert ECMO cannulae using a
Data are mean ± SE. Comparison between groups was performed with the percutaneous femoral approach and manage the ECMO circuit during
Student’s t test. *P <0.05. transport. A new ECMO retrieval service was set up in 2008 to allow the
cannulation and retrieval of patients from other referring hospitals. The
Conclusion The intratracheal administration of siRNA targeting FAS retrieval team comprises two intensivists to insert femoral cannulae
prevents the increase of the alveolar membrane permeability during and manage the ECMO circuit, a third physician to manage the
ischemia–reperfusion injury. ventilator and infusion pumps and a paramedic to manage the logistics
Acknowledgements Funded by PRIN and Regione Piemonte. of the patient transfer. We reviewed all consecutive patients from 2008
to 2011 with severe respiratory failure who received vv-ECMO and were
retrieved to our specialist center.
P94 Results There were 23 patients from 2008 to 2011. All cannulations
Acute lung injury in mice associates with p44/42 and c-Jun were successfully performed percutaneously at the referring hospital
N-terminal kinase activation and requires the function of TNFα by the intensivists. The underlying condition was H1N1 in 11 patients,
receptor I bacterial pneumonia in six, acute lung injury in four, metastatic
N Maniatis1, A Sfika1, I Nikitopoulou1, A Vassiliou1, C Magkou1, M Kardara1, seminoma in one and multiple lung abscesses in one. The average age
A Armaganidis1, C Roussos1, G Kollias2, S Orfanos1, A Kotanidou1 was 36 years (range 17 to 60 years). Males were 61%. Transport was by
1
University of Athens, Greece; 2‘Al. Fleming’ Biomedical Sciences Research fixed-wing aircraft in 35% and road ambulance in 65%. The retrieval
Center, Vari, Greece distance averaged 76 km (range 7 to 1,770 km). During transport,
Critical Care 2012, 16(Suppl 1):P94 (doi: 10.1186/cc10701) there were two transient pump failures requiring hand cranking and
one monitor failure. These resulted in no adverse clinical effects. The
Introduction Aspiration of hydrochloric acid-containing gastric juice average ICU length of stay was 14 days. Overall survival to hospital
leads to acute lung injury and hypoxemic respiratory failure due to an discharge was 17/23 (74%).
exuberant inflammatory response associated with pulmonary edema Conclusion An intensivist-led model of vv-ECMO cannulation and
from increased endothelial and epithelial permeability. The aim of this retrieval appears to be a safe and effective model for vv-ECMO retrieval.
study was to determine the role and signaling mechanisms of TNFα in This model may lead to a more rapid and cost-effective response and is
experimental acute lung injury from hydrochloric acid aspiration using the subject of further study.
a combination of genetic animal models and pharmacologic inhibition
strategies.
Methods Subjects were male and female C57Bl/6 mice, wild-type, P96
TNFα knockout, TNFα receptor I knockout (n = 135). Hydrochloric acid A new miniaturized extracorporeal membrane oxygenator with
was instilled intratracheally to mice, followed by respiratory system integrated rotary blood pump (Ilias): first results in a porcine model
elastance measurement, bronchoalveolar lavage and lung tissue of lung injury
harvesting 24 hours post injection. The TNFα inhibitor etanercept was K Pilarczyk1, J Heckmann1, K Lyskawa1, A Strauß2, U Aschenbrenner2,
administered as pretreatment to a subset of mice prior to hydrochloric H Jakob1, M Kamler1, N Pizanis1
1
acid exposure. West German Heart Centre Essen, University Hospital, Essen, Germany;
2
Results Hydrochloric acid instillation induced an inflammatory iliasmedical GmbH, Bochum, Germany
response in the lungs of wild-type mice, evidenced as increased Critical Care 2012, 16(Suppl 1):P96 (doi: 10.1186/cc10703)
bronchoalveolar lavage total cells, neutrophils and total protein,
histologic lung injury score and respiratory system elastance, while Introduction Extracorporeal membrane oxygenation (ECMO) is used
TNFα receptor I mRNA levels were maintained. These alterations could for most severe acute respiratory distress syndrome cases in specialized
be prevented by pretreatment with etanercept or genetic deletion centres. However, critically ill patients fulfilling ECMO criteria are often
of the 55 kDa TNFα receptor I, but not by deletion of the TNFα gene. not suitable for transportation and currently available ECMO systems
Hydrochloric acid induced a sixfold increase in apoptotic, caspase- are not designed for emergency use or interhospital transfer. Therefore,
3-positive cells in lung sections from wild-type mice, which was a new miniaturized ECMO (Ilias; Figure 1) with only 5 kg weight was
abrogated in mice lacking TNFα receptor I. In immunoblotting and developed to reduce filling volume and simplify management.
immunohistochemistry studies, hydrochloric acid stimulated signaling Methods Acute lung injury was induced with repeated pulmonary
via p44/42 and c-Jun N-Terminal kinase, which was blocked in TNFα saline infusion in 13 pigs until the Horowitz Index was <100 mmHg.
receptor I knockout mice. Pigs were assigned to the following three groups: group 1 (n = 3),
Critical Care 2012, Volume 16 Suppl 1 S35
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Figure 1 (abstract P103). Ers and EELV change with PEEP increase.
Critical Care 2012, Volume 16 Suppl 1 S38
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P106
Feasibility of early spontaneous breathing in acute respiratory
distress syndrome
S Mortaza, A Mercat
CHU Angers, France
Critical Care 2012, 16(Suppl 1):P106 (doi: 10.1186/cc10713)
P109 Results The study comprised 20 patients with mean age of 58.9 ± 20.69
Differential pulmonary and circulatory effects of preventive lung years, 11 men versus nine women (P >0.05). NT-proBNP was negatively
protective ventilation in an experimental postoperative sepsis correlated with PH on day 2 (P = 0.008, r = –0.53) and day 7 with
model (P = 0.02, r = –0.50). NT-proBNP was positively correlated with PEEP
J Sperber1, M Lipcsey2, A Larsson2, A Larsson2, J Sjölin2, M Castegren1 on day 2 (P = 0.05, r = 0.46) and day 7 (P = 0.035, r = 0.48). NT-proBNP
1
Centre for Clinical Research Sörmland, Eskilstuna, Sweden; 2Uppsala was negatively correlated with the PaO2/FiO2 ratio on day 7 (P = 0.0035,
University, Uppsala, Sweden r = 0.60). However, there was no significant correlation between NT-
Critical Care 2012, 16(Suppl 1):P109 (doi: 10.1186/cc10716) proBNP and other respiratory indices including PaCO2, HCO3, PaO2,
SaO2, FiO2, PAO2, P(A-a)O2 and a/A ratio (P >0.05). Neither troponin I
Introduction It has been proposed that low tidal volume (VT) nor troponin T showed any significant correlation with any respiratory
ventilation combined with higher PEEP should be used in patients with indices PH, PEEP, PaO2/FiO2, PaCO2, HCO3, PaO2, SaO2, FiO2, PAO2, P(A-a)
risk of developing postoperative lung injury instead of the commonly O2 and a/A ratio on any day (P >0.05). None of the cardiac markers NT-
used VT of 10 ml/kg with lower PEEP [1]. Such a ventilatory mode would proBNP, troponin I or troponin T showed any significant correlation with
in theory reduce postoperative lung and organ dysfunction. However, the lung mechanics parameters Cdyn, Raw, Ceff, PIP, Pplat, and Pmean (P >0.05).
this hypothesis has neither been tested clinically nor experimentally. Conclusion High NT-proBNP level was correlated with high PEEP, low
Therefore we developed an experimental endotoxemic postoperative PH and low PaO2/FiO2 ratio while troponin T and troponin I did not
sepsis model to evaluate the effect of different modes of ventilation. show significant correlations with respiratory parameters in ARDS
Methods Twenty-five healthy pigs were randomized to three ventilation patients with structurally normal hearts.
groups: I: PEEP 10 cmH2O, VT 6 ml/kg; II: PEEP 5 cmH2O, VT 10 ml/kg, Reference
changed to PEEP 10 cmH2O, VT 6 ml/kg at the end of laparotomy; III: 1. Mitaka C, et al.: Increased plasma concentrations of BNP in patients with
PEEP 5 cmH2O, VT 10 ml/kg. For all groups the plateau pressure was ALI. J Crit Care 1997, 12:66-71.
kept below 28 cmH2O, normocapnia was reached by respiratory rate
and FiO2 was adjusted to reach PaO2 >12 kPa. Laparotomy for 2 hours
was performed to simulate a surgical procedure and then a continuous P111
endotoxin infusion was started at 0.25 μg/kg/hour for 5 hours. Early application of high-frequency oscillatory ventilation in H1N1
Differences between groups were analyzed with ANOVA for repeated influenza-related severe ARDS is associated with better outcome
measures. S Jog, M Patel, D Patel
Results The groups were equal before and at the end of laparotomy. Deenanath Mangeshkar Hospital and Research Centre, Pune, India
During the endotoxin infusion, PaO2/FiO2 was higher in groups I and Critical Care 2012, 16(Suppl 1):P111 (doi: 10.1186/cc10718)
II than in group III, whereas in pulmonary compliance or functional
residual capacity no differences were found. In contrast, group I showed Introduction High-frequency oscillatory ventilation (HFOV) is a
greater negative changes than group III in the circulatory variables; promising rescue modality for refractory hypoxia and was used
that is, arterial blood pressure, cardiac index, oxygen delivery and extensively in H1N1 influenza-related ARDS in 2009 and 2010. The aim
oxygen consumption. In all measured variables, group II showed an of this study was to find predictors of successful outcome of HFOV in
intermediate response to groups I and III, but no significant differences H1N1 influenza-related severe ARDS [1].
were found between groups I and II. Groups I and II had slightly higher Methods Patients with H1N1 influenza-related severe ARDS by the
mean airway pressure at the end of the experiment than group III. new Berlin definition (applied retrospectively) receiving volume-
However, this does not explain the circulatory differences since they controlled ventilation (VCV) as per the ARDSnet protocol with PO2/FiO2
occurred early in the course, temporally different from the continuous ≤100 at PEEP ≥12 cmH2O and FiO2 ≥0.7 were connected to HFOV as a
slow increase of the airway pressures (P ≤0.01 ANOVA group by time rescue therapy for refractory hypoxia. All patients were followed until
interaction). discharge from the hospital (survivors) or death (nonsurvivors).
Conclusion Low VT ventilation combined with higher PEEP in healthy Results About 80 parameters were evaluated as outcome predictors
animals exposed to laparotomy and subsequent experimental post- of HFOV like demographics, comorbidities, clinical features, laboratory
operative sepsis leads to a less prominent pulmonary dysfunction parameters, X-rays, ventilatory and blood gas parameters and therapy-
but to a more hypodynamic circulatory state compared to animals related complications. Previously collected data of 19 patients were
ventilated with a medium–high VT and lower PEEP. analysed applying the new Berlin definition. Demographic, clinical,
Reference comorbidity, laboratory and radiological parameters were comparable
1. Schultz et al.: Anesthesiology 2007, 106:1226-1231. in survivors and nonsurvivors. Table 1 shows comparison of survivors
and nonsurvivors with respect mainly to ventilatory and gas exchange
parameters before application of HFOV. Duration of conventional
mechanical ventilation before HFOV, 1.4 ± 0.69 versus 3.66 ± 3.53 days
P110 (P = 0.03), was the only discriminating parameter between survivors
High NT-proBNP level is correlated with high PEEP, low PH and low and nonsurvivors.
PaO2/FiO2 in ARDS
Y Nassar, D Monsef, S Abdelshafy, G Hamed Table 1 (abstract P111). Comparison of survivors and nonsurvivors
Cairo University, Giza, Egypt
Variable Survivors Nonsurvivors P value
Critical Care 2012, 16(Suppl 1):P110 (doi: 10.1186/cc10717)
APACHE 13.3 ± 1.7 13.2 ± 2.2 0.14
Introduction Cardiac injury may occur in ARDS patients with structurally
normal hearts and may be correlated with respiratory parameters [1]. Time VCV 1.4 ± 0.69 3.66 ± 3.5 0.03
We aimed at observing NT-proBNP, troponin I and troponin T relations PIP 35.6 ± 7.1 35.2 ± 5.1 0.44
with different respiratory parameters in ARDS.
Methods Inclusion criteria were any adult patient diagnosed to have PEEP 13.4 ± 2.0 13.4 ± 2.8 0.48
ARDS according to the criteria of the American–European Consensus P/F 82.6 ± 31 68.8 ± 34 0.37
Conference in 1994. Exclusion criteria were any structural heart disease
by echo, pulmonary embolism, atrial fibrillation, renal insufficiency, OI 36.08 ± 24 25.32 ± 7 0.1
and age <18. All patients benefited from a lung protective ventilation
strategy. Plasma NT-proBNP, troponin I and troponin T were measured Conclusion In H1N1 influenza-related severe ARDS, early application of
on day 0 and on day 2 and day 7 of ARDS diagnosis. PH, PaCO2, PaO2, HFOV is a significant predictor of successful outcome.
P(A-a)O2 (alveolar–arterial gradient), PaO2/FiO2 ratio, a/A ratio, PEEP, PIP Reference
(peak airway pressure), Pmean, Pplat (plateau pressure) and Ceff (effective 1. European Society of Intensive Care Medicine: Conference Proceedings of 24th
compliance), and Raw (airway resistance) were monitored daily. Annual Conference of ESICM, Berlin.
Critical Care 2012, Volume 16 Suppl 1 S41
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and active breathing patients. The minute volume is adjusted according group (12.7 cmH2O (10.7 to 16.0 cmH2O)). There were fewer adherent
to end-tidal CO2 (ETCO2) information in passive breathing patients leukocytes (P = 0.005) and fewer migrated leukocytes (P = 0.002) in the
(and respiratory rate in active breathing patients), and oxygenation low-VT group (5 cells/100 μm length (IQR 4 to 7 cells/100 μm length)
is adjusted according to SpO2 information. This study reports the and 1 cell/5,000 μm2 (IQR 1 to 2 cells/5,000 μm2), respectively) and
ventilation and oxygenation delivered by IntelliVent-ASV® in long-term the high-VT/pentoxifylline group (5 cells/100 μm length (IQR 3 to 10
ventilated ICU patients. cells/100 μm length) and 1 cell/5,000 μm2 (IQR 1 to 3 cells/5,000 μm2),
Methods This prospective, observational study included 100 patients respectively) than in the high-VT group (14 cells/100 μm length (IQR 11
invasively ventilated using IntelliVent-ASV® from admission to weaning to 16 cells/100 μm length) and 9 cells/5,000 μm2 (IQR 8 to 12 cells/5,000
or death. The rate and reason for stopping automation were recorded. μm2), respectively).
Settings automatically selected, delivered ventilation, respiratory Conclusion Low VT with high PEEP was lung-protective, and early
mechanics and arterial blood gas results were collected once a day. pentoxifylline reduced the inflammatory response to high VT with
Patients were categorized in different lung conditions: normal lung, high PEEP (and presumed lung overdistention) during mechanical
ALI/ARDS, COPD. Analysis of variance compared the ventilation-days for ventilation.
each type of lung condition for active and passive breathing patients.
Results Patients (age 73 (64 to 79) years; SAPS II 56 (48 to 69)) were P117
ventilated using IntelliVent-ASV® to weaning or death (31%) for a A method for continuous noninvasive assessment of respiratory
median duration of 3.0 (2.0 to 7.0) days without any safety issue. The mechanics during spontaneous breathing
ventilation controller was deactivated in two patients because of high K Lopez-Navas1, S Brandt2, H Gehring2, M Strutz1, U Wenkebach1
1
PaCO2–ETCO2 gradient. Oxygenation controller was deactivated in Fachhochschule Lübeck, Germany; 2Universitätsklinikum Schleswig-Holstein,
seven patients for 1 day because of a poor SpO2 signal. In passive and Lübeck, Germany
active ventilation-days, minute volume, VT/PBW, respiratory rate, FiO2, Critical Care 2012, 16(Suppl 1):P117 (doi: 10.1186/cc10724)
and PEEP were statistically different based on lung condition. In passive
ALI/ARDS ventilation-days, VT/PBW was significantly lower (7.5 (6.9 to Introduction The proper assessment of patient’s work of breathing
7.9) ml/kg) than passive normal lung (8.1 (7.3 to 8.9) ml/kg; P <0.05) (WOB) is the key to a better or even automatic setting of ventilation
and passive COPD patients (9.9 (8.3 to 11.1) ml/kg; P <0.05). In passive parameters. We introduce the Occlusion+Delta method (O+D) to
ALI/ARDS ventilation-days, FiO2 and PEEP were statistically higher than continuously determine resistance (R) and compliance (C), allowing
passive normal lung (35 (33 to 47)% vs. 30 (30 to 31)% and 11 (8 to 13) one to assess noninvasively the inspiratory force.
cmH2O vs. 5 (5 to 6) cmH2O, respectively; P <0.05). In active normal lung Methods The O+D method uses a short expiratory occlusion producing
ventilation-days, VT/PBW was not different (8.4 (7.8 to 9.1) ml/kg) than immediate changes in airway pressure (Paw), flow (V’) and volume
in active ALI/ARDS (8.1 (7.5 to 9.3) ml/kg), and in active COPD (9.3 (8.6 to (V) but not in transdiaphragmatic pressure (Pdi). The differences
11.6) ml/kg). In active ALI/ARDS and COPD ventilation-days, PEEP was between an occluded and an undisturbed cycle are related by V’R +
significantly higher than active normal lung (8 (5 to 10) cmH2O, 7 (5 to V/C = Paw + Pdi. If both cycles are similar Pdi can be neglected, making
10) cmH2O, and 5 (5 to 5) cm H2O, respectively; P <0.05). its measurement unnecessary. Then R and C are derived from linear
Conclusion IntelliVent-ASV® can be used safely in long-term ventilated regression (MLR) and used to make a reconstruction of Pdi (rPdi).
ICU patients and selects automatically different ventilation and As control, R and C were calculated by MLR using the objectively
oxygenation settings according to the lung condition, especially for measured (with balloon catheters) Pdi. The inspiratory pressure time
passive breathing patients. product (PTPinsp) of measured Pdi (APdi) and reconstructed Pdi (ArPdi)
were compared as expression of WOB.
P116 Results After validation with simulations, we used data from two
Effects of low and high tidal volume and pentoxifylline on intestinal healthy adults breathing at several levels of WOB. The occlusions caused
blood flow and leukocyte–endothelial interactions in mechanically the expected signals reproducing Pdi as desired with R and C values
ventilated rats typical for healthy men (Table 1). Measured and assessed PTPinsp
N Nakagawa1, P Aikawa1, HZ Zhang2, C Correia1, R Pazzeti1, correlated well (R2 = 0.93 and 0.89) and had small mean differences
C Valente Barbas1, T Mauad1, E Silva1, P Sannomiya1 (mean ± 2SD = 1.78 ± 3.81 and 0.27 ± 4.80 cmH2O.second) (Figure 1).
1
Faculdade de Medicina da Universidade de São Paulo, Brazil; 2University of
Toronto and Saint Michael Hospital, Toronto, Canada Table 1 (abstract P117)
Critical Care 2012, 16(Suppl 1):P116 (doi: 10.1186/cc10723)
Male 1 Male 2
Introduction The combination of high positive end-expiratory pressure R estimated 3.7 ± 0.7 3.2 ± 0.7
(PEEP) and low tidal volume (VT) decreases some risks of mechanical R measured 5.2 ± 1.9 2.9 ± 1.2
ventilation, including pulmonary overdistention, damage due to cyclic
opening and closing of the alveoli, and inflammatory responses that C estimated 97.7 ± 20.6 85.4 ± 18.7
can lead to multiple-organ dysfunction. We hypothesized that high VT C measured 100.5 ± 21.9 76.5 ± 18.7
and high PEEP induce mesenteric microcirculatory disturbances and
Mean ± SD of R in cmH2O/l/second and C in ml/mbar (measured = MLR,
that those disturbances would be attenuated by pentoxifylline, which
estimated = O+D).
is anti-inflammatory.
Methods We anesthetized (isoflurane 1.5%), tracheostomized, and
mechanically ventilated 57 male Wistar rats with PEEP of 10 cmH2O and
FIO2 of 0.21 for 2 hours. One group received low VT (7 ml/kg), another
group received high VT (10 ml/kg), and a third group received high VT
(25 mg/kg) plus pentoxifylline. We measured mean arterial pressure,
respiratory mechanics, mesenteric blood flow, and leukocyte–
endothelial interactions.
Results The mean arterial pressure was similar among the groups
at baseline (108 mmHg (IQR 94 to 118 mmHg)) and after 2 hours of
mechanical ventilation (104 mmHg (IQR 90 to 114 mmHg)). Mesenteric
blood flow was also similar between the groups: low VT 15.1 ml/
minute (IQR 12.4 to 17.7 ml/minute), high VT 11.3 ml/minute (IQR 8.6
to 13.8 ml/minute), high-VT/pentoxifylline 12.4 ml/minute (10.8 to
13.7 ml/minute). Peak airway pressure was lower (P = 0.03) in the low- Figure 1 (abstract P117). PTPinsp from measured Pdi (APdi) versus
VT group (10.4 cmH2O (IQR 10.2 to 10.4 cmH2O)) than in the high-VT PTPinsp from reconstruction (ArPdi).
group (12.6 cmH2O (10.2 to 14.9 cmH2O)) or the high-VT/pentoxifylline
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Figure 1 (abstract P120). Venous admixture (Qva/Qt) plotted against CO (pooled data for each group). Solid circles, mechanical ventilation (MV); open
circles, spontaneous breathing (SB).
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Figure 1 (abstract P121). PaO2/FiO2 plotted against the proportion of atelectatic lung tissue. Open circles, SB; solid circles, MV.
Critical Care 2012, Volume 16 Suppl 1 S45
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the number of asynchronies (wasted efforts, double cycles, premature P <0.001) (Figure 1). In a multivariate model, BNP level at the end of SBT
cycling off ) divided by the total respiratory rate (ventilator cycles + was the only predictor of weaning failure from mechanical ventilation.
asynchrony events), multiplied by 100. Conclusion BNP was an independent predictor factor of failure to wean
Results Sixteen patients were enrolled (age 64 ± 11 years; SAPS II from mechanical ventilation after cardiac surgery, which suggests
66 ± 14; COPD 25%; days of mechanical ventilation before enrollment that optimization of the ventricular function must be a goal prior to
9 ± 4, number of SBTs 3 ± 1). The asynchrony index was lower with liberation from mechanical ventilation.
Smartcare (10% vs. 14%, P = 0.01), but not different between afternoon
and night. Mean PS level (11 vs. 12 cmH2O) was not different between P128
conventional and automated PSV, although the coefficient of variability Case–control study of failed extubation
of PS level was greater with Smartcare (20% vs. 0%, P <0.01). No J Krinsley, P Reddy, A Iqbal
differences were observed in PaCO2 (36 vs. 36 mmHg), PaO2 (106 vs. 102 Stamford Hospital, Stamford, CT, USA
mmHg), total respiratory rate (22 vs. 23), and P0.1 (1.4 vs. 1.6 cmH2O) Critical Care 2012, 16(Suppl 1):P128 (doi: 10.1186/cc10735)
between conventional PSV and Smartcare.
Conclusion As compared with conventional PSV, Smartcare may Introduction Failed extubation (FE), defined as reintubation within
reduce asynchronies in difficult-to-wean patients, possibly because of 48 hours of planned extubation (PE), is common. The literature suggests
greater variability of the PS level. This needs to be further confirmed. that FE complicates 10 to 20% of PE. The consequences of FE have not
been well described, nor have its risk factors.
P127 Methods We performed a retrospective study of prospectively
High levels of B-type natriuretic peptide predict weaning failure collected data involving 2,012 consecutive patients undergoing
from mechanical ventilation in adult patients after cardiac surgery mechanical ventilation (MV) in a 16-bed university-affiliated hospital
L Hajjar1, T Lara1, J Almeida1, J Fukushima1, C Barbas1, A Rodrigues1, between 1 October 2005 and 31 August 2011. Eighty-five patients with
E Nozawa1, JL Vincent2, F Jatene1, J Auler Jr1, F Galas1 FE were matched 1:3 with successfully extubated patients (SE) using
1
Heart Institute, São Paulo, Brazil; 2Erasme Hospital, Université libre de diagnostic category, age, Acute Physiology Score (APS) and duration of
Bruxelles, Belgium ventilation (DOV) before PE as matching criteria.
Critical Care 2012, 16(Suppl 1):P127 (doi: 10.1186/cc10734) Results Patients undergoing MV included 1,209 (60.1%) with SE; 224
(11.1%) died during ventilation (without prior FE); 206 (10.2%) were
Introduction Failure to wean from mechanical ventilation is related extubated to withdraw support; 180 (8.9%) were transferred from
to worse outcomes after cardiac surgery. The aim of the study was to the ICU while ventilated; 81 (4.0%) were liberated from MV after
evaluate B-type natriuretic peptide (BNP) as a predictor factor of failure tracheostomy; 85 (6.6%) failed PE. APS scores were higher (53 (42 to
to wean from mechanical ventilation after cardiac surgery. 69) vs. 43 (32 to 60), P <0.0001) and DOV before PE longer (1.8 (0.8 to
Methods We conducted a prospective and observational cohort study 4.4) vs. 0.9 (0.4 to 2.6), P = 0.0001) in FE than in SE. There was 100%
of 101 patients that underwent on-pump coronary artery bypass concordance of diagnostic category and no statistically significant
grafting. BNP was measured postoperatively after ICU admission differences between the groups in regards to age, APS and DOV
and at the end of a spontaneous breathing test (SBT). Demographic before PE. Table 1 illustrates the results of the case–control analysis. In
data, hemodynamic and respiratory parameters, fluid balance, need addition, FE had more days in the hospital after ICU discharge than did
for vasopressor or inotropic support, lengths of ICU and hospital stay SE: 11 (4 to 24) versus 5 (2 to 9), P <0.0001.
were recorded. Weaning failure was considered as either the inability
to sustain spontaneous breathing after 60 minutes or the need for Table 1 (abstract P128). Case–control analysis of failed extubation: key
reintubation within 48 hours. outcomes
Results BNP levels were significantly higher both at ICU admission and
FE SE P value
in the end of breathing test in patients with weaning failure than in
the other patients. A BNP concentration of 299 ng/l at the end of the ICU LOS 11.8 (7.7 to 17.5) 3.8 (2.1 to 7.5) <0.0001
SBT identified weaning failure with 92% sensitivity and 87% specificity,
resulting in an area under the curve value of 0.91 (95% CI (0.86 to 0.97), VAP (%) 7.1 0.8 0.0043
Mortality (%) 23.5 10.2 0.0052
P129
Out-of-bed extubation: changing paradigms
F Dexheimer Neto, R Cremonese, J Maccari, F Carlin, C Rodrigues,
A Raupp, P Vesz, C Leaes, J De Andrade
Hospital Ernesto Dornelles, Porto Alegre, Brazil
Critical Care 2012, 16(Suppl 1):P129 (doi: 10.1186/cc10736)
48 hours. All statistical analysis were done using SPSS version 16 and
the differences between the groups were assessed using Student’s
t test and the chi-square test.
Results Ninety-one patients were included in the analysis – from
December 2010 to June 2011. Mean (± SD) age of the population was
71 ± 12 years, mean APACHE II score was 21 ± 7.6, mean duration of
MV was 2.6 ± 2 days and mean number of spontaneous breathing
trials was 1.3 ± 0.6. Extubation was performed in 33 SA patients (36%)
and 58 SP patients (64%), with a similar success rate of 82% and 85%,
respectively (P >0.05). Furthermore, no significant differences between
these groups were found in terms of APACHE II score, time of MV and
postextubation distress or complications.
Conclusion The outcomes of proceeding extubation in patients seated
in armchairs are similar to those extubated in supine position with the
head elevated. This new practice can be considered safe and allow
extubations to be performed simultaneously with early mobilization.
P130
Prediction of post-extubation failure by portable ICU ultrasound
Y Sutherasan, P Theerawit, T Hongpanat, C Kiatboonsri, S Kiatboonsri Figure 1 (abstract P131). Intermittent aspiration of pharyngeal secretion.
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Critical Care 2012, 16(Suppl 1):P130 (doi: 10.1186/cc10737) oropharyngeal secretion, we devised a suctioning method: intermittent
aspiration of pharyngeal secretion (IAPS). IAPS is a simple, low-cost
Introduction Stridor and vocal cord oedema are common in ICU technique utilizing an intermittent suction unit and a common
patients. Currently, the cuff leak volume test is a standard technique to suction tube (Figure 1), which may reduce the risk of re-intubation on
assess these complications [1,2]; however, wide variations in terms of extubated patients requiring supraglottic airway management.
its sensitivity and specificity have been demonstrated in many studies. Methods A retrospective study was performed on 24 patients who
Recently, ultrasound is a promising noninvasive method widely used in received IAPS after extubation from June 2009 to May 2011. A suction
ICU patients and allows visualization of the vocal cords and larynx [3]. tube was placed in the pharynx after extubation. The same suction unit
Thus, we would like to determine the diagnostic accuracy of portable used in intermittent subglottic secretion drainage was applied. IAPS is
ultrasound for detection of these post-extubation complications. effective for patients with large amounts of oropharyngeal secretion
Methods We conducted a prospective, observational study from (A), patients with poor laryngopharyngeal function (B), and patients
December 2010 to September 2011 using portable critical care unable to expel viscous sputum (C). Efficacy of IAPS in each of these
ultrasound to examine air-column width differences of vocal cords patient groups was studied.
before and after deflation of a endotracheal cuff balloon. All patients Results The average age was 64.3 ± 17.8 years, APACHE II score
also underwent cuff leak volume tests and vocal cord examination by 21.0 ± 7.7, and SOFA score 8.4 ± 3.1. Six patients were diagnosed
direct video laryngoscopy. with A, three with B, two with C, and others had multiple diagnoses.
Results We enrolled 101 patients with planned extubation. The overall Combinations with NPPV or cricothyroidotomy were also successful.
prevalence of post-extubation stridor and/or vocal cord oedema was Of the patients who required re-intubation, four were re-intubated
17%. Age, gender, duration of intubation and BMI were not different for reasons other than aspiration. Two had possibly aspirated. Among
between patients with and without post-extubation complications. patients receiving IAPS, the rate of re-intubation due to oropharyngeal
The average sizes of endotracheal tubes were similar in both groups aspiration was 8.3%. No major complication was observed.
(No. 7.5). The mean difference of increasing of air-column width in Conclusion IAPS is a potential method for supraglottic airway
patients without complications was considerably higher than those management after extubation that may reduce the re-intubation risk.
with complications (1.9 mm vs. 1.1 mm; P <0.001). The sensitivity IAPS is a simple method requiring common instruments. Combined
and specificity at air-column width differences ≥1.6 mm were 0.706 effects of IAPS with NPPV or cricothyroidotomy can modify airway
and 0.702 respectively. The positive predictive value and negative management. IAPS is a temporary method in which the exact timing
predictive value were 0.324 and 0.922. The area under the ROC curve of for re-intubation should not be missed. To successfully apply IAPS and
tracheal ultrasound was 0.823 (95% CI: 0.698 to 0.947) and that of the reduce aspiration, the suctioning method, duration of application and
cuff leak volume test was 0.840 (95% CI: 0.715 to 0.964). position of the suctioning tube should be further optimized.
Conclusion Portable ICU ultrasound visualising air-column width
differences between pre and post deflation cuff balloon is a promising
objective tool which aids in prediction of successful extubation. P132
References Efficacy of biphasic cuirass ventilation in the critical care
1. De Bast Y, De Backer D, Moraine JJ, et al.: The cuff leak test to predict failure department
of tracheal extubation for laryngeal edema. Intensive Care Med 2002, T Yamashita1, Y Taniwaki2, H Takayama2, Y Sakamoto1
1
28:1267-1272. Saga University, Saga, Japan; 2National Hospital Organization Nagasaki
2. Chung YH, Chao TY, Chiu CT, et al.: The cuff-leak test is a simple tool to Medical Center, Omura, Japan
verify severe laryngeal edema in patients undergoing long-term Critical Care 2012, 16(Suppl 1):P132 (doi: 10.1186/cc10739)
mechanical ventilation. Crit Care Med 2006, 34:409.
3. Ding LW, Wang HC, Wu HD, et al.: Laryngeal ultrasound: a useful method in Introduction Biphasic cuirass ventilation (BCV) assists ventilation by
predicting post-extubation stridor. A pilot study. Eur Respir J 2006, 27:384. applying intermittent or continuous negative pressure to the thorax.
BCV has been reported to improve lung function in various respiratory
P131 failures. However, to determine the therapeutic effect of BCV is difficult,
Intermittent aspiration of pharyngeal secretion for re-intubation because it is too difficult to include animal experiments. Therefore it is
prevention important to compile amounts of clinical cases for discussion. We have
T Nakamura, O Nishida, J Shibata, N Kuriyama, Y Hara, M Yumoto tried to find a way of developing BCV in critical care.
Fujita Health University School of Medicine, Toyoake, Japan Methods This is a retrospective, nonrandomized study. Before and after
Critical Care 2012, 16(Suppl 1):P131 (doi: 10.1186/cc10738) BCV, we compared pO2, pCO2, tidal volume, P/F ratio, respiratory index,
A-aDO2, shunt ratio, dead space ventilation rate, and chest X-ray. We
Introduction The inability of extubated patients to clear oropharyngeal also performed a questionnaire study about BCV which focused on
secretion increases the risk of re-intubation. To eliminate excessive physicians and nurses working in the ICU.
Critical Care 2012, Volume 16 Suppl 1 S48
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Results From April 2008 to May 2010, BCV was performed by applying Methods We used the Sensewear Armband (Bodymedia Inc., USA) to
RTX (Medivent Ltd, London, UK) for 18 patients admitted to the ICU, measure the Galvanic Skin Response (GSR) in 11 healthy volunteers (36
National Hospital Organization Nagasaki Medical Center. All of them to 53 years). The 60-second averages of each test condition were made
had acute respiratory failure, and 15 of them were intubated and after 20 minutes of stabilization. Test conditions were pre and post
mechanically ventilated. Thirteen were men, and the mean age was 68 baseline (no intervention), 10 cmH2O CPAP (Resmed, Sydney, Australia)
years (1 to 82 years). One case could not continue the treatment due to and 15 LPM HFT (TNI, Würzburg, Germany) both in room air. Repeated
discomfort of wearing the cuirass. We used the control mode (negative ANOVA with P <0.05.
pressure –21 cmH2O, positive pressure +7 cmH2O, I:E ratio 1:1). It Results There were no statistically significant differences in GSR
improved the tidal volume, P/F ratio, shunt ratio in all cases during between pre and post baselines. CPAP produced an increase in GSR
BCV (P <0.05). Skin damage caused by the cuirass was observed in one compared to both baselines (45%; P <0.05) and to HFT (41%; P <0.05).
case. According to the questionnaire survey, they had some problems HFT produced no significant change in GSR compared to baseline. See
about the durability of the urethane of the cuirass, too close to a thin Figure 1.
body or deformation. Some of them had no confidence because of Conclusion GSR is a measurement of the sympathetic component
unfamiliarity with the machine. of the autonomic nervous system. It is commonly referred to as the
Conclusion We conclude that BCV is also useful for respiratory care in ‘Fight or Flight’ response, and when elevated indicates a state of
the ICU. Further confirmation is needed regarding problems such as psychological or physiological stress. Our data suggest that CPAP
the criteria to start and terminate BCV. produces an increase in the GSR compared to rest, whilst TNI therapy
References produces no change in GSR compared to rest. This increased stress may
1. Chari S, King J, Rajesh PB, Stuart-Smith K: Resolution of left lower lobe lead to lower patient compliance when using CPAP therapy compared
collapse postesophagectomy using the Medivent RTX respirator, a novel to TNI therapy, which has very high patient compliance rates.
noninvasive respiratory support system. J Cardiothorac Vasc Anesth 2004,
18:482-485.
2. Dolmage TE, De Rosie JA, Avendano MA, Goldstein RS: Effect of external
chest wall oscillation on gas exchange in healthy subjects. Chest 1995,
107:433-439.
3. Ciesla ND: Chest physical therapy for patients in the intensive care unit.
Phys Ther 1996, 76:609-625. P134
4. Rocker GM, Mckenzie MG, Williams B, Logan PM: Noninvasive positive Management of acute bronchospasm respiratory distress with
pressure ventilation:successful outcome in patients with acute lung CPAP ventilation associated with nebulization in the prehospital
injury/ARDS. Chest 1999, 115:173-177. emergency setting
5. Hill NS: Clinical applications of body ventilators. Chest 1986, 90:897. J Cuny, C Berteloot, P Goldstein, E Wiel
CHRU de Lille, France
Critical Care 2012, 16(Suppl 1):P134 (doi: 10.1186/cc10741)
P138 P139
Good response on high nasal oxygen flow reduces the need for An audit of airway complications in a district general hospital ICU
intubation in adult respiratory failure JW Chan, KJ Turner, R Lloyd, R Howard-Griffin
L Van Wagenberg, IM Hoekstra, GC Admiraal, M Slabbekoorn Ipswich Hospital NHS Trust, Ipswich, UK
Medisch Centrum Haaglanden, Den Haag, the Netherlands Critical Care 2012, 16(Suppl 1):P139 (doi: 10.1186/cc10746)
Critical Care 2012, 16(Suppl 1):P138 (doi: 10.1186/cc10745)
Introduction The 4th National Audit Project of The Royal College of
Introduction High nasal flow (HNF) therapy has proven its efficiency Anaesthetists and The Difficult Airway Society (NAP4) highlighted
in acute respiratory failure when compared to conservative oxygen the increased incidence of airway-related complications in an ICU
therapy [1]. This study was performed to find a responding and setting [1]. The aim of this audit was to establish our local ICU airway
nonresponding group on HNF therapy in adults with hypoxic respiratory intubation complication rate as well as our compliance with the NAP4
insufficiency measured by oxygenation and work of breathing. recommendation that continuous capnography should be used on all
Methods A prospective observational study during a 6-month period intubated patients.
in patients ≥18 years with acute hypoxic respiratory failure when Methods All intubated patients who were admitted to the Ipswich
conservative oxygen therapy (15 l/minute) failed. Arterial blood gas Hospital ICU between April and December 2010 were identified and
analysis was done before HNF therapy and after 1 hour on flow 50 l/ data relating to basic demographics, airway management and the use
minute with FiO2 1.0. Breaths per minute and saturation were noted. of capnography were collected. An airway was classed as difficult if
When patients remained respiratory insufficient they were intubated. there were two or more attempts at intubation, a bougie was used, or
Results A total of 20 patients was included. Mean age 63.95 ± 3 years it was Cormack–Lehane grade III/IV. Complications arising from airway
and APACHE II score 23 ± 7. Mean PaO2/FiO2 (P/F) ratio on admission was intubation were also noted.
77.7 ± 4.2. A total of seven out of 20 patients (35%) needed endotracheal Results A total of 139 intubations on 118 patients were identified.
intubation. After 1 hour of HNF therapy PaO2 and saturation measured Fifty-eight (42%) intubations occurred on the ICU, 41 (29%) in the
in arterial blood gas significantly increased from respectively 8.9 ± 0.3 emergency department (ED) and five (4%) on the ward; 29 (21%)
kPa to 16.1 ± 2.4 kPa (P = 0.023) and from 91.8 ± 1.2% to 96.5 ± 0.8% intubations occurred in theatre for surgery and six (4%) out of hospital.
(P = 0.001). Work of breathing, measured by the frequency of breathing, Of the 104 intubations on the ICU, ED or ward, nine (9%) were classed as
significantly decreased from 35 ± 3 times a minute to 22 ± 2 times a difficult and there were 21 (20%) documented complications (hypoxia,
minute. The group that was in need of endotracheal intubation showed hypotension, oesophageal intubation, cardiac arrest and aspiration).
a less prominent response to 1-hour HNF therapy, expressed in PaO2 Complication rates were similar across junior trainees, senior trainees
(13.2 ± 2.6 kPa vs. 16.1 ± 3.4 kPa, P = 0.548), saturation (94.4 ± 1.6% and consultants. Only 27% of all intubated patients received continuous
vs. 96.5 ± 0.8%, P = 0.228) and breathing frequency (25 ± 2.4/minute capnography.
vs. 22 ± 2/minute, P = 0.357). The duration of HNF therapy was Conclusion Our findings are consistent with the NAP4 view that airway
26.1 ± 6.3 hours in the nonintubated group and 15.1 ± 9.8 hours for management outside the controlled confines of a theatre setting has
those who were intubated (P = 0.345). the potential to be more difficult. Steps should be taken to minimise
Conclusion All included patients did have a reduced P/F ratio and are the risk associated with this procedure, including a thorough airway
therefore to be considered severely respiratory compromised. PaO2 assessment, use of continuous capnography and the presence of
and saturation increased with the use of HNF therapy, while work suitably trained operators and assistants. The finding that complications
of breathing decreased. These changes were less prominent in the occurred at a similar rate regardless of the seniority could be explained
nonresponding group (Figure 1). The nonresponders, except one, were by more senior staff intubating the most unwell patients.
intubated within 15 hours after the start of HNF therapy. Reference
Reference 1. Cook TM, et al.: Br J Anaesth 2011, 106:632-642.
1. Roca et al.: Respir Care 2010, 55:408-413.
P140
Multidisciplinary care for patients with tracheostomy shortened
time to decannulation
A Van Hees, F Van Beers, J Van Rosmalen, D Ramnarain,
W Van den Wildenberg
St Elisabeth Hospital, Tilburg, the Netherlands
Critical Care 2012, 16(Suppl 1):P140 (doi: 10.1186/cc10747)
out of 125 (34%) of cases were associated with alcohol abuse, 14/125 patients. We investigated the epidemiology of dysnatremia in a large
(11%) with malnutrition, 26/125 (21%) with use of diuretics and 9/125 cohort of surgical ICU patients and evaluated the possible influence
(7%) with use of psychoactive medication; none of these characteristics of the time of acquisition of dysnatremia and fluctuations in serum
were significantly related to outcome. The sodium concentration on sodium concentrations on hospital mortality in these patients.
admission was 107.3 ± 9.6 in the patients with a favourable outcome Methods All patients admitted to the ICU between January 2004 and
versus 108.4 ± 9.4 in the patients with a poor outcome (P = 0.54). The January 2009 were included retrospectively in this study. Hyponatremia
speed of sodium correction was 1.12 ± 1.6 mmol/hour versus 1.16 ± 0.9 was defined as a serum sodium concentration (sNa) <135 mmol/l and
mmol/hour respectively in the favourable and poor outcome cases hypernatremia as a sNa >145 mmol/l. Hyponatremia was defined as a
(P = 0.19). The highest sodium concentration after correction was sNa less than 135 mmol/l and hypernatremia as a sNa greater than 145
significantly higher in the patients with a poor outcome (139.0 ± 9.3 mmol/l. Patients were classified according to the onset of dysnatremia
vs. 134.0 ± 7.3, P = 0.003). Serum osmolality, and concentrations of into those who had abnormal sodium concentrations in the initial
potassium, chloride, creatinin and glucose were comparable between blood sample, analyzed within 2 hours of admission to the ICU, or those
the outcome groups. The development of tetraparesis (55/125 (44%), acquiring dysnatremia thereafter. We performed a logistic regression
P = 0.02) or a decreased level of consciousness (58/125 (46%), P <0.001) multivariate analysis with hospital outcome as the dependent factor to
were associated with a poor outcome. In contrast, mutism or dysarthria investigate the possible influence of dysnatremia on hospital outcome.
(82/125 (66%), P = 0.002), tremors (29/125 (23%), P = 0.001) or ataxia Results Of the 10,923 surgical ICU patients included in the study, 1,215
(58/125 (46%), P <0.001) were associated with a favourable outcome. (11.2%) had hyponatremia and 277 (2.5%) hypernatremia at admission
Conclusion The highest serum sodium concentration during sodium to the ICU. Among patients with normonatremia at admission to the
correction rather than the speed of sodium correction or severity of ICU (n = 9,431), the incidence of ICU-acquired dysnatremia was 31.3%.
the hyponatremia is a determinant of outcome in patients with ODS. Dysnatremia present at ICU admission (OR = 2.53; 95% CI: 2.06 to
The development of tetraparesis and decreased consciousness are 3.12, P <0.001) and ICU-acquired dysnatremia (OR = 2.06; 95% CI: 1.71
associated with a poor outcome in these patients. to 2.48, P <0.001) were independently associated with an increased
risk of in-hospital death. Dysnatremia at ICU admission (OR = 1.23;
95% CI: 1.01 to 1.50) was associated with a higher risk of in-hospital
P144 death, compared to ICU-acquired dysnatremia. Fluctuation in serum
Is inappropriate secretion of anti-diuretic hormone (SIADH) the sodium concentration was also independently associated with an
cause of hyponatremia in Legionella pneumonia? increased risk of in-hospital mortality; both in patients who remained
P Schuetz, S Haubitz, B Mueller, for the ProHOSP Study Group normonatremic (>6 mmol/l/ICU stay) and those with dysnatremia
Medical University Clinic, Kantonsspital Aarau, Switzerland (>12 mmol/l/24 hours or >12 mmol/l/ICU stay).
Critical Care 2012, 16(Suppl 1):P144 (doi: 10.1186/cc10751) Conclusion Dysnatremia was common in surgical ICU patients and
was independently associated with an increased risk of in-hospital
Introduction Medical textbooks list Legionella as a differential death in these patients. Dysnatremia at ICU admission was associated
diagnosis for the syndrome of inadequate anti-diuretic hormone (ADH) with a higher risk of death compared to ICU-acquired dysnatremia.
secretion (SIADH), but empirical evidence supporting this association Fluctuations in serum sodium concentrations were independently
is largely lacking. Partly this is explained by the analytical challenges of associated with an increased risk of in-hospital death, even in patients
ADH measurement. With the recent availability of an immunoassay that who remained normonatremic during the ICU stay.
measures the more stable ADH precursor peptide (CT-ProVasopressin),
we sought to investigate whether increased ADH levels would explain
hyponatremia found in Legionella patients. P146
Methods We measured CT-ProVasopressin and sodium levels in Impact of ketogenesis and strong ion difference on acid–base in our
a prospective cohort of 925 pneumonia patients from a previous CICU
multicenter study with 31 patients having positive antigen tests for T Clark, B McGrath, P Murphy, M Jayarajah
Legionella pneumophilia. We calculated Spearman rank correlations Derriford Hospital, Plymouth, UK
and multivariate regression models. Critical Care 2012, 16(Suppl 1):P146 (doi: 10.1186/cc10753)
Results Legionella patients had higher rates of hyponatremia
(sodium <130 mmol/l) (43% vs. 8%, P <0.01), but similar median CT- Introduction Persistence of a mild metabolic acidosis or base deficit
ProVasopressin levels (pmol/l) (20 (12 to 26) vs. 26 (13 to 53), P = 0.89) was occasionally observed in our otherwise well patients post cardiac
compared to pneumonia of other etiology. In Legionella patients, high surgery, sometimes delaying discharge. We hypothesised that this
CT-ProVasopressin was not associated with low sodium levels, but metabolic abnormality may be due to either ketogenesis caused by a
showed a positive correlation with sodium levels (r = 0.42, P <0.05). combination of starvation and the surgical stress response, or strong
Independent of pneumonia etiology, CT-ProVasopressin were ion imbalances following fluid administration. The administration
significantly correlated with the pneumonia severity index (r = 0.56, of large volumes of chloride-rich fluids (as may occur during cardiac
P <0.05) and showed an association with risk for ICU admission (odds surgery to prime the cardiopulmonary bypass circuit or resuscitate
ratio per decile, 95% CI) (1.4, 1.2 to 1.6) and 30-day mortality (1.3, 1.2 the patient) is known to induce hyperchloraemic metabolic acidosis
1.4). [1]. Using simplifications of the original Fencl–Stewart’s equations,
Conclusion We found no evidence that increased ADH secretion would it is possible to partition the base deficit into its constituent parts,
explain low sodium levels in Legionella patients, or other pneumonia subsequently determining the relative contribution of chloride,
patients, challenging the common believe of Legionella causing albumin and unmeasured anions to acidosis [2,3]. Ketone production
SIADH. Rather, ADH precursors were upregulated as a response to may contribute significantly to the unmeasured anion component.
severe disease. Future studies continuing to explore the cause of Methods A prospective cohort analysis. Fifty postoperative cardiac
sodium disturbance in Legionella are warranted. patients were recruited. For each we measured urinary ketones three
times per day for the first 48 hours of their CICU admission. Arterial
blood gas (ABG) data were recorded in conjunction each time. For
P145 each blood gas we partitioned the base deficit into its constituent
Fluctuations in serum sodium level are associated with an increased components using previously published equations [1-3].
risk of death in surgical ICU patients Results A total of 231 ABGs were analysed. Urinary ketones were
Y Sakr, S Rother, AM Ferreira, C Ewald, P Dünich, K Reinhart checked along with 181 of the ABGs. A total of 14 ketonuria checks
Friedrich Schiller University Hospital, Jena, Germany were positive (8%) in 11 patients (22%). In nine ABGs ketonuria was
Critical Care 2012, 16(Suppl 1):P145 (doi: 10.1186/cc10752) associated with a significant base deficit, whilst in three it was also
associated with a metabolic acidosis. The average starvation time was
Introduction Dysnatremia may have an impact on outcomes in critically 39 hours (SD 11 hours). In 121 (52%) ABGs the chloride component
ill patients, but this has not been widely investigated in surgical ICU of the base deficit (BECl) was below –2. In 104 (45%) ABGs the BECl
Critical Care 2012, Volume 16 Suppl 1 S53
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contributed to greater than 75% of the BETOTAL, whilst in 74 (32%) of Methods During a 12-month period, three patients on our ICU with
these the BECl was greater than the BETOTAL. In 18 ABGs a BECl of less unexplained high anion gap metabolic acidosis had their urine
than –2 caused a metabolic acidosis. screened for organic acids.
Conclusion Our observation of persistent metabolic abnormalities Results All had chronic methicillin-sensitive Staphylococcus aureus
in otherwise well postoperative cardiac patients may be due to infections treated with long-term paracetamol and flucloxacillin. All
iatrogenic strong ion imbalances caused by hyperchloraemic solutions. cases presented to intensive care with reduced level of consciousness
Ketogenesis was not a significant contributing factor. The impact of after several weeks of treatment. In each case, common causes of high
relative hyperchloraemia on pH was buffered by other counteracting anion gap metabolic acidosis were excluded and urine specimens
metabolic factors (for example, hypoalbuminaemia), as in 74 ABGs the contained grossly elevated levels of pyroglutamic acid. Flucloxacillin
BECl was greater than the BETOTAL. and paracetamol were stopped and N-acetylcysteine commenced,
References which led to resolution of the metabolic acidosis within 48 hours. All
1. Taylor et al.: Intensive Care Med 2006, 32:295-301. three patients made full recoveries. The first case has been previously
2. Story et al.: Br J Anaesth 2004, 92:54-60. described [2].
3. O’Dell et al.: Crit Care 2005, 9:R464-R470. Conclusion Pyroglutamic acidosis is an uncommon condition, but
should be considered in a high anion gap metabolic acidosis of
unknown cause. The incidence in critical care may be more prevalent
P147 due to lack of screening currently. It is associated with sepsis, hepatic
Buffer therapy in metabolic acidosis after surgery-associated and renal dysfunction [3], and in patients who are receiving drugs such
hemorrhage in pediatric oncology as paracetamol and flucloxacillin. If known precipitants are stopped,
N Matinyan, A Saltanov, I Letyagin, O Obukhova the condition can be rapidly reversed with full patient recovery.
N.N. Blokhin Russian Cancer Research Center, Moscow, Russia References
Critical Care 2012, 16(Suppl 1):P147 (doi: 10.1186/cc10754) 1. Croal BL, et al.: Clin Chem 1998, 44:336-340.
2. Myall K, et al.: Lancet 2011, 377:526.
Introduction Surgery in pediatric oncology is usually massive and 3. Peter J, et al.: Med J Aust 2006, 185:223-225.
traumatic and often leads to acute blood loss, which can result in
metabolic acidosis. To treat acidosis, sodium bicarbonate is often used;
however, its application has some side effects. In this situation tris-
hydroxymethyl aminomethane (THAM) seems to be more effective. P149
The objective of this study was to evaluate the effect of THAM for Metabolic acid–base disturbances in patients in the emergency
treating metabolic acidosis after surgery-associated hemorrhage in department
pediatric oncology. EM Antonogiannaki, E Lilitsis, D Georgopoulos
Methods The observational study included 50 children aged 12 months University Hospital of Heraklion, Greece
to 16 years (among them 27 boys) with metabolic acidosis after surgery- Critical Care 2012, 16(Suppl 1):P149 (doi: 10.1186/cc10756)
associated hemorrhage: 40% patients lost 58 ± 8.5% of total blood
volume, 26% lost 150 ± 9.5% of total blood volume. Patients received Introduction The aim of the present study is to determine in
3.66% THAM infusion. The dose of THAM infusion was calculated as unselected patients that visit the emergency department whether
the dose administered (ml):negative standard BE (mmol/l)×kg body the physicochemical approach improves the ability to diagnose acid–
weight, and did not increase 1.5 ml/kg body weight every 24 hours. base disorders compared with the two commonly used diagnostic
The following were analyzed: Na+, K+, ionized calcium, lactate, pH, pCO2, approaches; one relying on the plasma bicarbonate concentration
HCO3 and BE of arterial blood, before therapy, and after receiving a one- (HCO3–) and anion gap (AG), and the other on the base excess (BE).
half dose and a full dose of THAM. The significance of differences was Methods A prospective observational study took place in the
assessed by Student’s t test, Mann–Whitney coefficient and chi-square emergency department at a university hospital during the period of
test; P <0.05 was considered statistically valid. March to September 2011. Three hundred and sixty-five patients were
Results There were no differences in the concentrations of electrolytes included. Arterial and venous samples were drawn for blood gases and
and lactate. At the stages of the research the following significant a serum biochemical panel, respectively. The decision to collect arterial
dynamics have been noted: pH (7.27 ± 0.01; 7.31 ± 0.01; 7.35 ± 0.01; samples was made by the attending physician in the emergency
P <0,01), HCO3 (18.59 ± 0.26; 19.5 ± 0.3; 21.2 ± 0.41 mmol/l; P <0.01) department who was not involved in the study.
and BE (–8.34 ± 0.3; –6.58 ± 0.37; –4.47 ± 0.45 mmol/l; P <0.01). PaCO2 Results All patients were admitted to the hospital, while 103 of them
tension did not change significantly (38.9 ± 0.83; 37.3 ± 0.94; 37.5 ± 0.95 (28%) were transferred directly to the ICU. Hypoalbuminemia (serum
mmHg; P >0.05). albumin ≤35 g/l) was observed in 191 patients (52%). The BE and HCO3–
Conclusion THAM infusion resulted in metabolic acidosis correction were normal in 35% and 38% of the total patients, respectively. The
without the development of hypernatremia and increase of CO2 corresponding values in patients admitted to the ICU were 41% and
tension. However, the small number of observations does not allow 28%. In a significant proportion of patients in whom BE and/or HCO3–
one to assess accurately the clinical effect of THAM for these patients. were normal the physicochemical approach detected the presence
of acidifying and/or alkalinizing disturbances. Hypoalbuminemia
(metabolic alkalosis) was identified in 45% of patients with normal
P148 HCO3– and 48% of patients with normal BE. Strong ion difference (SID)
An unusual cause of high anion gap metabolic acidosis: acidosis (SID ≤36 mEq/l) was observed in 49% and 44% of patients
pyroglutamic acidosis with normal HCO3– and BE, respectively. A high unmeasured strong
RJ Wardell, LA Burrows, K Myall, A Marsh ion concentration ([XA–] ≥8 mEq/l, metabolic acidosis) was observed in
Frenchay Hospital, Bristol, UK 48% of patients with normal HCO3– and in 52% of patients with normal
Critical Care 2012, 16(Suppl 1):P148 (doi: 10.1186/cc10755) BE. Patients in whom hidden acidosis of high unmeasured strong
anion type was observed were identified by the common diagnostic
Introduction Metabolic acidosis is a common acid–base disturbance in approach only using the AG adjusted for hypoalbuminemia (AGadj
intensive care. A high anion gap indicates the presence of endogenous ≥13 mEq/l). Patients who were admitted to clinical wards with acidosis,
acids, which in critically ill patients are most commonly ketones, other than hyperchloremic, remained significantly more days in the
lactate and those accumulated in renal failure. However, excluding hospital than those without the disturbance.
these causes means more rare forms of acid must be considered, Conclusion Hypoalbuminemia is a common finding in patients in
including pyroglutamic acidosis. Pyroglutamic acidosis is caused by the the emergency department and complicates the interpretation of
accumulation of 5-oxoproline [1] due to the depletion of glutathione. acid–base data using the common diagnostic approaches. A physico-
This leads to loss of negative feedback and therefore the build-up of chemical approach may better identify metabolic disturbances in this
Y-glutamyl cysteine, which is converted to 5-oxoproline. population.
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The aim of our study was to evaluate the relationship between 25-OH P155
vitamin D deficiency at admission and the outcome in a medical ICU. Reduced cortisol metabolism drives hypercortisolism in critical
Methods A prospective observational study in a 10-bed medical ICU at illness
an inner-city hospital in Brussels. Patients with an expected stay in ICU E Boonen1, H Vervenne1, P Meersseman2, L Mortier3, YM Vanwijngaerden1,
>48 hours were included. I Spriet2, L Langouche1, I Vanhorebeek1, G Van den Berghe1
1
Results Vitamin D deficiency was defined as a serum 25-OH vitamin D KU Leuven, Belgium; 2University Hospitals, Leuven, Belgium; 3Virga Jesse
concentration <20 ng/ml. The study was conducted between February Hospital, Hasselt, Belgium
and August 2011. A total of 105 patients were included. Dosages were Critical Care 2012, 16(Suppl 1):P155 (doi: 10.1186/cc10762)
performed on day 3 (2, 4) (median, interquartiles). The number of
patients with 25-OH vitamin D <10 ng/ml, between 10 and 20 ng/ml, Introduction Critical illness is hallmarked by elevated cortisol levels,
between 20 and 30 ng/ml and >30 ng/ml was respectively 56, 26, 14 reflecting the severity of illness. Paradoxically, previous studies
and 9. No differences were seen between deficient and nondeficient reported suppressed ACTH, implicating another mechanism driving
patients if we compare SAPS III (58 ± 13 vs. 60 ± 15), predicted mortality elevated cortisol during critical illness. We hypothesized that cortisol
(34 ± 21% vs. 40 ± 25%), intra-ICU mortality (8.5 vs. 8.7%), intrahospital metabolism is reduced in critical illness, in part via elevated bile acids,
mortality (19.5 vs. 21.7%), mean length of stay in the ICU (10 days ± 8), which may explain the paradoxical ACTH–cortisol dissociation by
and median SOFA score during the first 5 days (5, 4, 4, 3, 3 vs. 4, 4, 3, negative feedback inhibition.
3, 4). A higher (but nonsignificant) prevalence of sepsis was found at Methods In a first clinical study (n = 59), we determined the time
admission in deficient patients (42/82 patients vs. 8/23 patients). Eleven course of ACTH and cortisol levels during the first week in the ICU. In a
deficient patients were treated with oral vitamin D (25,000 units/day) second study (n = 28), we calculated the plasma half-life of exogenous
for 5 days. After treatment, 25-OH vitamin D was above 20 ng/ml in cortisol in critically ill patients. In a third clinical study (n = 51), urinary
seven patients (31 ± 14 ng/ml). If we adjust groups for vitamin D post cortisol metabolites were quantified to estimate the activity of cortisol
treatment, no differences were found if we compare deficient versus metabolizing enzymes. In a fourth study (n = 64), we quantified the
nondeficient patients for intra-ICU mortality (9.3% vs. 6.6%) and intra- major cortisol metabolizing enzymes in the liver and adipose tissue
hospital mortality (14.6% vs. 23.3%). in relation to circulating cortisol and bile acids. We performed every
Conclusion Our study confirmed the high prevalence of vitamin D study in a similar, heterogeneous ICU population, in comparison with a
deficiency in ICU patients but not the association with an excess of healthy control group matched for age, gender and BMI.
mortality. Results In the presence of elevated total cortisol, ACTH remained much
Reference lower in patients than in healthy controls (P <0.001), confirming the
1. Lee P, et al.: N Engl J Med 2009, 360:1912-1914. ACTH–cortisol dissociation during critical illness. Cortisol half-life was
substantially prolonged in patients compared to controls. Based on
urinary metabolites, the activity of 5α-reductase and 5β-reductase was
significantly lower in patients than controls (P <0.0001). Furthermore,
P154 the calculated activity of 11-hydroxysteroid dehydrogenase type
Plasma levels of Coenzyme Q10 are reduced in critically ill patients 2 was reduced (P <0.0001). In the liver, gene and protein expression
as compared to healthy volunteers and correlate with age of 5α-reductase and 5β-reductase was reduced (P <0.0001) and
A Coppadoro1, L Berra2, A Kumar2, M Yamada2, R Pinciroli2, E Bittner2, correlated inversely with circulating cortisol. Moreover, the enzyme
U Schmidt2, M Kaneki2 expression correlated inversely with circulating levels of conjugated
1
University of Milan-Bicocca, Monza, Italy; 2Massachusetts General Hospital, bile acids, which were markedly elevated in patients [1] and which have
Boston, MA, USA been shown capable of suppressing expression and activity of cortisol
Critical Care 2012, 16(Suppl 1):P154 (doi: 10.1186/cc10761) metabolizing enzymes [2].
Conclusion Reduced expression and activity of cortisol metabolizing
Introduction The purpose of this study is to investigate Coenzyme enzymes, possibly driven by elevated bile acids, contributes to the
Q10 (Q10) levels in critically ill patients as compared to healthy hypercortisolism in the critically ill, which explains the increased
volunteers. Q10 is an essential cofactor for the electron transport cortisol plasma half-life and feedback-inhibited ACTH release. Reduced
chain reactions necessary for the aerobic cellular respiration. Q10 cortisol metabolism could inferentially suppress the cortisol response
insufficiency, therefore, leads to mitochondrial dysfunction. It also acts to an ACTH stimulation test, thereby reducing its diagnostic value for
as an antioxidant. Oxidative state is prominent in critically ill patients, adrenal failure.
favoring the production of oxygen-free radicals. A recent study showed References
reduced Q10 levels in septic shock patients [1]. 1. Vanwijngaerden et al.: Hepatology 2011, 54:1741-1752.
Methods We recruited 18 healthy volunteers and 36 critically ill 2. McNeilly et al.: J Hepatol 2010, 52:705-711.
patients in the surgical ICU of the Massachusetts General Hospital.
Ethical committee approval and written informed consent were
obtained. At the moment of blood sampling, height, weight, and age
as well as clinical data were collected. Plasma total Q10 concentrations P156
were measured by high-performance liquid chromatography. The Effect of low-dose hydrocortisone on the expression of
Assessment of Daily Living (ADL) score was obtained after discharge. glucocorticoid receptor alpha of the septic kidney in rats and its
Results Patients’ age and gender did not differ as compared to healthy protective effect on kidney injury
volunteers (P = NS). Plasma Q10 levels were lower in critically ill patients DW Wu, HP Guo
as compared to healthy volunteers (0.81 ± 0.22 vs. 0.50 ± 0.36 μg/ml, Qilu Hospital of Shandong University, Jinan, Shandong, China
P <0.001). In critically ill patients, plasma Q10 levels inversely correlated Critical Care 2012, 16(Suppl 1):P156 (doi: 10.1186/cc10763)
with age (R = 0.40, P = 0.015). Lower levels of plasma Q10 (<0.4 μg/
ml, median) were associated with lower ADL score after discharge Introduction Inflammation out of control caused by sepsis can
(P = 0.005). In our patient population, plasma Q10 levels were not eventually lead to multiple organ dysfunction, of which the kidney
related to PaO2/FiO2, septic shock, SAPS 2 at ICU admission, SOFA score is one of the most common injured organs. Sepsis-induced acute
or mortality (all P = NS). kidney injury (SI-AKI) can obviously increase the mortality of sepsis. At
Conclusion Plasma Q10 levels are reduced in critically ill patients, present, there are controversial views about the impact of exogenous
suggesting reduced antioxidant capacity. Older patients seem to be glucocorticoid to SI-AKI on kidney pathological changes and
more prone to exhibit low Q10 levels. Oral supplementation might be glucocorticoid receptor (GR) expression. So, we want to investigate
considered for those patients. whether low-dose glucocorticoid has a protective effect on SI-AKI and
Reference what is the mechanism.
1. Donnino MW, et al.: Coenzyme Q10 levels are low and may be associated Methods Healthy Wistar male rats were randomly divided into a sham
with the inflammatory cascade in septic shock. Crit Care 2011, 15:R189. group, SI-AKI group and SI-AKI hydrocortisone group (HC group). The
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SI-AKI model was reproduced using the cecum ligation and puncture P158
method. Pathological changes of the kidney were detected by H & E Nutritional status of patients occupying ICUs in the state of Rio de
staining. The expression of GRα and NF-κB in the kidney was detected Janeiro
by immunohistochemistry. The levels of IL-1, IL-6, TNFα and IL-10 in the SO Oliveira1, R Goldwasses2, U Melo3, M Bandeira4, F Dessa5, R Almeida1,
plasma were detected by ELISA. I Kouh6
1
Results The survival rate of the AKI group and HC group showed Albert Schweitzer State Hospital, Rio de Janeiro, Brazil; 2Healh Provider
no statistical difference (P >0.05). H & E stain showed renal tubular State Government, Rio de Janeiro, Brazil; 3Alberto Torres State Hospital, São
epithelial cells swelling and falling off, and the tubular brush border Gonçalo, Brazil; 4Real Cordis Hospital, Rio de Janeiro, Brazil; 5Bangu Hospital,
disappeared and vacuolated in the AKI group. Pathological changes of Rio de Janeiro, Brazil; 6UFRJ University Hospital, Rio de Janeiro, Brazil
the renal tubular could be alleviated after hydrocortisone treatment. Critical Care 2012, 16(Suppl 1):P158 (doi: 10.1186/cc10765)
Compared with the AKI group, immunohistochemistry showed that
GRα expression was increased and NF-κB expression was decreased in Introduction Nutritional status and anemia influence the clinical
the HC group (P <0.01). The level of TNFα, IL-6, and IL-1 were reduced course of hospitalized patients. Anemia appears in the first days of
and the level of IL-10 was increased in the HC group compared with the hospitalization and can sustain itself and grow worse over time and
AKI group (P <0.01). is caused by a number of factors such as dilution secondary to fluid
Conclusion Low-dose hydrocortisone can inhibit the NF-κB activity, replacement, hemolysis, abnormalities in iron metabolism, blood loss
possibly in part by increasing the expression of GRα in renal sepsis in the gastrointestinal tract and also due to decreased production of
rats. Accordingly, it could reduce the production of inflammatory erythropoietin, a consequence of decreased erythropoiesis caused by
factors participating in sepsis, effectively inhibit the inflammation and the presence of inflammatory cytokines.
extenuate the sepsis-induced renal pathological changes. Methods A cross-sectional study on 30 November, patients >18 years.
References Evaluated characteristics of all patients admitted with age, sex, APACHE
1. Robter W, et al.: N Engl J Med 2004, 351:159-169. II score, mean length of stay, cause of hospitalization in mechanical
2. Rittirsch D, et al.: Nat Protoc 2009, 4:31-36. ventilation, organ failure, sedation and analgesia, coma and underuse
3. Leelahavanichkul A, et al.: Am J Physiol Renal Physiol 2008, 295:1825-1895. of vasoactive drugs.
Results The study included 247 patients hospitalized in ICUs, mean
age 63 years and 60% (148 patients) were male. Sepsis was the most
frequent cause of hospitalization at 57% and the average hospital
stay was 16 days. The rate of albumin and mean hemoglobin level
were respectively 2.1 and 9.5 g/dl. For those patients hospitalized over
10 days were observed average levels of 1.5 and 8.9 g/dl. For mechanical
ventilation in patients with septic shock the results were 1.4 and
7.9 g/dl with a mean hospital stay of 14 days. The postoperative group
P157 was the highest level observed at 2.6 and 10.4 g/dl and mean total
Hydrocortisone increases the risk of dysglycemia in critically ill time of hospitalization of 5 days. The worst results based on diagnosis
patients were respectively pulmonary septic shock, ischemic hemispheric brain
RT Van Hooijdonk, JM Binnekade, RE Harmsen, MJ Schultz stroke and cardiogenic shock. All patients with length of stay over
Academic Medical Center, Amsterdam, the Netherlands 11 days resulted in a clinically malnourished state.
Critical Care 2012, 16(Suppl 1):P157 (doi: 10.1186/cc10764) Conclusion The age, length of stay and diagnosis associated with
the level of organ dysfunction are key factors to progress to the state
Introduction Hyperglycemia and hypoglycemia are independently of malnutrition. The multidisciplinary team has an ongoing role in
associated with mortality and morbidity of critically ill patients [1,2]. controlling the supply of proteins and calories with essential nutrients
Critically ill patients frequently receive hydrocortisone for refractory in order to improve the provision, preventing complications and
shock. While hydrocortisone infusion is associated with hyperglycemia adverse outcomes.
[3], the effect of hydrocortisone on the incidence of hypoglycemia is Reference
uncertain. We hypothesized hydrocortisone infusion to increase the 1. Heymsfield SB, Baumgartner RN, Pan FS: Nutritional assessment of
risk of hyperglycemia and hypoglycemia in critically ill patients. malnutrition by anthropometric methods. Treaty of Modern Nutrition in
Methods Blood glucose measurements (n = 73,400) of patients Health and Disease. Edited by Shils M, Olson JA, Shike M, Ross C. New York:
admitted to the ICU from January 2007 to December 2009 (n = 2,167) Manole; 2003.
were analyzed. Logistic regression was used to analyze the effect of
hydrocortisone infusion on mild (blood glucose level ≥150 mg/dl) and
severe hyperglycemia (≥180 mg/dl) and mild hypoglycemia (≤70 mg/
dl) separately. To adjust for severity of disease, patients were stratified P159
in APACHE II score groups (<15; 15 to 24; >24). Investigating diarrhoea on the ICU: a retrospective study
Results Hydrocortisone infusion was independently associated with N Tirlapur, M Kelsey, H Montgomery
mild hypoglycemia (APACHE II score <15, OR 2.40, 95% CI 2.01 to 2.85; Whittington Hospital, London, UK
APACHE II score 15 to 24, OR 1.53, 95% CI 1.44 to 1.62; APACHE II score Critical Care 2012, 16(Suppl 1):P159 (doi: 10.1186/cc10766)
>24, OR 1.10, 95% CI 1.05 to 1.15) and severe hyperglycemia in all
APACHE II groups (APACHE II score <15, OR 3.26, 95% CI 2.59 to 4.10; Introduction Diarrhoea is common in ICU patients, with a reported
APACHE II score 15 to 24 OR 1.45, 95% CI 1.33 to 1.68; and APACHE II prevalence of 15 to 38% [1]. Many factors may cause diarrhoea,
score >24 OR 1.09, 95% CI 1.02 to 1.17). Hydrocortisone infusion was including Clostridium difficile, drugs (for example, laxatives, antibiotics),
independently associated with mild hypoglycemia in patients with faecal impaction with overflow and enteral feeds. Diarrhoea increases
APACHE II score 15 to 24 (OR 1.74, 95% CI 1.42 to 2.13) and >24 (OR nursing workload, impacts on patient dignity, increases costs and
1.64, 95% CI 1.42 to 1.90), but not in patients with APACHE II score <15 exacerbates morbidity through dermal injury, impaired enteral uptake
(OR 1.83, 95% CI 0.94 to 3.55). and subsequent fluid imbalance. We aimed to identify prevalence, yield
Conclusion Hydrocortisone increases the risk of dysglycemia in of stool investigations and clinical impact of diarrhoea on our ICU.
critically ill patients. Whether these dysglycemic effects diminish the Methods A retrospective observational study of all ICU patients
beneficial effects of hydrocortisone treatment should be investigated treated in a 15-bed district general hospital from 1 January 2010 to 31
in future studies. December 2010 was performed. ICU patients from whom stool samples
References had been sent for microbiological analysis (including microscopy and
1. Krinsley JS, et al.: Crit Care Med 2007, 35:2262-2267. C. difficile toxin (CDT)) were assumed to have suffered diarrhoea. Stool
2. Bagshaw SM, et al.: Crit Care Med 2009, 37:463-470. sample results were compiled with patient demographics, ICU length
3. Annane D, et al.: JAMA 2009, 301:2362-2375. of stay (LOS) and mortality data.
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Results Of 782 patients (mean age ± 2SD 62.1 ± 37.1, 52.3% female) P161
treated on our ICU, 334 stool samples were sent from 133 (17.0%) Frequency, determinants and impact of feed intolerance amongst
patients. Two samples (0.6%) yielded abnormal results: one out of the critically ill
131 (0.8%) patients with CDT samples sent and one out of 108 (0.9%) U Gungabissoon1, K Hacquoil1, C Bains1, G Dukes2, M Irizarry3, D Heyland3
1
patients with stool microscopy samples sent had a positive sample. The GlaxoSmithKline, Stockley Park, UK; 2GlaxoSmithKline, Research Triangle Park,
prevalence of C. difficile (1/782) and other organisms (1/782) was 0.1% NC, USA; 3CERU, Queen’s University, Kingston, Canada
and 0.1% respectively. In terms of diagnostic yields, positive findings Critical Care 2012, 16(Suppl 1):P161 (doi: 10.1186/cc10768)
were found in one out of 191 (0.5%) CDT samples and one out of
141 (0.7%) stool microscopy samples (for Candida). When compared Introduction Provision of early and adequate enteral nutrition (EN)
to patients without diarrhoea, sufferers were older (64.1 ± 33.2 vs. to critically ill patients is associated with improved clinical outcomes;
61.7 ± 37.8 years, P = 0.16) with greater female preponderance (55.6% however, 50 to 60% of prescribed EN is received. We aimed to
vs. 51.6%, P = 0.40). Sufferers experienced longer ICU LOS (16.3 ± 45.6 characterise the incidence and determinants of intolerance and assess
vs. 4.6 ± 19.4 days, P <0.0001) and greater ICU mortality (19.5% vs. its influence on nutritional and clinical outcomes using the 2009 Critical
12.6%, P = 0.035) during the study period. Care Nutrition Survey (CCNS).
Conclusion Diarrhoea was common on our ICU, its prevalence (17%) Methods The CCNS survey is a prospective observational cohort study
being consistent with established literature. It was associated with of nutrition practices from over 150 ICUs around the world. Included
statistically increased ICU LOS and mortality, although any direction of patients were those that remained in ICU for ≥72 hours and were
causality remains to be established. A low stool investigation yield and mechanically ventilated ≤48 hours of admission to ICU. We collected
low prevalence of C. difficile suggests that other noninfective causes pertinent baseline and outcome data that included nutritional
of diarrhoea need excluding. Further research is required to establish adequacy, ventilator-free days, 60-day mortality and ICU stay.
the prevalence and pathogenesis of diarrhoea on UK ICUs, in order to Intolerance was defined as interruption of EN due to gastrointestinal
develop evidence-based management plans for reducing its incidence, (GI) reasons (high gastric residuals, increased abdominal girth/
and its clinical and financial impact. abdominal distension, vomiting/emesis, diarrhoea or subjective
Reference discomfort). In the analysis of intolerance we included each potential
1. Wiesen P, et al.: Curr Opin Crit Care 2006, 12:149-154. effect into a logistic regression analysis to determine its significance.
Results Data from 1,888 ICU patients receiving EN were analysed. The
incidence of intolerance was 30.5%, and occurred after a median 3 days
from EN initiation. Factors associated with intolerance were: diagnosis
category (P = 0.0009) (GI, cardiovascular and sepsis categories with
P160 the highest risk), pre-emptive motility agent use (P = 0.0125), non-
Preliminary report of surface electrogastrography in critically ill GI interruptions to feed (P = 0.0086) and global region (P = 0.0006).
septic patients after resuscitation Intolerance was associated with poor nutritional adequacy, increased
C Mancilla, R Galvez, G Landskron, E Tobar, A Madrid mortality, longer ventilator dependence and increased length of
Hospital Clinico Universidad de Chile, Santiago, Chile ICU stay (P <0.05) (Table 1). Poorer clinical outcomes were seen with
Critical Care 2012, 16(Suppl 1):P160 (doi: 10.1186/cc10767) increasing number of days of intolerance.
Introduction Impaired gastrointestinal motility is common in critically ill Table 1 (abstract P161). Nutritional adequacy and clinical endpoints in
patients. Multiple conditions such as shock with diminished splanchnic tolerant and intolerant EN patients
perfusion, surgery, fluid overload, intra-abdominal hypertension, and
% % Ventilator- Time to
drugs are responsible for this phenomena. Assessing gastric motility in
Calorific Protein free 60-day ICU stay discharge
this setting is complex. Surface electrogastrography (sEGG) is a recent
adequacy adequacy days mortality (days) alive
noninvasive technique that determines basal and postprandial gastric
motility [1]. Our aim is to study basal gastric motility in critically ill Tolerant 64.3 63.7 11.2 26.2 11.3 25.2
septic patients in the post-resuscitative phase, by sEGG.
Methods Eligible patients were those admitted to the ICU with Intolerant 55.5 55.6 2.5 30.8 14.4 31.1
diagnosis of septic shock as stated by the Sepsis Conference 2001 [2].
At the moment of the study the patients were in the post-resuscitative Conclusion Intolerance is common amongst the EN ICU population
phase, defined as normal clinical and laboratory perfusion parameters. and is associated with poor nutritional and clinical outcomes.
sEGG is a noninvasive technique that uses skin abdominal electrodes to
record myoelectrical stomach activity. The basal slow wave originates in
the proximal stomach and propagates to the antrum with a frequency P162
of approximately 3 cycles per minute (cpm). Basal activity below Gastric emptying assessment in critically ill patients with feed
2.4 cpm is defined as bradygastria and above 3.7 cpm as tachygastria intolerance; comparison of 13C octanoic acid, paracetamol and
[1]. Data were correlated with severity scores, lactate levels, and doses 3-O-methylglucose absorption tests
of sedatives. The study was approved by the Ethics Committee of the M Chapman1, R Fraser1, N Nguyen1, A Deane1, LS Vasist2, K Hacquoil2,
Hospital Clínico Universidad de Chile. M Barton2, GE Dukes2
1
Results We recruited 16 patients (10 females). Mean age 62 years (50 to University of Adelaide, Australia; 2GlaxoSmithKline, Research Triangle Park,
76) (P = 0.8). APACHE II score 25 (19 to 28) (P = 0.4) and SOFA score 9 (7 NC, USA
to 11) (P = 0.29). Lactate at admission 3.8 mmol/l (1.2 to 6.5) (P = 0.72). Critical Care 2012, 16(Suppl 1):P162 (doi: 10.1186/cc10769)
Fentanyl total dose 172.7 μg/kg (59 to 256.6) (P = 0.91) and midazolan
total dose 3.4 mg/kg (0.1 to 3.1) (P = 0.07). We obtained a reliable Introduction Delayed gastric emptying (GE) occurs frequently in
register in all the patients and found six patients with bradigastria, critically ill patients and may result in impaired small intestinal delivery
three with tachygastria and nine with normal motility. In this small of drugs and nutrients. Use of direct methods of GE assessment
sample size study there was a trend to bradygastria in relation to high (scintigraphy) in the ICU for clinical monitoring or research is challeng-
total doses of midazolam. ing. Indirect methods that utilize substances which rely on effective GE
Conclusion sEGG is a feasible technique in critically ill septic patients. In and rapid absorption from the small intestine offer a feasible estimate
the post-resuscitative phase 43.8% of patients present normal gastric of GE. Three substances with these characteristics are 13C-octanoic
motility, and 37% showed bradygastria. Future research is warranted in acid (13C), paracetamol (PA) and 3-O-methylglucose (OMG). We have
order to find risk factors of gastrointestinal dismotility. previously shown significant correlation to scintigraphy for 13C (r = 0.63)
References and OMG absorption (r = –0.77 to –0.87). The current study examined
1. Chang F-Y: J Gastroenterol Hepatol 2005, 20:502-516. the relationship between three indirect methods of GE assessment: 13C,
2. Levy MM, et al.: Crit Care Med 2003, 31:1250-1256. PA, OMG.
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TGC protocols with patients during their first few days of ICU stay, extra Methods We used the Eirus™ system (DipylonMedical, Solna, Sweden)
care should be afforded. Increased measurement frequency, higher based on microdialysis for CGM in three mechanically ventilated
target glycaemic bands, conservative insulin dosing and modulation patients necessitating continuous intravenous insulin. The CGM
of carbohydrate nutrition should be considered to safely minimize system consists of a dedicated triple-lumen central venous catheter, a
outcome glycaemic variability and reduce the risk of hypoglycaemia. disposable sensor on a reusable sensor holder outside the patient, and
Reference a monitor producing a new measurement each minute. Calibrations
1. Chase JG, et al.: Crit Care 2008, 12:R49. were performed every 8 hours using arterial blood samples and a blood
gas analyzer (Radiometer SAS, Neuilly-Plaisance, France). The attending
nurses also performed intermittent blood glucose measurements with
P168 a point-of-care glucometer in order to set the insulin rate according to
Endogenous insulin secretion in critically ill patients our glucose control method. GV was assessed by the variability index
C Pretty1, A Le Compte1, J Lin1, G Shaw2, JG Chase1 defined as the mean of the absolute value of the first derivative of the
1
University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, glucose signal during CGM. In order to simulate sCGM, we extracted
Christchurch, New Zealand CGM values every 15 minutes for calculating the corresponding
Critical Care 2012, 16(Suppl 1):P168 (doi: 10.1186/cc10775) variability index as the mean of the absolute value of the variation rate
between two consecutive measurements.
Introduction Glucose–insulin system models can be used for improved Results The variability indexes were respectively 1.97, 1.65, 1.55 mmol/l/
glycemic control of critically ill patients. A key component of glucose– hour for CGMS, and 1.07, 0.65, 0.83 mmol/l/hour for sCGMS.
insulin models is pancreatic insulin secretion. There are limited data Conclusion sCGM in comparison with CGM may considerably under-
in the literature quantifying insulin secretion in critically ill patients at estimate a marker of GV during glucose control in critical care patients.
physiologic levels. This study presents a model of pancreatic insulin Reference
secretion in critically ill patients based on data from a critically ill 1. Mackenzie et al.: The metrics of glycaemic control in critical care. Intensive
population. Care Med 2011, 37:435-443.
Methods Samples were collected from 19 patients enrolled in a
prospective clinical trial studying sepsis at the Christchurch Hospital
ICU. Fifteen of the patients had confirmed sepsis and three were P170
diagnosed type 2 diabetics. All patients were on the SPRINT glycaemic Evaluation of a continuous blood glucose monitoring system using
control protocol [1]. Each patient had arterial blood samples assayed a central venous catheter with an integrated microdialysis function
for insulin and C-peptide. Two sets of four samples were taken from F Möller, J Liska, A Öwall, A Franco-Cereceda
each patient, with each set collected over 60 minutes. Blood glucose Karolinska Institutet, Solna, Sweden
(BG) data were collected with a bedside glucometer. C-peptide data Critical Care 2012, 16(Suppl 1):P170 (doi: 10.1186/cc10777)
were deconvolved using the model and population parameter values
of van Cauter and colleagues [2] to determine pancreatic insulin Introduction Glycemic control in critically ill patients has been debated
secretion rates (ISRs). Data from Kjems and colleagues investigating the over the last decade. An accurate glucose monitoring system is
potentiating effects of glucagon-like peptide-1 on insulin secretion [3] essential to understand and study this concern. We have evaluated the
suggested a maximum secretion rate of 16 U/hour. A minimum rate of accuracy and technical feasibility of a continuous glucose monitoring
1 U/hour was also adopted. system using intravascular microdialysis.
Results The best model for insulin secretion was based on blood Methods Thirty patients undergoing cardiac surgery were monitored
glucose concentration alone. There was clear separation of secretion using a triple-lumen central venous catheter (Eirus TLC®; Dipylon
levels between normal glucose tolerant (NGT) and impaired glucose Medical AB, Sweden) with an integrated microdialysis membrane.
tolerant (IGT) patients. Hence, ISR was modeled as a constrained linear The catheter was placed with the tip in the superior vena cava, and
function of BG (in mmol/l) for NGT and IGT patients separately with functions both as a central venous catheter, enabling blood sampling
R2 = 0.61 and 0.69 respectively. NGT: ISR = 893×BG – 2,996 (mU/hour). and administration of medication, while simultaneously measuring
IGT: ISR = 296×BG – 1,644 (mU/hour). The glucose coefficients of 893
and 296 mU.l/mmol.hour were comparable to data published in a
number of other studies for healthy and diabetic subjects.
Conclusion This work presents a simple model for pancreatic insulin
secretion in critically ill patients based on clinical data. The model is
a function of blood glucose level and glucose tolerance status and
compares well with published data for healthy and diabetic subjects.
This model can be incorporated into glucose–insulin system models
and could potentially improve model-based glycaemic control.
References
1. Chase JG, et al.: Crit Care 2008, 12:R49.
2. Van Cauter E, et al.: Diabetes 1992, 41:368-377.
3. Kjems L, et al.: Diabetes 2003, 52:380-386.
P169
Impact of the type of glucose monitoring on the assessment of
glycemic variability in critical care patients
P Kalfon, M Chilles
CH Chartres, France
Critical Care 2012, 16(Suppl 1):P169 (doi: 10.1186/cc10776)
P172
Pilot trial of STAR in the medical ICU
LM Fisk1, AJ Le Compte1, GM Shaw2, S Penning3, T Desaive3, JG Chase1
1
University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital,
Christchurch, New Zealand; 3Université de Liege, Belgium
Critical Care 2012, 16(Suppl 1):P172 (doi: 10.1186/cc10779)
patient. The defined cut-off for ‘good’ control for a patient was ≥70%
of BG in 72 to 126 mg/dl (cTIB ≥0.7), and ‘poor’ as <70% (cTIB <0.7),
based on original observed clinical BG. The number of true BG profiles
that resulted in misclassification between ‘good’ and ‘poor’ control for a
patient was recorded over all Monte-Carlo runs. The maximum change
in true and observed BG mean and standard deviation were used to
evaluate potential worst-case scenarios.
Results Good control was clinically measured in 76% of patients (24%
with cTIB <0.7). Of these, 83% of ‘good’ and 64% of ‘poor’ control would
never be misclassified over all 100 runs due to sensor error. A total of
91% (good) and 87.5% (poor) could be misclassified 10% of the time.
Patients with cTIB near 0.7 were more likely to be misclassified when
accounting for glucometer error. Hence, a deadband around the cut-off
would reduce this misclassification. If ‘good’ cut-off was cTIB ≥0.5 (95%
of clinical patients) then 100% correct classification was 97% for good
control patients, but fell to 40% of poor control patients. The median
largest difference in observed and true mean BG across patients was
–54 mg/dl (90th percentile: –21 mg/dl) and the standard deviation was
3.2 mg/dl (90th percentile: 1.8 mg/dl). Figure 1 (abstract P174). ISO-modified Bland–Altman plot.
Conclusion Glucometers can distinguish between patients that
received good and poor BG control but risk of misclassification
rises for patients nearer cut-offs. Reliable classification to associate
with outcomes relies on the control protocol and cut-off choice to
achieve sufficient separation between groups so that device errors
do not result in significant misclassification confounding the results. A P175
deadband around cut-off values to eliminate patients at high risk of Preliminary ICU experience of a novel intravascular blood glucose
misclassification may be required. sensor
KP Mulavisala1, PB Gopal2, B Crane3, A Mackenzie3
1
Axon Anaesthesia Associates Care Hospital Nampally, Hyderabad, India;
2
Apollo Hospitals, Hyderabad, India; 3Glysure, Abingdon, UK
P174 Critical Care 2012, 16(Suppl 1):P175 (doi: 10.1186/cc10782)
Initial experience with continuous intra-arterial fluorescent glucose
monitoring in patients in the ICU following cardiac surgery Introduction A need for continuous blood glucose monitoring has
S Bird1, L Macken1, O Flower1, E Yarad1, F Bass1, N Hammond1, D LaCour2, always been expressed by critical care practitioners. The results from
P Strasma2, S Finfer1 several iterations of a novel optical fluorescence-based intravascular
1
Royal North Shore Hospital, St Leonards, NSW, Australia; 2GluMetrics, Inc., blood glucose sensor were examined for correlation with an accepted
Irvine, CA, USA laboratory assay. Ever since Van Den Berghe’s group demonstrated
Critical Care 2012, 16(Suppl 1):P174 (doi: 10.1186/cc10781) reductions in hospital mortality and morbidity from the application of
tight glycaemic control [1], many groups have attempted to replicate
Introduction Continuous glucose monitoring (CGM) in ICUs has those results with limited success. Practitioners have speculated
the potential to improve patient safety and outcomes. The GluCath upon the reasons behind this observation, and have cited manpower
Intravascular CGM System uses a novel quenched chemical fluorescence implications and incidence of hypoglycaemic episodes as contributing
sensing mechanism to measure glucose concentration (BG) in venous factors [2]. Investigators have speculated that a continuous blood
or arterial blood. This is the first report of its use in cardiac surgery glucose sensor might contribute towards safe effective glycaemic
patients. control [3].
Methods This ongoing clinical study is evaluating the system deployed Methods A series of postoperative and direct admission ICU patients
via a standard 20G radial artery catheter inserted for routine care in had an optical fluorescence-based intravascular glucose sensor
20 patients undergoing cardiac surgery. Data are presented from (GlySure Ltd, Abingdon, UK) placed into the left internal jugular vein
five run-in patients. Outcome measures are qualitative (ease-of-use, on admission to the ICU. The sensor remained in situ throughout the
workflow fit) and quantitative (accuracy vs. reference analyzer). Sensors ICU stay. Periodic blood samples and simultaneous real-time values
were inserted shortly after ICU admission with placement confirmed of blood glucose measured by the sensor were recorded. The results
by ultrasound and in vivo calibration 30 minutes later. Clinical staff were correlated with the results of blood sample analysed by a Yellow
managed blood glucose according to usual protocols. Glucose values Springs Instrument glucose analyser. The sensor, which has a heparin
were recorded each minute for 24 hours; hourly reference samples coating on its surface, required no further heparinisation; a ‘keep vein
from the same arterial catheter were analyzed on a Radiometer ABL open’ rate of normal saline infusion was maintained throughout the
Blood Gas Analyzer. period of operation.
Results The sensor was successfully deployed in all five patients and did Results Sixteen patients received the current configuration blood
not interfere with clinical care, blood pressure monitoring or sampling. glucose sensor; during their combined length of stay, 296 paired values
One patient suffered a cardiopulmonary arrest; the sensor functioned were obtained for correlation purposes. A total 99.6% of these values
successfully during resuscitation and urgent return to the operating fall within the A+B areas of the Clarke error grid. All sensors continued
room. One hundred and twenty reference samples ranging from 5.9 to to function throughout the length of stay, maximum 92 hours, and
13.4 mmol/l were collected; 107/120 (89.2%) of GluCath measurements were withdrawn immediately prior to discharge from the ICU.
met ISO 15197 criteria (within ±20% of reference when BG >4.2 mmol/l; Conclusion The pre-production intravascular blood glucose sensors
Figure 1). In Subject 1 the sensor was inadvertently retracted into the successfully track blood glucose values, with improved insight into
arterial catheter during the study, leading to measurement error from blood glucose variability in ICU patients.
arterial flush solution contamination. In a sensitivity analysis excluding References
this patient, 89/95 (93.7%) of measurements met ISO 15197 with a 1. Van den Berghe G, et al.: Intensive insulin therapy in critically ill patients.
mean absolute relative difference of 9.4%. N Engl J Med 2001, 345:1359-1367.
Conclusion The GluCath System measured glucose concentration 2. Aragon D, et al.: Evaluation of nurse work effort and perception about
continuously in a cardiac surgery ICU without compromising arterial blood glucose testing in TGC. Am J Crit Care 2006, 15:370-377.
line function or patient care. In all patients the sensor operated without 3. Krinsley J, Preiser JC: Moving beyond TGC to safe effective glycemic control
interruption for 24 hours following a single in vivo calibration. (SEGC). Crit Care 2008, 12:149.
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P176 in ‘tight’ glycaemic control [2]; however, recent negative studies have
Does tight glycemic control positively impact on patient mortality? dampened this interest [3]. In view of more recent analyses, which offer
S Penning1, AJ Le Compte2, M Signal2, P Massion3, JC Preiser4, GM Shaw5, possible explanations for equivocal results [4], it is possible there will
T Desaive1, JG Chase2 be renewed interest in glycaemic control. The purpose of this survey is
1
Université de Liege, Belgium; 2University of Canterbury, Christchurch, New to assess the utilisation of tight glycaemic control protocols in a sample
Zealand; 3CHU de Liège, Belgium; 4Erasme University Hospital, Brussels, of ICUs in England, as a reflection of current UK intensive care practice.
Belgium; 5Christchurch Hospital, Christchurch, New Zealand Methods We identified 171 large acute hospital trusts, of which 87
Critical Care 2012, 16(Suppl 1):P176 (doi: 10.1186/cc10783) were randomly selected. Of these, 85 had ICUs, which were contacted
by telephone. The senior nurse in charge at the time was asked whether
Introduction High and variable blood glucose (BG) levels have been their ICU used a protocol for the management of blood glucose, and
associated with increased mortality. Tight glycemic control (TGC) aims what were the upper and lower target limits.
at reducing BG levels to improve patient outcome and mortality. This Results A blood glucose protocol was used in 87.1% of ICUs
research evaluates the impact of TGC on mortality. surveyed. Of these, the median lower limit of allowed blood glucose
Methods This study used glycemic data from 1,488 patients of two concentration was 4.0 mmol/l (range 3.0 to 7.0), with an upper limit of
cohorts: Glucontrol (n = 704) and SPRINT (n = 784). TGC glycemic 8.0 mmol/l (range 6.0 to 12.0). Only 22 ICUs (25.9%) had a target range
outcome is measured by cumulative time in the 4 to 7 mmol/l band similar to the Leuven study. A further 34 ICUs used a lower limit similar
(cTIB), defined daily for each patient. Each day, patients were divided to the Leuven study, of 4.0 to 4.5 mmol/l, but had a higher upper limit.
into two groups: cTIB <70% and cTIB ≥70%. For each group, odds of This is reflective of the general opinion from the nurses contacted, that
living (OL = #lived / #died) was calculated. a tight protocol is difficult to achieve, can result in hypoglycaemia, and
Results OL for cTIB ≥70% patients tends to increase over time while OL has been recently relaxed in many departments.
for cTIB <70% patients decreases (Figure 1). On Day 1, OL for cTIB <70% Conclusion Our data suggest that glycaemic control has, to a very
patients and cTIB ≥70% patients are similar (OL = 5.1 and OL = 5.5 large extent, been accepted as a standard of care in the UK, although
respectively). The difference between the two groups increases over in most ICUs this does not constitute tight glycaemic control. The full
the ICU stay. On Day 10, OL = 2.8 and OL = 10.5 for cTIB <70% and cTIB benefit of tight glycaemic control, achieved by minimisation of mean
≥70% patients respectively. These results suggest that survival rate is glucose, glucose variability and episodes of hypoglycaemia, will not be
higher when cTIB ≥70% and thus when BG levels are tightly controlled achieved until robust techniques for continuous, or semi-continuous,
around normoglycemia. The longer patients’ ICU stay, the lower survival blood glucose measurement are available.
rate they have when cTIB <70%. References
Conclusion Results show that, irrespective of TGC protocols, high cTIB 1. Van den Berghe G, et al.: N Engl J Med 2001, 345:1359-1367.
and thus normoglycemia are associated with higher odds of living. This 2. Mackenzie et al.: Intensive Care Med 2005, 31:1136.
suggests that TGC positively influences patient outcome. 3. NICE-SUGAR Study Investigators: N Engl J Med 2009, 360:1283.
4. Mackenzie et al.: Intensive Care Med 2011, 37:435-443.
P177 P178
Glycaemic control in ICUs in large English hospitals: a follow-up Model-based regulation of glucose in critical care
telephone survey SP Gawel1, G Clermont2, RS Parker1
1
CR Bullock, A Pang, A Routledge, I Mackenzie University of Pittsburgh, PA, USA; 2University of Pittsburgh Medical Center,
Queen Elizabeth Hospital Birmingham, UK Pittsburgh, PA, USA
Critical Care 2012, 16(Suppl 1):P177 (doi: 10.1186/cc10784) Critical Care 2012, 16(Suppl 1):P178 (doi: 10.1186/cc10785)
Introduction Following van den Berghe’s landmark paper in 2001 Introduction Glucose control in critical care has been shown to
(Leuven study) [1], the critical care community became very interested improve patient outcome, yet tight glucose control has led to increased
Statistical analysis was performed with using ANOVA and the LPS post P181
hoc test. Data shown are mean ± standard deviation, n = number of Integral assistance process implantation for ST-elevated acute
patients. coronary syndrome
Results There were no statistical differences between the groups JC Rodriguez-Yañez, M Celaya-Lopez, MJ Huertos-Ranchal, I Diaz-Torres,
regarding age, height, weight, premedical history or intraoperative C Navarro-Ramirez, J Gomez-Ramos
amount of glucose administration during cardioplegia (33 ± 15 g). Hospital Universitario Puerto Real, Spain
Blood glucose levels in groups 1 and 2 stayed significantly longer in Critical Care 2012, 16(Suppl 1):P181 (doi: 10.1186/cc10788)
the target interval compared with group 3 (75 ± 19% vs. 72 ± 19%;
vs. 50 ± 34%, P <0.01, n = 25, respectively). There was no significant Introduction The objective was to evaluate the implantation of
difference between the groups regarding ICU or hospital stay and SSI assistance process implantation (PAI) for ST-elevated acute coronary
rates. syndrome (SCASTE) in our sanitary district. When we refer to PAI, we
Conclusion Early computer-based insulin therapy allows one to better mean protocolysed assistance guidelines developed and published
warrant normoglycemia in patients undergoing major cardiac surgery by Andalucia sanitary authorities that include recommendations to
with the use of blood cardioplegia. direct the assistance from the beginning of the process until patient
References discharge from the hospital.
1. Ann Intern Med 2007, 146:233-243. Methods All ICU patients from HUPR diagnosed with SCASTE within the
2. N Engl J Med 2001, 345:1359-1367. first 24 hours from January 2005 to December 2010 were included in
3. N Engl J Med 2006, 354:449-461. this study and registered in the ARIAM-Andalucia Project. This database
4. N Engl J Med 2009, 360:1283-1297. gathers the whole PAI from preadmission (PH), ER, ICU, hemodynamics
laboratory and cardiology ward to discharge. Within these 6 years
three main interventions were carried out: fibrinolysis protocol PH with
ER and critical care unit EMS involving the ICU, continuous update of
protocols based on AHA clinical guidelines, and 24-hour availability of
the hemodynamic laboratory for primary coronary intervention (P-ICP
available since 1 February 2007). Revascularization indexes are analyzed
and grouped in 2-year periods (A, B, C), the time justified as necessary
P180 for modification after the intervention, attention times and PH action.
Efficacy of the novel heart attack centre extension pathway: a pilot The latter was measured by a score (aspirin, nitroglycerine, ECG, vein
study access, intravenous treatment and monitoring during transport) up to
D Perera1, B Hoonjan1, K Krishnathasan1, M Selvanyagam1, H Neugebauer2 6 points. A correct intervention must obtain at least 4 points. Statistical
1
Barts and The London School of Medicine and Dentistry, London, UK; processing was by the R-UCA pack from R-Commander.
2
Queens Hospital, Barking Havering and Redbridge NHS Trust, London, UK Results A total of 590 patients were included in this study: 188 (A),
Critical Care 2012, 16(Suppl 1):P180 (doi: 10.1186/cc10787) 227 (B) and 175 (C). All groups were similar in mean age, gender, IAM
location and origin. A statistically significant increase was found in the
Introduction The Barts and the London Heart Attack Centre Extension revascularization and PHA attention between periods A versus C and
(HACX) programme was introduced to provide a direct pathway for B versus C with P <0.0001 and CI (0.15 to 0.42)/(0.17 to 0.45) and (0.2
high-risk non-ST elevation myocardial infarction (NSTEMI) patients to 0.6)/(0.11 to 0.39). No statistically significant difference was found
from the A&E of a district general hospital to a tertiary intervention among groups A versus B. No significant difference was observed in
centre. As a result, patients have earlier access to angiography and attention times.
subsequent treatment, including percutaneous coronary intervention Conclusion Coordination of the SCASTE attention, constant analysis
(PCI), coronary artery bypass grafting (CABG) or nonsurgical interven- by continuous registry of different action levels (ARIAM-Andalucia
tions. There is no research on the effectiveness of this novel HACX registry), clinical guideline updates and adjustment to resources
programme. and environment, in this case a rural setting, meaning quality
Methods Over 3 months, 33 patients transferred via the HACX pathway and a continuous improvement circle, reduce variability and lead
and 37 patients transferred via the conventional interhospital transfer undoubtedly to better assistance for our patients.
pathway (IHT) were followed up. All patients with acute coronary
syndrome symptoms, relevant ECG changes (ST segment depression
in two or more contiguous leads >1 mm, pathological T-wave inversion P182
in V1 to V4, a GRACE score >88 and troponin I levels >0.1 ng/ml) were Prognostic value of Killip classification in terms of health-related
discussed with the cardiology team at the interventional centre prior quality of life
to immediate transfer. We assessed patient suitability for angiography, A Ioannidis1, D Tsounis1, A Pechlevanis2, M Paraskelidou2
1
post-angiography procedures, and 3-month mortality outcomes. Data HOU, Kalamaria, Greece; 2GHT ‘Agios Pavlos’, Kalamaria, Greece
were obtained from the hospital’s PAS computer system. Critical Care 2012, 16(Suppl 1):P182 (doi: 10.1186/cc10789)
Results The average time for patients to have an angiography via the
IHT pathway was 5.5 days. Of the 33 patients (mean age 61 ± 15.2 SD) Introduction The aim of the study was to evaluate the prognostic value
transferred via HACX, 30 patients (91%) were appropriately identified of Killip classification in terms of health-related quality of life (HRQoL).
for an angiogram. Seventeen patients (52%) required PCI, five patients Methods The sample consisted of 112 patients treated for myocardial
(15%) required CABG, four patients (12%) required nonsurgical infarction (MI), as onset manifestation of coronary artery disease (CAD),
intervention, and four patients (12%) required no treatment. Controls during 2008/09 in a prefectural hospital in northern Greece. At 1-year
included 37 patients (mean age 71 ± 12.6 SD) of whom 17 patients follow-up visit, HRQoL was measured using a generic and a disease-
(46%) required PCI, six patients (16%) required CABG, eight patients specific instrument. The 15D consists of a visual analogue scale (VAS)
(22%) required nonsurgical intervention and six patients (16%) and a total score. The scoring algorithm of the MacNew generates a
required no treatment. At 3-month follow-up, 32 patients (97%) in the global score, and three separate domains scores: emotional, physical
HACX cohort and 36 patients (97%) in the IHT cohort were alive. and social.
Conclusion HACX is an effective pathway that accurately identifies and Results Patients were grouped into the four Killip classes according
rapidly transfers appropriate NSTEMI patients requiring early coronary to the degree of pulmonary congestion at admission (Table 1). Mean
revascularisation. However, there was no additional mortality benefit at HRQoL for each group differed in the expected manner: the higher
3-month follow-up compared to the conventional IHT pathway. Further the class, the lower the HRQoL. Statistical significant differences were
studies with larger patient cohorts and longer follow-up periods are observed in VAS of the 15D and the emotional and social domain scores
required to substantiate the benefits of the HACX programme in order of the MacNew. Accordingly, the majority of patients with no signs of
to consider whether this service could be implemented nationwide, or pulmonary congestion at admission were classified in NYHA functional
whether this is a service that does not need to exist at all. class I at 1-year follow-up visit. No difference was observed in the type
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Results Assay precision was characterised by CV levels of less than involve psychic or physical stressors such as a devastating disaster,
10%. NT-proBNP results correlated well with VIDAS (r = 0.89), with a but those clinical features have been not fully investigated. As Ibaraki
corresponding slope of the regression line of 1.12 (95% CI 1.01 to 1.22) prefecture suffered from the Great East Japan Earthquake, we tried to
and an intercept of 64.04 (95% CI –73.50 to 109.83). In the current clarify the characteristics of TC and investigate whether the Great East
format under development, the NT-proBNP assay time with plasma Japan Earthquake increased the occurrence of TC or not.
samples is only 5 minutes. We are in the process of adding a filter that Methods Eleven consecutive patients with TC (five men, six women)
will allow measurements from whole blood directly. Flow experiments were enrolled between October 2009 and October 2011 in this study.
show that the filling time of the cartridge with whole blood is less than Patients were diagnosed by echocardiography, left ventriculography,
30 seconds, resulting in a total assay time of less than 6 minutes, and a or nuclear scintigraphy. Absence of significant coronary stenosis
time-to-result of less than 8 minutes. was confirmed by coronary angiography or coronary computed-
Conclusion In its current implementation the Magnotech-based NT- tomography angiography. Clinical characteristics (age, season,
proBNP assay shows promising performance for rapid, reliable NT- coronary risk factors, the condition that preceded onset as possible
proBNP testing at the POC in emergency settings. Development work is triggering factors and so on), laboratory data (troponin T, creatinine
presently focused on the integration of a blood filter into the cartridge, kinase, and so on) and data of electrocardiography (ECG) were obtained
to allow fingerprick tests. from reviewing medical records.
Reference Results The number of cases of TC after the earthquake was five for
1. Bruls DM, et al.: Lab Chip 2009, 9:3504-3510. 7 months and that of before is six for 17 months. The occurrence rate of
TC seemed to increase after the earthquake. Reviewing all of our cases,
P185 45.5% (n = 5/11) of patients have TC in the autumn, 72.7% (n = 8/11)
Right ventricular apical versus septal pacing: impact on left of patients suffered from a physical stressor, and 27.3% (n = 3/11) of
ventricular synchrony and function patients a psychic stressor. No obvious stressor was found in only one
I Atteia, A Alazab, K Hussein, N Abeed, H Nagi patient. The patients complained of chest pain or dyspnea (54.5% each).
Cairo University, Cairo, Egypt The rate of coronary risk factors were; family history, 10% (n = 1/10);
Critical Care 2012, 16(Suppl 1):P185 (doi: 10.1186/cc10792) smoking, 60% (n = 6/11); diabetes, 57.1% (n = 4/7); hypertension, 63.6%
(n = 7/11); dyslipidemia, 44.4% (n = 4/9); and obesity, 22.2% (n = 2/9).
Introduction Right ventricular apical pacing alters the LV activation Laboratory data showed that elevated troponin T was observed in
resulting in an adverse effect on LV function and synchrony. On 60% (n = 6/10), high CK and CK-MB were 45.5% (n = 5/11) and 100%
the contrary, RV septal pacing results in narrower QRS and may be (n = 9/9), respectively. ECG findings of all of the patients; ST elevation
more physiological with less deleterious long-term effect on LV was observed in precordial leads of V2 to V4 (27.3%, 54.5% and
echocardiographic and hemodynamic parameters. 27.3%, respectively) and ST depression was in V5 (36.4%). Reversed
Methods Forty patients indicated for permanent DDD pacing were r progression was observed in 18.2%, poor r progression was 27.3%,
studied. All patients were subjected to transthoracic echocardiography abnormal Q was 18.2%, long QT interval was 72.7% and negative T was
calculating LVESD, LVEDD, EF% and CO together with tissue Doppler 63.6% of TC patients.
imaging (TDI) to detect LV dyssynchrony. Patients were randomly Conclusion Although TC seems to mimic anterior STEMI, limb leads
classified into two groups, group I having RV apical pacing and group did not tend to show ST change in ECG in our cases. The Great East
II having RV septal pacing. The acute threshold, R-wave sensing and Japan Earthquake could increase patients with TC until the tremendous
fluoroscopic time were measured in all patients and compared in both damage caused by the disaster will be over.
groups. Both groups were followed-up over a period of 6 months.
Results QRS durations were significantly narrower in group II patients
(148 ± 6.9 vs. 162 ± 6 ms, P = 0.001). Electrical parameters at the time P187
of implantation were satisfactory for all patients (acute stimulation Stress cardiomyopathy after live donor liver transplantation:
threshold was 0.5 ± 0.18 V; R wave sensing was 11 ± 1.6 mV and incidence, risk factors and mortality
ventricular impedance was 630 ± 90 Ohm). No single patient needed S Gupta, D Govil, S Bhatnagar, S Patel, S Srinivasan, P Pandey, M Sodhi,
ventricular lead repositioning. The acute pacing threshold, R-wave J KN, P Singh, S Saigal, A Soin, V Vohra, Y Mehta
sensing, ventricular impedance and fluoroscopic time did not change Medanta – The Medicity, Gurgaon, India
significantly in both groups. During follow-up, it was found that in Critical Care 2012, 16(Suppl 1):P187 (doi: 10.1186/cc10794)
group II patients with RV septal pacing there was significantly lower
LVESD (3.0 ± 0.6 vs. 3.4 ± 0.6 cm, P = 0.004), significantly higher LVEF% Introduction The incidence of cardiac complications in the post live
(69 ± 13 vs. 61 ± 8, P = 0.01), significantly higher CO (4.9 ± 0.3 vs. donor liver transplantation (LDLT) period has been reported to be
4.5 ± 0.6 l), and significantly lower septal to lateral wall delay in LV using nearly 70% [1]. Stress cardiomyopathy (SC) is a severe complication
TDI (72 ± 5 vs. 83 ± 6 ms, P = 0.001) if compared to group I patients with which has varied presentation and has grave prognosis if not diagnosed
RV apical pacing. and managed aggressively.
Conclusion Long-term RV septal pacing is feasible, and reliable with Methods Data for 250 LDLTs (June 2010 to July 2011) were collected
less adverse effects on LV synchrony and function when compared to to assess incidence, risk factors and mortality due to SC. Diagnostic
RV apical pacing. criteria [2] for SC were taken as: global hypokinesia or new ST segment
References elevation or T-wave inversion in absence of coronary artery disease
1. Kutarski A, Ruciniski P, Sodolski T, Trojnar M: Factors influencing differences (CAD) or pheochromocytoma. Etiologies of chronic liver disease and
of RVA and RVOT pacing hemodynamic effects. Europace 2005, 7:288. preoperative cardiac status along with intraoperative vasopressor use
doi:10.1016/j.eupc.2005.02.104. and dosages were noted.
2. Hafez M, Small GR, Hannah A, et al.: Impact of temporary right ventricular Results Out of 250 patients five patients had preoperative CAD and
pacing from different sites on echocardiographic indices of cardiac were excluded. Seven patients (incidence 2.8%) were diagnosed to have
function. Europace 2011. doi: 10.1093/europace/eur 207. SC. Five out of seven (71.4%) patients were ethanolic and vasopressor
requirement was high in all these patients (Figure 1). Echocardiography
P186 revealed global hypokinesia with left ventricular ejection fraction
Consecutive case series of Takotsubo cardiomyopathy: a disease between 10 and 25%. They were managed with inotropic support
potentially triggered by the Great East Japan Earthquake and four patients required an intraaortic balloon pump (IABP). Two
T Suzuki, S Sakai, T Abe patients succumbed to cardiogenic shock on the second day (mortality
Mito Kyodo General Hospital, University of Tsukuba, Mito City, Japan 28.5%). IABP was weaned between 7 and 9 days. Patients had normal
Critical Care 2012, 16(Suppl 1):P186 (doi: 10.1186/cc10793) cardiac status at the time of discharge around the fourth week post
liver transplant.
Introduction Takotsubo cardiomyopathy (TC) is a rare disease that Conclusion Our incidence was 3%. SC generally presents on the
mimics ST elevated myocardial infarction (STEMI). TC is known to second to third postoperative day and usually recovers by the second
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P189
P188 Patients with infective endocarditis patients in the ICU: how are they?
Short-term hemodynamic effects of nebivolol in acute P Fernandez Ugidos1, R Gomez Lopez1, P Vidal Cortes1,
decompensated heart failure: a randomized clinical trial AV Aller Fernandez2, JM Lopez Perez2
1
R Puig, M Ochiai, J Cardoso, K Vieira, E Brancalhao, M Lima, Complejo Hospitalario Universitario Ourense, Spain; 2Complejo Hospitalario
A Pereira Barretto Universitario A Coruña, Spain
Hospital Auxiliar de Cotoxo – InCor – HCFMUSP, São Paulo, Brazil Critical Care 2012, 16(Suppl 1):P189 (doi: 10.1186/cc10796)
Critical Care 2012, 16(Suppl 1):P188 (doi: 10.1186/cc10795)
Introduction The objective was to analyze clinical characteristics of
Introduction Acute decompensation heart failure in patients in use of patients with infective endocarditis (IE) requiring surgery when the
β-blocker has become frequent and maintenance of this drug remains disease is diagnosed.
controversial, mainly in low cardiac output. Nitric-oxide-dependent Methods A retrospective study of all patients, during 5 years in a
vasodilation of nebivolol could be useful in this situation. tertiary hospital in Spain, which required admission to the ICU with
Methods We evaluated hospitalized patients with acute decompen- the diagnosis of IE (Duke criteria modified) and required surgery at
sated heart failure, NYHA IV, EF <0.45, in use of dobutamine and the same time. We compiled demographics, clinical characteristics and
carvedilol. Intervention: patients were randomly assigned to complications. Data were analyzed with SPSS 17.
carvedilol maintenance or exchange to nebivolol according to Table 1. Results We had 73 patients, 79% male, mean age 65. Forty-five percent
Hemodynamic parameters were compared using a noninvasive model had previous heart disease. Eighty-four percent presented with fever,
flow technique (Nexfin®; BMEYE), 24 hours before, 6 and 24 hours after 56.5% general syndrome, 56.2% heart failure, 19.2% pain, and 7%
the randomization. P <0.05 was significant. coma. The duration of the clinic before diagnosis was mainly between
7 and 30 days (32%), followed by more than 30 days (27%). Less than
Table 1 (abstract P188) 3 days duration represented 13%. Blood cultures were positive in
82%. The most common agent was Streptococcus (39%), followed by
Carvedilol Nebivolol
Staphylococcus aureus MS (16%), SCN (12%), Enterococcus (12.3%),
6.25 mg/bid 2.5 mg/qd S. aureus MR (1.4%), Escherichia coli (1.4%), Pseudomonas Aeruginosa
12.5 mg/bid 5.0 mg/qd
(1.4%), Aspergillus (1.4%), and polymicrobial (1.4%). Twelve percent
were negative cultures. The valve more frequently affected was
25.0 mg/bid 10.0 mg/qd aortic. In all cases TTE was carried out for diagnosis. In 69 cases TEE
was performed. The principal echo findings were: vegetation (42%),
Results We selected 30 patients, 75% men, age 56.0 (SD = 13.0) years, new insufficiencies (26%), and also stenosis, perivalvular abscess and
ejection fraction 23.4 (SD = 7.2)%, ischemic myocardiopathy present in normal echo. Fifty-eight percent of patients had no distal emboli.
16.7%, Chagas disease in 40% and 43.3% of patients were nonischemic/ Other localizations: splenic (11%), hepatic (2.7%), bones (2.7%),
non-Chagas. Baseline indexed systemic vascular resistance was 2,255.9 brain (4%), lung (5%) and more than one (11%). Forty-one percent of
(SD = 792.4) dynes.second/cm5/m2, and cardiac index was 2.7 (SD = 0.6) patients required ICU admission before surgery with an average stay
l/minute/m. In the nebivolol group (n = 15) the indexed systemic of 5.6 days. A total of 31.5% suffered multiorgan failure. Antibiotics
vascular resistance reduced 0.6% and in the carvedilol group (n = 15) were given 17 days before surgery. In 6.8% it was not possible to give
it reduced 5.0% in 24 hours (mean difference 4.4%; 95% CI: –12.6 to them preoperatively. Eighty-two percent of patients took combination
21.4%; P = 0.513). The cardiac index maintained unchanged (P = 0.274). therapy (19% four). Cephalosporins, aminoglucosids and vancomycin
Comparing patients that received a high dose of nebivolol (5 to 10 mg/ were the most used. Two patients died before surgery. Thirty-five
day) to those with a low dose (<5 mg/day) or carvedilol, we observed a percent of the interventions were urgent. In 16.4%, reoperation was
tendency to superiority of high dose in reduction of systemic vascular necessary, mainly for bleeding, followed by prosthetic dysfunction,
resistance, although not statistically significant (Figure 1). recurrent IE, mediastinitis and pseudoaneurysm repair. A total 56% of
Conclusion Short-term nebivolol use in decompensated heart failure patients presented postoperative shock. MV was needed during 5 days
was hemodynamically safe. Further studies should be done to clarify (range 0 to 53). Acute renal failure post surgery was present in 58%.
this matter. Other complications were secondary infection, ventricular dysfunction,
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atrioventricular block, stroke, perioperative MI, and liver failure. The ICU Agatston score ≥239 has a sensitivity (Se) of 60.6% (95% CI: 0.42 to
stay was 33 days (median 6). The hospital mortality was 31.5%. 0.77), specificity (Sp) of 97.8% (95% CI: 0.88 to 0.99), positive predictive
Conclusion IE has high morbi-mortality. The subgroup of patients value (PPV) of 95.2% and negative predictive value (NPV) of 77.2%. The
requiring early surgery presents the most severe disease. This AUC of ECI to predict an optimal cut-off value for Agatston score was
corresponds with our patients: one-third of cases need urgent surgery, 0.90 (95% CI: 0.83 to 0.96); P <0.001. ECI ≥7 had a Se of 59.1% (95% CI:
56% have shock, about 60% ARF, and mortality reaches 30%. 0.36 to 0.79), a Sp of 93.3% (95% CI: 0.83 to 0.98), PPV of 76.5% and NPV
of 86.2%. There was a significant linear trend of ECI, and ECI ≥7 has in
MDCT a greater presence of both severe calcified wall and obstructive
P190 CAD, number of affected vessels, and mixed/calcified plaques (all
Malperfusion and branch compromise in acute type A aortic P <0.001). There were 23 coronary ischemic events. The AUC of ECI as a
syndrome predictor of adverse cardiac events post MDCT was 0.92 (95% CI: 0.852
R Gomez Lopez1, P Fernandez Ugidos1, P Vidal Cortes1, J Lopez Perez2, to 0.987); P <0.001. ECI ≥7 had a Se of 77.3% (95% CI: 54.6 to 92.2), a
J Priego Sanz1, M Bouza Vieiro2, A Aller Fernandez2, L Seoane Quiroga2, Sp of 90% (95% CI: 79.5 to 96.2), PPV of 73.9% and NPV of 91.5%.
S Fojon Polanco2 The Kaplan–Meier survival analyses show a statistically significant
1
Complexo Hospitalario Universitario de Ourense, Spain; 2Complexo difference between patients with VCSI ≥7 or not regarding an ischemic
Hospitalario Universitario de A Coruña, Spain event (χ2: 52, P <0.001). This accumulation of risk occurs mainly in the
Critical Care 2012, 16(Suppl 1):P190 (doi: 10.1186/cc10797) first 2 years after the determination of ECI.
Conclusion ECI ≥7 determines a poor CAD prognosis of coronary ischemic
Introduction Malperfusion is a factor associated with higher risk of events. Furthermore, ECI ≥7 may serve as a marker of the content of wall
death and complications in patients with acute type A aortic syndrome calcium, obstruction level and composition of the plaques. ECI seems to
(AAAS). Our objective is to determine the incidence and characteristics provide prognostic information as well as providing information about
of this disease in our population and to verify the relevance in morbidity the characteristics of the plaque of atheroma.
and in-hospital mortality.
Methods A historical cohort study that includes all patients with AAAS
admitted to the ICU after surgical management in a single institution P192
from January 2000 to July 2010. Anatomical, clinical, biochemical, Echocardiography in the ICU: an audit of 3 years practice
electrocardiographic and echocardiographic signs of ischemia were A Hall, J Walker, I Welters
considered. The events of interest were death or major complication Royal Liverpool Hospital, Liverpool, UK
(neurological damage, multiorgan failure (MOF), acute lung injury (ALI), Critical Care 2012, 16(Suppl 1):P192 (doi: 10.1186/cc10799)
postoperative hemorrhage) during hospitalization.
Results A total of 65 patients were identified (24.6% women, 61.86 ± 12 Introduction Assessment of the haemodynamically unstable patient
years old, APACHE II score 12.9 ± 7.2, EuroSCORE 7.4 ± 2.6). Thirty-three is a core part of ICU management and relies predominantly on a
(50.8%) presented branch compromise, affecting coronary arteries in combination of clinical skill and measurement of physiological variables.
12 patients (18.4%) (symptomatic (S) seven (10.5%), asymptomatic (A) Echocardiography in the ICU has become increasingly popular as a tool
five (7.7%)), nine (13.8%) carotid (S five (7.7%), A four (6.1%)), 28 (43%) for assessment of cardiac output, fluid status and ventricular function.
brachiocephalic or subclavian (S 17 (26.1%), A 11 (16.9%)), 15 (22.8%) Traditionally transoesophageal echo (TOE) has been favoured due to
mesenteric (S seven (10.5%), A eight (12.3%)), 13 (20%) renal (S nine the belief that it gave superior images [1]. Transthoracic echo (TTE)
(13.8%), A four (6.1%)), and 31 (47.7%) iliac (S 16 (24.6%), A 15 (23%)). is not often performed as it relies on 24-hour availability of trained
Twenty-eight (43.1%) showed clinical ischemia of at least one system personnel, availability of equipment and good patient windows [1].
and 54 (83%) clinical signs of global hypoperfusion. Comparing patients There was also a perceived lack of benefit; however, recent studies have
with and without data of hypoperfusion, differences in incidence of shown good or adequate images in over 85 to 90% of patients resulting
death (45.5% vs. 18.8%, P = 0.03), neurological complication (35.7% vs. in a change of management in 48% [1].
10.8%, P = 0.03), MOF (16.6% vs. 25%. P = 0.07) and ALI (21.3% vs. 29.6%, Methods Data were collected prospectively in all patients undergoing
P = 0.09) were found. echocardiography in a teaching hospital ICU from January 2008 to January
Conclusion More than 80% of the patients with AAAS suffered malper- 2011. The main focus of our investigation was to ascertain the clinical
fusion in our series. They had a higher risk of death and neurological questions to be answered and the outcome of echo on management.
complication during hospitalization. Results A total of 238 echoes were performed on 216 patients with an
average age of 59.75 years (TTE: 198, TOE: 19, and both: 14). The most
commonly asked questions were on filling status and contractility
P191 (40%) and left ventricular function (33%). Ninety percent of clinical
Prognostic value of the echocardiographic-derived calcium index in questions asked were answered fully (74%) or partially (16%) by echo.
coronary artery disease Sixty-one percent of echoes resulted in a change of management
J Jimenez, J Iribarren, J Lacalzada, A De La Rosa, R Juárez, A Barragán, (5% of which were to continue with increased confidence). TTE
J Bonilla, G Blanco, R Pérez, M Brouard, I Laynez performed by operators with basic training resulted in a 54% change
Hospital Universitario de Canarias, La Laguna, Spain in management. Changes included more filling (39%) and changes in
Critical Care 2012, 16(Suppl 1):P191 (doi: 10.1186/cc10798) inotropes or diuretics.
Conclusion Echocardiography in the ICU patient relies on numerous
Introduction Calcification of different cardiac structures is associated factors including skill and equipment availability and patient windows
with atherosclerotic risk factors. The aim of this study is to determine [1]. Our results confirm that there is a role for echo in these patients,
whether the echocardiography-derived calcium index (ECI) assessed important in a population where assessment of cardiac output and
by transthoracic echocardiography (TTE) predicts cardiovascular filling status is notoriously difficult. Our results also show that TTE
events, besides determining the coronary artery calcium score (CACS), performed by ICU physicians with basic training provides very useful
the presence of obstructive coronary artery disease (CAD) and the information for the management of patients. This makes the focused
composition of plaques, all of which determined by multidetector courses on echocardiography very important [2,3]. Limitations of the
computed tomography (MDCT). study: an unknown amount of missing data and a likelihood of patient
Methods We carried out a prospective study of 82 consecutive patients, and operator bias as to which patients had echocardiography. In
with an intermediate likelihood for CAD, who were evaluated by conclusion, echocardiography is a useful tool in the management of
noninvasive coronariography by MDCT. ECI was blindly assessed by TTE. the haemodynamically unstable patients.
A 36-month follow-up was conducted to detect cardiovascular events. References
Results The area under the ROC curve (AUC) of the Agatston score 1. Orme R, et al.: Br J Anaesth 2009, 102:340-344.
scale as a predictor of significant obstruction identified by MDCT 2. Vieillard-Baron et al.: Intensive Care Med 2008, 34:243-249.
was 0.80 (95% CI: 0.68 to 0.91); P <0.001. The optimal cut-off was 239. 3. Jensen et al.: Eur J Anaesth 2004, 21:700-707.
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P193
Left ventriculum diastolic dysfunction in pediatric septic shock
M Georgiyants, V Korsunov
Kharkov Medical Academy Post-Graduate Education, Kharkov, Ukraine
Critical Care 2012, 16(Suppl 1):P193 (doi: 10.1186/cc10800)
indicated that purine nucleosides such as guanosine, inosine or function, under similar hemodynamic conditions. Hepatic, renal and
adenosine might prolong survival in shocked rats, an effect potentially myocardial respiration of the measured mitochondrial complexes did
related to the stimulation of Na/K ATPase activity. This study aimed not significantly differ between the two treatment groups, except for
to evaluate the effects of intravenous administration of guanosine or renal Complex I, State 4 respiration.
inosine combined with lactate Ringer solution (LR) on hemodynamic
and oxygenation parameters and survival in an experimental model of
hemorrhagic shock (HS). P197
Methods HS was induced in 24 pigs (25 to 30 kg) by blood removal Goal-directed hemodynamic resuscitation in high-risk patients
for 20 minutes to target a mean arterial pressure (MAP) of 40 mmHg, undergoing cardiac surgery: a randomized controlled trial –
which was maintained for 60 minutes with additional blood removal preliminary data (GRICCS STUDY)
or retransfusion. Animals were treated with LR alone (three times the E Osawa1, A Rhodes2, J Fukushima1, J Almeida1, F Jatene1, R Nakamura1,
volume of blood withdrawn) or associated to 1 mmol/l guanosine or M Sundin1, J Auler Jr1, R Kalil Filho1, F Galas1, L Hajjar1
1
1 mmol/l inosine. Hemodynamic and oxygenation parameters were Heart Institute, São Paulo, Brazil; 2Charing Cross Hospital, Imperial College
evaluated at baseline, after HS, immediately after fluid resuscitation, NHS Trust, London, UK
and 30, 60, 120, 240 and 360 minutes after fluid resuscitation. Primary Critical Care 2012, 16(Suppl 1):P197 (doi: 10.1186/cc10804)
outcome was post-shock survival. Statistical analysis of parametric data
was performed with one-way ANOVA for repeated measures followed Introduction Low cardiac output is a frequent clinical circumstance
by Student–Newman–Keuls. Kruskal–Wallis followed by the Dunn test after cardiac surgery and results in higher morbidity and mortality rates.
was used for analysis of nonparametric data. The post-shock survival Goal-directed therapy (GDT) is a validated design that has been proved
was evaluated by the Kaplan–Meier curve. to reduce the number of perioperative outcomes. We investigated the
Results The hemodynamic and oxygenation parameters were not results of a cardiac index optimization protocol through the use of the
significantly different among pigs treated with RL alone or in combi- LiDCO rapid device.
nation with guanosine or inosine. No effects on post-shock survival Methods A prospective study that randomized 34 high-risk patients
were observed in any group. (EuroSCORE higher than 6 or LVEF lower than 45%) to a GDT protocol or a
Conclusion The actual preliminary results did not demonstrate conventional hemodynamic therapy. Patients from the GDT group were
any additional improvement induced by guanosine or inosine on resuscitated to a cardiac index higher than 3 l/minute/m2 through the
the hemodynamic and oxygenation parameters or on the post- implementation of a three-step approach: (1) fluid challenge of 250 ml
shock survival during HS. These findings need to be confirmed in aliquots, (2) dobutamine infusion up to a dose of 20 μg/kg/minute, and
a larger group of animals and further investigation with cellular and (3) blood transfusion to reach a hematocrit higher than 28%. The control
biochemical analysis may help to elucidate the effects of guanosine group was managed according to institutional protocol. Categorical
and inosine during HS. variables were compared using Fisher’s exact test and categorical
Acknowledgments Supported by FAPESP and CNPq. variables were compared using the Mann–Whitney U test.
References Results Sixteen patients from the GDT group were compared with
1. Darlington DN, Gann DS:. J Trauma 2005, 58:1055-1060. 18 patients from the control group. There was a tendency towards
2. Schmidt AP, et al.: Pharmacol Ther 2007, 116:401-416. reduction in ICU stay in patients from GDT group in relation to the
control group (7 days vs. 6 days, P = 0.18). Comparison of the primary
endpoint variable (composite of death or major postoperative
P196 complications within 30 days after surgery or before discharge)
Norepinephrine versus angiotensin II in septic shock: effects on between groups showed a reduced complication rate in the GDT group
isolated kidney, heart and liver mitochondrial respiration (52.2% vs. 45.6%, P = 0.12), mainly attributed to worse acute renal
V Jeger, M Vuda, T Correa, J Takala, S Djafarzadeh, SM Jakob failure RIFLE criteria in the control group.
Inselspital University Hospital Bern, Switzerland Conclusion Goal-directed hemodynamic resuscitation with the use
Critical Care 2012, 16(Suppl 1):P196 (doi: 10.1186/cc10803) of a minimally invasive device seems to be a promising perioperative
strategy aimed at reducing the rates of worse outcomes and the ICU
Introduction Mitochondrial dysfunction has been proposed to stay after cardiac surgery.
influence organ function and outcome in sepsis. Both vasopressor
agents norepinephrine and angiotensin II can interfere with
mitochondrial function. The aim of this study was to compare P198
mitochondrial respiration after exposure of septic animals to either of Economic evaluation of early-goal directed therapy for high-risk
these two drugs. surgical patients
Methods In 16 anesthetized pigs, evolving septic shock after 12 hours C Ebm, M Cecconi, H Aya, M Geisen, A Rhodes, M Grounds
of fecal peritonitis was randomly treated with either norepinephrine St George’s Healthcare Trust, London, UK
(0.8 ± 0.6 μg/kg/minute; mean ± SD) or angiotensin II (0.31 ± 0.37 μg/ Critical Care 2012, 16(Suppl 1):P198 (doi: 10.1186/cc10805)
kg/minute; n = 8, each) and fluids for 48 hours. Organs were harvested
at the end of the experiment, and mitochondria isolated by tissue Introduction Early goal-directed therapy (EGDT) has been shown
homogenization and differential centrifugation. Mitochondrial oxygen to reduce postoperative morbidity and length of hospital stay. Our
consumption (VO2) was measured by high-resolution respirometry objective was to analyse the cost-effectiveness of early goal-directed
(Oroboros Instruments, Innsbruck, Austria). Groups were compared proactive therapy versus standard reactive care in patients at high risk
using Mann–Whitney U test. In addition, mitochondrial respiration was of developing postoperative complications.
also compared to a similarly instrumented control group without fecal Methods Patient-level outcome data used were based on a previous
peritonitis (n = 8; Kruskal–Wallis test). randomised, controlled trial. A Markov decision model was constructed
Results Achieved blood pressure levels and cardiac output were not to analyse costs and outcomes associated with the use of EGDT.
different between the two septic groups, and both groups received Outcomes assessed were postoperative complications, mortality,
the same amount of fluids (norepinephrine: 1.6 ± 0.5 ml/kg/hour, quality-adjusted life expectancy (QALY) and incremental costs/QALY.
angiotensin II: 1.3 ± 0.8 ml/kg/hour; P = NS). Compared to controls, Results The main analysis, based on 28-day survival data of 122
mitochondrial VO2 was not different in septic animals. The only patients, revealed an incremental cost-effectiveness ratio of EGDT of
difference between the two septic groups was higher renal Complex I, £280.15 per patient. Additional costs of £525.43 per patient associated
State 4 respiration in norepinephrine-treated (median (range): 309 (164 with EGDT were mainly due to costs related to monitor acquisition
to 415) pmol/(second*mg)) versus angiotensin-II-treated animals (210 and staffing (two additional nurses). These costs were balanced by
(89 to 273) pmol/(second*mg); P = 0.05). savings due to the significant reduction in length of stay in the hospital
Conclusion We found no significant effects of septic shock treated with and in the ICU and lower complication rates in the GDT arm (mean
either angiotensin II or norepinephrine and fluids on mitochondrial expenditures/patient £4,511.25 vs. £5,218.75). This outcome was
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ICER (£/QALY) 280.15 – Introduction The microcirculation plays a pivotal role in oxygen delivery
ICER, incremental cost-effectiveness ratio. to the tissue. Microcirculatory alterations have been observed to occur
independently of the major inflow variable for microcirculation: mean
robust to variations in treatment effect (probability of morbidity and arterial pressure. According to physiological theory, the microcirculation
mortality) and sensitive to implementation costs of EGDT. See Table 1. is considered to be a low-pressure compartment. Maximum optimal
Conclusion The implementation of EGDT appears clinical and cost- central venous pressure (CVP) according to Surviving Sepsis Campaign
effective. Additional implementation costs will be offset by savings (SSC) guidelines is 12 to 15 mmHg in mechanically ventilated patients.
due to a marked decrease in complication rates and hospital length of We hypothesized that a CVP >12 mmHg would hamper microcirculatory
stay. We conclude that GDT provides significant benefits with respect perfusion but not diffusion, by acting as outflow obstruction.
to both clinical and financial outcomes. Methods We retrospectively analyzed combined measurements of CVP
Reference and sidestream dark-field derived sublingual microcirculatory variables
1. Pearse R, Dawson D, Fawcett J, Rhodes A: Early goal directed therapy after in patients with severe sepsis or septic shock. Measurements were made
major surgery reduces complications and duration of hospital stay. A 0, 0.5, 2, 12 and 24 hours after resuscitation in accordance with SSC
randomized, controlled trial. Crit Care 2005, 9:R687-R693. guidelines. Differences in small vessel microvascular flow index (MFI) and
total vessel density (TVD) between two groups (CVP ≤12 mmHg and CVP
>12 mmHg) were analyzed with a Mann–Whitney U test.
P199 Results A total of 345 measurements in 70 patients (APACHE II 21 (6.5)
What matters during a hypotensive episode: fluids, vasopressors, (mean (SD))) were included. MFI in patients with CVP >12 mmHg was
or both? significantly lower than in CVP ≤12 mmHg (1.83 (0.92 to 2.75) vs. 2.25
J Lee1, R Kothari2, JA Ladapo3, DJ Scott1, LA Celi1 (1.35 to 2.90) (median (IQR)), P = 0.032), whereas TVD in both groups
1
Massachusetts Institute of Technology, Cambridge, MA, USA; 2Mount Sinai did not differ significantly (14 (12.84 to 15.75) vs. 14.3 (13 to 15.8) mm/
School of Medicine, New York City, NY, USA; 3New York University School of mm2, P = 0.38). See also Figure 1.
Medicine, New York City, NY, USA Conclusion In septic patients with CVP >12 mmHg after resuscitation,
Critical Care 2012, 16(Suppl 1):P199 (doi: 10.1186/cc10806) microcirculatory flow was significantly lower as compared to patients
with CVP ≤12 mmHg, whereas capillary density did not differ between
Introduction The objective of this retrospective study was to investigate groups.
the relationships between fluid and vasopressor interventions and
patient outcomes. In intensive care, it is imperative to resolve hypotensive
episodes (HEs) in a timely manner in order to minimize end-organ
damage. The current clinical practice is first to attempt fluid resuscitation
and then to follow with vasopressor therapy if fluid resuscitation is
unsuccessful. However, the effects of fluid and vasopressor interventions
on patient outcomes have not been clearly established.
Methods Hypotension was defined as MAP below 60 mmHg. The
primary outcome was in-hospital mortality. Secondary outcomes
included ICU LOS, HE duration, Hypotension Severity Index (HSI) (MAP
curve area below 60 mmHg during the HE), and rise in serum creatinine.
The patient cohort included patients in the MIMIC-II database [1] who
experienced a single HE. Multivariate logistic regression and propensity
score analysis were employed. Sensitivity analyses were conducted in
subpopulations stratified by treatment type and diagnosis.
Results A total of 3,163 patients in MIMIC-II met the inclusion criteria.
The multivariate regression results showed that fluid resuscitation was
significantly associated with shorter ICU LOS (OR = 0.71, P = 0.007) and
greater HSI (OR = 1.26, P = 0.04). Vasopressor administration significantly
decreased HE duration (OR = 0.29, P <0.001) and HSI (OR = 0.72,
P = 0.002) but was correlated with increased in-hospital mortality risk
(OR = 2.86, P <0.001) (even after propensity adjustment; OR = 2.44, Figure 1 (abstract P200). Boxplots of microvascular flow index (MFI) in
P <0.001), prolonged ICU LOS (OR = 1.29, P = 0.04), and rise in serum patients with a central venous pressure (CVP) ≤12 mmHg or >12 mmHg.
creatinine (OR = 1.44, P = 0.002). Sensitivity analyses in treatment-
specific and diagnosis-specific subpopulations corroborated the
relationship between vasopressors and increased in-hospital mortality.
Conclusion Regarding the relationship between vasopressor therapy P201
and in-hospital mortality, similar findings have been reported in Human protein C concentrate to restore physiological values in
previous studies analyzing sepsis [2], cardiac surgery [3], and heart adult septic shock patients: effects on microcirculation
failure [4]. We speculate that benefits of vasopressor use may be A Morelli 1, A Donati2, A Di Russo1, F D’Ippolito1, C Raffone1, A D’Egidio1,
restricted to subsets of patients with specific conditions. This study MR Lombrano2, S Tondi2, E Damiani2, V Cecchini1, A Orecchioni1, P Pietropaoli1
1
illustrates the utility of electronic medical records in research when University La Sapienza, Rome, Italy; 2Marche Polytechnique University,
randomized controlled trials are difficult to conduct. Ancona, Italy
References Critical Care 2012, 16(Suppl 1):P201 (doi: 10.1186/cc10808)
1. Saeed M, et al.: Crit Care Med 2011, 39:952-960.
2. Dunser M, et al.: Crit Care 2009, 13:R181. Introduction We investigated whether human protein C (PC) concen-
3. Shahin J, et al.: Crit Care 2011, 15:R162. trate to restore physiological values in adult septic shock patients can
4. Thackraya S, et al.: Eur J Heart Fail 2002, 4:515-529. influence microcirculatory blood flow.
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Methods We enrolled 36 septic shock patients with plasma protein the small vessels (MFIs) and norepinephrine requirements did not vary
C activity <60%. Patients were randomly allocated to be treated with during the 24-hour observational period. Results are summarized in
either a continuous infusion of PC concentrate at 3 UI/kg/hour for Table 1.
72 hours to reach plasma protein C activity between 70 and 120% or Conclusion In patients with established septic shock who remained
a standard treatment (control; each n = 18). In both groups, NE was tachycardic after hemodynamic optimization in accordance with the
titrated to achieve a MAP between 65 and 75 mmHg. Data from right current guidelines, titration of esmolol to reduce the HR to a predefined
heart catheterization and sidestream dark-field imaging were obtained threshold did not affect microcirculatory blood flow.
at baseline and after 24, 48 and 72 hours.
Results For the same MAP and cardiac output, no significant differences
were found between groups in terms of microvascular flow index of P203
the small vessels (MFIs) and perfused vessel density (PVD). Results are Early course of microcirculatory perfusion in the eye and digestive
summarized in Table 1. tract during experimental sepsis
A Pranskunas1, R Rasimaviciute1, E Milieskaite1, A Vitkauskiene1,
Table 1 (abstract P201). Microcirculatory variables P Dobozinskas1, V Veikutis2, Z Dambrauskas1, D Vaitkaitis1, V Pilvinis1
1
Lithuanian University of Health Sciences, Kaunas, Lithuania; 2Institute of
Baseline 24 hours 48 hours 72 hours
Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
MFIs Critical Care 2012, 16(Suppl 1):P203 (doi: 10.1186/cc10810)
Treated 2.8(2.6; 3) 3 (2.7; 3) 2.9 (2.8; 3) 3 (2.9; 3) Introduction Studies show that sublingual mucosa is a reproducible
Controls 2.8 (2.1; 2.9) 2.8 (2.1; 2.8) 2.8 (2.2; 3) 3 (2.6; 3) part for small intestine mucosal microcirculatory perfusion in sepsis,
when they are not exposed by local factors. However, it is of great
PVD interest how sublingual microcirculation can reflect other beds of
Treated 17.8 (16.5; 22.2) 19.7 (17.4; 22.5) 19.7 (18.1; 23) 19.9 (17; 22.2) microcirculation. The aim of the study is to evaluate and compare the
microcirculatory perfusion of potentially available parts of the body,
Controls 20.2 (17.4; 23.5) 18.8 (17.6; 20.2) 19.4 (17.5; 20.7) 18.7 (17.5; 21.2) such as sublingual mucosa, conjunctiva of the eye, mucosa of jejunum
and rectum, at the same time points during experimental sepsis.
Conclusion The administration of human PC concentrate did not Methods Pigs were randomly assigned to sepsis (n = 9) and sham
influence microcirculatory blood flow in septic shock patients. (n = 4) groups. The sepsis group received a fixed dose of live Escherichia
coli infusion over 1 hour. Animals were observed 5 hours after the start
of E. coli infusion. In addition to systemic hemodynamic assessment,
P202 we performed conjunctival, sublingual, jejunal and rectal evaluation
Heart rate reduction with esmolol in septic shock: effects on of microcirculation using sidestream dark-field videomicroscopy at the
microcirculation same time points: at baseline, 3 and 5 hours after the start of live E.
A Morelli1, A Donati2, A Di Russo1, F D’Ippolito1, A Carsetti2, R Domizi2, coli infusion. Assessment of microcirculatory parameters of convective
A D’Egidio1, C Raffone1, C Scarcella2, C Ertmer3, S Rehberg3, P Pietropaoli1, oxygen transport (microvascular flow index (MFI), proportion of
M Westphal3 perfused vessels (PPV)) and diffusion distance (perfused vessel density,
1
University La Sapienza, Rome, Italy; 2Marche Polytechnique University, total vessel density) was done using a semiquantitative method.
Ancona, Italy; 3University Hospital of Muenster, Germany Results Infusion of E. coli resulted in a hypodynamic state of sepsis
Critical Care 2012, 16(Suppl 1):P202 (doi: 10.1186/cc10809) despite fluid administration. Significant decreases in MFI and PPV of
small vessels were in sublingual, conjunctival, jejunal and rectal lodges
Introduction Preclinical and clinical studies report that β-blockers 3 and 5 hours after the start of E. coli infusion in comparison to baseline
may be an interesting option to attenuate the deleterious effects of variables. Correlation between sublingual and conjunctival (r = 0.80,
prolonged catecholamine exposure during septic shock. Nevertheless, P = 0.036), sublingual and jejunal (r = 0.94, P = 0.005), sublingual and
there are concerns that β-blockers may have negative chronotropic rectal (r = 0.79, P = 0.03) MFI was observed 3 hours after onset of sepsis.
and inotropic effects leading to inappropriately low cardiac output. There was no correlation in change of MFI and PPV between sublingual
The objective of the present study was therefore to elucidate mucosa and other evaluated regions. However, the sublingual mucosa
whether a reduction in heart rate (HR) with esmolol may negatively exhibited the most pronounced alterations of microcirculatory flow in
affect microcirculation in patients with septic shock who remained comparison to conjunctival, jejunal and rectal mucosa microvasculature
tachycardic after hemodynamic optimization. (P <0.05).
Methods After 36 hours of initial hemodynamic stabilization, 11 septic Conclusion Microcirculatory alterations were observed in all investi-
shock patients with HR >95 bpm and requiring norepinephrine (NE) gated lodges, including sublingual, jejunal and rectal mucosa, and
to maintain mean arterial pressure (MAP) between 65 and 75 mmHg, conjunctiva of the eye at the same time point during experimental
despite adequate volume resuscitation, received a continuous esmolol sepsis. There is a clear association between sublingual microcirculation
infusion to maintain HR between 94 and 80 bpm. NE was titrated to and conjunctival, jejunal or rectal microcirculation in the very early
achieve a MAP between 65 and 75 mmHg. Data from right heart course of an extreme hypodynamic state of sepsis.
catheterization and sidestream dark-field imaging were obtained at
baseline and after 24 hours.
Results Apart from a statistically significant decrease in HR and cardiac P204
index (CI) (P <0.05), stroke volume (SV), microvascular flow index of Microcirculation and blood transfusion: effects of three different
types of concentrated red blood cells – preliminary results
Table 1 (abstract P202) A Donati, E Damiani, R Domizi, C Scorcella, A Carsetti, MR Lombrano,
V Fiori, P Pelaia
Baseline 24 hours Università Politecnica delle Marche, Ancona, Italy
HR 119 ± 12 85 ± 9* Critical Care 2012, 16(Suppl 1):P204 (doi: 10.1186/cc10811)
CI 4.4 ± 1 3.1 ± 1* Introduction Red blood cell (RBC) transfusions are used to increase
SV 81 ± 35 80 ± 23 oxygen delivery; however, a restrictive transfusion strategy (predefined
hemoglobin threshold of 7 g/dl) was demonstrated to be associated
MFIs 2.6 ± 0.6 2.8 ± 0.3 with lower mortality and incidence of nosocomial infections than
a liberal one [1,2]. This may be related to the storage process, which
NE 0.7 ± 0.7 0.5 ± 0.4
could affect the ability of RBCs to transport and delivery oxygen, or to
*P <0.05. immunomodulating effects of cytokines from residual leukocytes [2].
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P207 16%). All right-sided catheters lay at an angle <30°. However, 38%
Supraclavicular ultrasound-guided subclavian vein cannulation in (14/37) of left-sided catheters had not crossed the midline, and 59%
infants under 5 kg (22/37) lay at an angle >30° to the vertical. Only 11% (4/37) of left-sided
P Kenderessy catheters had crossed the midline and lay at an angle of <30°, and all of
Faculty Children Hospital, Banska Bystrica, Slovakia these lay below the level of the carina. No immediate complications of
Critical Care 2012, 16(Suppl 1):P207 (doi: 10.1186/cc10814) insertion were identified. See Table 1.
Introduction Central venous cannulation is at some point difficult in Table 1 (abstract P208). Site of CVC insertion (n = 137)
small children and is associated with many complications especially in
Internal jugular Subclavian
multiple-attempt cases. Various techniques exist to achieve successful
cannulation. Ultrasound (US)-guided techniques are reported to be Right 95 5
safe and reduce the rate of complications for internal jugular vein (IJV)
cannulation. We describe an US-guided supraclavicular approach to Left 32 5
another central vein – the subclavian vein (SCV). The supraclavicular
approach to the SCV with anatomical landmarks was described by Conclusion There was a wide variation of catheter tip placements
Yoffa, but physicians are hesitant to use this technique because of the accepted without re-positioning. Left-sided catheter tips are more at
short distance to pleura. risk of less precise (and thus potentially nonoptimal) placement. Our
Methods The principle of the US-navigated technique is to find the SCV results indicate that a clearer placement strategy is required.
at the supraclavicular level and to obtain a longitudinal view of the SCV References
and to allow access to the vein in-plane view (absolute control of the 1. Stonelake PA, et al.: The carina as a radiological landmark for central venous
needle). The ultrasound probe (2.5 cm, 6 to 13 MHz) was placed above catheter tip position. Br J Anaesth 2006, 96:335-340.
the clavicle to visualize the IJV and tilted showing the subclavian artery 2. Bodenham A: Reducing major procedural complications from central
and SCV in longitudinal view. This view permitted an in-plane puncture venous catheterization. Anaesthesia 2011, 66:1-9.
of the vein avoiding arterial or plural hit.
Results Seventy-eight infant and newborns under 5 kg (1.2 to 5 kg) and
83 SCV cannulations were enrolled in this observational study during a P209
period of 11 months (January 2011 to November 2011). All cannulations Power-injectable peripherally inserted central catheters in intensive
were performed by a single anesthesiologist trained for ultrasound care patients
in central line cannulation with established eye–hand coordination MG Annetta, C Marano, A Brutti, D Celentano, M Pittiruti
(5 years experience with peripheral blocks under US). For all cases Catholic University, Rome, Italy
the SCV was easily and quickly visualized, one case had an extremely Critical Care 2012, 16(Suppl 1):P209 (doi: 10.1186/cc10816)
narrow SCV. The US window for cannulation was always established
for free in-plane placement of the needle. The overall success rate for Introduction In ICUs, peripherally inserted central catheters (PICCs)
puncture was 100% and for cannulation was 98%. In the case with an may be an alternative option to standard central venous catheters,
extremely narrow vein (because of oedema and stricture) the SCV was particularly in patients with coagulation disorders or at high risk
punctured but it was impossible to pass the catheter in. The success for infection. Some limits of PICCs (such as low flow rates) may be
rate of puncture at first attempt was 97%, at second attempt was overcome by the use of power-injectable catheters.
100%. A second attempt was necessary in two cases because needle Methods We have retrospectively reviewed all of the power-injectable
visualization and angle of the needle movement were not considered PICCs inserted in adult and pediatric patients in the ICU during a
correct. No complication was reported. 12-month period, focusing on the rate of complications at insertion
Conclusion A supraclavicular US-guided approach to SCV cannulation and during maintenance. All PICCs were inserted by specifically trained
is safe and effective possibility for central vein cannulation in small nurses, using ultrasound guidance and the microintroducer technique,
infants. More studies are needed to establish a learning curve for pure according to a specific insertion protocol.
paediatric intensivists without experience with US navigation. Results We have collected 89 power-injectable PICCs (65 in adults and
24 in children), 4 to 6 Fr, both multiple and single lumen. All insertions
were successful. There were no major complications at insertion and no
P208 episodes of local infection or catheter-related bloodstream infection.
Central venous catheter placement: where is the end of the line? Noninfective complications during management were not clinically
K Tizard, I Welters relevant. There was one episode of symptomatic thrombosis during
Royal Liverpool University Hospital, Liverpool, UK the stay in the ICU and one episode after transfer of the patient on a
Critical Care 2012, 16(Suppl 1):P208 (doi: 10.1186/cc10815) nonintensive ward.
Conclusion Power-injectable PICCs have many advantages in the
Introduction There is still controversy regarding safe placement ICU: they can be used as multipurpose central lines for any type of
of central venous catheters (CVCs) as to where the tip should lie to infusion including high-flow infusion, for hemodynamic monitoring,
avoid mechanical complications whilst maintaining effective use and for high-pressure injection of contrast media during radiological
[1,2]. The carina has previously been suggested as a useful landmark procedures. Their insertion is successful in 100% of cases and is not
to avoid intracardiac placement and its associated risks, and also that associated with significant risks, even in patients with coagulation
the catheter tip should lie within the superior vena cava parallel to disorders. Their maintenance is associated with an extremely low rate
its walls [1,2]. However, this has been disputed and there remains no of infective and noninfective complications.
consensus as to optimal tip placement. To gauge our current practice
we performed a retrospective review of CVCs placed via the internal
jugular or subclavian route in intensive care patients to assess where P210
CVC tips were placed. Comparison of internal jugular and subclavian access for central
Methods We retrospectively reviewed the chest radiographs of 197 venous catheterization in pediatric cardiac surgery
consecutive intensive care patients admitted on and before 30 June A Pirat1, A Camkiran1, P Zeyneloglu1, M Ozkan1, E Akpek2, G Arslan1
1
2011. A total of 101 patients had evidence of 137 new CVCs. For each Baskent University, Ankara, Turkey; 2Acibadem University, Istanbul, Turkey
new catheter the Picture Archiving & Communication System was used Critical Care 2012, 16(Suppl 1):P210 (doi: 10.1186/cc10817)
to record the tip position (after any repositioning) in relation to the
carina and the degree of angulation from the vertical. Introduction Central venous catheterization (CVC) is an essential com-
Results Twenty-five per cent (34/137) of all catheter tips lay >10 mm ponent of perioperative care in pediatric cardiac surgery. Traditionally
below the carina, therefore potentially increasing the likelihood of the internal jugular vein (IJV) is used for CVC in cardiac surgery. The aim
intracardiac placement. This was reduced for left-sided catheters (6/37; of this study was to compare IJV and subclavian vein (SV) routes for CVC
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in pediatric cardiac surgery in terms of success rate and mechanical and P212
infectious complications. Errors in the arterial blood pressure measurement
Methods After Ethics Committee approval and written informed F Franchi1, V De Palo1, A Faltoni1, S Cecchini1, L Cubattoli2, P Giomarelli1
1
consent from the parents of the children were obtained, 200 children University of Siena, Italy; 2Hospital of Siena, Italy
who were scheduled for cardiac surgery were randomly allocated to IJV Critical Care 2012, 16(Suppl 1):P212 (doi: 10.1186/cc10819)
(n = 100) and SV (n = 100) groups.
Results The mean age was 37 months (95% CI, 29 to 45 months) in group Introduction The artefacts affecting arterial wave morphology may
IJV and 35 months (95% CI, 29 to 42 months) in group SV (P = 0.619). The compromise recorded values of arterial blood pressure (ABP) and
95% CI for weight in groups IJV and SV were 10.4 to 14.2 kg and 10.2 to can lead to therapeutic errors. The aim of this study is to evaluate the
13.0 kg, respectively (P = 0.595). The CVC success rates at first attempt errors between invasive and noninvasive arterial pressure values, the
for groups IJV and SV were 67% and 70%, respectively (P = 0.761). incidence of artefacts due to an inadequate dynamic response of the
An alternative location was required to perform CVC in 90 patients transducer-tubing system, and their detection by the ICU staff.
in group IJV and in 92 patients in group SV (P = 0.806). The overall Methods Seventy-five consecutive patients (50 male, mean age 55 ± 18)
frequency of mechanical complications during the catheter insertion admitted to the ICU for heterogeneous pathologies were enrolled.
and its use was 26% in group IJV and 28% in group SV (log-rank test: Inclusion criteria were: the presence of an intra-arterial catheter (IAC)
P = 0.753). Significantly more arterial punctures occurred in group IJV for invasive blood pressure monitoring, and age >18 years. Pregnancy
than in group SV (14% vs. 4%, P = 0.024). Catheter tip misplacement was excluded. At admission and every time the IAC was replaced we
was observed more frequently in group SV than group IJV (12% vs. acquired invasive systolic, diastolic, and medium arterial pressure
1%, P = 0.003). Catheter colonization rates were significantly higher in values (I-SP, I-DP, I-MP) during hemodynamic stability (variations of
group IJV than group SV (15% vs. 5%, log-rank test: P = 0.020). There mean arterial pressure <10%); at the same time, noninvasive systolic
was no difference in bloodstream infection per 1,000 catheter days and diastolic arterial pressure values (Ni-SP, Ni-DP) were measured
between group IJV and group SV (3.4 vs. 1.4, respectively: P = 0.319). with a sphygmomanometer at the same arm of the IAC. Noninvasive
Conclusion In pediatric cardiac surgery patients, IJV and SV catheters medium arterial pressure (Ni-MP) was calculated as follows: (SP + 2DP) / 3.
had similar success rates as well as overall mechanical complication At every time of the study, before ABP value acquisition, medical and
rates. Although the catheter colonization rate was significantly higher nursing staff answered a questionnaire on the reliability of the arterial
with IJV than SV, both access routes had similar rates of bloodstream waveform. The staff could perform the fast flush test if considered
infection. appropriate. However, the fast flush test was executed by the main
investigator at the end of questionnaire in all patients. Bland–Altman
analysis was performed.
P211 Results We compared 130 pairs of Ni-SP, Ni-DP and Ni-MP and I-SP,
Ultrasound-guided central venous line placement in critically I-DP and I-MP. The mean bias between Ni-SP and I-SP was –11 mmHg
ill patients: is chest X-ray needed to assess post-insertion (limit of agreement (LoA) –43.6 to 21.4 mmHg). The mean bias between
pneumothorax? Ni-DP and I-DP and between Ni-MP and I-MP was 6.1 mmHg (LoA
O Samir Abdel Gelil Kotb, A Ali Abel Aziz, Y Awad –15.5 to 27.7 mmHg) and 0.37 mmHg (LoA –21.0 to 21.7 mmHg),
Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates respectively. We performed the fast flush test 130 times; an inadequate
Critical Care 2012, 16(Suppl 1):P211 (doi: 10.1186/cc10818) dynamic response of the transducer-tubing system was observed 55
times: in 45 cases the arterial signal was underdumped and in 10 cases
Introduction Critically ill patients, mostly on positive pressure was overdumped. The arterial dumping was correctly detected by the
ventilation, are at higher risk of pneumothorax as well as their need for medical staff in 95% of cases, by nursing staff and postgraduates in 35%
a central venous line (CVL) to optimize fluid status, CVP measurement, of cases.
and so forth, and where the CVL is not being placed in the best Conclusion The bias between invasive and noninvasive ABP measure
circumstances with the patients being critically ill, unstable and with can be relevant and mislead in the therapeutic management. These
higher chances of error predisposed by pre-existing lung disease, errors can be avoided by identifying the artefacts that affect arterial
obesity or whatever the admitting diagnosis. Before CVL placement signal and so the ICU staff must pay attention to the recognition of
was a blind technique relying on the anatomical positions identifying arterial dumping in critically ill patients.
the position of major blood vessels and thus post-insertion X-ray was Reference
needed to confirm correct placement and to assess for pneumothorax. 1. Pickering TG: Principles and techniques of blood pressure measurement.
But with ultrasound (US) being more widely available, and most CVLs Cardiol Clin 2002, 20:207-223.
placed as US guided, the ultimate question develops: is post-insertion
chest X-ray still needed?
Methods A retrospective study of 856 lines placed in 602 patients being P213
evaluated over a period of 11 months. All cases were performed in a The T-Line TL-200 system for continuous noninvasive blood
controlled ICU environment. Chest X-rays were performed 30 minutes pressure measurement in medical ICU patients
post-insertion in the D0 adult ICU unit in a tertiary medical center in B Saugel, F Fassio, A Hapfelmeier, AS Meidert, RM Schmid, W Huber
Abu Dhabi, UAE. The D0 ICU has a capacity of 24 beds with an average Klinikum Rechts der Isar, Technischen Universität München, Munich, Germany
admission rate of 55 to 60 patients per month. Records were assessed Critical Care 2012, 16(Suppl 1):P213 (doi: 10.1186/cc10820)
and evaluated, and data collected and statistically studied.
Results A total of 856 lines performed in 602 patients were evaluated. Introduction The T-Line TL-200 (Tensys Medical Inc., San Diego, CA,
In 607 US-guided cannulating internal jugular veins with only four USA) is a noninvasive arterial blood pressure (BP) monitoring system
cases of malposition, there were no cases of pneumothorax recorded. allowing continuous beat-to-beat monitoring of systolic arterial
A total of 161 subclavian veins were cannulated with no US, of which six pressure (SAP), mean arterial pressure (MAP), and diastolic arterial
cases of pneumothorax were reported; two cases needed intercostal pressure (DAP). It provides a real-time BP waveform like that obtained
tube insertion. Eighty-eight femoral vein cannulations with no US were using an arterial catheter for BP monitoring. The aim of this study was
performed and no complications were recorded. to compare BP measurements obtained using the T-Line TL-200 system
Conclusion Chest X-ray is not necessary after US-guided CVL place- with simultaneous invasive BP measurements using a femoral arterial
ment. Cutting out the chest X-ray procedure post insertion proved to catheter in unselected critically ill medical patients.
be cost-effective. Methods In 28 patients treated in a medical ICU of a German university
References hospital, BP values were simultaneously obtained using a femoral
1. Ultrasound detects central line placement and postprocedure arterial catheter and the T-Line TL-200 device. All recorded data were
pneumothorax. Emerg Med 2009. included in the final analysis. For comparison of BP measurements,
2. Ultrasound-guided central line placement: no X-ray needed. Emerg Med Bland–Altman analysis accounting for repeated measurements was
2011. performed.
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P217
Effects of cardiac output levels on the measurement of
transpulmonary thermodilution cardiac output in patients with
Figure 1 (abstract P218).
acute lung injury
K Kao, H Hu, C Hung, C Chang, C Huang
Chang Gung Memorial Hospital, Kwei-Shan,Taoyuan, Taiwan
Critical Care 2012, 16(Suppl 1):P217 (doi: 10.1186/cc10824) probe (CardioQ™; Deltex Medical, UK) was inserted, connected to the
CardioQ-ODM™ monitoring system and correct positioning verified.
Introduction Transpulmonary thermodilution cardiac output (CO) Simultaneous determination of cardiac output by ODM and ECOM™
correlates closely with pulmonary artery (PA) thermodilution CO. was performed before and after cross-clamping of the aorta.
Levels of CO may contribute varying amounts of thermal indicator Results Cardiac output ranged from 1.4 to 13.1 l/minute. Linear
loss and recirculation during thermodilution CO measurement. This regression is represented by the equation y = 0.30x + 2.2 and the
study aimed to investigate the effects of CO levels on the agreement correlation coefficient r2 = 0.15. The bias was +1.5 l/minute with 95%
between transpulmonary and PA thermodilution CO in acute lung limits of agreement between –2.1 and 5.1 l/minute (Figure 1).
injury (ALI) patients. Conclusion Using the CardioQ™ as a reference, the ECOM™ system
Methods Twenty-two ALI patients were prospectively enrolled. cannot be recommended as a clinical cardiac output measurement
Paired bolus transpulmonary thermodilution cardiac index (BCItp) technique in abdominal aortic surgery, due to its poor correlation and
and continuous PA thermodilution cardiac index (CCIpa) data were wide limits of agreement.
recorded at baseline and repeated immediately and at 2, 4, and 6 hours
after volume expansion with a 500 ml infusion of 10% pentastarch (HES
200/0.5). P219
Results One hundred and ten paired CI measurements were recorded Cardiac output monitoring in cirrhotic patients: EV1000 versus
and divided into four quartiles from the lowest to the highest CCIpa. pulmonary artery catheter – preliminary data
The mean BCItp was higher than CCIpa, and the Bland–Altman analysis G Costa, T Cecconet, D Baron, G Serena, P Chiarandini, L Pompei,
revealed a bias of 0.57 ± 0.75 l/minute/m2. The limits of agreement (2SD) L Vetrugno, G Della Rocca
were +2.07 to –0.93 l/minute/m2. BCItp correlated closely with CCIpa University of Udine, Italy
(R = 0.887). CCIpa negatively correlated with the difference between Critical Care 2012, 16(Suppl 1):P219 (doi: 10.1186/cc10826)
BCItp and CCIpa (R = –0.26). The bias of quartile 1 with the least CCIpa
was significantly greater than those of the three other quartiles. Introduction The EV1000 platform, a new calibrated device for
Conclusion In ALI patients, transpulmonary thermodilution is a clinically intermittent and continuous cardiac output monitoring, has recently
acceptable and interchangeable alternative to PA thermodilution for been introduced into clinical practice [1]. This study aims to assess
CO measurement. Levels of CO weakly and negatively correlate with the the level of agreement between intermittent and continuous cardiac
difference between BCItp and CCIpa. There is greater overestimation of output obtained from VolumeView (ICOvv and CCOvv) connected
BCItp over CCIpa in low than in high CO states. to the EV1000 platform (Edwards Lifesciences, Irvine, CA, USA) and
References intermittent (ICOvig) and continuous cardiac output (CCOvig) obtained
1. Harvey S, et al.: Lancet 2005, 366:472-477. using an advanced pulmonary artery catheter (PAC) connected to
2. Koo KKY, et al.: Crit Care Med 2011, 39:1613-1618. the Vigilance System (Edwards Lifesciences) in cirrhotic patients
undergoing liver transplantation.
Methods Seven consecutive patients (seven male, zero female), mean
P218 age 56.5 (± 12) years, were enrolled into the study. ICO data were
Comparison of bioimpedance and oesophageal Doppler cardiac
output monitoring during abdominal aortic surgery
Table 1 (abstract P219). Bias, 2SD and PE for all data pairs and for CO higher
HK Jørgensen, J Bisgaard, T Gilsaa
and lower than 8 l/minute
Littlebaelt Hospital Kolding, Denmark
Critical Care 2012, 16(Suppl 1):P218 (doi: 10.1186/cc10825) Bias 2SD PE (%)
obtained from the two devices after ICU admission (T0) and after 12 5 hours and 33 minutes (range 14 minutes to 15 hours). The correlation
(T12) and 24 hours (T24). CCOvig and CCOvv were recorded every hour coefficient between the COTPTD and PCCO was 0.85 (P <0.0001). The
from T0 up to 48 hours after ICU admission. Agreement and precision Bland–Altman analysis showed a mean bias of 0.06 l/minute (limits of
between CO values were evaluated with Bland–Altman analysis. The agreement (LoA) ± 2.22 l/minute) (Figure 1). The percentage error was
percentage error (PE) was calculated as 2SD / mean CO [2]. 43%. The correlation coefficient between the recalibration interval and
Results Twenty-one ICO data pairs were compared. Two patients were the bias between COTPTD and PCCO was –0.26 (P = 0.05). There was no
excluded from CCO data analysis for technical reasons. A total 240 CCO correlation between COTPTD and PCCO (r = 0.09 (P = 0.57)).
data pairs from five patients were analysed. Data yielded were analysed Conclusion The PCCO method cannot replace the transpulmonary
as total and for CO values lower and higher than 8 l/minute (Table 1). thermodilution method in critically ill children.
Conclusion These data, even if very preliminary, showed low agreement
and high PE either for intermittent and continuous CO obtained from
the VolumeView. However, for CO data lower than 8 l/minute the PE P221
was improved. Impact of arterial catheter location on the accuracy of cardiac
References output provided by an endotracheal bioimpedance device
1. Bendjelid et al.: Crit Care 2010, 14:R209. F Gennart, S Beckers, C Verborgh, A De baerdemaeker, J Poelaert
2. Cecconi et al.: Crit Care 2009, 13:201. UZ Brussels, Belgium
Critical Care 2012, 16(Suppl 1):P221 (doi: 10.1186/cc10828)
Figure 1 (abstract P220). Bland–Altman analysis of COTPTD and PCCO. Figure 2 (abstract P221).
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a patient in each group. There was a statistical difference between the higher LVSVs resulting in higher EV than TTE measurements. The
two groups (P = 0.02). In the impaired LV group, the cardiac index fell bias defined by the difference of the means of the two methods was
from 3.2 l/minute/m2 (± 0.5) to 2.9 l/minute/m2 (± 2.5). 9.65%, with a mean percentage error of the individual measurements
Conclusion In this small observational study we demonstrated a of 55%. Based on the Bland–Altman analysis, a deduced approximated
consistent fall in cardiac index post extubation in patients with known correction factor between TTE-LVSV and EV-LVSV was TTE-LVSV = EV-
cardiac ventricular dysfunction when compared with patients with LVSV0.539×100.335 (EV-LVSV)×2.2.
normal hearts. These data suggest that bioreactance monitoring may Conclusion Correlation between EV and TTE in LVSV measurement
be valuable during spontaneous breathing trials and extubation. was significant. Bland–Altman analysis showed that – despite a large
References mean error of the individual measurements of 55% – the bias between
1. Benomar B, Ouattara A, Estagnasie P, Brusset A, Squara P: Fluid the means of the two methods was only 9.65%. A correction factor
responsiveness predicted by non-invasive bioreactance-based passive leg between TTE and EV could be deduced.
raise test. Intensive care Med 2010, 36:1875-1881.
2. Papanikolaou J, Makris D, Saranteas T, et al.: New insights into weaning from P226
mechanical ventilation: left ventricular diastolic dysfunction is a key Validation of less-invasive hemodynamic monitoring with Pulsioflex
player. Intensive Care Med 2011, 37:1976-1985. in critically ill patients
M Peetermans, W Verlinden, J Jacobs, A Verrijcken, S Pilate,
P225 N Van Regenmortel, I De laet, K Schoonheydt, H Dits, ML Malbrain
Left ventricular stroke volume measurement by impedance ZNA Stuivenberg, Antwerp, Belgium
cardiography correlates with echocardiography in neonates Critical Care 2012, 16(Suppl 1):P226 (doi: 10.1186/cc10833)
ME Blohm1, J Hartwich1, D Obrecht1, G Müller2, J Weil2, D Singer1
1
University Medical Center Hamburg – Eppendorf, Hamburg, Germany; Introduction Thermodilution (TD) is a gold standard for cardiac index
2
University Center for Cardiology and Cardiothoracic Surgery, Hamburg, (CI) measurement. The aim of this study is to compare intermittent
Germany bolus TDCI with intermittent automatic calibration CI (AutoCI) and
Critical Care 2012, 16(Suppl 1):P225 (doi: 10.1186/cc10832) continuous CI (CCI) obtained by pulse contour analysis with PiCCO2
(PiCCI) and Pulsioflex (PuCCI).
Introduction The aim of this study was to validate impedance Methods A prospective study in 20 patients (all mechanically ventilated,
cardiography (electrical velocimetry (EV)) as a continuous noninvasive 14 male). Age 54.4 ± 16.7, BMI 28.1 ± 7.3, SAPS II 52.9 ± 13.4, APACHE II
cardiac output monitoring in neonates and infants. As the reference score 26.7 ± 7.8 and SOFA score 10 ± 3. All patients underwent PiCCO
method, discontinuous transthoracic echocardiography (TTE) was monitoring via a femoral line whilst the radial line was kept in place
used. during four 8-hour time periods (in the first two periods the Pulsioflex
Methods In a prospective single-center observational study, was connected to the radial line, in the last two it was connected to
simultaneous left ventricular stroke volume (LVSV) measurements by the femoral line). In the first and third 8-hour periods the Pulsioflex
EV (using an Aesculon® Monitor) and by TTE were compared. LVSV was calibrated with the TDCI obtained at baseline, for the second and
measurement by TTE was based on the aortic valve velocity time fourth 8-hour periods the Pulsioflex was calibrated with the AutoCI
integral multiplied by the area of the aortic valve outflow tract. A total value. Simultaneous PiCCI and PuCCI measurements were obtained
of 102 healthy neonates with normal biventricular cardiac morphology every 2 hours while simultaneous TDCI and AutoCI were obtained
(including PDA or patent foramen ovale) were included – further every 8 hours. The PiCCI and PuCCI values were recorded within
patient details: 43 female, 59 male, median weight 3.32 kg, median 5 minutes before TDCI was determined. We also looked at the effects of
length 51 cm, median age 49.24 hours, mean heart rate 133 ± 22/ 22 interventions: passive leg raise (n = 6), fluid bolus (n = 5), change in
minute. In total 328 simultaneous LVSV measurements in triplicate vasopressor (n = 9) or dobutamine (n = 1), increase in sedation (n = 1).
irrespective of respiratory cycle were analyzed. Statistical analysis was performed using Pearson correlation and
Results Significant correlations (P <0.05) were noted between EV-LVSV Bland–Altman analysis.
and body weight, TTE-LVSV and body weight, EV-LVSV and age, Results In total, 305 paired PiCCI–PuCCI and 128 paired AutoCI–TDCI
TTE-LVSV and age. A significant inverse correlation was seen between values were obtained. TDCI values ranged from 1.5 to 6.7 l/minute/m2
EV-LVSV and heart rate, and TTE-LVSV and heart rate. No significant (mean 3.9 ± 1), AutoCI from 2.4 to 6.5 (3.8 ± 0.8), PiCCI from 1.5 to 7.1
correlation was found for EV-LVSV and age (if age ≤120 hours). No (3.8 ± 1.2) and PuCCI from 2 to 7.6 (3.8 ± 1). The Pearson correlation
significant effect was seen for a small persistent foramen ovale (n = 66) coefficient comparing all and mean PuCCI and PiCCI values had an R2 of
and a small PDA (n = 26) on EV-LVSV and TTE-LVSV in the observed 0.77 and 0.86 respectively; for AutoCI and TDCI, R2 was 0.76. The above
cohort. Bland–Altman analysis of logarithmic data showed a bias of the R2 values were 0.73, 0.84 and 0.71 respectively when the Pulsioflex
EV-LVSV measurements in comparison to the TTE-LVSV measurements was connected to a radial line. Changes in AutoCI correlated well with
with smaller LVSVs resulting in lower EV than TTE measurements and changes in TDCI (R2 = 0.68), as did changes in PuCCI versus changes
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in PiCCI (R2 = 0.53). PPV obtained from Pulsioflex and PiCCO correlated immunocompromised and immobile state of ICU patients. This
better than SVV (R2 = 0.86 vs. 0.62). Changes in PiCCI and PuCCI induced research retrospectively tests the ability of a computer-based method
by an intervention correlated well with each other (R2 = 0.94). Bland– to monitor acute hemodynamic changes in pigs. If proven, this method
Altman analysis comparing AutoCI with TDCI revealed a mean bias could assist ICU staff by providing a clear physiological, patient-specific
±2SD (LA) of 0.05 ± 0.94 l/minute/m2 (with 27.3% error) while analysis picture of cardiovascular status for decision support.
of PuCCI versus PiCCI showed a bias ±LA of 0.01 ± 1.12 (29.1% error). Methods In two porcine studies, APE (n = 5) and SS (n = 4) were induced
Conclusion Although TDCI remains a gold standard, the preliminary using autologous blood clots and endotoxin infusions. Hemodynamic
results of an ongoing prospective study indicate that in unstable measurements were recorded every 30 minutes for 4 hours (n = 80).
critically ill patients CI can be reliably monitored with Pulsioflex Subject-specific cardiovascular models were identified from typical ICU
technology. Moreover, the Pulsioflex was also able to keep track of measurements obtained from each of these datasets, including aortic
changes in CI. and pulmonary artery pressure, stroke volume, heart rate, global end-
diastolic volume, and mitral and tricuspid valve closure times. Model
P227 outputs and identified parameters were compared to experimentally
A preliminary study on the use of noninvasive hemodynamic derived indices, measurements not used in the identification process,
monitoring with the Nexfin monitor in critically ill patients and known trends to validate the accuracy of the models.
M Peetermans, W Verlinden, J Jacobs, A Verrijcken, S Pilate, Results The models accurately predicted maximum ventricular
N Van Regenmortel, I De laet, K Schoonheydt, H Dits, ML Malbrain pressures and volumes, not used in the identification process, to
ZNA Stuivenberg, Antwerp, Belgium mean percentage errors of 7.1% and 6.7% (less than measurement
Critical Care 2012, 16(Suppl 1):P227 (doi: 10.1186/cc10834) error ~10%). Mean modelled pulmonary vascular resistances (PVR)
compared well (R2 = 0.81 for APE and R2 = 0.95 for SS) to experimentally
Introduction Noninvasive hemodynamic monitoring may become a new derived values. Importantly, in the APE study a 91% rise from baseline
tool in the ICU armamentarium. The Nexfin monitor (BMEYE, Amsterdam, in the mean PVR was identified with an 89% increase seen in the SS
the Netherlands) enables continuous noninvasive analysis of the finger pigs. Contrasting behaviour between the two studies was observed for
blood pressure waveform using an inflatable finger cuff, a technology systemic vascular resistance (SVR) with a maximum drop of 40% from
based on the volume-clamp principle of Penaz in combination with baseline recorded at T120 for SS, indicating a loss of vascular tone as
the physical criteria of Wesseling. The aim of the present study was to expected, where at the same time in the APE study the average SVR
validate the Nexfin in a mixed population of medical ICU patients and to had increased by 13%. An increase in the ratio of right to left ventricle
look for a pattern recognition that may be linked with outcome. end volume was identified in all nine pigs, indicating right ventricular
Methods A prospective study in 40 patients admitted to the medical distension and a leftward shift in the intraventricular septum.
ICU (17 patients mechanically ventilated, M/F ratio 1/1). Age 63.5 ± 16.7, Conclusion These results indicate that subject-specific cardiovascular
BMI 26.4 ± 5.4, APACHE II score 20.8 ± 9.5, SAPS II 45.9 ± 18.9, SOFA score models are capable of tracking well-known global hemodynamic
7.2 ± 4.2. For all patients, simultaneous recording of arterial pressure by trends of two common forms of shock in the ICU. The method shows
radial line (n = 46), by PiCCO monitor (n = 15) or by NIBP measurement potential and could provide a means for continuous cardiovascular
with arm cuff (n = 17) was compared with noninvasive hemodynamic monitoring at little extra cost as no extra measurements or expensive
parameters obtained with the Nexfin monitor. Statistical analysis was devices are required.
performed with Student’s t test, Pearson correlation and Bland–Altman
analysis.
Results A total of 69 measurements in 40 patients were performed. P229
In three patients measurement with the Nexfin was not possible. For Homeodynamic complexity: multifractal analysis of physiological
CO (26 paired measurements), values were 6.4 ± 2.1 l/minute (range instability
3.3 to 12). The Pearson correlation coefficient comparing Nexfin-CO A Ercole, SM Bishop, SI Yarham, VU Navapurkar, DK Menon
with reference CO showed a good correlation (R2 = 0.5). Bland–Altman University of Cambridge, UK
analysis comparing both CO techniques revealed a mean bias ±2SD Critical Care 2012, 16(Suppl 1):P229 (doi: 10.1186/cc10836)
(LA) of 0.7 ± 3.9 l/minute (58.3% error). The MAP was 84.6 ± 17.7 mmHg
(57.5 to 131.5) and values obtained with the Nexfin correlated well with Introduction Physiological instability is a common clinical problem in
the reference method (PiCCO in eight; radial line in 43) with an R2 of the critically ill. Physiological adaptation can be regarded as a dynamic
0.75. Bland–Altman analysis comparing both MAP techniques revealed process, with stability being conferred by a number of apparently
a mean bias ±2SD (LA) of 0.2 ± 19.7 mmHg (23.3% error). However, complex, fluctuating homeokinetic processes [1]. Many natural
Nexfin-MAP did not correlate well with NIBP (R2 = 0.1). The nine patients systems are nonlinear, and seemingly random fluctuations may result
that died in the ICU had higher APACHE II (P = 0.07), SAPS II (P = 0.07) as a consequence of their underlying dynamics. Fractal geometry offers
and SOFA (P = 0.01) scores and significantly lower MAP (P = 0.028) and a method to characterize the underlying nonlinear state, providing a
lower dp/dtmax (P = 0.029), a marker for contractility. There were no technique for monitoring complex physiology in real time, which may
outcome differences with regard to subgroup analysis in patients with be of clinical importance.
either low or high CO or SVR. Methods We employ the wavelet modulus maxima technique to
Conclusion The preliminary results of this ongoing prospective trial characterize the multifractal properties of physiological time series such
indicate that in unstable critically ill patients CO and MAP can be as heart rate (HR) and mean arterial pressure (MAP) under conditions of
monitored noninvasively with the Nexfin. The exact patient population clinical physiological instability. We calculated point estimates for the
for this technology has yet to be defined and more patients are dominant Hölder exponent (hm) and multifractal spectrum width-at-
probably needed for pattern recognition, although the results indicate half-height (WHH). We investigated how these parameters changed
that low MAP and dp/dtmax are associated with poor outcome. with pharmacological interventions such as vasoconstriction.
Results Hypotensive patients showed lower values of hm for MAP,
P228 consistent with a more highly fluctuating, antipersistent and
Computer-based monitoring of global cardiovascular dynamics complex behavior. Blood pressure support with pharmacological
during acute pulmonary embolism and septic shock in swine vasoconstriction led to a transient increase in hm for MAP (Figure 1)
JA Revie1, DJ Stevenson1, JG Chase1, BC Lambermont2, A Ghuysen2, revealing the appearance of longer-range correlations, but did not
P Kolh2, GM Shaw3, T Desaive2 affect hm as estimated for HR. On the other hand, supporting the heart
1
University of Canterbury, Christchurch, New Zealand; 2University of Liege, rate with atropine had no effect on hm for MAP, but did tend to increase
Belgium; 3Christchurch Hospital, Christchurch, New Zealand hm for HR.
Critical Care 2012, 16(Suppl 1):P228 (doi: 10.1186/cc10835) Conclusion We demonstrate increasing signal complexity under
physiological challenge consistent with the activation of homeokinetic
Introduction Acute pulmonary embolism (APE) and septic shock processes. Differential fractal behavior for HR and MAP suggests that
(SS) are highly prevalent dysfunctions in the ICU due to the the homeokinetic systems are recruited in a targeted way depending
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To ensure appropriate indication of fluid administration, evaluation of Conclusion Prediction of a fluid response with SVV/PPV was less
fluid responsiveness by dynamic parameters is suggested, although reliable in spontaneous breathing. PLR predicted fluid responsiveness,
it requires specific conditions not always present in ICU patients. The but was less accurate than previously reported.
aim of this study was to analyze the applicability of parameters for References
evaluation of fluid responsiveness in the ICU. 1. Marik et al.: Crit Care Med 2009, 37:2642-2647.
Methods We conducted a prospective observational study in two 2. Monnet et al.: Crit Care Med 2006, 34:1402-1407.
ICUs. Volume expansions performed in ICU patients at the discretion
of the physician in charge were analyzed for the presence of
conditions that allowed adequate fluid responsiveness evaluation. The P237
presence of central venous, pulmonary arterial or peripheral arterial Microcirculatory blood flow is related to clinical signs of impaired
catheters, invasive mechanical ventilation and ventilator settings, organ perfusion, and its dynamics to the macrohemodynamic
echocardiography availability, presence of arrhythmias, use of sedation concept of fluid responsiveness
and vasoactive drugs were registered. Percentages of patients who A Pranskunas1, M Koopmans2, V Pilvinis3, P Koetsier2, EC Boerma2
1
fulfilled conditions for dynamic parameters (such as pulse pressure Lithuanian University of Health Sciences, Kaunas, Lithuania; 2Medical Centre
variation, stroke volume variation and echocardiographic analysis) Leeuwarden, the Netherlands; 3Hospital of Lithuanian University of Health
were recorded. Sciences, Kaunas, Lithuania
Results Ninety volume expansions in 68 patients were performed Critical Care 2012, 16(Suppl 1):P237 (doi: 10.1186/cc10844)
during the study period. Central venous catheter was present 58.9% of
the time. In 41.1% of the cases patients were in spontaneous ventilation. Introduction Fluid responsiveness is not equal to a clinical need for
No patients used a pulmonary artery catheter. An echocardiography fluid therapy. The aim of our study was to assess the incidence of
machine with an attending physician trained for critical care microcirculatory flow alterations, according to a predefined arbitrary
echocardiography was available in 8.9%. An arterial catheter was cut-off value, in patients with clinical signs of impaired organ perfusion.
available in 21% of the volume expansions and mechanical ventilation The secondary endpoint was to establish the correlation between the
was present in 31.1% of the cases (67.3% of ventilated patients were microcirculatory and macrocirculatory response to a fluid challenge.
using controlled mode of ventilation). The association of mechanical Methods We performed a prospective, single-centre, observational
ventilation in controlled mode with an arterial catheter in place and no study. Included were ICU patients ≥18 years with invasive hemo-
restrictions for performing analysis of dynamic parameters was present dynamic monitoring and clinical signs of impaired organ perfusion,
in only 7.7% of patients. Considering all dynamic parameters described as the principal reason for fluid administration. Fluid challenge was
here, the use of any method for predicting fluid responsiveness was performed by the infusion of 500 ml crystalloid or a balanced colloid
possible in 15.6% of the volume expansions performed in our ICU. (Volulyt®) solution in 30 minutes. Before and after fluid challenge,
Conclusion The use of dynamic parameters for predicting fluid systemic hemodynamics and direct in vivo observation of the micro-
responsiveness in the ICU may have restricted applicability since the circulation were obtained with sidestream dark-field imaging. Assess-
necessary conditions are often not present. ment of microcirculatory parameters of convective oxygen transport
(microvascular flow index (MFI) and proportion of perfused vessels),
and diffusion distance (perfused vessel density and total vessel density)
P236 was done using a semiquantitative method.
Fluid responsiveness during weaning from mechanical ventilation Results We enrolled 50 patients. MFI <2.6 was present in 66% of the
M Geisen, UM Schmid, O Dzemali, A Zollinger, CK Hofer patients. After fluid challenge, signs of impaired organ perfusion
Triemli City Hospital, Zürich, Switzerland reduced from 100% to 68% of the patients, P <0.001. The incidence of
Critical Care 2012, 16(Suppl 1):P236 (doi: 10.1186/cc10843) MFI <2.6 decreased to 46%, and was higher in patients with persistent
signs of impaired organ perfusion: 56% versus 25%, P = 0.04. Median
Introduction To overcome the limited accuracy of functional MFI increased from 2.5 (2.3 to 2.8) at baseline to 2.7 (2.4 to 2.8) after
hemodynamic parameters such as stroke volume and pulse pressure fluid challenge, P = 0.003, but its change was only significant in fluid-
variation (SVV and PPV) during spontaneous breathing, a passive leg responsive patients.
raising (PLR) maneuver has been suggested as a reliable predictor of Conclusion These data demonstrate a relationship between clinical
fluid responsiveness [1,2]. The aim of this study was to evaluate fluid signs of impaired organ perfusion and MFI <2.6. Fluid responsiveness
responsiveness using SVV, PPV and PLR during the transition from did not discriminate between patients with and without clinical
controlled to spontaneous breathing. signs of impaired organ perfusion or MFI <2.6. However, significant
Methods Thirty-four patients after off-pump CABG were enrolled. improvement of microvascular alterations and attenuation of clinical
Measurements were performed in the ICU using a PiCCO2 system. Fluid signs of impaired organ perfusion was restricted to patients who were
(500 ml) was given: (A) during controlled mechanical ventilation, (B) fluid responsive. Noninvasive assessment of microvascular perfusion
during pressure support ventilation with spontaneous breathing and may help to define patients with potential need for fluid therapy, and
(C) after extubation. The stroke volume (SV), SVV and PPV as well as to evaluate its effect.
the mean arterial pressure and heart rate were assessed. A PLR was
performed before fluid administration at all three time points. Fluid
response was defined as an increase in SV >15%. Prediction of fluid P238
responsiveness was tested using ROC analysis. Frank–Starling and Guyton together at bedside during a fluid
Results In 34 patients significant hemodynamic changes were challenge
observed, with 19 (55.9%), 22 (64.7%), and 13 (40.6%) responders at H Aya, M Cecconi, M Geisen, C Ebm, M Grounds, N Fletcher, A Rhodes
time points A, B and C, respectively. Prediction of fluid responsiveness St George’s Hospital, London, UK
is depicted in Table 1. Critical Care 2012, 16(Suppl 1):P238 (doi: 10.1186/cc10845)
Table 1 (abstract P236). Prediction of fluid responsiveness Introduction According to Guyton, the difference between mean
A B C systemic filling pressure (Pms) and right atrial pressure (RAP) is the
venous pressure gradient (VP). This is proportional to venous return
AUC P value TS% AUC P value TS% AUC P value TS% and cardiac output (CO). According to the Frank–Starling law a fluid
challenge successfully increases the stroke volume if the preload
SVV 0.88 0.0001 15.5 0.70 0.056 12.5 0.56 0.604 13.5
increases in the ascending part of the curve. The aim of this study was
PPV 0.83 0.001 14.5 0.69 0.063 11.0 0.48 0.863 11.5 to assess the significance of the analogue of the Pms (Pmsa) measured
with the Navigator™ (Applied Physiology, St Leonards, Australia), the
PLR SV% 0.72 0.028 8.0 0.74 0.021 10.0 0.70 0.058 8.0
central venous pressure (CVP) (as a surrogate of RAP) and the VP during
TS, threshold. a fluid challenge.
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P242
Goal-directed fluid and hemodynamic therapy in major colon
surgery with the pressure recording analytical method cardiac
output monitor (MostCare®-PRAM®): prospective analysis of 58
patients
JM Alonso-Iñigo, MJ Fas, V Osca, A Nacher, JE Llopis
Hospital Universitario de la Ribera, Alzira, Spain
Critical Care 2012, 16(Suppl 1):P242 (doi: 10.1186/cc10849)
examine the effect of the OFM protocol in comparison with historical P245
controls. Indexation of extravascular lung water in unselected adult patients
Methods A retrospective study was conducted in a Japanese mixed with and without mechanical ventilation: a prospective study in
ICU of a tertiary-care teaching hospital from July 2007 to March 2011. 50 patients with 843 transpulmonary thermodilutions
Our protocol includes daily volume assessment using the PiCCO system W Huber, B Saugel, D Paradellis, J Hoellthaler, V Phillip, C Schultheiss,
after ICU admission and a change of fluid therapy after evaluation; for P Thies, U Mayr, A Herrmann, RM Schmid
example, additional diuretic use or fluid restriction. We retrospectively Klinikum Rechts der Isar, Technischen Universität München, Munich, Germany
analyzed 96 consecutive patients with severe sepsis or septic shock Critical Care 2012, 16(Suppl 1):P245 (doi: 10.1186/cc10852)
who required mechanical ventilation between July 2007 and December
2010. We divided patients into the OFM protocol group (P; n = 49; April Introduction Extravascular lung water (EVLW) has been indexed to
2009 to December 2010) and the control group (C; n = 47; July 2007 to actual BW (BW-act), termed the EVLW index (ELWI). Since in obese
March 2009) and compared their clinical and laboratory data. patients indexation to BW-act might inappropriately diminish the
Results Median (IQR) age was 69.5 (55.5 to 78.5) years, and the median indexed ELWI-act, ELWI indexed to predicted BW (ELWI-pred) has been
APACHE II score and SOFA score were 23.0 (19.0 to 27.0) and 10.0 (7.0 introduced. Indexation of EVLW to height might be superior to ELWI-
to 12.0), respectively. The proportion of patients with septic shock was pred/-act. Recent data in a selected collective of ARDS patients suggest
75%. There was no difference in patient characteristics between the that indexation to height might improve the predictive capabilities of
two groups. At 28 days, the mortality rate was similar in both groups (P: ELWI regarding pO2/FiO2. We aimed to investigate which indexation of
14.3%; C: 17.0%; P = 0.78). The incidence of ARDS after ICU admission in EVLW provides the best association of ELWI and pO2/FiO2 in patients
the P group was significantly lower than that in the C group (P: 20.4%; C: without pulmonary impairment or without ventilation.
57.4%; P = 0.02). In addition, the onset of ARDS in the P group occurred Methods In 50 consecutive ICU patients with PiCCO monitoring, 843
later than that in the C group (P <0.01). Achievement of a negative triplicate measurements of EVLW and simultaneous blood gas analysis
water balance in the P group occurred earlier than in the C group. The were performed. The endpoint was prediction of pO2/FiO2 <200 mmHg
incidence of AKI (RIFLE criteria: failure) and another organ failure was and other critical thresholds provided by unindexed EVLW as well as
similar in both groups. Multivariate regression analysis revealed that ELWI indexed to ideal BW, adjusted BW, BMI, body surface area, height
the OFM protocol independently suppressed the onset of ARDS (OR and total lung capacity.
0.17 (P = 0.001; 95% CI: 0.06 to 0.51)). Results Measurements in patients without pulmonary impairment
Conclusion Implementation of an OFM protocol using the PiCCO 463/843 (54.9%); acute 188/843 (22.3%), chronic 106/843 (12.6%), and
system significantly decreased the development of ARDS secondary to both acute and chronic pulmonary disease 86/843 (10.2%). Mechanical
severe sepsis with no other complications. ventilation in 458/843 (54.3%) measurements. The largest ROC AUCs
regarding pO2/FiO2 <200 mmHg were found for ELWI-height (AUC
0.658; 95% CI 0.554 to 0.735) and EVLW (0.655; 95% CI 0.544 to 0.732),
the lowest AUC for ELWI-act (0.629; 95% CI 0.514 to 0.742). Similarly
ELWI-height and unindexed EVLW provided the largest ROC AUCs
regarding pO2/FiO2 >300 mmHg (0.659 and 0.657), normal pO2/FiO2
(>381 mmHg; 0.665 and 0.657) and acute and/or chronic pulmonary
P244 impairment (0.622 and 0.625). All these associations were significant
Confrontation of the increase in ELWI rate regarding the septic with P <0.001. Among patients with pulmonary impairment, first values
polytraumatised patient administering furosemide: is it effective? of ELWI-height and EVLW provided the largest ROC AUCs regarding
P Sarafidou, E Pappa, D Dimitriadou, D Litis, I Pavlou mortality (0.815 and 0.815; P = 0.016) compared to ELWI-act (0.694;
KAT General Hospital Kifisia, Athens, Greece P = 0.136) and APACHE II score (0.792; P = 0.025).
Critical Care 2012, 16(Suppl 1):P244 (doi: 10.1186/cc10851) Conclusion Indexation to BW-act results in reduced predictive
capabilities compared to no indexation at all. ELWI-pred performs
Introduction The ELWI rate (measurable with the PICCO catheter) slightly better than ELWI-act, but our data do not support that
conveys the extravascular lung water. The increase of the ELWI rate ELWI-pred is superior to no indexation at all in adult ICU patients. In
is a frequent finding in heavily septic patients and it is connected this unselected and prospectively evaluated collective, the highest
with very high mortality. The purpose of this study is to find out if predictive capabilities regarding several predefined thresholds were
the administration of furosemide is possible to reduce effectively the found for ELWI-height.
ELWI rate and if this decrease can be maintained regardless of the
confrontation of the sepsis.
Methods We studied 20 septic poytraumatized patients (mean ISS P246
score 35) with ARDS syndrome and ELWI >10, with good renal function How to perform indexing of extravascular lung water data
and on medical treatment with levophed. We administered furosemide S Wolf 1, A Riess2, J Landscheidt2, C Lumenta2, L Schuerer2, P Friederich2
1
10 mg/hour, for 24 hours, while at the same time we confronted the Charite Berlin, Germany; 2Klinikum Bogenhausen, Munich, Germany
septic source. During all these we noted PO2/FiO2, MAP, CVP and ELWI Critical Care 2012, 16(Suppl 1):P246 (doi: 10.1186/cc10853)
every 8 hours. Moreover, we noted the changes in the levophed dose
and the total balance of fluid at the end of the 24-hour interval. Introduction Extravascular lung water (EVLW) is a marker for the
Results The ELWI rate was up 12 to 16 before the administration of severity of acute lung injury. To allow assessment of normal and
furosemide. We marked that after the administration of furosemide and pathologic states, traditionally EVLW data are either indexed to real
at the end of the first 8-hour interval, the ELWI rate decreased about 2 or predicted body weight. Surprisingly and despite widespread
to 3 units but we had to increase the dose of vasoconstriction, until the use, this has so far not been validated in a larger cohort of subjects
end of the 24-hour interval the ELWI rate restored to the initial high without cardiopulmonary compromise. The aim of the study was to
level and could not manage to decrease the dose of vasoconstriction prospectively evaluate a different ways of indexing EVLW data.
to have a negative balance of fluids. The improvement of PO2/FiO2 was Methods EVLW was measured using single indicator transpulmonary
insignificant statistically and we confronted operatively the septic thermodilution at predefined time points in 101 patients requiring
source for five to 20 patients at the end of the 24-hour interval. elective brain tumor surgery. This database was used to investigate the
Conclusion We managed to decrease very little the ELWI rate, only properties of indexing EVLW data to real and predicted body weight,
temporarily after the administration of furosamide about a 24-hour body surface area and body height.
interval. The small improvement of the PO2/FiO2 finally leads to a Results EVLW indexed to predicted body weight was inversely
decrease of the ELWI rate but it is not important statistically and on correlated with a patient’s body height (P <0.001), while values
the other side leads to an increase of vasoconstriction. Therefore, this indexed to real body weight remained inversely dependent on weight
method is not effective. We gain only a short time for the safer surgical (P <0.001). Indexing to estimated body surface area, again based on
treatment if it is needed. real or predicted body weight, provided no advantage. In contrast,
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P249
Fluid therapy tactics in patients with polytrauma during
interhospital transportation
D Skopintsev, S Kravtsov, A Shatalin, V Agadzhanyan
Federal State Budgetary Medical Prophylactic Institution, Scientific Clinical
Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia
Critical Care 2012, 16(Suppl 1):P249 (doi: 10.1186/cc10856)
24 hours after trauma. The distance was 177 ± 9 km. The components P251
of the fluid therapy in the CG were crystalloids and dextrans. The latter Effect of balanced versus unbalanced HES solution on cytokine
were not used in degree I shock. Crystalloid infusion was carried out on response in a rat model of peritonitis
the basis of 3 ml crystalloids per 1 ml blood loss. The crystalloids and M Schläpfer1, M Urner1, S Voigtsberger1, R Schimmer2, B Beck-Schimmer1
1
HES 130/04 starch were used in the EG. The dose of HES 130/04 starch University Hospital Zurich, Switzerland; 2University of Zurich, Switzerland
comprised 10 to 25 ml/kg of the body mass and depended on the Critical Care 2012, 16(Suppl 1):P251 (doi: 10.1186/cc10858)
shock severity state. Statistical analysis was performed using Statistica
6.1. We used the Mann–Whitney criterion. Introduction Sepsis with multiple organ failure remains a leading cause
Results The EG patients with degree I shock had higher hemodynamics of death in ICUs. Acute renal failure is a common complication of severe
parameters (BPsys, BPdias, MAP) and less expressed tachycardia as sepsis and septic shock. The effect of hydroxyethyl starch (HES) on the
compared to the CG patients with degree I shock (P <0.05). The EG kidney as well as on liver tissue remains controversial and has never
patients with degree II shock had higher hemodynamics parameters been tested in detail. We investigated in a model of fecal peritonitis
(BPsys, MAP, ESV, CI, SVR) as compared to the CG patients with degree the influence of fluid resuscitation with HES 6% in unbalanced versus
II shock (P <0.05). The change of the fluid therapy tactics in the EG balanced solutions on inflammatory mediator expression in renal and
resulted in the normalization of the HR, SVR and in the increase of the hepatic tissue.
BPsys, MAP, ESV and CI in patients of both degrees of shock during Methods Cecal ligation and puncture was performed in anesthetized
transportation. The values of the EG were higher than in the CG during Wistar rats (CLP group). Sham group animals were treated in the
all periods of the transportation (P <0.05). same manner but without CLP. One hour after this procedure, Ringer
Conclusion Inclusion of the HES 130/04 starch in the fluid therapy lactate (RL) was intravenously infused to all animals at a volume of
complex of the patients with traumatic shock in polytrauma allows 30 ml/kg. Two hours after initiation of injury rats received RL (control,
one to normalize hemodynamics values at short notice and to support 75 ml/kg), unbalanced HES 130/0.42 (HES, 25 ml/kg) or balanced HES
them adequately during all periods of transportation. 130/0.42 (Tetraspan, 25 ml/kg). Animals were euthanized 4 hours after
induction of peritonitis. Monocyte chemotactic protein-1, intercellular
adhesion molecule-1, and TNFα mRNA expression were assessed in the
kidneys and liver. Linear regression was used to evaluate influence of
the different fluid resuscitation procedures on inflammatory mediator
P250 expression.
A prospective, randomized, clinical trial comparing the Results CLP had a significant effect on production of inflammatory
hemodynamics, efficacy, and safety of 6% hydroxyethyl starch mediators in the kidneys (P ≤0.03) and liver (P ≤0.02). While HES did
130/0.4 compared to albumin in postoperative patients undergoing not alter expression of inflammatory mediators compared to RL,
pancreaticoduodenectomy fluid resuscitation with Tetraspan provoked a burst in inflammatory
SK Hong1, K Kyoung2, Y Kim1, S Kim1 mediator expression, which was at least threefold higher in the kidneys
1
Ulsan University College of Medicine, Asan Medical Center, Seoul, South (P <0.001) and eightfold in the liver (P = 0.001) compared to the RL
Korea; 2Inje University College of Medicine, Harundae Paik Hospital, Busan, group.
South Korea Conclusion While unbalanced HES did not show a proinflammatory
Critical Care 2012, 16(Suppl 1):P250 (doi: 10.1186/cc10857) effect on renal and hepatic tissue in early sepsis, the balanced HES
solution upregulated inflammatory mediators. Further studies have to
Introduction Hypovolemia is often present in patients undergoing be performed to elucidate this phenomenon in detail and to assess the
extensive abdominal surgery. As the first colloid used in the clinical functional implication of these results.
setting, albumin is still widely employed during perioperative
periods. We hypothesized that 6% hydroxyethyl starch (HES) 130/0.4
is equally efficacious and has the added advantages of its low cost P252
and convenience of use. This study’s objective is to compare the Evaluation of effectiveness and safety of hydroxyethyl starch
hemodynamics, efficacy, and safety of HES 130/0.4 compared with that (HES 130 kDa/0.4) in burn resuscitation
of albumin. A Mokline, I Rahmani, L Gharsallah, H Oueslati, B Gasri, I Harzallah,
Methods This study was a prospective, randomized, active-controlled A Ksontini, A Messadi
study comparing the hemodynamics, efficacy, and safety of HES 130/0.4 Burn and Trauma Center, Tunis, Tunisia
to that of albumin in patients undergoing pancreaticoduodenectomy. Critical Care 2012, 16(Suppl 1):P252 (doi: 10.1186/cc10859)
Eligible adult patients of both sexes were assigned following the
surgery into either the HES group or the albumin group at a ratio of 1:1. Introduction Excessive fluid resuscitation of large burn injuries has
Crystalloids for hydration and colloid therapy for volume support were been associated with adverse outcomes including worsening of burn
administered. The primary endpoint of this study was the hemodynamic oedema, conversion of superficial into deep burns, and compartment
evaluation. Secondary endpoints were measurement of the input– syndromes. So, there have been efforts recently to address these
output, ICU stay, ventilation time, length of hospital stay, time to liquid concerns, particularly with the use of physiologically balanced fluids.
mealtime and the use of blood products. Safety assessment was carried Starches, as effective plasma expanders, may limit resuscitation
out by performing physical examination, laboratory examination, and requirements and burn oedema. This study aims to evaluate clinical
assessment of any adverse events during the study period. results of HES in early burn resuscitation of major burn-injured patients.
Results A total of 50 patients were randomized to study groups (25 Methods A case–control study conducted in a burn care center in
each). The volume of the crystalloid was the same in both groups; Tunis. Adult burned patients admitted within the first 24 hours post
however, significantly more colloids were infused after 24 hours post burn, with a burn injury exceeding 30% of total body surface area,
surgery in the HES group than in the albumin group, the voluven from 1 January to 31 December 2010 were included. Exclusion criteria
patient group had lower heart rates, and the difference in the lowest were pregnancy, history or biochemical evidence of renal impairment
MAP value was –1.64 mmHg (lower limit of confidence interval, on admission (serum creatinine >130 μmol/l), history or hematological
–8.228 mmHg) than in the albumin group. Routine hematology and evidence of disorders of hemostasis. Fluid volume resuscitation was
biochemical profiles, including blood coagulation test and renal evaluated according to the Parkland formula. HES supplementation
function assessment, were comparable in the two groups. The mean was limited to 33 ml/kg/24 hours. The HES supplementation group was
duration of the ICU stay, ventilation, hospital stay, and tolerance of a compared with a group of patients from the same center matched in
liquid meal were similar. The mean cost of the colloid was significantly age, sex and severity of burns at baseline.
lower in the HES 130/0.4 group than in the albumin group (P <0.001). Results Patients were assigned to two groups: G1 (n = 15): HES
Conclusion This study demonstrated that 6% HES 130/0.4 may be supplemented, and G2 (n = 15): crystalloids only. The mean age was
used as a valuable alternative to 5% albumin in patients undergoing 44 ± 18 years old for G1 and 43 ± 17 years old for G2. The average
extensive abdominal surgery, as its low cost is also of value. TBSA was 51.8% ± 19 for G1 versus 43.6 ± 7 for G2. The addition of
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HES 130 kDa/0.4 reduces significantly body weight gain within the biomarkers in a pilot study of early septic shock patients resuscitated
first 72 hours after injury: 8 kg for G1 versus 13.6 kg for G2 (P = 0.002), with either 5% albumin or normal saline.
occurrence of ALI (35% for G1 versus 65% for G2) (P = 0.01), and length Methods Patients presenting in early septic shock received albumin
of ICU stay (19 days ± 13 for G1 vs. 30 days ± 15 for G2). There was no or saline in a randomized, double-blind pilot study. Blood and urine
evidence of renal dysfunction with the use of HES in burns patients was collected at enrolment and 6, 12, 24, 72 hours and 7 days later
comparative to the crystalloids group. and processed using standard operating procedures. A panel of 27
Conclusion HES supplementation in early burn resuscitation allows, for cytokines, chemokines and growth factors was measured by multiplex
smaller fluid volume requirement, less tissue oedema. This along with a technology. Mean values were separated by treatment and analyzed
significantly lower in ALI occurrence and length of ICU stay. using R to generate heat maps, by principal component analysis (PCA)
and hierarchal clustering. Urinary neutrophil gelatinase-associated
lipocalin (NGAL) was measured by ELISA.
P253 Results Twenty-five patients (median age 66 years, median APACHE II
Normal saline resuscitation worsens lactic acidosis in experimental score 26) received albumin (median amount 3 l) and 21 (median age
sepsis 62 years, median APACHE II score 22) received normal saline (median
F Zhou, ME Cove, ZY Peng, J Bishop, K Singbartl, JA Kellum amount 3.5 l) as study fluid over 7 days. PCA revealed that 60% of
University of Pittsburgh Medical School, Pittsburgh, PA, USA the variance in the chemokines was accounted for with the first two
Critical Care 2012, 16(Suppl 1):P253 (doi: 10.1186/cc10860) components. Analyzing the first component using a threshold of
greater than 0.5 or –0.5 we saw a clustering of IL-17, IL-12p70, IL-9 and
Introduction Infusing large volumes of 0.9% sodium chloride (saline) IL-5. Heat map analysis suggests that by 72 hours albumin-resuscitated
causes hyperchloremic acidosis. The clinical relevance of this effect patients are distinguished by the cluster of IL-17, IL-9 and Il-12p70 and
remains contentious and saline is still the most commonly used VEGF when compared to saline. Hierarchal clustering also separates
resuscitation fluid in the US. However, a recent trial showed that saline IL-17, IL-19, IL-12p70 and IL-2 in the albumin-treated patients but not
or albumin in saline increased mortality in children with malarial sepsis, the saline-treated patients at 72 hours. At enrolment, mean urine
compared to no fluid [1]. Infusion of these fluids may have perpetuated NGAL levels were greater than 1,000 ng/ml (albumin 1,121 ± 2,172
the underlying metabolic acidosis sepsis, causing cardiovascular (n = 21), saline 1,375 ± 3,197 (n = 17)). Over the next 24 hours there was
collapse and death. In this study, we investigated the effect of a marked increase in urine NGAL in the saline-resuscitated patients,
saline versus a balanced crystalloid (plasmalyte) in a cecal ligation peaking at 5,793 ± 15,948 ng/ml, whereas levels remain blunted over
and puncture (CLP) model of sepsis. We hypothesized that saline the first 12 hours, peaking at 2,216 ± 3,177 ng/ml at 24 hours in the
resuscitation would increase acidosis and worsen hemodynamics, albumin group.
compared to resuscitation using a balanced crystalloid. Conclusion In this cohort of patients treated with albumin or saline
Methods Fifty adult male Sprague–Dawley rats were subjected to in early septic shock, there appeared to be a marked increase in the
CLP (25% cecum length, two punctures with a 25-gauge needle). clustering of early T-cell-mediated immune responses. Also striking was
Eighteen hours later, they were randomly assigned to receive either the blunted rise in urine NGAL over time for patients in the albumin
30 ml/kg saline (n = 25) or plasmalyte (n = 25) over 4 hours. Arterial fluid group. These results should be considered hypothesis generating
blood gases, serum creatinine, urea, and lactate were measured at and prompt further studies to explore possible biological mechanisms
baseline, 18 hours after CLP (before resuscitation), after resuscitation, for albumin resuscitation in sepsis.
and 24 hours after resuscitation. Blood pressure and pulse rate were
measured during fluid infusion.
Results Saline-treated animals developed significantly higher levels of P255
serum chloride (111 mmol/l vs. 102 mmol/l, P <0.0001) and lower pH Study of the correlation between central venous oxygen saturation
(7.35 v. 7.44, P <0.01) compared to plasmalyte. In addition, lactate was and venous saturation from the antecubital vein in severe sepsis/
significantly higher after fluid infusion in the saline group (4.8 mmol/l septic shock patients
vs. 2.5 mmol/l, P <0.001) compared to plasmalyte, despite being similar K Piyavechviratana, W Tangpradubkiet
before infusion (2.61 vs. 2.39, P >0.05). However, neither mean arterial Phramongkutklao Hospital, Bangkok, Thailand
blood pressure (83 mmHg vs. 91 mmHg, P >0.10) nor heart rate (310 vs. Critical Care 2012, 16(Suppl 1):P255 (doi: 10.1186/cc10862)
299, P >0.10) differed between the two groups.
Conclusion Saline infusion worsens lactic acidosis, despite similar blood Introduction Early goal-directed therapy has been used for severe
pressure, when compared to plasmalyte. The mechanisms responsible sepsis and septic shock in the ICU to achieve a balance between
for this effect are unclear. However, deoxygenated hemoglobin readily systemic oxygen delivery and oxygen demand before global tissue
binds hydrogen ions, forming HbH+, which is stabilized in the presence hypoxia develops and proceeds to multiorgan failure. One of the
of chloride [2]. Consequently, the oxygen affinity for hemoglobin is resuscitation end points includes normalized values for central venous
reduced, which could impair oxygen delivery, perpetuating the lactic oxygen saturation (ScvO2) that needs insertion of a central venous
acidosis. Further study is needed to better understand the mechanisms catheterization, which is still impractical in small-to-medium-sized
of this effect and their clinical relevance. hospitals in Thailand. The purpose of this study was to examine whether
References the venous oxygen saturation from the antecubital vein has correlation
1. Maitland K, et al.: N Engl J Med 2011, 364:2483-2495. with the central venous oxygen saturation or can be applied instead of
2. Prange HD, et al.: J Appl Physiol 2001, 91:33-38. the central venous oxygen saturation.
Methods This was an observational study performed during 4 July
2007 to 31 March 2009 in the 10-bed ICU of Pramongkutklao Hospital
P254 in severe sepsis or septic shock patients who already had a central
Albumin in early septic shock resuscitation: examination of plasma venous catheter inserted. Two blood samples were collected and sent
and urine inflammatory markers to the laboratories for blood gas analysis. We then calculated for the
A Fox-Robichaud1, C Leger2, KD Burns3, E Sabri3, B Lo1, P Kubes2, correlation using correlation and linear regression analysis.
LA McIntyre3 Results Of the 44 enrolled patients, 24 were males (54.54%). Mean
1
McMaster University, Hamilton, Canada; 2University of Calgary, Canada; age was around 69.86 ± 16.819 years. A total of 84.1% was in septic
3
Ottawa Hospital Research Institute, Ottawa, Canada shock. The most common source of infection was pneumonia (38.6%).
Critical Care 2012, 16(Suppl 1):P254 (doi: 10.1186/cc10861) The central ScvO2 and peripheral venous oxygen saturation ranges
and means were 46.0 to 93.2%, 31.5 to 99.0% and 71.66 ± 10.39%,
Introduction A recent meta-analysis has suggested that albumin may 71.18 ± 19.79% respectively. The correlation between ScvO2 and
be beneficial in sepsis; however, there is no clear biological rationale antecubital venous oxygen saturation significant P value was 0.000:
for the pharmacological use of this negative acute-phase protein. Our calculated ScvO2 = 52.386 + 0.271(peripheral), R2 = 0.266. The specificity,
objective was to describe the temporal production of plasma and urine sensitivity, positive predictive value and negative predictive value of
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P257
Curve analysis of tissue oxygen desaturation after a venous
occlusion test does not identify the central venous hemoglobin
oxygen saturation
G Friedman1, C Alan2, A Meregalli2, A Lima3, J Bakker3
1
UFRGS, Porto Alegre, Brazil; 2Complexo Hospitalar Santa Casa, Porto Alegre,
Brazil; 3University Medical Center Erasmus, Rotterdam, the Netherlands
Critical Care 2012, 16(Suppl 1):P257 (doi: 10.1186/cc10864)
respectively. Also, the PL cut-off value for prediction of mortality was is a good prognostic finding, whereas persistent BL elevation portends
4 mmol/l with a good sensitivity (86%) and specificity (92%). The area poor outcome. Microdialysis (MD) enables direct monitoring of tissue
under the ROC curve was 0.96. metabolic changes. This study aimed to describe the dynamics of
Conclusion Lactate appears to be a powerful predictor biomarker MD-assessed tissue lactate (TL) vis-à-vis BL in septic patients with and
of sepsis and mortality in burn patients. A serum lactate of 4 mmol/l without shock.
provides the best sensitivity and specificity. Methods We measured BL and thigh adipose tissue TL serially every
4 hours for 6 days in 88 patients with septic shock and 45 patients
at various sepsis stages hospitalized in a tertiary-care hospital ICU.
P259 Analysis was done with measurement of the area under the curve
Can we predict arterial lactate from venous lactate in the (AUC) of lactate*hours, cross-approximate entropy (X-ApEn) and
emergency department? cross-correlation. Comparisons of septic shock versus nonseptic shock
A Mikami1, S Ohde2, G Deshpande2, T Mochizuki1, N Otani1, S Ishimatsu1 patients’ results were done with t tests and z statistics.
1
St Luke’s International Hospital, Tokyo, Japan; 2St Luke’s Life Science Institute, Results BL and TL were higher in septic shock patients compared to
Tokyo, Japan nonseptic shock patients (AUCs of 276 vs. 176 and 355 vs. 273 mmol/
Critical Care 2012, 16(Suppl 1):P259 (doi: 10.1186/cc10866) l*hours, respectively; Welch’s t test: P <0.0001). X-ApEn for MDL/BL was
lower in septic shock patients compared to those without septic shock
Introduction Analysis of arterial blood has an important role in the (mean ± SD: 0.79 ± 0.12 vs. 1.14 ± 0.13, respectively; t test: P <0.0001).
clinical assessment of critically ill patients. Particularly, measured Cross-correlation of TL versus BL was stronger in septic shock patients,
arterial lactate (a-Lac) provides valuable information on peripheral with TL leading BL by 4 hours compared to TL versus BL with no lag
circulatory failure, although it is invasive and frequent measurement time (r = +0.85, P <0.0001 and r = +0.66, P <0.0001, respectively) than
is often impractical. The aim of this study is to clarify the relationship in nonseptic shock patients (r = +0.58, P = 0.0003 with TL leading BL by
between a-Lac and the more easily accessed venous lactate (v-Lac) and 4 hours and r = +0.66, P <0.0001 with no lag time; z statistic = 2.41 and
to generate a formula to predict a-Lac using v-Lac and other laboratory P = 0.016 for leading BL compared to z statistic=0.036, P = 0.971 for no
data. lag time).
Methods A prospective cohort study was conducted from June to Conclusion In septic shock patients, tissue lactate levels – measured by
November 2011 in the emergency department at a tertiary-level MD – are higher compared to nonseptic shock patients. Furthermore,
community hospital in Tokyo, Japan. Patients were eligible for entry TL is better correlated with and precedes – within 4 hours – BL in septic
into the study if an arterial blood gas (ABG) analysis was required for shock patients compared to nonseptic shock patients. Further studies
appropriate diagnostic care by the treating physician. Arterial and are warranted to assess the clinical value of serial TL monitoring.
venous samples were taken within 5 minutes of each other from the
ipsilateral radial artery and cephalic vein. Samples were analyzed
as soon as possible after collection on the same blood gas analyzer. P261
Univariate linear regression analysis was conducted to generate Admission lactate and outcome after high-risk surgery
an equation to calculate a-Lac incorporating only v-Lac. Then, a M Geisen, HD Aya, C Ebm, N Arulkumaran, MA Hamilton, M Grounds,
multivariate forward stepwise logistic regression model (P value of 0.05 A Rhodes, M Cecconi
for entry, 0.1 for removal) was used to generate an equation including St George’s Hospital NHS Trust, London, UK
v-Lac and other potentially relevant variables including age, sex, Critical Care 2012, 16(Suppl 1):P261 (doi: 10.1186/cc10868)
systolic blood pressure, heart rate, and venous blood parameters (pH,
pO2, pCO2, hemoglobin, creatine kinase, potassium). A Bland–Altman Introduction The aim of this study was to assess the ability of serum
plot was drawn and the two equations were compared for model lactate level in patients admitted to the ICU after surgery to predict
fitting using R-squared. outcome.
Results Seventy-two arterial samples from 72 patients (61% male; Methods A retrospective, clinical observational study in patients
mean age, 58.2 years) were included in the study. Indications for ABG undergoing high-risk surgery admitted to a 17-bed ICU of a large
included respiratory failure (16%), assessment of shock (21%), altered teaching hospital. Data were obtained during haemodynamic
mental status (26%), and others (36%). An initial regression equation optimization using an established GDT protocol in the first 8 hours after
was derived from univariate linear regression analysis: (a-Lac) = –0.259 admission and included demographic data as well as haemodynamic
+ (v-Lac)×0.996. Subsequent multivariate forward stepwise logistic and laboratory parameters. Outcome data included morbidity (defined
regression analysis, incorporating venous lactate and venous pO2 as >1 complications on the postoperative morbidity survey) and clinical
(v-pO2), generated the following equation: (a-Lac) = –0.469 + (v- outcome (hospital mortality, length of ICU stay, length of hospital stay,
pO2)×0.005 + (v-Lac)×0.997. Calculated R-squared values by single and readmission to the ICU).
multiple regression were 0.94 and 0.96, respectively. Results Sixty-seven patients were included. Lactate clearance (decrease
Conclusion Venous lactate estimates showed a high correlation with of lactate >10% in 2 hours) occurred in 64 patients (96%). Sixty patients
arterial values and our data provide two clinically useful equations developed at least one surgical complication. There were no significant
to calculate a-Lac from v-Lac data. Considering clinical flexibility, correlation between lactate levels on admission and development of
Lac = –0.259 + VLac×0.996 might be more useful, while avoiding a
time-consuming and invasive procedure. Table 1 (abstract P261). Lactate on admission, complications and clinical
outcome
P262 P263
Effects of induced relative hypoxia during the postoperative period Pre-emptive hypothermia during resuscitated porcine hemorrhagic
of abdominal oncologic surgery, on hemoglobin and reticulocyte shock
levels: a prospective, randomized controlled clinical trial J Matallo1, W Stahl1, M Gröger1, A Seifritz1, O Mccook1, M Georgieff1,
M Khalife1, K Wiams1, M Ben Aziz1, M Paesmans1, C Balestra2, M Sosnowski1 P Asfar2, M Matejovic3, E Calzia1, P Radermacher1, F Simon1
1
Institut Jules Bordet, Brussels, Belgium; 2Divert Alert Network Europe Research 1
University Medical School, UIm, Germany; 2University Hospital, Angers,
Division, Brussels, Belgium France; 3Charles University, Plzeñ, Czech Republic
Critical Care 2012, 16(Suppl 1):P262 (doi: 10.1186/cc10869) Critical Care 2012, 16(Suppl 1):P263 (doi: 10.1186/cc10870)
Introduction Anemia is a frequent complication in oncologic patients. Introduction The role of hypothermia in hemorrhagic shock is still a
Erythropoietin (EPO) stimulating agents are known as alternatives matter of debate [1]. Therefore, we studied the effects of deliberate,
to transfusion. However, they expose patients to thrombosis and are pre-emptive hypothermia on hemodynamics and organ function
expensive. Recently, a new phenomenon, the normobaric oxygen during long-term porcine hemorrhage and resuscitation.
paradox (NOP), has been described. In brief, transient hyperoxia Methods Anesthetized and instrumented pigs were randomly assigned
followed by a prolonged return to normoxia acts as an effective trigger to 32°C (n = 7), 35°C (n = 7), and 38°C (n = 6) of core temperature and
for EPO production. The mechanism depends on free oxygen radicals subjected to 4 hours of hemorrhage (removal of 40% of the calculated
and on reduced glutathione (GSH) availabilities. Also, N-acetylcystein blood volume, additional removal/retransfusion of blood to maintain
(NAC) is known to regenerate the stock of GSH. Very few clinical trials mean arterial pressure (MAP) = 30 mmHg). After 12 hours of reperfusion
have investigated this phenomenon [1]. The goal of this study was to comprising retransfusion of shed blood, colloid fluid resuscitation and
test the NOP theory on the evolution of hemoglobin and reticulocytes noradrenaline to keep MAP at pre-shock levels, animals were rewarmed
in patients receiving intermittent oxygen with or without NAC to 38°C. Data (median, quartiles) were obtained before and at the
compared to a control group. end of the shock phase as well as at 12 and 22 hours of resuscitation,
Methods This prospective, randomized study included 78 patients intergroup differences were analyzed using a Kruskal–Wallis ANOVA on
(three groups). The first group (G1; n = 26) received 60% FiO2 for 2 ranks.
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to reduce the differences of pre-hospital variables between patients Table 2 (abstract P270). Effects of type and origin by bystander CPR on
arriving during off-hours and on-hours. Primary endpoint was 90-day survival of bystander-witnessed OHCAs having bystander CPR
survival after cardiac arrest. We evaluated the survival difference using
Factor Adjusted odds ratio 95% CI
the log-rank test and identified the significant interventions affecting
outcome using the Cox regression model. Type of CPR
Results Of 185 patients, 131 arrived during off-hours (the off-hours CC-only CPR 0.96 0.88 to 1.04
group) and 54 arrived during on-hours (the on-hours group). The
matching process selected 37 patients each from both groups. The Conventional CPR Reference
matched off-hours group had a lower survival rate than the matched Origin of CPR
on-hours group (10.8% vs. 37.8%; log-rank P = 0.025). Multivariate Cox Following telephone-CPR 0.73 0.67 to 0.80
regression analysis showed that TH was associated with 90-day survival
after cardiac arrest (adjusted hazard ratio (HR), 0.43; 95% CI, 0.23 to On bystander’s own initiative Reference
0.79), but there were no significant associations of ECPR (adjusted HR, Aetiology
0.83; 95% CI, 0.50 to 1.37) and primary PCI (adjusted HR, 0.76; 95% CI, Presumed cardiac 2.27 2.05 to 2.51
0.42 to 1.38).
Conclusion Lower survival rates after OOHCA during nights and Noncardiac Reference
weekends were seen at our institute. TH was more likely to be induced Time intervals
in patients arrived during daytimes of weekdays, and independently Witness-call 0.99 0.98 to 0.99
associated with survival benefit.
Witness-first CPR performed either by 0.98 0.97 to 0.99
Reference
citizens or by EMTs
1. Peberdy MA, Ornato JP, Larkin GL, et al.: Survival from in-hospital cardiac
arrest during nights and weekends. JAMA 2008, 299:785-792. Call-arrival at patients 0.88 0.87 to 0.90
Effects of type and origin by bystander CPR on 1-month survival with favourable
neurological outcomes of bystander-witnessed OHCAs having bystander CPR
P270 (multiple logistic regression analysis).
CPR initiated after telephone-assisted instruction produces a
better outcome of bystander-witnessed out-of-hospital cardiac Methods From the Japanese nationwide database for 431,968 OHCAs
arrests than no bystander CPR but is less effective than CPR on the that occurred from January 2005 to December 2008, we extracted
bystander’s own initiative and analyzed 112,144 bystander-witnessed OHCAs without any
H Inaba1, T Kamikura1, K Takase1, W Omi2, S Sakagami2, Y Myojo3, involvement of physicians, using multiple logistic regression analysis.
J Taniguchi3 Results The analysis for all bystander-witnessed OHCAs revealed that
1
Kanazawa University Graduate School of Medicine, Kanazawa, Japan; both CC-only and conventional CPR following telephone CPR produce
2
Kanazawa Medical Center, Kanazawa, Japan; 3Ishikawa Prefectural Central better outcomes than no bystander CPR (Table 1). The analysis for
Hospital, Kanazawa, Japan bystander-witnessed OHCAs with bystander CPR disclosed that CPR
Critical Care 2012, 16(Suppl 1):P270 (doi: 10.1186/cc10877) on the bystander’s own initiative produces a better outcome than CPR
following telephone CPR (Table 2).
Introduction Telephone CPR has been shown to increase the incidence Conclusion Telephone CPR improves the outcomes of bystander-
of bystander CPR and is expected to improve the outcomes of out-of- witnessed OHCAS. However, efforts to increase the incidence of early
hospital cardiac arrests (OHCAs). The aim of present study was to clarify CPR on the bystander’s own initiative would be necessary to obtain a
if the outcomes of bystander-witnessed OHCAs having CC-only and higher incidence of survival in bystander-witnessed OHCAs.
conventional CPR following telephone CPR may be better than those
having no bystander CPR and if the type (CC-only and conventional) P271
and origin (following telephone CPR and on bystander’s own initiative) Critical times in pediatric out-of-hospital cardiac arrest
may affect the outcomes of bystander-witnessed OHCAs with J Tijssen1, C Zhan2, C Parshuram1, L Morrison2, J Hutchison1
1
bystander CPR. Hospital for Sick Children, Toronto, Canada; 2University of Toronto, Canada
Critical Care 2012, 16(Suppl 1):P271 (doi: 10.1186/cc10878)
Table 1 (abstract P270). Comparison of survival between OHCAs without Introduction Pediatric out-of-hospital cardiac arrest (OHCA) has a less
bystander CPR and bystander CPR in bystander-witnessed OHCAs than 10% survival. Studies of the scene time and level of emergency
Factor Adjusted odds ratio 95% CI medical services (EMS) training in pediatric OHCA are lacking. The
objectives of this study are to describe the scene time, level of training
Type of CPR and the order and timing of arrival of first responders to pediatric OHCA
No bystander CPR Reference in a large, densely populated area, the Toronto region.
Methods The Resuscitation Outcomes Consortium (ROC) Epistry-
CC-only CPR following telephone-CPR 1.66 1.49 to 1.84
Cardiac Arrest database was queried for all patients <19 years old from
Conventional CPR following telephone-CPR 1.67 1.48 to 1.89 December 2005 to November 2011 in the Toronto region for age, sex,
CC-only CPR on bystander’s own initiative 2.22 1.99 to 2.49 event characteristics, underlying conditions, cause of the cardiac arrest,
level of EMS care, time to EMS arrival, scene time, return of spontaneous
Conventional CPR on bystander’s own initiative 2.36 2.10 to 2.66
circulation (ROSC) and survival to hospital discharge. Patients were
Aetiology excluded if they were declared dead at the scene.
Presumed cardiac 2.44 2.27 to 2.63 Results Four hundred and fifty-two patients with OHCA were included.
Noncardiac Reference Thirty-one percent were infants, 29.4% age 1 to 11 years (child), and
37.4% age 1 to 18 (adolescent) years with 62.8% of cases male. Thirty
Time intervals percent had a significant past medical history. The causes of the cardiac
Witness-call 0.98 0.97 to 0.98 arrest were trauma (14.4%), drowning (6.2%), sudden infant death
Witness-first CPR performed either by 0.97 0.96 to 0.98 syndrome (4.0%), and unknown in 63%. The first EMS responders
citizens or by EMTs were fire in 52.2%, advanced care paramedics in 25%, and primary
care paramedics in 22.3%. Survival was increased the earlier the EMS
Call-arrival at patients 0.93 0.92 to 0.94 arrived (P = 0.015). The timing of arrival of advanced paramedics at the
Comparisons of 1-month survival with favourable neurological outcomes scene appeared to be associated with survival although this was not
between OHCAs without bystander CPR and with four types of bystander CPR in statistically significant (P = 0.22). Infants had a shorter scene time (P
bystander-witnessed OHCAs (multiple logistic regression analysis). <0.001) and an earlier arrival of advanced care paramedics at the scene
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(P = 0.04). A shorter scene time was associated with ROSC on arrival conducted to test our hypothesis that the relation of the bystander to
at the emergency department (P <0.001) and a nonsignificant trend the victim may affect the outcomes of OHCAs.
for improved survival (P = 0.13). Adolescents were more likely to have Methods From a Japanese nationwide database for 431,968 OHCAs
ROSC on arrival at the emergency department (P <0.001) and more that occurred from January 2005 to December 2008, we extracted and
likely to survive (P <0.05) compared to children or infants. then analyzed 45,248 bystander-witnessed, bystander-CPR-performed
Conclusion The timing of arrival of advanced paramedics at the scene OHCAs without any involvement of physicians. Backgrounds,
may have been associated with survival and a larger study is needed characteristics and outcomes were compared among the three groups
to confirm this trend. A shorter scene time was associated with ROSC of OHCAs categorized by the bystander’s relation to victims. Multiple
and a trend for increased survival. However, infants have shorter scene logistic regression analysis was applied to clarify if the relation may
times but worse outcomes. To provide increased power and scope affect the 1-month survival with favourable neurological outcomes.
for this study we will expand it to include all 10 Regional Clinical ROC Results When the bystander was family, CPR was more frequently
Centers and future analyses will include the remaining Utstein data initiated following telephone-assisted instruction and the interval
fields and compare the effects of advanced versus basic life support between collapse and bystander CPR was significantly prolonged.
interventions during resuscitation. Univariate analysis followed by multiple logistic regression analysis
revealed that family as a CPR performer significantly decreases the
P272 1-month survival with favourable neurological outcomes. See Tables 1
Don’t stop your heart in front of your family: family as a bystander is and 2.
associated with poor outcome of bystander-witnessed, bystander- Conclusion Despite educational efforts, most family members do not
CPR-performed out-of-hospital cardiac arrest appear to be good CPR performers. The first responder system that
H Inaba1, K Takase1, T Nishi1, T Kamikura1, Y Wato2, H Hamada3 enables a good CPR performer to reach the scene quickly may be
1
Kanazawa University Graduate School of Medicine, Kanazawa, Japan; needed for OHCAs witnessed by the family.
2
Kanazawa Medical University, Uchinada, Japan; 3Suzu General Hospital,
Suzu, Japan
Critical Care 2012, 16(Suppl 1):P272 (doi: 10.1186/cc10879)
Table 1 (abstract P272). Backgrounds, characteristics and outcomes of OHCAs with reference to relation of bystander to victim
Relation of bystander to victim
Family Friends, colleagues and Others
Background, characteristics and outcome (n = 25,119) passers-by (n = 5,191) (n = 14,938) P value
Patient’s age, median (25 to 75%) 77 (66 to 84) 61 (50 to 73) 84 (75 to 90) <0.001
Sex – male (%) 61.6 76.8 44.7 <0.001
CPR following telephone CPR (%) 75.1 42.7 36.1 <0.001
Initial rhythm shockable (%) 16.3 33.4 9.8 <0.001
Tune intervals, minutes, median (25 to 75%)
Collapse-call 2 (0 to 5) 2 (0 to 4) 2 (0 to 5) <0.001
Collapse-bystander CPR 3 (1 to 6) 1 (0 to 4) 0 (0 to 2) <0.001
Call arrival at patient 8 (6 to 11) 8 (6 to 11) 8 (6 to 10) <0.001
Outcomes
1-month survival (%) 8.1 17.2 9.2 <0.001
1-month survival with favorable 4.0 11.9 4.8 <0.001
neurological outcomes (%)
Table 2 (abstract P272). Relation of bystander to victim as a factor associated with 1-month survival of bystander-witnessed OHCAs having bystander CPR
Adjusted odds ratio (95% confidence interval)
Bystander-witnessed OHCAs Of presumed Of presumed cardiac etiology
Factor with bystander CPR cardiac etiology with shockable initial rhythm
Etiology of arrest
Presumed cardiac 1.39 (1.24 to 1.55) Undefined Undefined
Noncardiac Reference
Initial rhythm
Shockable 4.38 (3.95 to 4.85) 4.82 (4.29 to 5.42) Undefined
Nonshockable Reference Reference Reference
Patient’s age 0.97 (0.97 to 0.98) 0.97 (0.97 to 0.97) 0.98 (0.97 to 0.98)
Sex
Male 1.14 (1.02 to 1.26) 1.16 (1.02 to 1.32) 1.07 (0.90 to 1.26)
Female Reference Reference Reference
Relation of bystander to victim
Family Reference Reference Reference
Friend, colleague and passers-by 1.70 (1.49 to 1.95) 1.40 (1.19 to 1.64) 1.61 (1.42 to 1.81)
Others 1.59 (1.42 to 1.78) 1.46 (1.27 to 1.68) 1.32 (1.10 to 1.59)
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has shown a good predictive value for estimating 1-month survival Results Seventy patients had a hospital admission of post-cardiac
with favorable neurological outcome in OHCA patients. Although this arrest. Five failed the inclusion criteria and six fulfilled exclusion criteria.
novel model needs to be validated using another external dataset, this A total of 36 (51%) were cooled (Table 1). Twelve (33%) of the cooled
model may help to minimize the cost and save medical resources. population survived to hospital discharge (D/C), one (8%) cooled
within 4 hours, three (25%) cooled for over 12 hours. Ten (28%) patients
were cooled despite not having a cardiac cause. One (4%) of the 23
P279 noncooled patients survived to hospital discharge, four (17%) had
Helium ventilation is safe and feasible in ICU patients admitted a cardiac cause. The median age of cooled population was 66 years
after cardiac arrest (quartile range 53.5 to 74 years) and 44 years (quartile range 41 to 52
D Brevoord, C Beurskens, N Juffermans, W Van den Bergh, W Lagrand, years) of the noncooled.
B Preckel, J Horn
Academic Medical Centre, University of Amsterdam, the Netherlands Table 1 (abstract P280). Population cooled post cardiac arrest
Critical Care 2012, 16(Suppl 1):P279 (doi: 10.1186/cc10886)
D/C (n = 12) Died (n = 26)
Introduction Most patients admitted to the ICU after cardiac arrest die VF arrest 10 (83%) 18 (75%) P = 0.69
or have an unfavourable neurological outcome due to brain damage.
Currently, the only treatment to reduce brain injury after cardiac arrest DT >30 minutes 1 (8%) 14 (58%) P = 0.005
is mild hypothermia. Helium inhalation has shown promising results First CPR <5 minutes 11 (92%) 17 (71%) P = 0.22
as a neuroprotective agent in animal models of cerebral infarction.
If helium inhalation ameliorates neurological damage by reducing Cardiac aetiology 10 (83%) 16 (67%) P = 0.44
reperfusion injury in humans as well, this could be of great benefit
to patients. As no studies exist that investigate the use of helium Conclusion Survival is improved in patients cooled post-out-of-
ventilation in patients after cardiac arrest we investigated whether this hospital cardiac arrest [1,2]. Downtime is statistically significant in the
treatment is safe and feasible. survival of cooled patients. Achieving optimal timing of cooling was
Methods A single-centre open-label intervention study was performed no better in surviving versus dying populations. Cooling post-out-of-
in a mixed 30-bed academic ICU, approved by the local medical hospital cardiac arrest is expensive and time-consuming; selection
ethics committee. Inclusion criteria: admission after a witnessed criteria need to be evaluated to concentrate this resource on patients
cardiac arrest, presenting with ventricular fibrillation or tachycardia, where there is a higher prospect of a positive outcome [2].
return of spontaneous circulation within 30 minutes, treatment with References
hypothermia. Exclusion criteria: pre-existing neurological disorders or 1. Holzer M, et al.: Crit Care Med 2005, 33:414-418.
the need for a FiO2 >50% or >10 mmHg PEEP on ICU admission. Helium 2. Hay A, et al.: Anaesthesia 2008, 63:15-19.
was administered during 3 hours as a 1:1 mixture with oxygen, using
a Servo-i ventilator. An independent data safety monitoring board
reviewed all problems arising from the helium ventilation itself and all
fatalities. Poor outcome was assessed with the Glasgow Outcome Score P281
at 30 days: death and vegetative state were defined as poor outcome. Therapeutic hypothermia for nonventricular fibrillation/ventricular
Data are presented as mean ± SD or numbers and proportions. tachycardia cardiac arrest
Results In total 25 patients were included, 20 (80%) male, age S Jog1, D Patel1, M Patel1, R Kulkarni1, N Chouthai2
1
64.8 ± 12.1 years, APACHE II score 20.0 ± 8.6, SAPS II 53.6 ± 18.6. Helium Deenanath Mangeshkar Hospital and Research Centre, Pune, India; 2Wayne
treatment was started 4:57 ± 0:54 hours after arrest. In one patient the State University, Detroit, MI, USA
treatment was stopped due to inadequate ventilation using the preset Critical Care 2012, 16(Suppl 1):P281 (doi: 10.1186/cc10888)
limits. This was not due to the helium ventilation and no adverse events
due to helium ventilation were noted. Overall, nine (36%) patients had Introduction Although efficacy of therapeutic hypothermia (TH)
a poor outcome. for cardiac arrest following ventricular tachycardia (VT)/ventricular
Conclusion In this small study, we encountered no problems associated fibrillation (VF) is a recommended therapy, the efficacy of TH for non-
with helium treatment in patients admitted to the ICU after cardiac VF/VT cardiac arrest is still not well studied. We conducted a study
arrest. This opens the way for studies investigating the hypothesis that to evaluate efficacy and outcomes of TH in non-VF/VT cardiac arrest
helium treatment reduces neurological injury in these patients. patients in terms of survival and neurological outcome.
Methods TH was initiated with intravenous ice-cold saline and
maintained with an external servo controlled cooling system (ESCCS);
P280 by Blanketrol II Hypo-Hyperthermia system (Cincinnati Sub-Zero
Therapeutic hypothermia in an out-of-hospital arrest population: Inc.) between 34 and 32°C for 24 hours. Gradual rewarming was also
are we selecting appropriately? done with ESCCS. Non-VF/VT cardiac arrest patients with GCS ≤7 at 60
A Short, M Brett, L Donaldson minutes of return of spontaneous circulation (ROSC) were enrolled.
Glasgow Royal Infirmary, Glasgow, UK Standard hemodynamic monitoring and management was continued
Critical Care 2012, 16(Suppl 1):P280 (doi: 10.1186/cc10887) in all patients.
Results A total of 13 patients with average GCS of 3.4 at 1 hour
Introduction We question how appropriately we select patients to after ROSC were enrolled in the study. Average time for ROSC was
undergo therapeutic hypothermia following out-of-hospital cardiac 16.5 minutes. Demographic and baseline variables were comparable
arrest. amongst survivors and nonsurvivors except age (survivors 43 years
Methods The population was identified through searching and nonsurvivors 65 years). Average duration to achieve target
Wardwatcher between August 2006 and February 2011. Inclusion temperature was 4.9 hours. Five out of 13 (38.46%) patients survived
criteria were all patients with an ICU admission of out-of-hospital without any neurological deficit or cognitive dysfunction (Cerebral
cardiac arrest. Exclusion criteria were: no CPR within the preceding Performance Category – 1). Out of eight nonsurvivors, six died due to
24 hours; admission from theatre; insufficient data. Data were gathered cardiogenic shock, one died due to refractory hypoxia and in one case
from Wardwatcher, Careview and patients’ case notes for age, arrest relatives opted for withhold of aggressive care. Cardiac arrest was out
rhythm, downtime (DT) – time from arrest to return of spontaneous of hospital in eight patients (three survivors and five nonsurvivors) and
circulation, time to initiation of CPR, temperatures at various time intra-hospital in five (two survivors and three nonsurvivors).
points, cause of arrest and outcome. Statistical analysis was performed Conclusion TH may have beneficial effects in the neurological outcome
with Fisher’s exact test, significance level of P <0.05. Permission for use of patients having non-VT/VF cardiac arrest. Additional controlled
of patient notes was granted from the consultant group of the ICU studies are warranted to establish efficacy of TH as a treatment for non-
audited. VT/VF cardiac arrest.
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P285 maintained for 48 hours and rewarmed to 36°C over another 48 hours.
Simplified EEG/aEEG to monitor the injured brain after cardiac As induction of patients’ sedation, we injected 5 mg midazolam and
arrest 0.2 μg fentanyl intravenously just as we recognized patients’ movement
H Friberg1, M Rundgren1, E Westhall1, N Nielsen2, T Cronberg1 or immediately before induction of TH. For maintenance of sedation,
1
Lund University, Lund, Sweden; 2Helsingborg Hospital, Helsingborg, Sweden midazolam at dose 0.1 mg/kg/hour, dexmedetomidine at dose 0.4 μg/
Critical Care 2012, 16(Suppl 1):P285 (doi: 10.1186/cc10892) kg/hour and fentanyl at doses 0.8 μg/kg/hour were administrated
continuously. The midazolam and the dexmedetomidine infusion were
Introduction Once hemodynamics is stabilized, the main concern in adjusted to a target BIS value of 40 or less. BIS monitoring was ceased
the comatose cardiac arrest patient is the status of the brain and the after completion of both rewarming and discontinuation of sedative
potential recovery of brain functions. Approximately 30% of comatose drugs.
cardiac arrest patients develop electrographic seizures, many of whom Results In all six patients, TH was completed without severe
have associated clinical seizures that may be concealed by sedation complication, especially shivering movement and serious hypostatic
and paralyzers. As part of the Lund coma project, we have continuously pneumonia. Three patients presenting unstable BIS values lower than
monitored and evaluated simplified EEG/aEEG in consecutive 10 during TH showed poor neurological outcome, while the other
hypothermia-treated cardiac arrest patients. three patients presenting stable BIS values about 40 showed favorable
Methods Needle electrodes corresponding to the F3 to P3 and F4 to neurological outcome. Myoclonic movement or convulsion, regarded
P4 leads were applied at admission to the ICU. The Nervus NicoletOne® as signs of bad outcome, was observed in two poor neurological
monitor (CareFusion Inc.) was used to display the continuous raw outcome patients. Cough reflex was observed in two favorable
EEG curves as well as the amplitude integrated EEG (aEEG). The EEG neurological outcome patients throughout their TH.
data were available to the treating intensivist and were linked to the Conclusion BIS oriented sedation without neuromuscular blocker is
Department of Neurophysiology, where the accumulated data were feasible in maintaining TH for survivors from CA. By keeping muscular
interpreted once daily, 5 days a week. function, both noxious and beneficial movements are preserved and
Results Monitoring of aEEG was successfully applied in all patients. these help us to predict neurological outcome and prevent patients
Four dominating patterns were defined; flat, continuous, suppression- from hypostatic disorders.
burst (SB) and electrographic status epilepticus (ESE) [1]. We identified Reference
three groups of patients: one group with mild brain injury and a good 1. Chamorro et al.: Anesth Analg 2010, 110:1328-1335.
outcome, characterized by a return of a continuous EEG pattern during
the first 24 hours. A second group with severe brain injury and a poor
outcome had a flat EEG or a SB pattern during the first 24 hours, which P287
evolved into alfa-coma or a treatment refractory ESE. In this group, Predictive factors of neurologic outcome in therapeutic
early myoclonus was common. The third group with a presumed hypothermia after prehospital return of spontaneous circulation
intermediate brain injury often developed a late ESE during rewarming, Y Ohta, S Shiraishi, Y Ono, G Matsumoto, T Tagami, T Masuno, H Yokota
from a continuous and sometimes reactive background EEG. In this Nippon Medical School, Tokyo, Japan
third group, which presented with low brain damage biomarkers and Critical Care 2012, 16(Suppl 1):P287 (doi: 10.1186/cc10894)
unremarkable MR brain imaging, there were survivors, some of whom
received prolonged care in the ICU [2]. Introduction Induction of hypothermia is generally accepted to
Conclusion Simplified EEG/aEEG is easily applied and well adapted improve neurologic recovery of out-of-hospital cardiopulmonary
to the ICU environment. In combination with the raw EEG, the aEEG arrest (CPA). Early prognostication of post-CPA patients is challenging.
serves as a trend monitor of the injured brain in the comatose patient The aim of the present study was to evaluate the predictive factors
after cardiac arrest. The simplified EEG/aEEG helps detect ESE and is for neurologic outcome in out-of-hospital cardiac arrest patients who
of importance for guiding anticonvulsive treatment. The evolution of returned their spontaneous circulation in a prehospital setting (PROSC)
the EEG pattern mirrors the natural recovery of cortical function after and underwent therapeutic hypothermia (TH).
cardiac arrest and gives useful positive as well as negative prognostic Methods PROSC patients transported to our institution between
information. Simplified EEG/aEEG serves the needs of the intensivist January 2007 and May 2011 were retrospectively analyzed. TH was
and has the potential to become part of a standard monitoring regimen. performed for all comatose PROSC patients admitted to the hospital
References for post-resuscitation care, regardless of the etiology of cardiac arrest
1. Rundgren M, et al.: Crit Care Med 2010, 38:1838. or patient’s age, except for those whose hemodynamic and pulmonary
2. Cronberg T, et al.: Neurology 2011, 77:623. status could not be maintained. Neurological outcome at 1 month
was compared as a primary end-point using the Pittsburgh cerebral
performance category (CPC) scale and patients were classified into a
P286 favorable outcome group (CPC 1 and 2) or poor outcome group (CPC
Usefulness of a Bispectral index oriented sedative method without 3 to 5). Clinical parameters were compared between patients whose
neuromuscular blocker for therapeutic hypothermia after cardiac neurologic outcomes were favorable and poor.
arrest Results There were 33 PROSC patients: 27 (81%) survived and 14 (42%)
S Shiraishi, Y Ohta, T Tagami, Y Ono, T Masuno, H Yokota achieved a favorable neurological outcome. The cause of the CPA
Nippon Medical School, Tokyo, Japan was cardiac attack in 17, noncardiac attack in 10, and unknown in six
Critical Care 2012, 16(Suppl 1):P286 (doi: 10.1186/cc10893) patients. Average age in the favorable recovery group was significantly
younger than in the poor recovery group (62.5 vs. 70.3, P <0.05). The
Introduction During therapeutic hypothermia (TH) after cardiac favorable group was all the proportion of patients with ventricular
arrest (CA), neuromuscular blockers are often used to prevent or treat fibrillation (VF) at the scene. Of the 14 that achieved a favorable
thermogenic shivering [1]. But the following risks due to neuromuscular neurological outcome, the cause of the CPA was cardiac attack in 12
paralysis are encountered: prolonged muscle weakness, hypostatic and unknown in two patients. On the other hand, electrocardiograms
pneumonia and venous thromboembolism. So we evaluated the of poor neurological outcome showed VF, pulseless electrical activity,
usefulness of Bispectral index (BIS) oriented sedation without and asystole. The cause of the CPA was cardiac attack in five, noncardiac
neuromuscular blocker in six cases of post CA patients receiving TH. attack in 10, and unknown in four. Average pH of artery blood gas
Methods Six consecutive patients admitted after CA and treated (ABG) in the favorable recovery group was significantly higher than in
with TH by the same attending physicians’ group were included. BIS the poor recovery group (7.31 vs. 7.17, P <0.004). The receiver-operator
monitoring was applied immediately after the admission to ER. After characteristic curve for pH of ABG on arrival was analyzed. The area
initial resuscitation and radiological examination, including coronary under the curve was 0.76.
angiography and angioplasty, patients were admitted to the ICU and Conclusion A suitable pH at the time of hospital arrival was associated
cooled down to a target body temperature of 34°C using a surface with a favorable neurologic outcome among post-cardiac arrest
cooling system with an external pad. Target body temperature was patients without presumed noncardiac etiology.
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P288 times the serum levels, and remained high after the peak of 23,500 pg/
Employment status 1 year after out-of-hospital cardiac arrest in ml at the time of admission. CSF and serum IL-10 levels were high, but
comatose patients treated with therapeutic hypothermia not abnormally high as for IL-6 and IL-8, and decreased with time. The
K Kragholm1, M Skovmoeller1, AL Christensen1, K Fonager2, HH Tilsted2, difference in CSF and serum levels, as seen for IL-6 and IL-8, was not
H Kirkegaard3, I De Haas1, BS Rasmussen1 seen for IL-10.
1
Cardiovascular Research Center, Aalborg, Denmark; 2Aarhus University Conclusion We elucidated the following points concerning the acute
Hospital, Aalborg, Denmark; 3Aarhus University Hospital, Skejby, Aarhus, inflammatory response following severe traumatic brain injury. High
Denmark levels of IL-6 and IL-8 are maintained in both CSF and serum. CSF levels
Critical Care 2012, 16(Suppl 1):P288 (doi: 10.1186/cc10895) of IL-6 and IL-8 are one or two orders of magnitude greater than serum
levels. Upregulation of IL-10 is minimal in comparison with IL-6 and IL-8,
Introduction Therapeutic-induced mild hypothermia (TIMH) with a suggesting that in neuroinflammation IL-10 functions poorly as an anti-
core temperature of 32 to 34°C for 12 to 24 hours for comatose survivors inflammatory cytokine.
of out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation or
tachycardia has improved survival and neurologic outcome [1,2]. The
aim of this study was to evaluate the incidence of patients returning to P290
work 1 year after survival of OHCA treated with TIMH. Noninvasive cerebral oxygenation monitoring during rapid
Methods From 30 June 2004 to 30 June 2009, OHCA patients between ventricular pacing in transcutaneous aortic valve implant
18 and 65 years of age treated with TIMH were identified by the Danish J Dens, I Meex, F Jans, H Gutherman, C De Deyne
National Patient Registry and intensive unit registrations. Data were Ziekenhuis Oost-Limburg, Genk, Belgium
collected from ambulance and hospital records. Employment status Critical Care 2012, 16(Suppl 1):P290 (doi: 10.1186/cc10897)
was registered prior to and 1 year after OHCA from the Danish Ministry
of Employment and Welfare database, using five work categories (WC): Introduction Most recent attention in interventional cardiology is now
WC 1, working full-time and independent of any social welfare; WC 2, directed towards treatment of valvular heart disease. In patients with
unemployed but able to work; WC 3, on sick leave and receiving social high-risk cardiac surgery, transcutaneous aortic valve implantation
welfare; WC 4, substantially reduced ability to work: and WC 5, on early (TAVI) could offer a therapeutic solution. Near-infrared spectroscopy
retirement. (NIRS) has been introduced as a useful noninvasive cerebral monitoring
Results One hundred and thirty-three patients were identified. Forty technique assessing cerebral oxygenation. As of today, no reports
eight patients were excluded from the final analysis, of which 29 have been published on the use of any NIRS technology during TAVI
patients were not able to work at baseline (WC 3 to 5), 14 patients in procedures. During valve prosthesis implantation, a cardiac standstill
WC 1 to 2 at baseline died in hospital, three patients died after hospital by rapid ventricular pacing (RVP) is induced to minimize cardiac motion.
discharge and two patients had turned 65 years of age at follow-up While RVP is advantageous for valve positioning, a combination of
and went on regular retirement. A total of 85 patients in WC 1 to 2 at rapid heart rate and ventricular hypertrophy can induce a complete
baseline were included in the final analysis, of which 55 (64.7%) of these loss of cardiac output. In most cases, this hemodynamic deficit is well
initially comatose patients with OHCA treated with TIMH had returned tolerated, due to the brief duration of RVP. But as of today no data are
to work 1 year after OHCA. available on cerebral oxygenation during these critical periods of RVP.
Conclusion Approximately two-thirds of the survivors belonging to WC Methods We report on 10 consecutive patients (>75 years, major
1 to 2 at baseline have returned to work at 1 year follow-up after OHCA comorbidities) suffering from severe aortic stenosis. Bilateral ForeSight
treated with TIMH. A larger study is needed to confirm these results and sensors were applied after induction of anesthesia. We were especially
to determine predictors of returning to work in comatose patients after interested if any change in cerebral oxygenation (SctO2 monitoring)
OHCA treated with TIMH. occurred during these RVP periods.
References Results In all patients, the procedure was technically successfully
1. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K: performed. Mean SctO2 before RVP was 67% (59 to 71%) and
Treatment of comatose survivors of out of hospital cardiac arrest with immediately decreased during RVP to mean 54% (37 to 70%). In seven
induced hypothermia. N Engl J Med 2002, 346:557-563. patients, RVP resulted in SctO2 decreases below 55% (mean 44%; range
2. Hypothemia After Cardiac Arrest Study Group: Mild therapeutic 37 to 52%). These decreases lasted for mean 20 minutes (14 seconds to
hypothermia to improve the outcome after cardiac arrest. N Engl J Med 87 minutes). Systolic blood pressure before RVP was mean 135 mmHg
2002, 346:549-556. (95 to 165 mmHg) and decreased to mean 74 mmHg (112 to 42 mmHg)
during RVP. In six patients, RVP resulted in a decrease in systolic blood
pressure below 90 mmHg, which was immediately countered by
vasoactive drugs (adrenaline). In two patients, extensive hypotension
P289 persisted despite vasoactive support and CPR had to be initiated. In
Changes in cerebrospinal fluid and serum cytokine levels in severe one patient, SctO2 values remained below 55% for 87 minutes and the
traumatic brain injury patients patient was declared brain dead 48 hours later.
T Saito1, H Kushi2, J Sato1, A Yoshino1, K Tanjo1 Conclusion Transcutaneous cardiac interventions, especially those
1
Nihon University, School of Medicine, Tokyo, Japan; 2Nihon University, College with transient cardiac standstill, can induce longlasting intraprocedural
of Humanities and Sciences, Tokyo, Japan inadequacy of cerebral perfusion, despite immediate restoration of
Critical Care 2012, 16(Suppl 1):P289 (doi: 10.1186/cc10896) normal blood pressure. Future strategies should therefore be focused
on optimalizing cerebral oxygenation before RVP.
Introduction Inflammatory response following brain injury begins
with brain tissue injury triggered neuroinflammation, which induces
a systemic inflammatory response syndrome. We investigated the P291
characteristics of the acute inflammatory response following severe Novel models to predict elevated intracranial pressure during
traumatic brain injury through changes in cerebrospinal fluid (CSF) and intensive care and long-term neurological outcome after TBI
serum cytokine levels. F Guiza1, B Depreitere1, I Piper2, G Van den Berghe1, G Meyfroidt1
1
Methods The subjects were 24 patients with severe traumatic brain UZ Leuven, Belgium; 2Southern General Hospital, Glasgow, UK
injury. We measured levels of the proinflammatory cytokines IL-6 and Critical Care 2012, 16(Suppl 1):P291 (doi: 10.1186/cc10898)
IL-8, and the anti-inflammatory cytokine IL-10 in peripheral blood and
CSF on four occasions, at the time of admission and after 24 hours, Introduction Elevated intracranial pressure (ICP) episodes are
72 hours and 1 week. associated with poor outcome and should be prevented. We developed
Results CSF and serum IL-6 levels continued to rise until 72 hours after models to predict these episodes 30 minutes in advance, and to predict
admission. CSF IL-6 levels were 50 to 400 times serum levels. Serum long-term neurological outcome by using dynamic characteristics of
IL-8 levels remained at 20 to 30 pg/ml. CSF IL-8 levels were 100 to 800 continuous ICP and mean arterial pressure (MAP) monitoring.
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Methods The Brain-IT [1] dataset has records for 264 patients from 22 achieve favourable outcome. In the literature the value of noninvasive
neuro-ICUs in 11 European countries. Logistic regression and Gaussian measurement of transcranial Doppler (TCD)-derived pulsatility index
processes (machine learning method) were used. CRASH [2] and (PI) in predicting increased intracranial pressure remains questionable.
IMPACT [3] predictors were used together with dynamic data. The aim of this study was to examine the value of PI in predicting
Results Predictions of elevated ICP episodes (Figure 1) were externally hydrocephalus in patients with aSAH.
validated with good calibration and discrimination (AUROC 0.87). Methods In a retrospective cohort study from January 2010 to June
Prediction of poor neurological outcome at 6 months (GOS 1 to 2) with 2011, 61 patients with aSAH were diagnosed with hydrocephalus on
static data had 0.72 AUROC; adding dynamic information increased CT scan during treatment in our ICU. On 93 occasions of TCD recordings
performance to 0.9 (Table 1). of the middle cerebral artery, PI was calculated on the same day.
Results See Table 1 and Figure 1. Ninety-three CT scans could be
Table 1 (abstract P291). Model performance correlated with PI on the same day of the scan. Using a cut-off value
Elevated ICP GOS 1 to 2 static GOS 1 to 2 dynamic
AUROC 0.87 0.72 0.90
HL P value 0.12 0.51 0.95
Brier scaled 39.4% 7.7% 46%
P292
Transcranial Doppler pulsatility index is a poor predictor of
hydrocephalus in patients with aneurysmal subarachnoid
haemorrhage
MH Kiel, AW Oldenbeuving, M Sluzewski, JA Van Oers, D Ramnarain
St Elisabeth Hospital, Tilburg, the Netherlands
Critical Care 2012, 16(Suppl 1):P292 (doi: 10.1186/cc10899)
Photonics). ORx and Mx were derived from continuous correlation of the brainstem were observed. There was a tendency to increase of
between BP and neuromonitoring [1]. HHb was compared identically the I to III and III to V intervals in 46 to 61% in TIA. The I to III and III to
deriving HHBx. Comparisons used Pearson correlation, subsequent V IPI were significantly increased in LI and NLI, in 35% and 47% cases
analysis characterised time lags between BP and monitored variables respectively. The patients with NLI demonstrated an increase of the I to
(0.05 to 0.003Hz) with wavelet lag coherence. V IPI. There was such neurophysiological dynamics. The reconstruction
Results There was correlation between HHBx (r = –0.62, P <0.01), of the amplitude and peak latency in TIA was observed in 100% of cases
ORx (r = 0.52, P <0.05) and Mx. TOx showed no significant correlation in the treatment process. This was not registered in LI and NLI.
(r = 0.18) as individual recordings demonstrated TOI fluctuations Conclusion All strokes in the VBB are characterized by functional
paradoxical to other monitoring. The mean lag between BP and HHb changes on the part of the brain stem structures predominantly
(24 seconds) was shorter than PbrO2 (68 seconds). at the pontomedullary and pontomesencephalic levels. There is a
Conclusion HHb may provide a surrogate to inform cerebrovascular dependence between stroke severity, brainstem structure damage and
reactivity assessment. Complexity in the oxyhaemoglobin component neurophysiological dynamics. ABEP allow one to objectivise the brain
of TOI may be introduced by vasopressor-related skin artefact or stem structure dysfunction in the VBB’s disturbed circulation.
arterial volume changes [2] explaining poor agreement of TOx. HHb is
theoretically free of this effect but will vary with cerebral metabolism, P297
venous dynamics and oxygenation and demonstrates lag behind Examination of the autonomic nervous system in the ICU: a pilot
BP changes. Future analyses might compensate using model-based study
analysis [3], potentially describing measures of vascular reactivity from L Wieske, E Kiszer, C Verhamme, IN Van Schaik, MJ Schultz, J Horn
multiple NIRS and neuromonitoring variables, incorporating widely Academic Medical Center, Amsterdam, the Netherlands
different aspects of cerebral physiology. Critical Care 2012, 16(Suppl 1):P297 (doi: 10.1186/cc10904)
References
1. Zweifel C, et al.: Stroke 2010, 41:1963-1968. Introduction The most widely used test for autonomic dysfunction
2. Ogoh S, et al.: Clin Physiol Funct Imaging 2011, 31:445-451. in the ICU is the heart rate variability (HRV) test [1]. HRV is thought
3. Banaji M, et al.: PLoS Comput Biol 2008, 11:e1000212. to be a very sensitive but less specific test [1]. Several other tests are
available. For this pilot study we have investigated the ability of two
P296 tests, the skin wrinkle test (SWT), a test for postganglionic sympathetic
Study of the acoustic stem evoked potentials in blood circulation function, and the cold face test (CFT), a reflex slowing heart rate after
disorder in the vertebral basilar basin cold application to the forehead, to detect autonomic dysfunction in
I Vlasova, T Vizilo, V Tsiuriupa critically ill patients alongside the HRV.
Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Methods ICU patients mechanically ventilated for at least 3 days were
Russia included. Exclusion criteria: polynomic or autonomic neuropathy,
Critical Care 2012, 16(Suppl 1):P296 (doi: 10.1186/cc10903) admission after stroke or cardiac arrest. HRV was investigated using
power spectral analysis of continuous 5-minute ECG recordings [1]. The
Introduction Acoustic brainstem evoked potentials (ABEP) offer a simulated SWT was used and wrinkling was assessed on a five-point
possibility to objectivise disorder of the brain stem structure function. scale [2]. Under continuous ECG recording a cold pack was applied to
Methods There were flicks of 9.5 Hz with intensity 70 dB higher than measure the CFT [3]. Changes in SWT and CFT results over time were
the hearing threshold. The latency time of the I to V peaks, the interpeak compared to the changes in the SOFA score. Studies procedures were
intervals (IPI), the peak amplitudes (PA) and the amplitude correlations also performed in 17 healthy controls.
were measured. The clinical neurophysiological assessment of 30 Results Twelve patients were included (mean age: 54 (SD: 15)). HRV
patients (16 men and 14 women, age from 40 to 70 years) with analysis showed decreased heart rate variability in all patients (median
clinical presentation of ischemic stroke in the vertebral basilar basin total power: 32 ms2 (IQR: 11 to 320)). The SWT could be performed in 10
(VBB) allowed us to determine the following forms of acute ischemic patients. SWT results were abnormal (score ≤2) in 60% of cases (6% in
disorders of the brain circulation: transitory ischemic attacks (TIA) healthy controls; P <0.01). The CFT was done in nine patients. Critically
(n = 16), lacunar infarction (LI) (n = 10), and nonlacunar infarction (NLI) ill patients showed a blunted response on the CFT (2.5% increase in
in VBB (n = 4). RR length (95% CI: –0.2% to 5.2%) vs. 7.1% in healthy controls (95% CI:
Results According to the ABEP the common feature in all groups of 3.7% to 10.5%; P = 0.03)). Figure 1 displays the CFT results over time.
patients was the decrease of the correlation of the V PA to I PA that Conclusion CFT detected autonomic dysfunction in critically ill patients
was significant in 56% cases in NLI, in 47% cases in LI and in 15% cases better than the SWT and was easier to perform. Diagnostic accuracy
in TIA; the decrease of all PA (to 0.12 to 0.15 mkV) was significant in and prognostic value need to be investigated.
49% cases in NLI and in 39% cases in LI. A distinct tendency to the References
laterality of the peak latency increase in TIA and LI in 49% of cases, 1. Buchman TG, et al.: Curr Opin Crit Care 2002, 8:311-315.
and a significant laterality of the peak latency increase in 35% that 2. Wilder-Smith EP, et al.: Clin Neurophysiol 2009, 120:953-958.
reflected the dissymmetric disorder of the neuronal acoustic activity 3. Reyners AK, et al.: Eur J Appl Physiol 2000, 82:487-492.
Figure 1 (abstract P297). Changes in cold face test (CFT) results over time.
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P298 Conclusion Serum GFAP levels following TBI were significantly higher
Predictive value of glial fibrillary acidic protein for prognosis in patients showing an unfavourable prognosis (death or GOS ≤3).
in patients with moderate and severe traumatic brain injury: a The small number of studies included precluded further exploration
systematic review and meta-analysis of statistical heterogeneity. More investigations of the association
E Laroche1, AF Turgeon1, A Boutin1, E Mercier1, F Lauzier1, R Zarychanski2, between serum GFAP levels and prognosis following TBI are needed
L Moore1, J Granton3, P Archambault1, F Lamontagne4, F Rousseau1, before recommending for routine use for neuroprognostication.
F Légaré1, E Randell5, J Lapointe1, J Lacroix6, D Fergusson7
1
Université Laval, Québec, Canada; 2University of Manitoba, Canada; 3University P299
of Toronto, Ontario, Canada; 4Université de Sherbrooke, Québec, Canada; Prevalence of pituitary disorders associated with traumatic brain
5
Memorial University, NewFoundland, Canada; 6Université de Montréal, Québec, injury: a systematic review
Canada; 7Ottawa Hospital Research Institute, Ontario, Canada F Lauzier1, O Lachance1, B Senay2, I Côté2, P Archambault2, F Lamontagne3,
Critical Care 2012, 16(Suppl 1):P298 (doi: 10.1186/cc10905) A Boutin1, L Moore1, F Bernard4, C Gagnon2, D Cook5, AF Turgeon1
1
CHA-Hôpital de l’Enfant-Jésus, Université Laval, Québec, Canada; 2Université
Introduction Biomarkers have been proposed as potential prognostic Laval, Québec, Canada; 3Université de Sherbrooke, Canada; 4Université de
indicators following a traumatic brain injury (TBI). Among those, glial Montréal, Canada; 5McMaster University, Hamilton, Canada
fibrillary acidic protein (GFAP) has been one of the most studied. The Critical Care 2012, 16(Suppl 1):P299 (doi: 10.1186/cc10906)
objective of this study was to assess the prognostic value of GFAP levels
in patients with moderate to severe TBI. Introduction Pituitary disorders are an often-neglected consequence
Methods We systematically searched Medline, Embase, Cochrane of traumatic brain injury (TBI). We systematically reviewed their
Central, Scopus, BIOSIS, TRIP, conference abstracts, bibliography of prevalence in studies with low risk of bias including moderate/severe
selected studies and narrative reviews. Cohort studies including TBI patients.
≥4 patients with moderate or severe TBI and reporting GFAP levels Methods We searched EMBASE, MEDLINE, Scopus, Cochrane Central
(sampled within the first 24 hours of care) from any biological tissue Register, BIOSIS, Trip Database, references of included studies and
or fluid, and mortality or Glasgow Outcome Scale (GOS), were eligible. narrative reviews. We included cohort studies, cross-sectional studies
Two independent reviewers screened all citations, selected eligible and RCTs that tested the integrity of ≥1 pituitary axis in adult victims
studies and extracted data using a standardized data extraction of TBI. Two investigators independently reviewed selected citations,
form. Pooled results from random effect models are presented using extracted data and assessed the risk of bias. Studies including <10% of
geometric mean ratios (GMRs). I2 tests were used to measure statistical mild TBI victims were considered as involving mainly moderate/severe
heterogeneity. TBI patients. Prevalence is reported as weighted mean (lowest and
Results We retrieved 4,709 citations and eight studies were deemed highest prevalence) in three time-frames: acute (<1 month post TBI),
potentially eligible. Among those, one was found to be a duplicate mid (3 to 12 months) and long-term setting (>12 months). Studies were
publication. Seven studies were thus included (n = 404). Four studies considered at low risk of bias if the authors defined inclusion/exclusion
presented data on mortality (3 or 6 months) and four studies used the criteria, avoided voluntary sampling, and tested >90% of included
GOS (6 or 12 months) as an outcome measure. We found significant patients with proper detailed diagnostic criteria. Studies testing all
associations between serum GFAP levels and mortality in pooled pituitary axes were considered as evaluating hypopituitarism, which
analysis of three studies (GMR 14.73 (95% CI 5.93 to 34.12); I2 = 79%), was defined as the dysfunction of at least one axis.
and between GFAP and GOS ≤3 in three studies (GMR 8.80 (95% CI 3.94 Results Among 12,514 citations, we included 55 studies (4,648
to 19.66); I2 = 77%). Two studies could not be used in pooled analyses: patients). Patients suffered from mild (11.9%, n = 555), moderate (7.9%,
one presented means of GFAP levels from multiple samplings over time n = 367) and severe (30.4%, n = 1,415) TBI, others being of unknown
(GMR 1.98 (95% CI 1.06 to 3.70)) while the other presented the highest severity. Prevalences of pituitary axis dysfunction are reported in
peak levels of GFAP during the acute phase of care (GMR 3.20 (95% CI Table 1. Few studies considering mainly moderate/severe TBI patients
1.82 to 5.65)). were at low risk of bias.
Conclusion Pituitary disorders frequently arise after TBI, but prevalence anticoagulants for 4 weeks along with the induction therapy. They were
remains uncertain due to low overall quality of available data. Factors assessed for; their clinical presentation, disease severity (progressive or
other than methodological quality and TBI severity are likely to explain nonprogressive), hospital course, adverse effects of the used treatment
the observed wide prevalence ranges. The clinical significance of TBI- and outcome. Reports of their neuroimaging studies were also
associated pituitary disorders also requires further rigorous evaluation. collected.
Results Studied patients were 42 (62.76%) boys and 26 (38.23%)
girls. Their mean age was 8.5 ± 3.5 years. The commonest presenting
symptoms were motor deficit (70%), headache (64%) and fever (20%),
P300 while the commonest presenting neurological signs were hemiparesis
Mannose binding lectin deficiency attenuates neurobehavioral (60%), seizure 55% (focal 35%, generalized 20%), and decreased
deficits following experimental traumatic brain injury level of consciousness (30%). Neuroradiological studies of the brain
L Longhi1, F Orsini2, N Fedele2, N Stocchetti1, MG De Simoni2 revealed: ischemic strokes in 50 children (73.5%), hemorrhagic
1
University of Milano, Milan, Italy; 2Mario Negri Institute, Milan, Italy strokes in 10 (14.7%) and ischemic–hemorrhagic lesions in eight
Critical Care 2012, 16(Suppl 1):P300 (doi: 10.1186/cc10907) (11.8%). Conventional angiography (CA) and/or magnetic resonance
angiography (MRA) at the time of admission revealed that 51 (75%)
Introduction Mannose binding lectin (MBL) is the activator of the patients had nonprogressive and 17 (25%) had evidence of progressive
lectin complement pathway. After cerebral ischemia it has been arteriopathy. Out of the studied patients, 56 (81.5%) survived and
shown that MBL could be a mediator of secondary brain damage, in 12 (18.5%) died. Male sex, deep coma and intracerebral bleeding
contrast after traumatic brain injury (TBI) there are data suggesting causing severe raised intracranial pressure were poor prognostic signs.
that it could be linked to neuroprotection. We tested the hypothesis Survivors were discharged on oral aspirin and 15 of them commenced
that MBL is involved in the pathophysiology of TBI. We characterized (1) also on azathioprine. On follow-up it was found that out of the 56
the temporal activation of MBL and (2) the effects of its inhibition in a survivors, 11 were normal (19.65%), 14 (25%) had minor disabilities,
model of experimental TBI. another 11 (19.65%) had moderate disabilities and 20 (35.7%) had
Methods (1) Male C57/Bl6 mice were subjected to intraperitoneal severe disabilities.
anesthesia (pentobarbital, 65 mg/kg) followed by the controlled Conclusion The spectrum of cPACNS includes progressive and non-
cortical impact brain injury model of experimental TBI (injury progressive forms. Characteristic features on presentation may predict
parameters: velocity of 5 m/second and 1 mm depth of deformation). later progression and outcome; identify a distinct high-risk cPACNS
MBL immunostaining was evaluated at various time points after TBI: cohort; and guide the selection of patients for immunosuppressive
30 minutes, 1, 6, 12, 24, 48, 96 hours and 1 week using anti MBL-A therapy. Further studies are required to substantiate our findings.
and MBL-C antibodies (n = 3). (2) The effects of MBL inhibition were
evaluated by comparing functional and histologic outcomes in C57/
Bl6 mice (WT) and in MBL knockout (–/–) mice. Functional outcome was
tested using the Composite Neuroscore and Beam Walk test weekly up
to 4 weeks postinjury (n = 11). Histologic outcome was evaluated by
calculating the contusion volume at 4 weeks postinjury (n = 6). Sham- P302
operated mice received identical anesthesia without brain injury. Changes of ribosomal protein S3 immunoreactivity and its
Results We observed a robust MBL-positive immunostaining in the new expression in microglia in the mice hippocampus after
injured cerebral cortex starting at 30 minutes postinjury and up to lipopolysaccharide treatment
1 week, suggestive of an activation of this pathway following TBI. JH Cho, CW Park, HY Lee, MH Won
MBL was observed both at endothelial and tissue levels. Consistently, Kangwon National University, Chuncheonsi, South Korea
injured WT and MBL (–/–) mice showed neurological motor deficits up Critical Care 2012, 16(Suppl 1):P302 (doi: 10.1186/cc10909)
to 4 weeks postinjury when compared to their sham controls. Notably,
MBL (–/–) mice showed attenuated behavioral deficits when compared Introduction Lipopolysaccharide (LPS) has been commonly used as
to their WT counterpart at 2 to 4 weeks postinjury (P <0.01 for both a reagent for a model of systemic inflammatory response. Ribosomal
Neuroscore and Beam Walk test). In contrast we observed similar protein S3 (rpS3) is a multifunctional protein that is involved in
contusion volumes at 4 weeks postinjury (WT = 15.6 ± 3.2 cm3 and MBL transcription, metastasis, DNA repair and apoptosis. In the present
KO = 13.9 ± 3.2 cm3, P = 0.3). study, we examined the changes of rpS3 immunoreactivity in the
Conclusion We observed that: (1) MBL deposition and/or synthesis mouse hippocampus after systemic administration of 1 mg/kg LPS.
is increased following TBI; and (2) MBL deficiency is associated with Methods Six-week-old male ICR mice were purchased from the Jackson
functional neuroprotection, suggesting that MBL modulation might be Laboratory (Bar Harbor, ME, USA). LPS (Sigma, St Louis, MO, USA) was
a potential therapeutic target after TBI. dissolved in saline, and administered intraperitoneally with 1.0 mg/
kg/10 ml dose. The control animals were injected with the same volume
of saline. Mice (n = 7 at each time point) were sacrificed at designated
times (3, 6, 12, 24, 48 and 96 hours after LPS treatment). The brain
P301 tissues were cryoprotected by infiltration with 30% sucrose overnight.
Azathioprine and aspirin in treatment of childhood primary arterial Thereafter, frozen tissues were serially sectioned on a cryostat (Leica,
stroke: therapeutic benefits and side effects Wetzlar, Germany) into 30-μm coronal sections, and they were then
A Alhaboob, G Ahmed collected into six-well plates containing 0.1 M PBS.
King Khalid University Hospital and College of Medicine, King Saud University, Results From 6 hours after LPS treatment, rpS3 immunoreactivity was
Riyadh, Saudi Arabia decreased in pyramidale cells of the hippocampus proper and granule
Critical Care 2012, 16(Suppl 1):P301 (doi: 10.1186/cc10908) cells of the dentate gyrus. At this point in time, rpS3 immunoreactivity
began to increase in nonpyramidal cells and nongranule cells in the
Introduction The objectives were to describe a cohort of children hippocampus. From 1 day after LPS treatment, rpS3 immunoreactivity
presenting with medium/large vessel childhood primary angiitis of the in pyramidal and granule cells was hardly detected, and nonpyramidal
central nervous system (PACNS); to report their short-term neurological and nongranule cells showed strong rpS3 immunoreactivity. Based
outcome; and to evaluate efficacy and safety of implemented on double immunofluorescence staining, microglia, not astrocytes,
management. expressed strong rpS3 immunoreactivity at 1 and 2 days after LPS
Methods The study included 68 patients, aged less than 16 years. treatment.
They had their symptoms within 14 days of admission. They Conclusion These results indicate that changes in rpS3
received induction therapy with pulses of intravenous steroids and/ immunoreactivity in pyramidal and granule cells and rpS3 expression
or intravenous immunoglobulin followed by maintenance therapy in activated microglia after LPS treatment may be associated with the
with azathioprine and low-dose aspirin. They were also treated with neuroinflammatory responses in the brain.
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Conclusion In our model of global cerebral ischaemia, the administration of the mobilization phase. Although the exact etiopathogenesis has
of xenon reduced the number of ischaemic neurons compared to not yet been fully elucidated, sepsis, systemic inflammatory response
control, both in the cerebral cortex and in the hippocampus. syndrome, and multiple organ failure seem to play an important
Reference role. CIP is diagnosed by signs of denervation in electromyography.
1. Wilhelm S, et al.: Effects of xenon on in vitro and in vivo models of neuronal Although there is no causal treatment for CIP, retrospective data
injury. Anesthesiology 2002, 96:1485-1489. suggest that early IgM-enriched intravenous immunoglobulin (IVIG)
application may prevent or mitigate CIP. Therefore we aimed to
investigate the use of IVIG in the early treatment of CIP in critically ill
P306 patients in a prospective, randomized, double-blind and placebo-
Seizures in the respiratory ICU: single-center study of patients with controlled setting.
new-onset seizures Methods In this prospective, randomized, double-blind and placebo-
D Talwar, V Nair, J Chudiwal controlled trial critically ill patients with clinical evidence for incipient
Metro Center for Respiratory Diseases, Noida, India CIP, a diagnosis of SIRS/sepsis and failure of at least two organ
Critical Care 2012, 16(Suppl 1):P306 (doi: 10.1186/cc10913) systems were randomized to be treated either with IgM-enriched
IVIG or with human albumin 1% as placebo over a period of 3 days.
Introduction New-onset seizures in the ICU are a diagnostic and The primary objective was to demonstrate that administration of IVIG
management challenge as patients have multiple comorbidities and prevents and/or mitigates CIP in critically ill patients, measured by
receive various antibiotics. In the respiratory ICU with different patient electrophysiological stimulation of the median, ulnar and tibial nerves
profiles, etiopathogenesis of seizures is unreported. on days 0, 4, 7 and 14. Electrophysiological measures were graded
Methods We retrospectively analyzed the profile of 3,342 patients according to compound muscle action amplitude size (CIP score) of the
admitted to the RICU from 2006 to 2011. A computerized search respective nerve. Secondary objectives were mortality from any cause
revealed 79 patients (2.4%) with new-onset seizures. Complete clinical, within a 28-day period and lengths of ICU stay.
laboratory, radiological and treatment profiles were recorded and Results Thirty-eight critically ill patients were included and randomized
statistically analyzed using the chi-square test, odds ratio and relative to either receiving IgM-enriched IVIG (n = 19) or placebo (n = 19).
risk of individual variable. Baseline characteristics including CIP score on day 0 were similar
Results Of 79 patients, 44 patients (55.7%) were males and the mean between the two groups. CIP could not be improved significantly by
age was 61.28 ± 19.57 years. Severe sepsis was diagnosed in 32 (40.5%) IVIG treatment for three consecutive days, represented by similar CIP
and multiorgan failure in 19 (24.1%). Head CT done in 65 (82.3%) scores of all three measured nerves on days 4, 7 and 14 in the IVIG and
patients was reported abnormal in 34 (52.3%; P = 0.072) patients. the placebo group. Mean CIP score levels of all three nerves significantly
Lumbar puncture was done in 40 (50.6%) with five (12.5%) patients increased from baseline to day 4 in both groups.
having meningitis. Thirteen of 37 (35.1%) patients showed focal Conclusion Results suggest that early treatment with IVIG neither
activity on EEG (P = 0.27; OR = 1.73). Electrolyte abnormalities were: significantly improves CIP nor influences the length of stay or mortality
hypermagnesemia in 20 patients (25.3%), hypocalcemia in 17 patients in critically ill patients. Consistent with the literature, CIP deteriorated
(21.5%), and hypernatremia in 13 patients (16.5%), hyponatremia during the course of disease in critically ill patients with a diagnosis of
in three patients (3.8%) and hypomagnesia in four (5.17%) cases. SIRS/sepsis and failure of two organ systems.
The antibiotics received revealed 27 (34.2%; RR = 1.27) patients on
levofloxacin alone or in combination. Twenty-eight of 79 (35.4%)
patients were on carbapenems with meropenem in 23/79 (29.1%; P308
RR = 1.21) and imipenem in 5/79 (6.32%; RR = 0.41). See Table 1. Intracranial pressure monitoring in acute liver failure:
a retrospective cohort study
Table 1 (abstract P306). Attributable causes of seizures in RICU cases (n = 79) C Karvellas1, O Fix2, H Battenhouse3, V Durkalski3, C Sanders4, W Lee4
1
University of Alberta, Edmonton, Canada; 2UCSF, San Francisco, CA, USA;
Anoxia 8 10.1% 3
Medical University of South Carolina, Charleston, SC, USA; 4University of
Metabolic 15 19.0% Texas-Southwestern, Dallas, TX, USA
Drugs only 16 20.3% Critical Care 2012, 16(Suppl 1):P308 (doi: 10.1186/cc10915)
CNS infection 5 6.3%
Introduction Intracranial hypertension (ICH) complicates roughly 25%
Trauma 2 2.5% of acute liver failure (ALF) patients with grade III/IV encephalopathy.
Alcohol 5 6.3% Intracranial pressure (ICP) monitoring is controversial due to
complications in 5 to 20% and absence of documented mortality
Multiple 22 27.8%
benefit.
Miscellaneous 6 7.6% Methods Using prospectively collected data from the US Acute Liver
Study Group registry, we reviewed 630 ALF patients with severe
Conclusion New-onset seizure in RICU cases is multifactorial in origin. encephalopathy (grade III/IV) and INR >1.5 enrolled between 1 March
Use of levofloxacin in combination had the highest relative risk of 2004 through 31 August 2011. ICP monitoring was used in 143 patients
developing seizure although when given alone the risk is rare (2.1%). (23%); 487 control patients with grade III/IV hepatic coma (n = 487)
Severe sepsis with multiorgan failure being seen in nearly one-half of were not monitored.
RICU cases may decrease seizure threshold in these patients. Results The most common etiology of ALF was acetaminophen (51%,
P = 0.13 between groups). Of ICP monitored (ICPM) patients, 85%
(n = 121) received devices within 24 hours of admission to study. ICPM
P307 patients were significantly younger (36 ± 6 years vs. 43 ± 15 years,
Early treatment with intravenous immunoglobulins in patients with P <0.001) than controls, more likely to be on renal replacement therapy
critical illness polyneuropathy: a randomized controlled, double- (48% vs. 31%, P <0.001) but less likely to be on vasopressors (20% vs.
blinded study 32%, P = 0.008). ICPM patients were given more ICH directed therapies
R Brunner, W Rinner, R Kitzberger, T Sycha, J Warszawska, U Holzinger, (mannitol 43% vs. 13%, hypertonic saline 21% vs. 6%, hypothermia 29%
C Madl vs. 11%, P <0.001 for each comparison). For ICPM patients, the median
Medical University of Vienna, Austria INR on the day of monitor insertion was 2.2 (1.6 to 2.9) and platelet
Critical Care 2012, 16(Suppl 1):P307 (doi: 10.1186/cc10914) count 116 (84 to 171); 74% were given FFP (vs. 46% controls, P <0.001)
and 19% (vs. 14% controls, P = 0.14) received platelets. ICP monitoring
Introduction Critical illness polyneuropathy (CIP) is a severe was also strongly associated with listing (78% vs. 27%, P <0.001) and
complication of critical illness. The clinical features of CIP are muscle receipt of liver transplant (42% vs. 18%, P <0.001). Twenty-one-day
weakness and atrophy causing delayed weaning and prolongation mortality was similar between ICPM patients (33%) and controls (37%,
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P = 0.33) when all or only nontransplanted patients (46% vs. 45%, multicenter study to evaluate long-term prognosis in severe TBI,
0.8) were considered. Of 66 ICPM patients with detailed information, we conducted a prospective pilot study evaluating the patterns of
18 (29%) had evidence of ICH (ICP >25 mmHg) at the time of ICPM enrollment, the compliance to the schedule of prognostic tests and the
insertion (maximum ICP on day 1 ~18 (12 to 26) mmHg). Of 49 patients completeness of follow-up for 6-month functional outcome measures.
with a known ICPM device, 14 patients received epidural catheters, six Methods We conducted a pilot study in nine level I trauma centers in
subdural, 11 intraparenchymal, seven intraventricular and 11 lumbar Canada. Adult patients with severe TBI expected to require mechanical
monitors. In only one of 49 ICPM patients was intracranial hemorrhage ventilation for ≥48 hours were enrolled on their first day in the ICU.
reported, and this patient survived. Prognostic tests were performed on arrival (CT scan), day 1 (serum
Conclusion In ALF patients, ICP monitor placement is strongly biomarker), day 3 (serum biomarker, CT scan) and day 7 (serum
associated with liver transplantation but not with overall or transplant biomarker, CT scan, MRI, SSEP, EEG) with time windows of 24 or 48 hours
free mortality. In the absence of ICP monitoring, ALF patients may be depending on the test. Prognostic measures were collected during the
less aggressively treated for intracranial hypertension. The value of first week in the ICU to examine the association with the extended
ICP monitoring in ALF remains to be determined but ICPM placement Glasgow Outcome Scale score. We considered as appropriate a
clearly affects the frequency of interventions for elevated ICP. compliance to the schedule of prognostic tests ≥90% and a proportion
of lost to follow-up <10%. We obtained REB approval from participating
P309 centers and written informed consent from SDMs.
Retrospective observation of 6-month survival following Results Among 116 consecutive eligible patients, 50 were enrolled over
decompressive craniectomy in a London major trauma and stroke a total of 204 weeks of screening between May 2010 and May 2011.
centre Two centers used a deferred consent approach. Patients were primarily
J Dawson, P Hopkins, J Ling, D Walsh, C Tolias male with a median age of 45 years and a GCS of 5 (25th to 75th: 3
King’s Health Partners, London, UK to 7). The two main reasons for nonenrollment were the time window
Critical Care 2012, 16(Suppl 1):P309 (doi: 10.1186/cc10916) for inclusion being after regular working hours (35%, n = 23) and
oversight (24%, n = 16). The compliance to the different tests ranged
Introduction This study describes 5.5 years of retrospective data from 93 (three missing tests) to 100%. All blood samples but one (day
examining hospital and 6-month outcome of patients following 7) were performed. The main reason for missing a test was the patient’s
decompressive craniectomy (DC). The effectiveness of DC remains instability (hemodynamic or increased ICP) (n = 5). In six patients, the
uncertain with conflicting results in patients with TBI and stroke [1,2]. MRI had to be delayed due to the presence of material not compatible
Methods Data were drawn (1 January 2006 to 30 June 2011) from three with the procedure. No patient was lost to follow-up at 6 months.
hospital databases following approval by the institutional board. Conclusion These results demonstrate the feasibility of enrollment and
Results There were 2,148 neurosurgical admissions with 71 undergoing complying to a structured protocol of prognostic tests in a prospective
DC. Forty-eight of 71 (67.6%) survived to hospital discharge and 21/33 multicenter study in severe TBI patients.
in both TBI and stroke groups survived to 6 months. See Table 1.
CI 15.97 to 35.83), I2 = 60%) and GOS ≤3 (10 studies: WMD 17.69 (95% References
CI 12.14 to 23.24), I2 = 64%). Similar results were found with or without 1. Patlak et al.: Graphical evaluation of blood-to-brain transfer constants from
extracerebral injuries. The number of studies included in pooled multiple-time uptake data. J Cereb Blood Flow Metab 1983, 3:1-3.
analyses precluded performing relevant sensitivity analyses. 2. Maeda et al.: Ultra-early study of edema formation in cerebral contusion
Conclusion We observed a significant association between serum using diffusion MRI and ADC mapping. Acta Neurochir Suppl 2003,
NSE levels and unfavorable outcomes (mortality or GOS ≤3) not 86:329-331.
influenced by extracerebral injuries. Further studies need to evaluate
the usefulness of serum NSE levels for prognosis assessment in TBI and
its potential impact on clinical decision-making.
References
1. Papa L, et al.: Use of biomarkers for diagnosis and management of
traumatic brain injury patients. Exp Opin Med Diagn 2008, 2:937-945. P313
2. Zitnay GA, et al.: Traumatic brain injury research priorities: the Conemaugh Can urinary 8-OHdG be a good indicator of vasospasm occurrence
International Brain Injury Symposium. J Neurotrauma 2008, 25:1135-1152. following subarachnoid hemorrhage?
K Ikeda, T Ikeda, H Taniuchi, S Suda, Y Ikeda, H Jimbo
Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
P312 Critical Care 2012, 16(Suppl 1):P313 (doi: 10.1186/cc10920)
Blood–brain barrier permeability following traumatic brain injury
M Jungner, P Bentzer Introduction There is substantial evidence to suggest that oxidative
Lund University, Lund, Sweden stress is associated with cerebral vasospasm following subarachnoid
Critical Care 2012, 16(Suppl 1):P312 (doi: 10.1186/cc10919) hemorrhage (SAH). Urinary 8-OHdG is the most common biomarker of
DNA damage by oxidative stress. The aim of this study was to determine
Introduction Brain edema and intracranial hypertension is deleterious whether 8-OHdG is a good indicator of vasospasm occurrence
after traumatic brain injury (TBI), but the underlying pathophysiology following SAH.
is complex and poorly understood. One major subject of controversy Methods The subjects were 23 patients who received surgical clipping
is the time course and extent of blood–brain barrier dysfunction or endovascular coiling within 24 hours after the onset of SAH. We
following trauma, and previous studies in humans have only provided classified the patients according to the occurrence of angiographic
semi-quantitative data. The objective of the present study was vasospasm. We examined the urinary 8-OHdG levels with high-
therefore to quantify changes in blood–brain barrier permeability in performance liquid chromatography for 10 days following SAH. The
the early course of TBI. urinary 8-OHdG levels were adjusted according to serum creatinine
Methods Seventeen nonconsecutive brain trauma patients and levels.
two controls were included in this prospective observational study. Results The urinary 8-OHdG levels were elevated on day 2 compared
Following i.v. injection of iohexol and CT perfusion scans, patients were with those on day 1 only in the vasospasm (+) group. The urinary 8-OHdG
scanned eight times from 4 to 25 minutes. The blood-to-brain transfer levels in the vasospasm (+) group were significantly higher than those
constant (Ki) for iohexol, reflecting permeability and area available for in the nonvasospasm (–) group on days 1, 2, 8 and 9. Furthermore,
diffusion, was calculated by Patlak plot analysis of the enhancement we examined the correlations between the urinary 8-OHdG levels
curves of intracerebral large venous vessels and pericontusional brain on admission to the ICU and the grades of the World Federation of
parenchyma. Neurologic Surgeons and Fisher, but none were observed. Discussion
Results Fourteen patients were included within 1 day and three were An elevated urinary 8-OHdG level on day 2 was observed only in the
included within 5 days of the injury. In nonischemic tissue surrounding vasospasm group. Therefore, we speculated that free radicals may
contusions and hematomas, Ki was focally increased in 11 of all included have a role in inducing vasospasm in the early phase following SAH.
trauma patients and in six of seven patients with raised intracranial The urinary 8-OHdG levels were higher in the vasospasm group than
pressure. In noninjured areas and in controls, Ki was about 0.06 ml/ in the nonvasospasm group, but we did not find any correlation with
minute/100 g and increased by 100 to 2,000% in pericontusional tissue. severity of SAH. We suspect that the higher urinary 8-OHdG levels on
See Figure 1. days 8 and 9 in the vasospasm group indicated ischemic brain injury
Conclusion TBI is associated with early focal increases in blood–brain after vasospasm.
barrier permeability. The results suggest that in the injured brain, Conclusion We believe that oxidative stress has a role in the
capillary hydrostatic and oncotic pressures are likely to influence development of cerebral vasospasm and that urinary 8-OHdG may be a
edema formation. good indicator of vasospasm occurrence following SAH.
Figure 1 (abstract P312). CBF (left) and permeability (right) maps, and contrast-enhanced CT scan (middle).
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P314 Results We excluded two patients with bleeding for more than
Cortical capillary recruitment by rosuvastatin in experimental brain 72 hours. There was no significant change in the levels of CK total, renal
trauma is associated with increased NO production or liver function. We included 21 patients, 11 in the SVT group and
P Bentzer, M Jungner nine in the control group. The mortality was eight patients (38%), six
Lund University, Lund, Sweden patients in the control group and two of the SVT group. Vasospasm was
Critical Care 2012, 16(Suppl 1):P314 (doi: 10.1186/cc10921) confirmed by cerebral arteriography examination in four patients in the
control group and one patient in the SVT group. All patients that had a
Introduction Microvascular dysfunction, characterized by edema bad outcome (death) had Fisher IV scale.
formation secondary to increased blood–brain barrier (BBB) Conclusion SVT at a dose of 80 mg was effective in reducing the
permeability and decreased blood flow, contributes to poor outcome mortality (18.1% against 66%) compared to the group that did not use
following brain trauma. Recent studies have indicated that statins may SVT, and also decreased the incidence of cerebral vasospasm despite
counteract edema formation following brain trauma but little is known the APACHE II score being higher in the group that used SVT (14.3
about other circulatory effects of statins in this setting. The objective vs. 10.7). There was less morbidity in the SVT group with an average
of the present study was to investigate whether statin treatment Glasgow Outcome Scale of 3.25 vs. 2.1.
improves brain microcirculation early after traumatic brain injury, and References
whether microvascular effects are associated with altered production 1. Lynch JR, Wang H, et al.: Simvastatin reduces vasospasm after aneurysmal
of nitric oxide and prostacyclin. subarachnoid hemorrhage: results of a pilot randomized clinical trial.
Methods After fluid percussion injury, rats were randomized to Stroke 2005, 36:2024-2026.
intravenous treatment with 10 mg/kg rosuvastatin or vehicle. Brain 2. McGirt MJ, Lynch JR: Simvastatin increases endothelial nitric oxide
edema (wet/dry weight), BBB integrity (51Cr-EDTA blood to brain synthase and ameliorates cerebral vasospasm resulting from
transfer), cerebral blood flow (14C-iodoantipyrine autoradiography), and subarachnoid hemorrhage. Stroke 2002, 33:2950-2956.
the number of perfused cortical capillaries (FITC-albumin fluorescence
microscopy) were measured at 4 and 24 hours. Production of NO and P316
prostacyclin was estimated by measuring the stable degradation Evaluation of arterial and venous ophthalmic hemodynamics in
products nitrite and nitrate (NOx), and 6-keto-PGF-1α in plasma. Sham preeclamptic pregnant women
injured animals were treated with vehicle and analyzed at 4 hours. EM Shifman, NV Khramchenko, SV Sokologorskiy
Results Trauma resulted in brain edema, BBB dysfunction, and reduced Federal Centre for Obstetrics, Gynecology & Neonatology, Moscow, Russia
cortical blood flow, and no effect of treatment on these parameters Critical Care 2012, 16(Suppl 1):P316 (doi: 10.1186/cc10923)
could be detected. Trauma also induced a reduction in the number of
perfused capillaries, which was improved by statin treatment. Statin Introduction The aim of the study was to evaluate arterial and venous
treatment led to increased plasma NOx levels and reduced mean ophthalmic blood flow parameters in mild and severe preeclampsia
arterial blood pressure. The 6-keto-PGF-1α levels tended to increase pregnancies and in normotensive pregnancies.
after trauma, and were significantly reduced by rosuvastatin. Methods A total of 117 women 25 to 30 years old with singleton
Conclusion Rosuvastatin treatment improves microcirculation after pregnancies 30 to 40 weeks of gestation were recruited. Among
traumatic brain injury by increasing the number of perfused capillaries. them 40 pregnant women developed severe preeclampsia, 42 mild
This effect is associated with increased NO and reduced prostacyclin preeclampsia, and 35 were normotensive. Using color flow mapping
production. (CFM) and pulse-wave Doppler imaging (PWD), maximum blood
References flow velocity (mFV) in the right/left arterial and venous ophthalmics
1. Béziaud et al.: Crit Care Med 2011, 39:2300-2307. along with Gosling’s Doppler pulsatility index (PI) [1] in both arterial
2. Cherian, Robertson: J Neurotrauma 2003, 20:77-85. ophthalmics were evaluated. Mean blood pressure in all patients was
3. Prinz, Endres: Anesth Analg 2009, 109:572-584. also registered.
Results The highest mFV values (59.2 ± 4.61 and 23.6 ± 4.03 cm/second)
were in the severe preeclampsia group while in the mild preeclampsia
group mFV increased slightly or remained normal (35.6 ± 2.97 and
P315 13.6 ± 0.81 cm/second). There was no mFV increase in the normotensive
Effects of sinvastatin in prevention of vasospasm in nontraumatic pregnancy group (31.5 ± 2.21 cm/second). No significant correlation
subarachnoid hemorrhage: preliminary data was found between gestation age and mentioned hemodynamic
S Macedo, V Aguiar, PF Rosa, IT Ladeia, YK Castro, LA Ferreira, DR De Melo, parameters in the normotensive pregnancy group. PI values in the
LG Rezende arterial ophthalmic in normotensive pregnant women were 2.92 ± 0.59
São Jose do Avai Hospital, Itaperuna, Brazil and the highest in all groups. In group with mild preeclampsia this
Critical Care 2012, 16(Suppl 1):P315 (doi: 10.1186/cc10922) parameter was 1.47 ± 0.30 and the lowest one was in patients with
severe preeclampsia – 1.17 ± 0.08.
Introduction Some trials have shown that statins in the acute phase Conclusion In women with preeclampsia significant changes in
of aSAH reduce the incidence, morbidity and mortality of cerebral ophthalmic hemodynamics take place – mFV in arterial and venous
vasospasm. Independent of their cholesterol-lowering effect, statins ophthalmics increases while PI values go down. This might be evidence
have multiple biological properties, including downregulating of orbital hyperperfusion in preeclamptic pregnant women. Low PI
inflammation and upregulating endothelial NO synthase. The purpose values may be used as the markers of severe preeclampsia.
of this study is to evaluate the potential of sinvastatin (SVT) as Reference
prevention against vasospasm. 1. Gosling RG, King DH: Arterial assessment by Doppler shift ultrasound. Proc
Methods We realized a prospective study, randomized, nonblind, with R Soc Med 1974, 67:447-449.
the use of 80 mg SVT (night) in the first 72 hours of the beginning of
bleeding, and a control group that did not use SVT, for 21 days, between P317
January and December 2008. Informed consent was obtained for all Data classification of magnetic resonance tomography and
patients. CT scans were performed as control and another CT scan in computer tomography images of brain in parturients with
patients with altered neurological signals. In the presence of changes neurological complications of eclampsia
suggestive of vasospasm or correlation in clinical and CT scans, the G Tikhova, E Shifman
patients were taken for cerebral arteriography examination followed Kulakov Scientific Center of Obstetrics, Gynecology and Perinatology, Moscow,
by an angioplasty procedure if necessary. Liver and renal function and Russia
LDL cholesterol were evaluated every 3 days. Exclusion criteria: liver Critical Care 2012, 16(Suppl 1):P317 (doi: 10.1186/cc10924)
and renal disease, pregnancy, elevation of serum transaminases (three
times the value of normality), creatinine ≥2.5, rhabdomyolysis or CK Introduction The goal of the study was to classify protocol data
total ≥1,000 U/l. recorded during magnetic resonance tomography (MRT) and
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efficiency, number of awakenings and wake time after sleep onset nursing and medication may play a more important role than ICU
were determined with actigraphy and compared to PSG. The accuracy, design.
sensitivity (percentage correctly scored as sleep) and specificity References
(percentage correctly scored as awake) were calculated for actigraphy 1. Cooper AB, et al.: Chest 2000, 117:809-818.
using high, medium, low and automatic threshold sensitivity settings 2. Gabor JY, et al.: Am J Respir Crit Care Med 2003, 167:708-715.
of the actigraphy software.
Results The only parameter that showed a significant correlation
between PSG and actigraphy was the number of awakenings (r = 0.76, P322
P = 0.049, high threshold setting). Actigraphy underestimated wake Oral melatonin in high-risk critically ill patients: quality of sedative
time after sleep onset and overestimated total sleep time and sleep effect
efficiency. The median specificity for actigraphy was below 19% and G Sabbatini, G Mistraletti, B Cerri, S Miori, I Galluccio, M Tozzi, C Villa,
the median sensitivity above 94% for all threshold settings. M Umbrello, F Fraschini, G Iapichino
Conclusion Actigraphy is not reliable for one-night sleep–wake Università degli Studi di Milano, Milan, Italy
detection in short-stay postoperative ICU patients. Critical Care 2012, 16(Suppl 1):P322 (doi: 10.1186/cc10929)
References
1. Figueroa-Ramos M, et al.: Intensive Care Med 2009, 35:781-795. Introduction Analgesic/sedative therapy is necessary in ICU patients;
2. Beecroft J, et al.: Intensive Care Med 2008, 34:2076-2083. however, it presents important side effects. Critically ill patients have
3. de Souza L, et al.: Sleep 2003, 26:81-85. altered circadian rhythm, delirium and agitation often requiring
4. Schweickert WD, et al.: Chest 2007, 131:1541-1549. additional sedation. The dramatically reduced endogenous blood
melatonin level (basal and night peaks) could play a role in this
context. We evaluated the effects of oral melatonin administration on
P321 the adaptation to critical illness and invasive procedures in high-risk
Quality and quantity of sleep in multipatient versus single-room critically ill patients [1] consciously sedated [2].
ICUs Methods Double-blind RCT between placebo and melatonin (3 mg
M Van Eijk, A Slooter bid, 8:00 and 12:00 p.m., from third ICU day until discharge). Inclusion:
University Medical Center Utrecht, the Netherlands age >18, SAPS II >32, expected mechanical ventilation (MV) >4 days,
Critical Care 2012, 16(Suppl 1):P321 (doi: 10.1186/cc10928) practicability of the gastroenteric tract. Patients were treated according
to local guidelines [2], titrating sedatives to a conscious target
Introduction Sleep fragmentation and deprivation is common in ICU (Richmond Agitation Sedation Scale (RASS) = 0) as early as possible.
patients [1]. It is assumed that the ICU environment (overexposure Each day, the physician in charge stated the RASS target; nurses
to sound and light during night-time) leads to disturbed sleep [2]. assessed the actual RASS.
In our hospital, a new ICU was built with quiet, single-patient rooms Results Eighty-two patients enrolled: age 72 (60 to 77), SAPS II 41 (34
with much daylight. This created an opportunity to study the effects to 54), MV length 11 (6 to 22) days. Fifteen pancreatitis, 33 acute lung
of nursing environment on sleep quality and quantity in ICU patients. diseases, 13 acute heart diseases, 21 other. The analgesic/sedative
Methods We included 21 postcardiothoracic surgery patients: 11 therapy during the first 3 days was not different between groups.
subjects were admitted to the old, ward-like ICU, and 10 patients to the Melatonin administration determined early weaning from sedatives
new, single-room ICU (see Figure 1). Hypnograms were derived from a and analgesics. The prevalence of conscious sedation (RASS = 0) was
polysomnography from 07:00 p.m. to 07:00 a.m. higher in the melatonin group (67.9 vs. 60.1%, P <0.01), while deeper
Results Both groups did not differ with respect to age, duration levels of sedation (RASS = –3/–4) were lower in the melatonin group
of surgery or use of psychoactive medication. Polysomnography (RASS –3: 2.4 vs. 7.7%, P <0.01; RASS –4: 1.9 vs. 4.3%, P <0.01). Melatonin
recordings showed no differences in total sleep time and awakenings administration caused no oversedation (26.3 vs. 24.2%, P = 0.94), while
(63 ± 26 in the old ICU and 56 ± 30 in the new ICU). The mean decreased undersedation (18.6% vs. 26.2%, P = 0.05). RASS targets were
percentage of sleep stages in the old versus new situation did not joined more frequently in the melatonin group, even if not significantly
essentially different either: N1: 12.9% versus 8.0%, P = 0.21, ANOVA; N2: (55.1 vs. 49.6%, P = 0.12).
80.3% versus 87.2%, P = 0.07, ANOVA; N3: 5.2% versus 2.5%, P = 0.18, Conclusion Oral melatonin increased the prevalence of conscious
ANOVA. Only REM sleep latency was longer in the old ICU: 314.7 versus sedation in high-risk critically ill patients; it allowed a better
633.5 minutes, P = 0.02, ANOVA. achievement of RASS target, particularly decreasing undersedation
Conclusion Except for REM onset latency, sleep improvement was episodes.
not achieved by changing a ward-like into a single-patient-room ICU Clinicaltrial.gov NCT00470821
environment. When striving for more natural sleep, attitudes towards References
1. Iapichino et al.: Crit Care Med 2006, 34:1039.
2. Cigada et al.: J Crit Care 2008, 23:349.
P323
Sedation depth and mortality in mechanically ventilated critically
ill adults
Y Shehabi1, S Kadiman2, L Chan3, W Ismail4, M Saman5, A Alias6
1
University New South Wales, Randwick, Australia; 2National Heart Institute,
Kuala Lumpur, Malaysia; 3University Malaya, Kuala Lumpur, Malaysia; 4Raja
Perempuan Zainab II Hospital, Kota Bharu, Malaysia; 5Sarawak General
Hospital, Kuching, Malaysia; 6Malacca General Hospital, Malacca, Malaysia
Critical Care 2012, 16(Suppl 1):P323 (doi: 10.1186/cc10930)
a multicentre prospective longitudinal cohort study in 11 centers in Conclusion Sedation scales are widely used in Belgium, while use of
Malaysia. Critically ill patients ventilated and sedated ≥24 hours were DSI is low. Barriers impairing adherence to recommendations were
followed from ICU admission to hospital discharge. The administration identified. Perception that sedation scales are not used for sedative
of all sedatives was measured daily. Four-hourly RASS assessments dosing adjustments is present, as well as inadequate use for analgesia.
were conducted and delirium assessed daily (CAM-ICU during light Fear of worsening patient outcomes using DSI is present, contrasting
sedation RASS –2 to +1). Multivariable Cox regression proportional with current literature. A similar survey addressing physicians’
hazard was used to quantify relationships between early deep sedation perceptions is ongoing.
and time to extubation and delirium occurring after 48 hours and Reference
hospital mortality adjusting for diagnosis, age, gender, APACHE II score, 1. Jacobi et al.: Crit Care Med 2002, 30:119-141.
operative, elective, early use of vasopressors and dialysis.
Results We studied 259 patients with mean (SD) age 53.1 (15.9) years
and APACHE II score 21.3 (8.2), ventilated for median (IQR) 5 (3 to 8.8) P325
days. Hospital mortality was 82 (31.7%). Midazolam and morphine were Implementation of a national guideline for analgesia and sedation:
the commonest agents used, given to 241 (93.1%) and 201 (77.6%) how often can a RASS of 0 to –2 be achieved?
patients respectively. Over 2,657 study days, 13,836 assessments R Riessen, P Tränkle, R Pech, G Blumenstock, M Haap
were conducted. Deep sedation was recorded in 187 (72%) patients University Hospital Tübingen, Germany
within 4 hours of commencing ventilation and in 159 (61%) patients at Critical Care 2012, 16(Suppl 1):P325 (doi: 10.1186/cc10932)
48 hours. Daily interruption was used on 20% of study days. Delirium
occurred in 114 (43%) of assessed patients with a mean (SD) duration Introduction Based on a new national guideline we implemented in
of 1.3 (2.2) days. Early deep sedation independently predicted time our medical ICU an interdisciplinary algorithm for the management of
to hospital death (HR 1.11, 95% CI 1.05 to 1.18, P <0.001) and time to analgosedation, in which nurses had to adjust the dose of the analgesics
extubation (HR 0.93, 95% CI 0.89 to 0.96, P = 0.001) but not time to and sedatives based on sedation goals given by the physicians. Within
delirium occurring after 48 hours (HR 0.98, 95% CI 0.93 to 1.03, P = 0.46). this project we investigated in what portion of mechanically ventilated
Midazolam cumulative dose in the first 48 hours was significantly patients a sedation level of Richmond Agitation and Sedation Scale
associated with the number of RASS assessments ≤–3 (P <0.001). (RASS) of 0 to –2, which is generally recommended by the guideline,
Conclusion Early ICU sedation depth is a modifiable risk factor can be achieved. We also asked the nurses for an explanation when this
for delayed extubation and increased risk of death and should be goal was not reached.
considered in future sedation trials. Methods After an educational program the level of sedation was
Reference measured 364 times in 37 mechanically ventilated patients at different
1. Devlin JW: The pharmacology of over sedation in mechanically ventilated time points by an independent observer. In all cases in which the RASS
adults. Curr Opin Crit Care 2008, 14:403-407. was outside the desired level of 0 to –2, the nurse in charge was asked
to fill out a structured as well as open questionnaire, in which the
reasons for this deviation could be stated.
P324 Results The independent observer documented only in 13% (47/364)
Sedation in the ICU: nurses’ perceptions of practices and influencing of all measurements a RASS of 0 to –2. We analyzed 295 questionnaires,
factors in which 368 reasons for a deviation from a RASS of 0 to –2 were
B Sneyers1, PF Laterre2, MM Perreault3, A Spinewine1 stated (multiple answers were possible). In 113 questionnaires (38%)
1
Université catholique de Louvain, Louvain Drug Research Institute, Brussels, the nurses mentioned that a short-term increase in sedation depth
Belgium; 2Université catholique de Louvain, Cliniques Universitaires St-Luc, was required for nursing procedures or medical interventions. In 89
Brussels, Belgium; 3Université de Montreal, Canada questionnaires (30%) a RASS of 0 to –2 was considered reasonable
Critical Care 2012, 16(Suppl 1):P324 (doi: 10.1186/cc10931) but could not be achieved at the time of measurement with the
current medication (n = 32) or the consciousness was impaired by CNS
Introduction Our goals are to describe adherence to sedation diseases (n = 52). In 100 questionnaires (34%) a RASS of 0 to –2 was
recommendations [1] in Belgian ICUs and to identify major factors not considered reasonable. The following reasons were stated: disease
influencing practices. with coma (n = 25), controlled ventilation (n = 32), distressed patient
Methods A national survey including all nurses working in Belgian ICUs (n = 12), increased intracranial pressure (n = 7), status epilepticus
was conducted with seven nurses sampled per hospital. A validated (n = 7), hypothermia (n = 4), dying patient (n = 4), delirium/(auto)
self-administered paper survey was designed based on a literature aggression (n = 4). Other reasons were mentioned in 66 questionnaires
review and data from a previous qualitative study. Topics addressed (22%), most commonly a physician order for a deeper sedation (n = 19)
were current practices and reasons for (non)compliance to sedation or a missing sedation goal (n = 14).
recommendations such as use of sedation scales and daily sedation Conclusion In mechanically ventilated patients of a medical ICU
interruption (DSI). Four postal reminders were sent. including also patients with neurologic diseases, a sedation goal of
Results The response rate was 70% (n = 587/840 nurses from 99/120 RASS 0 to –2, as recommended by a current guideline, could only be
hospitals). Sedation scales are available to 89% of nurses and frequency achieved in a minority of patients despite intensive instructions and
of use is variable (≤1×/day: 13%, 3 to 4×/day: 31%, ≥6×/day: 56%). When a motivated team. In most cases the nurses were able to provide
sedation scales are available, perceived indications are monitoring reasonable medical explanations for a deeper sedation or an otherwise
of sedation and analgesia (96% and 31% of nurses respectively) and impaired consciousness.
dosing adjustment for sedatives and analgesics (14% and 28% of
nurses respectively). DSI is infrequently used (never used: 38% of
respondents, used for <25% of patients: 47% of respondents, used for P326
25 to 75% of patients: 12% of respondents, used for >75% of patients: Comparison of the RAMSAY score and the Richmond Agitation
3% of respondents). Numerous barriers for wide implementation are Sedation Score for the measurement of sedation depth
identified, mainly lack of outcome expectancy, as DSI is perceived to R Riessen, R Pech, P Tränkle, G Blumenstock, M Haap
impair patient outcomes. It is perceived that DSI increases the risk of University Hospital Tübingen, Germany
complications such as unplanned extubation and pulling of lines and Critical Care 2012, 16(Suppl 1):P326 (doi: 10.1186/cc10933)
tubes (79% of nurses agree), impairs patients’ comfort (59% of nurses
agree), and creates traumatic memories in the intubated patients Introduction We implemented an interdisciplinary algorithm for
(36% of nurses agree). Moreover, 63% of nurses agree that they would the management of analgosedation in mechanically ventilated
prefer no DSI if they were an intubated patient. Other barriers are patients based on a new national guideline. As part of this project
related to knowledge, as 26% of nurses do not know the practice, and we investigated whether the newly introduced Richmond Agitation
to behaviour, as 53% of respondents feel DSI is difficult to implement Sedation Score (RASS) allowed a better monitoring of sedation depth
because of organizational constraints. than the formerly used RAMSAY score.
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Methods During the baseline phase of the study we investigated the References
RAMSAY score, which had been routinely used for several years in our 1. Lowenstein E, et al.: Cardiovascular response to large doses of intravenous
unit. Following an educational program the RAMSAY was replaced by morphine in man. N Engl J Med 1969, 281:1389-1393.
the RASS. During both study phases the actual sedation score was 2. Jalonen J, et al.: Dexmedetomidine as an anesthetic adjuvant in coronary
determined within a short period of time by the nurse in charge and an artery bypass grafting. Anesthesiology 1997, 86:331-345.
independent observer. In addition, the nurses were asked to evaluate
on a six-point Likert scale whether the score appeared to be suitable
to describe the actual state of sedation or to discriminate between P328
different levels of sedation (1 = very good). The measurements took Cerebral ischemia–reperfusion model in rabbits: relationship
place at three defined time points (7, 9 and 12 o’clock) during the between dexmedetomidine and biochemical parameters in
morning shift on weekdays. lowering intraparenchymal pressure
Results In the baseline phase (36 patients/422 measurements) using A Tavlan1, ME Ustun1, A Yosunkaya1, A Ak1, A Kiyici1, HK Bardakcı2, F Gok1
1
the RAMSAY score, sedation depth documented by the nurses and Selcuk University, Meram Medical Faculty, Konya, Turkey; 2Farabi Hospital,
the observer matched in only 39% of the measurements. The nurses Konya, Turkey
documented in 246 (58%) measurements a lighter sedation and in 12 Critical Care 2012, 16(Suppl 1):P328 (doi: 10.1186/cc10935)
measurements (3%) a deeper sedation than the observer. In the post-
implementation phase (37 patients/346 measurements) using the RASS, Introduction The effect of dexmedetomidine in two different doses on
we found a significantly higher matching rate of 76% between nurses the levels of endothelin-1 (ET-1) and prostoglandin I2 (PGI2) in blood
and observer compared to RAMSAY (P <0.001). Nurses documented and cerebrospinal fluid (CSF) of rabbits via the transient global cerebral
in 47 measurements a lighter (14%) and in 37 measurements (11%) a ischemia model was studied to determine its intraparenchymal
deeper sedation than the observer. The nurses evaluated the RASS in pressure (IPP) reduction mechanism.
terms of the ability to describe the actual depths of sedation with a Methods Twenty-four New Zealand type rabbits were employed and
mean of 1.7 on the six-point Likert scale significantly better than the randomly distributed into four groups. Group I (sham group, n = 6):
RAMSAY score with 3.2 (P <0.001). Similar results were found regarding craniotomy was performed only. Group II (control group, n = 6):
the discrimination between different levels of sedation (RASS 1.7, bilateral carotid arteries were clamped for 60 minutes after craniotomy,
RAMSAY 3.1, P <0.001). then reperfusion was performed for 60 minutes. In Group III (n = 6)
Conclusion In routine use the RAMSAY score showed a poor and Group IV (n = 6), 80 μkg–1 and 320 μkg–1 dexmedetomidine was
performance regarding the measurement of sedation depth. After administered within the first 10 minutes of the reperfusion procedure
implementation of the RASS, measurement of sedation depth respectively. Blood and CSF samples were collected 120 minutes after
appeared significantly improved. craniotomy. Mean arterial pressures (MAP), heart rates (HR), IPP and
temperature values were recorded.
Results There was no significant difference in MAP values between
P327 groups (P ≥0.05). A decrease of HR in Group IV was significantly lower
Dexmedetomidine is associated with better outcomes in patients after reperfusion (P <0.05). IPP values after the reperfusion in Groups II
undergoing cardiac surgery and IV were significantly higher than Group I (P <0.05), but no significant
PG Brandão1, S Lobo1, M Nassau Machado1, J Duarte1, F Lobo1, Y Sakr2 increase in Group III (P ≥0.05). ET-1 levels of both blood and CSF were
1
Hospital de Base de São José do Rio Preto, Brazil; 2Friedrich Schiller University increased in the group with performed ischemia and reperfusion
Hospital, Jena, Germany and no treatment (Group II) and the group administered high-dose
Critical Care 2012, 16(Suppl 1):P327 (doi: 10.1186/cc10934) dexmedetomidine (Group IV) (P <0.05), while the group administered
low-dose dexmedetomidine (Group III) was similar to the sham group
Introduction Cardiac anesthesia has changed over the years from high- (P ≥0.05). However, PGI2 levels of CSF were significantly decreased in
dose opioids to fast-track surgery. The use of high doses of opioids was the group administered low-dose dexmedetomidine (P <0.05).
justified based on the hemodynamic stability [1] at a cost of prolonged Conclusion Dexmedetomidine could decrease intraparenchymal
mechanical ventilation support. Our study aims to analyze the use of pressure in the transient global cerebral ischemia model when
dexmedetomidine as an anesthesia adjuvant during the induction and administered at low doses [1,2]. It probably contributed to this
maintenance of anesthesia for patients undergoing coronary artery reduction by preventing an increase of endothelin levels in blood and
bypass graft (CABG) and valvular heart surgeries. CSF as well as decreasing PGI2 levels in CSF.
Methods This study is a retrospective analysis from a prospective References
database collected from January 2003 to April 2011. The patients 1. Zornow MH, Scheller MS, Sheehan PB: Intracranial pressure effects of
were divided into two groups, based on the use of dexmedetomidine dexmedetomidine in rabbits. Anesth Analg 1992, 75:232-237.
(DEX group) intraoperatively or conventional opioid-based technique 2. Jolkkonen J, Puurunen K, Koistinaho J, et al.: Neuroprotection by the alpha
(Control group). Isoflurane was used for anesthesia maintenance in 2-adrenoceptor agonist, dexmedetomidine in rat focal cerebral ischemia.
both groups. Eur J Pharmacol 1999, 7:31-36.
Results We included 1,302 consecutive patients undergoing cardiac
surgery during the study period (63% male; median age = 57 years),
796 patients in the DEX group and 506 patients in the control group. P329
CABG was the most commonly performed surgery (63%) followed by Evaluation of sedation using pupilometry in ICUs: a pilot study
valve surgeries (37%). The overall 30-day hospital mortality rate was O Rouche, A Wolak-Thierry, Q Destoop, L Milloncourt, T Floch, P Raclot,
5.8%. Length of stay was significantly lower for patients in the Dex J Cousson
group (3.7 ± 4.4 days) than for patients in the control group (4.5 ± 6.3 Centre Hospitalier Universitaire, Reims, France
days) (P = 0.02). Thirty-day mortality rates were 3.4% in the Dex group Critical Care 2012, 16(Suppl 1):P329 (doi: 10.1186/cc10936)
and 9.7% in the control group (P <0.001). In the multivariable Cox
regression analysis with in-hospital death as the dependent variable, Introduction The depth of hypnosis is correlated with the decrease
dexmedetomidine (OR = 0.39, 95% CI: 0.23 to 0.64, P ≤0.001), a high in photomotor reflex (PMR) [1]. It would be beneficial to develop an
L-EuroSCORE (OR= 1.05, 95% CI: 1.01 to 1.10, P = 0.004) and older age automated, noninvasive, simple and reproducible technique allowing
(OR = 1.03, 95% CI: 1.01 to 1.05, P = 0.003) were independently related one to efficiently evaluate the depth of sedation in ICUs. The objective of
to in-hospital death. Need for reoperation (2.0% vs. 2.8%, P = 0.001), this observational study is to evaluate the effectiveness of pupilometric
neurologic lesion type 1 (2.0% vs. 4.7%, P = 0.005) and prolonged video in comparison to the Bispectral index (BIS).
hospitalization (3.1% vs. 7.3%, P = 0.001) were significantly less frequent Methods Sedation level was based on the Richmond Score (RASS
in the DEX group than in the control group. between –4 and –5). Exclusion criteria were neurological pathologies
Conclusion Use of dexmedetomidine as anesthesia adjuvant was asso- interfering with the PMR. Following a 320 lux flash of light, the PMR
ciated with better outcomes in patients undergoing cardiac surgery. was measured by the Neurolight (IDmed). Three measurements a day
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were taken during 48 hours along with the collection of the BIS value correlated with EEG frequency, with maximal slowing in the delta
(Bis Vista Anandic Medical Systems). The data collected included the (≤4 Hz) range.
variation of pupillary diameter (PD), latency time (LT) and maximal Conclusion Midazolam concentrations while on continuous infusion
speed of pupillary constriction (Vmax). These parameters were analyzed were associated with EEG tracings suggestive of deep sedation.
after having classified BIS values into three groups. Although clearance was relatively preserved, it varied over a wider
Results A total of 186 analyses of PMR and BIS were conducted on 31 range than found in healthy populations. The apparent lower threshold
patients. The averages and standard deviations for each class of BIS for onset of coma may be a reflection of illness severity, concomitant
were as shown in Table 1. We conducted an analysis of variance in order medication use, and variable clearance during the course of illness.
to compare these three groups of BIS. For the values Vmax and the PD, These preliminary results suggest that the combination of continuous
the ANOVA was significant. Therefore, we proceeded to compare the bedside EEG and therapeutic drug monitoring may be useful for
groups two by two using Bonferroni tests. They revealed significant titrating midazolam infusions and to guide tapering to avoid prolonged
difference between the BIS <40 and 40 ≤ BIS ≤ 60 group (P <0.0001 for coma in patients with variable clearance of midazolam.
both variables) and between BIS <40 and BIS >60 (Vmax P <0.0001 and
PD P <0.05). There was no correlation between any of the BIS groups
and the LT variable. P331
Effect of propofol and midazolan on microcirculation of septic
Table 1 (abstract P329). Values of Vmax, PD and TL shock patients
G Penna1, F Fialho2, A Japiassu3, D Salgado4, P Kurtz1, G Nobre1,
BIS <40 (n = 68) 40 ≤ BIS ≤ 60 (n = 62) BIS >60 (n = 37)
M Kalichsztein1, N Villela5, E Bouskela5
1
Vmax (mm/second) 0.98 ± 0.44 1.45 ± 0.73 1.66 ± 0.95 Casa de Saúde São José, Rio de Janeiro, Brazil; 2IFF-FIOCRUZ, Rio de Janeiro,
TL (ms) 253.8 ± 68.6 241.6 ± 41.8 240.6 ± 52.2
Brazil; 3IPEC-FIOCRUZ, Rio de Janeiro, Brazil; 4UFRJ, Rio de Janeiro, Brazil;
5
UERJ, Rio de Janeiro, Brazil
PD% 12.95 ± 5.58 18.3 ± 6.12 17.7 ± 6.72 Critical Care 2012, 16(Suppl 1):P331 (doi: 10.1186/cc10938)
Conclusion The Vmax and the PD seem to be relevant criteria when Introduction Septic shock patients are submitted to many therapeutic
compared to the BIS. This noninvasive technique of monitoring the strategies, including sedation. It is unknown if different sedative drugs
depth of sedation could be beneficial especially with patients under influence microcirculation.
myorelaxant drugs. A larger study is necessary in order to confirm these Methods We performed a prospective observational study, using
results and enable one to set cut-off values for the Vmax and PD. sidestream dark-field imaging (SDF), to evaluate sublingual mucosa
Reference of septic shock patients admitted to our ICU. SDF was applied in two
1. Leslie K, et al.: Anesthesiology 1996, 84:52-63. settings: continuous sedation with propofol and with midazolan. We
repeated each examination after an interval of 30 minutes. Eight fields
(videos) were analyzed during propofol and midazolan infusion. Two
videos were obtained from each side of the tongue. The Bispectral
P330 index was monitored along with the Richmond Agitation Sedation
Effect of critical illness on the pharmacokinetics and dose–response Scale: the dose of both sedatives was titered to maintain light sedation.
relationship of midazolam All demographic and severity of illness data were collected. Vasopressor
D Ovakim, KJ Bosma, GB Young, M Sen, LE Norton, F Priestap, RG Tirona, agents were maintained to a mean arterial pressure of 70 mmHg and
R Kim, GK Dresser the cardiac index was kept stable through the protocol study.
University of Western Ontario, London, Canada Results We included 15 patients; APACHE II score was (median) 17.5
Critical Care 2012, 16(Suppl 1):P330 (doi: 10.1186/cc10937) points and SOFA score 9 points. The Bispectral index was lower in
the midazolan group (43 vs. 48.5 points, P = 0.005), although RASS
Introduction Critically ill patients require sedation to tolerate the was the same for both groups. Large-vessel perfusion was similar for
interventions necessary to facilitate their care. There is growing both groups. The small perfusion vessel proportion was significantly
evidence, however, that use of sedatives, such as the benzodiazepine reduced with propofol (92 vs. 96.3%, P = 0.003). The microvascular
midazolam, is associated with delirium and other complications flow index was also lower during propofol infusion (MFI – 2.4 vs. 2.7,
that can lead to prolonged ICU stay and increased mortality. The P = 0.002). We observed a higher heterogeneity index when patients
pharmacokinetics of midazolam in healthy populations has been were sedated with propofol (0.4 vs. 0.19, P = 0.01).
well characterized, and pharmacodynamic studies demonstrate a Conclusion Propofol reduces small-vessel perfusion and increases the
predictable dose–response relationship. However, in critical illness, heterogeneity of circulation in the sublingual mucosa, when compared
where midazolam is often administered as a continuous infusion, with the use of midazolan in septic shock patients.
the pharmacokinetic properties are often altered. We sought to
investigate whether analysis of midazolam plasma concentrations in
combination with electroencephalography (EEG) will better define the P332
effect of critical illness on the pharmacokinetics and clinical response Current use of pain scores in Dutch ICUs: a postal survey in the
to midazolam, while providing a method to assess the adequacy of Netherlands
sedation thereby minimizing the risks associated with prolonged or M Van der Woude1, L Bormans1, J Hofhuis2, P Spronk2
1
over-sedation. Atrium Medical Center, Heerlen, the Netherlands; 2Gelre Hospitals, Apeldoorn,
Methods For this observational study, patients admitted to the ICU with the Netherlands
a diagnosis of sepsis and receiving a continuous infusion of midazolam Critical Care 2012, 16(Suppl 1):P332 (doi: 10.1186/cc10939)
were screened for inclusion. Upon enrollment, a continuous subhairline
EEG was applied and blood samples were collected daily for plasma Introduction Pain is a common problem for patients admitted to
midazolam quantification. Clinical data and laboratory parameters the ICU, causing patient discomfort, agitation and accidental self-
were followed. Plasma midazolam levels were quantified using liquid extubation. For this reason the recognition of pain and its severity
chromatography with tandem mass spectroscopy. is extremely important. Several pain scores and protocols are in use.
Results Data were available for nine patients. Midazolam clearance We aimed to elucidate current practice of pain measurements and
demonstrated wide intersubject variability (range 31 ml/minute to treatment in Dutch ICUs.
1,157 ml/minute) although average clearance among all patients Methods In March 2011, a questionnaire was sent to all Dutch adult
(418 ml/minute) was comparable to that of healthy controls. Mean ICUs irrespective of the number of ICU beds with active follow-up by
midazolam concentrations for patients with coma were significantly telephone calls to optimize the participation rate.
higher than for patients without coma (218 ± 185 ng/ml vs. Results A total of 84 ICUs (84/107) returned the survey, representing
106 ± 107 ng/ml). The plasma midazolam concentration inversely a response rate of 87%. Most ICUs are community teaching hospitals
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P336
Delirium could be an indicator of sepsis in patients under 65 years
old with urinary tract infections
U Yamada, K Yokota, D Ohta, K Furukawa
St Luke’s International Hospital, Tokyo, Japan
Critical Care 2012, 16(Suppl 1):P336 (doi: 10.1186/cc10943)
were the relative power of the delta and alpha frequency band and the Methods A prospective observational study in a university hospital
peak frequency. None of these studies addressed the optimal electrode including patients over 18 years old, in the first 48 hours of ICU
deviation or the question of how to distinguish sleep from delirium. admission, with an expected ICU stay of at least 72 hours and signed
Conclusion Given the feasibility for continuous EEG monitoring in ICU, informed consent. Pregnancy, cognitive impairment prior to admission,
EEG delirium monitoring in ICU patients seems to be promising. hepatic encephalopathy, Glasgow Coma Scale ≤9, active psychiatric
References illness, need for sedation or neuromuscular blockade, aphasia, foreign
1. Ely EW, et al.: JAMA 2004, 291:1753-1762. language, deafness and brain death were exclusion criteria. CAM-ICU
2. Girard TD, et al.: Lancet 2008, 371:126-134. was applied and doctors and nurses asked about the presence of
3. van Eijk MM, et al.: Am J Respir Crit Care Med 2011, 184:340-344. delirium. Demographic data, SOFA score, mechanical ventilation and
4. van Eijk MMJ, et al.: Crit Care Med 2009, 37:1881-1885. drugs used were determined. Patients were followed for 14 days or
5. Romano J, et al.: Arch Neurol Psychiatry 1944, 51:356-377. until discharge from the ICU. The agreement between CAM-ICU and
clinical diagnosis was assessed using Cohen’s kappa statistic (κ). Risk
factors were assessed by a multivariate regression model.
P339 Results In the 119 patients included, the incidence of delirium
Performance of SAPS 3 in predicting delirium among critically ill was 24.4% (29 patients) and time to development of delirium was
patients 68.3 ± 63.6 hours. The agreement between clinical diagnoses and CAM-
T Cosentino, J Biatto, I Souza, M Dutra, L Ilnicki, P Martins, G Schettino, ICU was better for medical residents (Table 1). Patients with delirium
F Machado had a longer ICU (10.83 ± 15.08 and 4.98 ± 9.57, P = 0.015) and hospital
Hospital Sírio-Libanês, São Paulo, Brazil (36.93 ± 31.33 and 19.10 ± 19.48, P = 0.0004) length of stay, higher ICU
Critical Care 2012, 16(Suppl 1):P339 (doi: 10.1186/cc10946) mortality (13.79% and 2.22%, OR = 7.04 (1.22 to 40.7)) and hospital
mortality (27.6% and 6.66%, OR = 5.33 (1.67 to 17.04)) than patients
Introduction Delirium is a common complication in critically ill patients, without delirium. Risk factors were: mechanical ventilation (P = 0.018,
occurring in up to 80% of patients on mechanical ventilation [1]. OR = 3.09 (1.21 to 7.86)) and APACHE II score greater than 8.5 (P = 0.011,
Recent studies showed that sicker patients at ICU admission, assessed OR = 5.35 (1.48 to 19.43)).
by severity scores, are more susceptible to developing delirium [2]. To
further evaluate this hypothesis, we undertook this study to assess the Table 1 (abstract P340). κ values
performance of SAPS 3 in predicting delirium, among adult patients
Health provider Delirium Hypoactive
admitted to a general ICU.
Methods This was a prospective observational cohort study performed Attending physicians 0.530 0.019
between June 2010 and June 2011, in a 26-bed ICU at Hospital Sírio-
Libanês, São Paulo, Brazil. All consecutive adult patients admitted to Medical residents 0.615 0.018
the ICU were included. Patients with a previous diagnosis of advanced Nurses 0.588 0.025
dementia and those with acute neurological disease (Glasgow <13)
were excluded. The evaluation of delirium was performed using the
CAM-ICU during routine bedside rounds in the morning. Discrimination Conclusion Delirium had a higher incidence in intensive care patients
and calibration of SAPS 3 in predicting delirium were assessed by the and was related to longer hospital stay and higher mortality. Specific
area under the receiver operating curve (AUR ROC) and the goodness of tests should be used for diagnosis, since the clinical suspicion has
fit (GoF) test, respectively. Secondary outcomes were hospital mortality low sensitivity, especially in cases of hypoactive delirium and among
and lengths of stay among patients with delirium. attending physicians.
Results A total of 225 patients were included. The incidence of delirium Reference
was 24%. Patients who develop delirium during the ICU stay were older 1. Ely EW, et al.: Crit Care Med 2001, 29:1370-1379.
(OR 1.04, 1.02 to 1.07) and more likely to have a previous diagnosis of
hypertension (OR 2.36, 1.24 to 4.52). The SAPS 3 (OR 1.09, 1.06 to 1.13)
score, SOFA (OR 1.23, 1.09 to 1.39) score, and mechanical ventilation P341
requirement (OR 3.6; 1.35 to 9.60) were higher among patients with Investigation into detection and treatment rates of hyperactive and
delirium. These patients had longer ICU and hospital length of stay, and hypoactive delirium in the ICU setting
a higher crude mortality rate (24.07 vs. 7.02%). In a multivariate analysis, S Kudsk-Iversen, J Wong, H Kingston, L Poole
age (OR 1.03, 1.00 to 1.05), use of mechanical ventilation (OR 3.91, 1.22 The Royal Liverpool University Hospital, Liverpool, UK
to 12.96) and SAPS 3 score (OR 1.08, 1.04 to 1.12) were independently Critical Care 2012, 16(Suppl 1):P341 (doi: 10.1186/cc10948)
associated with delirium. SAPS 3 performed well in predicting delirium
with an AUR ROC of 0.785 (0.714 to 0.856, best cut-off value ≥54 points) Introduction We aimed to investigate the link between the type of
and a GoF of 0.175. delirium (that is, hyperactive or hypoactive), its detection by the day
Conclusion We found that SAPS 3 was a good parameter for predicting staff and the subsequent treatment. The morbidity related to delirium
delirium during the ICU stay. Future studies are needed to confirm our is well known to critical care medical staff ; however, some findings
results in a larger and different patient sampling. suggest insufficient and inconsistent recognition and management
References of delirium [1]. Hypoactive delirium, despite being more common in
1. Ely EW, et al.: JAMA 2001, 286:2703-2710. the ICU setting, often goes undetected and undertreated due to its
2. Van Rompaey B, et al.: Crit Care 2009, 13:R77. withdrawn and drowsy presentation [2].
Methods A prospective cohort study over 8 weeks in a 25-bed ICU
setting. Daily CAM-ICU assessments were done by three trained
P340 doctors. It was noted whether the ICU team had assessed the individual
Incidence of delirium and inadequacy of the clinical diagnosis in patient for delirium. If the patient was delirious, the team was informed
patients in intensive care and their management was noted. Eligible patients had to have a RASS
A Okada, R Azevedo, F Freitas, A Bafi, M Jackiu, M Assunção, B Mazza, score above –4 and be able to comply with the assessment. The Fisher’s
F Machado exact test was used to calculate statistical significance of detection and
Universidade Federal de São Paulo, Brazil treatment.
Critical Care 2012, 16(Suppl 1):P340 (doi: 10.1186/cc10947) Results A total of 139 patients were included, providing a total of 507
patient-days. On 32 occasions (6%) the patient assessed was found
Introduction This study aims to assess the incidence, risk factors to be delirious. Twelve patients in ITU (19%) and nine in HDU (9%)
and impact of delirium on outcome and to analyze the concordance were delirious at least once. Of the 32 cases of delirium, 53% were
between the Confusion Assessment Method for the Intensive Care hyperactive. Seventy-six percent of the hyperactive and 27% of the
(CAM-ICU) and clinical diagnosis. hypoactive cases had been detected by the day team (P = 0.0118). Once
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Table 1 (abstract P341). Hyperactive and hypoactive cases and their a convenience sample so was not powered to detect a significant
detection rate difference. No differences in factual or delusional memories or PTSD-
related symptoms between the treatment groups were found. These
Number of Number of
data could be the basis of a sample size calculation for a larger study.
hyperactive (%) hypoactive (%)
References
Detected 13 (76) 4 (27) 1. Schelling G, et al.: Crit Care Med 1998, 26:651-659.
2. Stoll C, et al.: J Thorac Cardiovasc Surg 2000, 120:505-512.
Not detected 4 (24) 11 (73) 3. Shehabi Y, et al.: Anesthesiology 2009, 111:1074-1083.
P344 change in creatinine). Nine patients (33% of all patients, 64% of AKI
Data mining techniques for predicting acute kidney injury after patients) received RRT. ICU mortality was three out of 14 (21%) patients
elective cardiac surgery with AKI and one out of 13 (8%) patients without AKI. This difference
J Van Eyck, J Ramon, F Guiza, G Meyfroidt, M Bruynooghe, was not statistically significant. Thirteen out of 20 (65%) ventilated
G Van den Berghe patients developed AKI, compared with one out of seven (14%)
K.U. Leuven, Heverlee, Belgium nonventilated patients. This difference was statistically significant
Critical Care 2012, 16(Suppl 1):P344 (doi: 10.1186/cc10951) (P = 0.0329). Excluding fatalities, the duration of IPPV was longer in
patients with AKI (median 11 days, range 0 to 54 days) than in patients
Introduction Development of acute kidney injury (AKI) during the without AKI (median 1 day, range 0 to 20 days). This difference was
postoperative period is associated with increases in both morbidity statistically significant (P <0.05). Excluding fatalities, the length of stay
and mortality. The aim of this study is to develop a statistical model was longer in patients with AKI (median 19 days, range 10 to 68 days)
capable of predicting the occurrence of AKI in patients after elective than in patients without AKI (median 5 days, range 2 to 29 days). This
cardiac surgery. difference was statistically significant (P <0.02).
Methods A total of 810 adult (>18 years) elective cardiac surgery Conclusion We noted a higher incidence of AKI in critical illness
patients, admitted to the surgical ICU of the University Hospital associated with A/H1N1 (52%) compared to that of a larger study [1].
of Leuven between 18 January 2007 and 8 January 2009, were AKI was associated with the incidence as well as duration of mechanical
retrospectively selected for this study. Patients with an ICU stay of less ventilation and length of stay in the ICU. The use of RRT in the current
than 24 hours, as well as patients suffering from chronic kidney disease, study (60%) was much higher than in the modeling study (16%). We
were excluded. Relevant patient records were extracted from an found a trend towards greater mortality with AKI, although (unlike
electronic database system and analyzed using data mining techniques Petillä and colleagues [1]) this failed to reach significance.
[1]. The main advantage of these techniques is that they are capable of Reference
automatically selecting the variables that are relevant to a particular 1. Pettilä V, et al.: Acute kidney injury in patients with influenza A (H1N1)
problem. Using such a data mining algorithm, predictive models were 2009. Intensive Care Med 2011, 37:763-767 .
built on a development cohort of 385 patients and validated on a
separate cohort of 425 patients.
Results In this study, two separate models were developed for predicting P346
the occurrence of AKI (defined as RIFLE stage three or need for renal A RIFLE score-based trigger for renal replacement therapy and
replacement therapy) within a week after the patient’s admission. An survival after cardiac surgery
initial model was built using only readily available admission data A Schneider, G Eastwood, S Seevanayagam, G Matalanis, R Bellomo
(including demographic information, previous treatments and pre- Austin Health, Heidelberg, Australia
admission values for physiological variables). This resulted in an AUC Critical Care 2012, 16(Suppl 1):P346 (doi: 10.1186/cc10953)
of 0.6056 (95% CI, 0.4874 to 0.7239) on the validation cohort. The initial
model was then extended by adding information on administered Introduction It is controversial whether all critically ill patients with
medication, measurements of physiological parameters and laboratory RIFLE-F class acute kidney injury (AKI) should receive renal replacement
results available during the first four hours of the patient’s ICU stay. This therapy (RRT). We reviewed the outcome of open-heart surgery
new model resulted in an AUC of 0.8339 (95% CI, 0.7364 to 0.9315) on patients with severe AKI who did not receive RRT.
the validation cohort. Methods We identified all patients who developed AKI after cardiac
Conclusion In this study, we have shown that data mining techniques surgery during a 4-year period, and obtained baseline characteristics,
are a viable option for developing predictive models in a clinical intraoperative details and in-hospital outcomes. We analyzed
setting. Furthermore, we have shown that by adding information physiological and biochemical features at the time of RRT initiation or
gathered during the patient’s stay, a model’s performance can at peak creatinine if no RRT was provided.
drastically improve compared to a model using only admission data. Results We reviewed 1,504 patients. Of these, 137 (9.1%) developed
Thus, it might be possible to further improve existing scoring systems postoperative AKI with 71 meeting RIFLE-F criteria and 23 (32.4% of
such as the Thakar score [2] and the simplified renal index [3]. RIFLE-F cases) not receiving RRT. Compared with RRT-treated RIFLE-F
References patients, no-RRT patients had lower APACHE III scores, less intra-
1. Meyfroidt G, et al.: Best Pract Res Clin Anaesthesiol 2009, 23:127-143. aortic balloon pump requirements, shorter intensive care stay and a
2. Thakar C, et al.: J Am Soc Nephrol 2005, 16:162-168. trend toward lower mortality. At peak creatinine, their urinary output,
3. Duminda N, et al.: JAMA 2007, 297:1801-1809. arterial pH and PaO2/FIO2 ratio were all significantly higher. Their serum
creatinine was also higher (304 vs. 262 μmol/l, P = 0.02). Only three died
in-hospital. Detailed review of cause and mode of death was consistent
P345 with non-RRT-preventable deaths. In contrast, 27 patients with RIFLE-R
Acute kidney injury in critically ill patients with A/H1N1 or RIFLE-I class received RRT. Compared with RRT-treated RIFLE-F
pneumonitis in 2010/11 patients, they had a trend towards a more severe presentation and a
M Atkinson, A Krige, S Chukkambotla higher mortality (51.8% vs. 29.2%, P = 0.02). See Figure 1.
East Lancashire Hospitals NHS Trust, Blackburn, UK Conclusion After cardiac surgery, RRT is typically applied to patients
Critical Care 2012, 16(Suppl 1):P345 (doi: 10.1186/cc10952) with the most severe clinical presentation irrespective of creatinine
levels. A RIFLE score-based trigger for RRT is unlikely to improve patient
Introduction A/H1N1 infection is a major seasonal cause of illness survival.
requiring critical care admission. A high proportion of these patients
develop acute kidney injury (AKI) [1].
Methods We studied all A/H1N1-positive admissions to a district P347
general hospital (DGH) ICU during the months of December 2010 and Effect of off-pump versus on-pump coronary artery bypass grafting
January 2011. The study aimed to describe the incidence of AKI using in patients with chronic kidney disease
the creatinine score from the RIFLE criteria and its associations with ME Schroeder1, L Chawla1, Y Zhao2, F Lough1, F Najam1, M Seneff1,
mortality, incidence and duration of intermittent positive pressure JM Brennan3
1
ventilation (IPPV), length of stay in the ICU and provision of renal George Washington University Hospital, Washington, DC, USA; 2Duke Clinical
replacement therapy (RRT). Research Institute, Raleigh, NC, USA; 3Duke University Medical Center, Raleigh,
Results Twenty-seven patients were admitted to the ICU who tested NC, USA
positive for A/H1N1. Fourteen (52%) met the RIFLE criteria for AKI. Of Critical Care 2012, 16(Suppl 1):P347 (doi: 10.1186/cc10954)
these, three (11%) met the RIFLE criterion for Risk (>150% change in
creatinine), three (11%) met the criterion for Injury (>200% change Introduction Patients with chronic kidney disease (CKD) have been
in creatinine), and eight (30%) met the criterion for Failure (>300% largely excluded from clinical trials of off-pump coronary artery bypass
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Figure 1 (abstract P346). Flow chart. ASCTS, Australian Society of Cardio Thoracic Sugery.
grafting (OPCAB). We sought to determine if the pump status affected dopamine to protect the kidneys against hypoperfusion injury following
outcomes in patients with CKD. cardiac surgery remains controversial. Cystatin C has been described
Methods Using a nonrandomized cohort of 742,909 nonemergent, as a sensitive biomarker of early renal tubular injury. We aimed to
isolated CABG cases (including 158,561 OPCAB cases) in the Society evaluate the effect of renal-dose dopamine on renal tubular functions
of Thoracic Surgery Database from 2004 through 2009, we evaluated in patients undergoing coronary artery bypass grafting (CABG) surgery.
the association between pump status (off-pump vs. on-pump) and Methods Thirty-six patients undergoing CABG surgery were prospec-
in-hospital death or incidence of renal replacement therapy (RRT) tively randomized to receive either 2 μg/kg/minute dopamine infusion
across strata of preoperative renal function. We used both propensity (Group D, n = 19) or saline as placebo (Group P, n = 17) starting from
methods and an instrumental variable (IV) approach to account for induction of anesthesia for 48 hours. Serial blood and urine samples
imbalances in baseline patient risk. after induction of anesthesia and 2, 12, 24, 48 hours post CPB
Results Compared with on-pump cases, off-pump cases were of similar were collected to measure serum cystatin C, creatinine levels and
age (65.6 vs. 64.9 years) with a similar distribution of preoperative urinary β2-microglobulin. Intraoperative and daily measurements of
estimated glomerular filtration rate (eGFR). In a propensity weighted hemodynamic parameters and urine output were recorded.
analysis, OPCAB was associated with a reduction in composite in- Results The groups were similar in terms of physical characteristics,
hospital death or RRT, with a progressively increased benefit among perioperative hemodynamic measurements, urine outputs and surgical
those with lower preoperative renal function (eGFR ≥90 ml/minute: times. Serum cystatin C levels demonstrated similar increases during
risk difference = 0.05 per 100 patients (on-pump minus off-pump), 95% 12, 24 and 48 hours post CPB in the dopamine and placebo groups
confidence interval = –0.06 to 0.16; 60 to 89 ml/minute: 0.14, 0.05 to 0.23; (P >0.05 for all). See Table 1. No differences were detected with respect
30 to 59 ml/minute: 0.66, 0.45 to 0.87; and 15 to 29 ml/minute: 3.66, 2.14 to serum creatinine and urine β2-microglobulin levels between the
to 5.18). A similar trend was observed for both component endpoints. groups (P >0.05 for both). GFR was preserved equally in both groups on
However, while the IV analysis confirmed the protective effect of OPCAB postoperative day 2 (104.1 ± 23.1 vs. 101.4 ± 35.8 ml/minute, P >0.05).
on composite in-hospital death or RRT among patients with a reduced
eGFR, this result was driven by an effect on RRT and not mortality.
Conclusion Patients with CKD experience less death or incidence of Table 1 (abstract P348). Serum cystatin C levels (ng/ml) of the patients
RRT when treated with off-pump versus on-pump CABG; however,
Group D (n = 19) Group P (n = 17) P value
this composite effect is driven by a reduction in incidence of RRT (not
death) among low eGFR patients. Prospective trials comparing these Induction 803 ± 173 789 ± 285 0.987
procedures in patients with impaired preoperative renal function are
warranted. 2 hours CPB 857 ± 236 861 ± 347 0.664
12 hours CPB 807 ± 239 1,132 ± 396 0.052
(pNGAL and uNGAL) levels are affected by the presence of sepsis in a P354
general ICU population. These novel biomarkers are currently being Additive value to clinical judgement of blood neutrophil gelatinase-
evaluated for acute kidney injury (AKI) prediction. However, they are associated lipocalin in diagnosis of acute kidney injury and
also increased in sepsis, which can be a confounding factor regarding prediction of mortality in patients hospitalized from the emergency
their specificity for AKI [1,2]. department
Methods Ninety-six patients consecutively admitted to the ICU were L Magrini1, B De Berardinis1, R Marino1, G Gagliano1, E Ferri1, P Moscatelli2,
included in the study. Exclusion criteria were chronic renal failure, P Ballarino2, B Gliozzo3, G Carpinteri3, S Di Somma1
1
AKI prior to ICU admission, brain death, pregnancy, age <18 years S. Andrea Hospital ‘Sapienza’ University, Rome, Italy; 2S. Martino Hospital,
and predicted ICU stay less than 48 hours. Patients’ demographic Genoa, Italy; 3S. Elia Hospital, Catania, Italy
characteristics, APACHE II and SOFA score, existing comorbidities, Critical Care 2012, 16(Suppl 1):P354 (doi: 10.1186/cc10961)
primary reason for admission to intensive care, pNGAL, uNGAL, white
cell count and C-reactive protein levels were recorded on admission, Introduction Acute kidney injury (AKI) is a common and difficult to
while the RIFLE score and sepsis status were recorded until day 7 post diagnose complication among hospitalized patients with increasing
admission. The Mann–Whitney U test was used to compare pNGAL and incidence.
uNGAL levels in septic and nonseptic patients. Methods A total of 665 (357 M:308 F; mean age 74 ± 14 years)
Results Out of 96 patients included, 56 were male, 12 had AKI and 30 emergency department (ED) patients designated for hospitalization
had sepsis on admission. The mean age was 55.5 ± 19.6 years, the mean were included in a multicenter prospective study to evaluate the utility
APACHE II score was 14.8 ± 5.6 and the mean admission SOFA score was of blood neutrophil gelatinase-associated lipocalin (NGAL) assessments
6.6 ± 2.9. There were 43 medical admissions, 17 elective surgical, and 36 as an aid in the early risk evaluation for AKI. NGAL and serum creatinine
emergency surgical including trauma. (sCr) were determined at ED presentation (T0), 6, 12, 24 and 72 hours
Both pNGAL and uNGAL were higher in patients with AKI on admission after hospitalization. The clinical certainty of AKI was determined by ED
(P <0.001). Their levels were also found to be higher in septic compared physician (Ph) while blinded to NGAL results.
with nonseptic patients (septic pNGAL = 153.13 ± 144.86 vs. nonseptic Results Preliminary diagnosis of AKI by the ED Ph occurred in 218/665
pNGAL = 102.45 ± 95.65, P = 0.076; septic uNGAL = 306.66 ± 532.88 vs. patients (33%). Final adjudicated AKI clinical diagnosis was confirmed
nonseptic uNGAL = 123.41 ± 354.07, P = 0.002). When patients with in 49/665 patients (7%). The AUC for NGAL alone in the final diagnosis
AKI as well as patients who developed AKI within the first 7 days post of AKI was 0.80 (± 0.07). When NGAL was added to the ED Ph’s clinical
admission were excluded from the analysis, higher uNGAL and pNGAL judgement in a logistic model, the AUC was increased to 0.89 (± 0.06).
values in the group of septic patients were not significant at the level The AUCs for the additional endpoints are shown in Table 1. When the
of 5%. The estimated sample size for significance 5% and power 80% same model combining NGAL with the ED Ph’s clinical judgement was
is 74 for uNGAL (2,200 for pNGAL). Moreover pNGAL and uNGAL had compared to a clinical model combining T0 sCr results with the ED Ph’s
a similar area under the ROC curve (0.773 and 0.779 respectively) for clinical judgement, the net reclassification index was 32.4%, meaning
predicting AKI in septic patients. that the correction classification of AKI improved 32.4 percentage
Conclusion Both biomarkers are increased in the case of sepsis in points.
our population. Septic AKI affecting uNGAL more than pNGAL could
explain the smaller P value for uNGAL in the group of patients with Table 1 (abstract P354)
sepsis.
Event No event AUC (95% CI)
References
1. Int Care Med 2010, 36:1333-1340. Diagnosis of AKI 49 616 0.80 (0.07)
2. Am J Respir Crit Care Med 2011, 183:907-914.
RIFLE 25 640 0.72 (0.12)
sCr bump 10 655 0.85 (0.10)
P353 Oliguria 14 651 0.81 (0.14)
Urinary neutrophil gelatinase-associated lipocalin as an early Mortality 27 638 0.76 (0.11)
marker of acute kidney injury complicating circulatory shock
H Sherif, M Foda, M Shehata, A Ibrahim
Faculty of Medicine, Cairo University, Cairo, Egypt Conclusion Our study demonstrated that blood NGAL measurements
Critical Care 2012, 16(Suppl 1):P353 (doi: 10.1186/cc10960) in patients hospitalized from the ED for critical conditions may improve
the clinical diagnosis of AKI development. The routine use of NGAL in
Introduction We evaluated the novel urinary neutrophil gelatinase- the ED may provide utility in deciding the appropriate treatment and
associated lipocalin (NGAL) as an early biomarker that rapidly releases management strategies for patients at risk for AKI development.
in acute kidney injury (AKI) complicating circulatory shock.
Methods We measured the urinary NGAL level from collected urine in
45 patients with circulatory shock, during the first 6 hours and after 24 P355
hours. Eleven patients responded to fluid infusion ± vasopressors and Is cystatin C reliable in the anesthetized pig? An experimental study
were considered as a separate control group. with special reference to septic shock
Results The estimated urinary NGAL at day 1 and day 2 post circulatory M Eriksson1, E Söderberg1, M Lipcsey1, J Sjölin2, M Castegren3, M Sjöquist4,
shock could predict AKI presented at days 2 and 3 and days 3 and 4 A Larsson5
1
(P <0.05, P <0.001 and P <0.001, P <0.001) respectively. Apart from all Surgical Sciences, Anesthesia & Intensive Care, Uppsala, Sweden; 2Medical
conventional kidney parameters and biomarkers, significant inverse Sciences, Infectious Disease, Uppsala, Sweden; 3Centre for Clinical Research,
correlations could be detected only between urinary NGAL at days Eskilstuna, Sweden; 4SLU, Uppsala, Sweden; 5Medical Sciences, Clinical
1 and 2 with the corresponding urine output in the patient group Chemistry, Uppsala, Sweden
(r = –0.51 and –0.64, P <0.05 and P <0.001, respectively). The best cut- Critical Care 2012, 16(Suppl 1):P355 (doi: 10.1186/cc10962)
off value of urinary NGAL at day 1 was 26 ng/ml, for which sensitivity
was 62% and 69% and specificity was 75% and 80% for prediction of Introduction Our aim was to investigate renal function during 24 hours
AKI presented at days 2 and 3, respectively. While the best cut-off at day of endotoxemic shock with special focus on the reliability of analysis
2 was 29 ng/ml, for which sensitivity was 70% and 74% and specificity options in kidney damage.
was 90% and 80% for prediction of AKI presented at days 3 and 4, Methods Twenty anesthetized pigs received randomly a continuous
respectively. Urinary NGAL at day 2 could significantly predict mortality 24-hour endotoxin infusion at 0.063 μg/kg/hour (n = 8) or 0.25 μg/kg/
complicating AKI rather than at day 1 (P <0.05). hour (n = 9) or NaCl (controls n = 3). Boluses (10 ml/kg) of succinylated
Conclusion Urinary NGAL seems to be a potential early and sensitive gelatin were given when the arterial blood pressure was 50 mmHg or
biomarker for AKI and a persistently increased level at day 2 can predict below. Samples for analysis of cystatin C as well as clearances of inulin,
mortality following circulatory shock. PAH and creatinine were noted and urine was collected.
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to reach steady state. However, given the simplicity of the method Methods The Critical Care Minimum Dataset records of patients
we hypothesise that changes in iohexol concentration may provide admitted to our mixed general ICU were investigated. Those patients
valuable real-time information about the GFR in AKI. Changes are likely who received renal organ support were investigated further. The
to occur before serum creatinine rises. In conclusion, the continuous change in serum creatinine levels in the 48 hours prior to institution of
iohexol infusion method of measuring GFR appears to be accurate and RRT was used to determine the AKIN score. Patients in whom there was
precise. In stable subjects, a steady plasma concentration is achieved not a significant rise in creatinine, but who received RRT, were staged
before it is observed with creatinine changes. zero. Unfortunately, urine output data were not available to improve
accuracy.
Results There were a total of 276 patients whose records were
P359 adequate for this audit. Several records were incomplete and not used.
Investigation into the effects of commencing haemodialysis in the Demography and APACHE II scores were similar across all groups.
critically ill Length of stay and days of RRT were similar across the groups. ICU
R Docking1, L Moss1, M Sim1, D Sleeman2, J Kinsella1 survival was as follows: AKIN stage: (0) 42.2%, (1) 50.6%, (2) 51.7%, (3)
1
University of Glasgow, UK; 2University of Aberdeen, UK 70.4%. Pearson chi-square P <0.001.
Critical Care 2012, 16(Suppl 1):P359 (doi: 10.1186/cc10966) Conclusion We were not able to demonstrate improved survival when
RRT was initiated at an earlier AKIN stage. A small nonsignificant trend
Introduction We aimed to describe haemodynamic changes when was observed with increasing stage and the differences between
haemodialysis is instituted in the critically ill. Three hypotheses are groups were significant. Very early initiation of RRT was associated with
tested: (1) the initial session is associated with cardiovascular instability; increased mortality. Stage (3) included patients with chronic kidney
(2) the initial session is associated with more cardiovascular instability disease, which probably skewed the results in this group. We cannot
compared to subsequent sessions; and (3) looking at unstable sessions recommend the use of the AKIN score as a pointer to when to initiate
alone, there will be a greater proportion of potentially harmful changes RRT, based on these data.
in the initial sessions compared to subsequent ones. References
Methods Data were collected for 209 patients, identifying 1,605 1. Uchino S, et al.: Intensive Care Med 2007, 33:1563-1570.
dialysis sessions. Analysis was performed on hourly records, classifying 2. Bagshaw SM, et al.: J Crit Care 2009, 24:129-140.
sessions as stable/unstable by a cut-off >±20% change in baseline 3. Mehta RL, et al.: Crit Care 2007, 11:R31.
physiology (HR/MAP). Data from 3 hours prior to and 4 hours after
dialysis were included, and average and minimum values derived. Three
time comparisons were made (pre-HD:during, during HD:post, pre- P361
HD:post). Initial sessions were analysed separately from subsequent Timing for initiation of continuous renal replacement therapy in
sessions to derive two groups. If a session was identified as being patients with septic shock and acute kidney injury
unstable, then the nature of instability was examined by recording HP Shum, KC Chan, MC Kwan, WT Yeung, WS Cheung, WW Yan
whether changes crossed defined physiological ranges. The changes Pamela Youde Nethersole Eastern Hospital, Hong Kong
seen in unstable sessions could be described as to their effects: being Critical Care 2012, 16(Suppl 1):P361 (doi: 10.1186/cc10968)
harmful/potentially harmful, or beneficial/potentially beneficial.
Results Discarding incomplete data, 181 initial and 1,382 subsequent Introduction The optimal timing for initiation of renal replacement
sessions were analysed. A session was deemed to be stable if there was therapy (RRT) in septic acute kidney injury (AKI) remains controversial.
no significant change (>±20%) in the time-averaged or minimum MAP/ The aim of this study is to investigate the impact of early versus late
HR across time comparisons. By this definition 85/181 initial sessions initiation of continuous RRT (CRRT), as defined using the simplified
were unstable (47%, 95% CI SEM 39.8 to 54.2). Therefore Hypothesis 1 RIFLE classification, on organ dysfunction among patients with septic
is accepted. This compares to 44% of subsequent sessions (95% CI 41.1 shock and AKI.
to 46.3). Comparing these proportions and their respective CI gives a Methods Patients were divided into early (sRIFLE Risk) or late (sRIFLE
95% CI for the standard error of the difference of –4% to 10%. Therefore Injury or Failure) initiation of RRT. Patients with chronic kidney disease
Hypothesis 2 is rejected. In initial sessions there were 92/1,020 harmful stage 5 or on dialysis were excluded.
changes. This gives a proportion of 9.0% (95% CI SEM 7.4 to 10.9). In Results One hundred and twenty patients admitted within a 3.5-year
the subsequent sessions there were 712/7,248 harmful changes. This period fulfilled inclusion criteria. Thirty-one (26%) underwent early, 89
gives a proportion of 9.8% (95% CI SEM 9.1 to 10.5). Comparing the two (74%) had late CRRT. No significant difference was noted between the
unpaired proportions gives a difference of –0.08% with a 95% CI of the two groups with respect to change in total SOFA score/non-renal SOFA
SE of the difference of –2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact score in the first 24/48 hours after initiation of CRRT, vasopressor use,
test gives a result of P = 0.68, reinforcing the lack of significant variance. dialysis requirement and mortality (at 28 days, 3 months and 6 months).
Conclusion Our results reject the claims that using haemodialysis is an The change of nonrenal SOFA score 48 hours after CRRT correlated with
inherently unstable choice of therapy. Although proportionally more of the SOFA score at the start of CRRT (P = 0.034) and the APACHE IV risk of
the initial sessions are classed as unstable, the majority of MAP and HR death (P = 0.000), but not the glomerular filtration rate (GFR) at the start
changes are beneficial in nature. of CRRT (P = 0.348). See Tables 1 and 2.
Conclusion For septic shock with AKI, no significant difference in organ is to evaluate the relationship between timing of RRT and 28-day
function and outcome was noted when the timing of initiation of CRRT mortality in patients with severe sepsis and septic shock.
was classified using sRIFLE criteria. Subsequent improvement of organ Methods All patients diagnosed with severe sepsis and septic shock
function correlated with initial SOFA and APACHE scores instead of and treated at the medical ICU in a university-affiliated, tertiary-referral
the GFR (which determine sRIFLE class) on starting of CRRT. The use of center, from January 2005 to December 2006 were reviewed. Timing of
more global assessment tools, such as the SOFA score, for stratification RRT was stratified into early and late by RIFLE (Risk, Injury, Failure, Loss,
purposes on appropriate timing of CRRT warrants further investigation. and End-stage) criteria and blood urea nitrogen (BUN) at the time RRT
was started. The primary outcome was 28-day death from any cause.
P362 Results Of the 326 patients diagnosed with severe sepsis and septic
Early application of CVVH In the complex treatment of patients with shock and admitted to the medical ICU during the study period, 78
early severe acute pancreatitis patients received RRT. The mean age of the patients was 61.5 ± 14.7 years
I Aleksandrova, M Ilynsky, S Rei, G Berdnikov, L Marchenkova, V Kiselev and 54 patients were male (69.2%). The timing of RRT was categorized
Hospital Research Institute for Emergency Medicine N.V. Sklifosovsky, Moscow, into early (Risk, and Injury) and late (Failure) by RIFLE criteria and also
Russia categorized into early (BUN <75 mg/dl) and late (BUN ≥75 mg/dl).
Critical Care 2012, 16(Suppl 1):P362 (doi: 10.1186/cc10969) Comparing the relationship between RIFLE criteria (Risk and Injury vs.
Failure) and 28-day mortality showed no significant difference (70.8%
Introduction A large population-based study of 1,024 deaths from acute vs. 73.3%, P = 0.81). The timing of RRT by serum BUN also showed no
pancreatitis (AP) has revealed that the median time lapse between the significant difference in 28-day mortality before start of RRT by BUN
onset of AP and death was 6 days [1]. A number of authors considered ≥75 mg/dl versus BUN <75 mg/dl (77.3% vs. 69.6%, P = 0.50).
the patients with persistent or progressive early multiple organ failure Conclusion Timing of RRT, stratified into early and late by RIFLE and
(MOF) as patients with early severe acute pancreatitis (ESAP) [2]. BUN, showed no significant difference in 28-day mortality in patients
Methods The aim of current study was to evaluate the efficiency of with severe sepsis and septic shock.
early CVVH in a complex treatment of ESAP. The retrospective analysis
involved 106 patients. The patients were divided into three groups: the P364
first group (n = 45) received CVVH dose <30 ml/kg/hour, the second Amino acid concentrations in serum, urine and dialysate/ultrafiltrate
group (n = 20) received the dose >30 ml/kg/hour, and in the third solutions of continuous venovenous hemodiafiltration patients
group (n = 41) CVVH was not used during the early phase of disease JM Lee, YJ Lee, J Hong
(Table 1). In the first and second groups the median time interval Ajou University School of Medicine, Suwon, Kyeonggi-do, South Korea
between admission and start of CVVH was 2 (2; 3) days. Critical Care 2012, 16(Suppl 1):P364 (doi: 10.1186/cc10971)
Table 1 (abstract P362) Introduction A prospective study was performed for evaluating the
amino acid losses during continuous venovenous hemodiafiltration
Variable First group Second group Third group
(CVVHDF).
Age 42 ± 15 39 ± 13 47 ± 16 Methods Serum, 24-hour urine and dialysate/ultrafiltrate solutions of
BMI 31 ± 5 29 ± 4 29 ± 5
CVVHDF were obtained on days 1, 3, and 5 from 11 critically ill patients
(five males, six females, mean age 63.0 ± 18.1 (24 to 90)) in the surgical
APACHE II score 17 (5) 17 (9) 15 (7) ICU. We analyzed 40 kinds of amino acid concentrations in serum
SOFA score 5 (4) 5 (3) 5 (3) (34 samples), urine (15 samples) and dialysate/ultrafiltrate solutions
Ranson score 8 (6) 8 (7) 10 (9) (30 samples) by high-performance liquid chromatography analysis.
The mean dialysate amount was 918.2 ml (600 to 1,500 ml), mean
Early mortality (%) 27 10* 42 replacement fluid amount 1,136.4 ml (1,000 to 2,000 ml) and mean
Infection (%) 47 35 29 blood flow rate 175 ml (100 to 200 ml), respectively. Nutritional support
Overall mortality (%) 49 25* 51 for CVVHDF patients was guided as protein intake at 1.2 to 1.5 g/kg/
day, caloric intake at 30 kcal/kg/day.
Data presented as median (IQR). *P <0.05, second group versus third group. Results Among the analyzed 40 amino acids, the five highest mean
concentration levels of 24-hour dialysate/ultrafiltrate solutions were
Results As compared to reference group 3, significant (P = 0.022) glutamine (65,178.3 μmol/l (hereafter, all units for amino acids are
reduction of early mortality (14 days) was observed in the second group, μmol/l)), alanine (48,633.3), glycine (33,959.5), proline (27,701.5), lysine
and decreasing tendency (P = 0.093) of mortality rate was detected in (26,519.4); of serum were glutamine (694.4), alanine (438.1), glycine
the first group. The median time interval between admission and death (349.7), lysine (275.7), proline (262.4); and of 24-hour urine were glycine
was 14 days (in the first and second groups) and 5 days in the third (1,523.0), histidine (957.5), alanine (920.7), glutamine (904.6), lysine
group. (699.1), respectively. Amino acid concentrations of 24-hour dialysate/
Conclusion The early application of the CVVH increases time interval ultrafiltrate solutions showed significant correlation with amino acid
for care delivery and allows reducing early mortality. The best results concentrations of serum (P = 0.000). The mean amount of total amino
were obtained in the group of patients who were treated with the acid loss on day 5 of CVVHDF was 2.8 times that of day 1 and 1.7 times
higher dose of CVVH (earlier restoration of homeostasis and decreased that of day 3. The increase of amino acid loss according to CVVHDF
severity of early MOF). progression was most prominent in glutamic acid (8.9 times from day
References 1 to day 5).
1. Mole DJ, et al.: HPB 2009, 11:166-170. Conclusion The highest concentration level of 24-hour dialysate/
2. Isenmann R, et al.: Pancreas 2001, 22:274-278. ultrafiltrate solution was glutamine. The amount of amino acid loss
after CVVHDF was correlated with the serum amino acid amount and
increased according to CVVHDF progression.
P363
Timing of the initiation of continuous renal replacement therapy P365
and clinical outcome in patients with severe sepsis and septic shock Evaluation of the potential adverse effects associated with calcium
S Cho carbonate precipitate during continuous venovenous hemofiltration
Seoul Asan Hospital, Seoul, South Korea J McKee, B Brooks, J Daller, J Gass, D Pantaleone, P Zieske
Critical Care 2012, 16(Suppl 1):P363 (doi: 10.1186/cc10970) Baxter, Round Lake, IL, USA
Critical Care 2012, 16(Suppl 1):P365 (doi: 10.1186/cc10972)
Introduction Timing of renal replacement therapy (RRT) in critically
ill severe sepsis and septic shock patients with acute kidney injury is Introduction This study evaluated the potential adverse effects
highly subjective and may influence outcome. The aim of this study associated with exposure to calcium carbonate precipitate during
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continuous venovenous hemofiltration (CVVH). The clinical use of (P = NS), BE –2.8 ± 2.1 versus –1.6 ± 1.2 (P <0.01), serum phosphate
Accusol 35 Solution (Accusol 35) has been associated with occasional 0.85 ± 0.2 versus 1.3 ± 0.5 mmol/l (P = 0.027), serum K+ 4 ± 0.2 versus
formation of calcium carbonate precipitate in the tubing set during 4.2 ± 0.3 mmol/l (P = NS) with KCl infusion 4 ± 0.2 versus 1.4 ± 1.5 mmol/
therapy. hour (P <0.0001). Protocol A required NaHCO3 and Na-phosphate
Methods Fourteen mongrel dogs were anesthetized, instrumented, infusion (8.9 ± 2.8 mmol/hour and 5g/day, respectively) while protocol
and received CVVH with the test (n = 6) or negative control article (n = 8) B allowed one to stop both supplementations. Systemic and circuit Ca2+
for 6 hours. The test article was Accusol 35 with induced precipitate were easily maintained in the target range with both protocols.
formation prior to CVVH. The test article contained visible particles Conclusion Although needing confirmation in an adequate number of
and subvisible particles 36× higher than the maximum concentration patients, protocol B was able to provide a buffer balance more positive
specified in the European Pharmacopoeia (EP). The negative control than protocol A and allowed one to adequately control the A–B status
article was Accusol 35 containing no visible particles and subvisible without additional NaHCO3 infusion and in the absence of alkalosis,
particles within EP specification. One-half of the dogs in the negative despite the use of a standard HCO3– concentration HF solution.
control article group received a central venous injection of Sephadex Furthermore, the combination of a phosphate-containing replacement
G-50 beads (10 mg/kg) following CVVH as a positive control. Select fluid appeared effective to prevent hypophosphatemia. Finally, the use
cardiovascular (CV) parameters were monitored continuously or were of a mathematical model allowed predicting the effects of different
calculated at predetermined times. Arterial samples were obtained replacement solutions and/or RCA-CVVH settings on the mass balance
at predetermined times for analysis of blood gases and electrolytes. of the main solutes.
Samples of the test and negative control articles were obtained hourly
during CVVH for determination of pH and subvisible particles. Dogs
were euthanized and lung tissue samples were examined histologically.
Results All CV parameters remained stable and no differences were
observed between the test and negative control articles. Sephadex P367
beads caused an increase (P <0.01) in mean pulmonary arterial Regional citrate anticoagulation with a low-concentration solution
pressure due solely to a similar increase (P <0.01) in pulmonary vascular in predilution–postdilution CVVH
resistance. No differences in blood gases or electrolytes were observed V Pistolesi, S Morabito, L Tritapepe, L Cibelli, M Ambrosino, F Polistena,
between the test and negative control articles. Sephadex beads caused L Zeppilli, E Strampelli, MI Sacco, A Pierucci
a decrease (P >0.05) in arterial blood PO2 and an increase (P >0.05) in Policlinico Umberto I, Rome, Italy
arterial blood PCO2. No differences in lung histology were observed Critical Care 2012, 16(Suppl 1):P367 (doi: 10.1186/cc10974)
between the test and negative control articles. The lungs from all dogs
given Sephadex beads contained multiple intravascular particles in Introduction Systemic anticoagulation (AC) can increase the bleeding
large-caliber blood vessels. risk in CRRT. However, regional citrate anticoagulation (RCA) is a valid
Conclusion CVVH performed on anesthetized dogs for 6 hours using alternative to heparin (Hep) in patients at high risk of bleeding. The
Accusol 35 containing visible and subvisible particles 36× higher than aim was to evaluate efficacy and safety of RCA-CVVH using a low-
the maximum concentration specified in the EP resulted in no adverse concentration citrate (Citr) solution.
effects on CV parameters, blood gases and electrolytes, and lung Methods In cardiac surgery patients with AKI we adopted RCA-CVVH
histology as compared with Accusol 35 containing no visible particles as an alternative to Hep or no-AC CRRT. Criteria for switching to RCA:
and subvisible particles that were within EP specification. early circuit clotting (24 hours) or Hep-related complications. RCA-
CVVH was performed with a predilution Citr solution (12 mmol/l) and
a postdilution hemofiltration solution (HCO3– 32 mEq/l). In relation to
P366 blood flow rate (Qb), the Citr solution rate was set to meet a circuit
Regional citrate anticoagulation in CVVH: a new protocol combining Citr concentration of 3 mmol/l and modified to obtain circuit Ca2+
citrate solution with a phosphate-containing replacement fluid <0.4 mmol/l. CaCl2 (10%) was infused to maintain systemic Ca2+ (s-Ca2+)
S Morabito1, V Pistolesi1, L Tritapepe1, E Vitaliano2, E Strampelli1, of 1.1 to 1.25 mmol/l. To facilitate CVVH settings, we developed a
F Polistena1, L Zeppilli1, A Pierucci1 mathematical model to estimate the metabolic Citr load, buffer balance
1
Policlinico Umberto I, Rome, Italy; 2Pertini H, Rome, Italy and Ca2+ loss.
Critical Care 2012, 16(Suppl 1):P366 (doi: 10.1186/cc10973) Results In 30 patients at high bleeding risk (age 70.5 ± 9.3, SOFA
score 13.7 ± 2.5) the AC modality was switched to RCA-CVVH from no
Introduction Regional citrate anticoagulation (RCA) is a highly effective AC or Hep. CVVH initial settings: dialysis dose 33.6 ± 3.4 ml/kg/hour;
anticoagulation (AC) method in CRRT and different combinations of Qb 135 ± 14 ml/minute; Q Citr 1,703 ± 250 ml/hour; Q postdilution
citrate (Citr) and CRRT solutions can affect the acid–base (A–B) balance. 761 ± 181 ml/hour; Citr load 11.6 ± 2.1 mmol/hour; CaCl2 3.7 ± 1.5 ml/
Regardless of the AC protocol, hypophosphatemia occurs frequently in hour. Target circuit Ca2+ and s-Ca2+ were maintained (0.37 ± 0.09 and
CRRT (80%). The aim was to evaluate safety and effects on A–B balance 1.18 ± 0.13 mmol/l) with few modifications of Citr and CaCl2 infusion
of a new RCA-CVVH protocol using 18 mmol/l Citr solution combined rates. We used 146 RCA-CVVH circuits with filter life 50.5 ± 35.8 hours
with a phosphate-containing hemofiltration (HF) solution. (median 41; total 7,372). RCA-stopping causes: 34% CVC malfunction,
Methods In our center, RCA-CVVH is routinely performed with 24% alarm handling/technical issues, 20% scheduled, 14% medical
a 12 mmol/l predilution Citr solution (Prismocitrate 10/2) and a procedures, 8% others. Before starting RCA, we used 69 Hep circuits
postdilution HF solution (HCO3– 32, Ca2+ 1.75, Mg2+ 0.5, K+ 2 mmol/l) (2,015 hours) and 74 no-AC circuits (1,827 hours) with a filter life of
(protocol A). In the case of persistent acidosis, not related to Citr 29.2 ± 20.7 hours (median 22) and 24.7 ± 20.6 hours (median 20), shorter
accumulation, NaHCO3 infusion is started. In order to optimize the than RCA (P <0.0001). Circuits running at 24, 48 and 72 hours (%): RCA
buffer balance, a new protocol has been designed throughout a 73, 42 and 28; Hep 43, 23 and 10; and no-AC 38, 12 and 5 (log-rank test
mathematical model developed to estimate Citr and HCO3– mass P <0.0001). During RCA-CVVH no patients had bleeding complications
transfer. Recently introduced solutions have been adopted: 18 mmol/l and the transfusion rate was lower if compared to other AC modalities
predilution Citr solution (Prismocitrate 18), postdilution HF solution (0.29 vs. 0.69 blood units/day, P = 0.001). PLT count (P = 0.018) and
(Phoxilium, HCO3– 30, phosphate 1.2, Ca2+ 1.25, Mg2+ 0.6, K+ 4 mmol/l) AT-III activity (P = 0.009) increased throughout days of RCA, reducing
(protocol B). In relation to Qb, the Citr solution rate was set to meet supplementation needs. RCA has been stopped for Citr accumulation
the target circuit Citr concentration (3 mmol/l). To maintain systemic in one patient (calcemia/s-Ca2+ >2.5).
Ca2+ (1.1 to 1.25 mmol/l), CaCl2 10% was started according to estimated Conclusion In this experience, RCA allowed one to safely prolong the
Ca2+ loss. filter life, decreasing the transfusion rate and supplementation needs
Results In a cardiac surgery patient with AKI, A–B status and electrolytes for AT-III and PLT. The use of a mathematical model allowed one to
have been evaluated comparing protocol A (five circuits, 301 hours) simplify the CVVH settings. Therefore, RCA should be worthy of more
versus protocol B (two circuits, 97 hours): pH 7.39 ± 0.03 versus consideration as the first-choice CRRT AC modality in patients at high
7.44 ± 0.03 (P <0.0001), blood HCO3– 22.3 ± 1.8 versus 22.6 ± 1.4 mmol/l risk of bleeding.
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P368 P369
Exposure to intermittent hemodialysis and renal recovery after Sustained low-efficiency dialysis for renal replacement therapy in
acute kidney injury: a systematic review the ICU: a cost–benefit analysis of the years 2006 to 2010
A Schneider1, M Bagshaw2, NJ Glassford1, R Bellomo1 T Neuenfeldt, HB Hopf
1
Austin Health, Heidelberg, Australia; 2University of Alberta, Edmonton, Asklepios Klinik, Langen, Germany
Canada Critical Care 2012, 16(Suppl 1):P369 (doi: 10.1186/cc10976)
Critical Care 2012, 16(Suppl 1):P368 (doi: 10.1186/cc10975)
Introduction Sustained low-efficiency dialysis (SLED) as primary renal
Introduction Renal replacement therapy (RRT) in critically ill patients can replacement therapy in acute renal failure is still not widely used
be applied in a continuous (CRRT) or intermittent (IRRT) fashion. To date, compared to continuous venovenous hemodiafiltration (CVVHDF),
there is no systematic comparison on the impact of these two modalities despite possible economical advantages. Based on one key paper [1]
on renal recovery after an episode of acute kidney injury (AKI). We sought we use SLED as primary renal replacement therapy. However, since
to compare the rates of renal recovery with RRT independence between medical and economical data with SLED are scarce, we evaluated costs
CRRT and IRRT as an initial modality for RRT in AKI. and outcome in a 5-year retrospective study on our ICU.
Methods We searched MEDLINE and EMBASE. We retrieved all studies Methods During 2006 to 2010 we performed a search on our KIS
published between 2000 and 2010 that report original data on renal selecting all patients with the diagnoses N17 and N18 who were
recovery to RRT dependence after AKI in adults. Authors of studies treated with SLED or CVVHDF on our ICU. We excluded all patients with
with incomplete data were contacted. Search date: January 2011. Two a stay <2 days or with an extrarenal indication for dialysis or with pre-
authors independently assessed the trial quality and extracted data. existing chronic dialysis. The following variables were extracted from
Pooled analyses were performed and a chi-square test performed. the chart: number of SLED, stay in ICU and hospital, mortality in ICU and
Sensitivity analyses were performed after stratification by premorbid hospital, SAPS II, TISS 28, blood urea and creatinine, C-reactive protein,
chronic kidney disease, number of centers, type of study and illness mechanical ventilation, and diagnoses. We evaluated the long-term
severity index. In a subsequent analysis we pooled the studies according outcome by sending all discharged patients a questionnaire.
to the percentage of patients exposed to IHD into low-exposure (<50% Results During the period from 2006 to 2010, 3,247 SLED treatments
of patients exposed) or high-exposure (>50% patients exposed). in 421 patients (mean SAPS II was 52 patients) were performed. ICU
Results We identified 50 studies (14,796 patients). Overall, as compared mortality was 36% and hospital mortality was 46%. A persistent need
with those that received IRRT as an initial modality (IRRT group), those for dialysis (end-stage kidney disease) was registered in 9%. Total costs
that received CRRT (CRRT group) had higher average illness severity for SLED were €518.431 and total reimbursements amount to €734.996
scores (mean APACHE III equivalent 88 vs. 72, P <0.01) and higher in- (Figure 1). Assuming for cost comparisons also 3,247 CVVHDF-days,
hospital mortality (57.7% vs. 37.9%, P <0.0001). When reported at 28 we estimated costs of €722.734 with reimbursements of €690.876 for
days after initiation of RRT (outcome reported in 25 studies), 19.4% of CVVHDF.
survivors were RRT dependent in the CRRT group versus 26.9% in the Conclusion Thus, since short-term and long-term outcome of our
IRRT group (P = 0.004). At hospital discharge (reported in 26 studies), patients was comparable to published outcome data with CVVHDF,
RRT dependence was present in 10.9% of the CRRT group versus 20.8% SLED is at least comparable to CVVHDF even in a busy ICU environment.
in the IRRT group (P <0.0001). At day 90 (reported in 22 studies), RRT Moreover, in view of costs, SLED is the preferable dialysis form for renal
dependence was 7.8% in the CRRT group versus 36.1% in the IRRT replacement therapy also in the ICU.
group (P <0.0001). The sensitivity analyses confirmed these findings in Reference
all subgroups. The rates of RRT dependency in the low-exposure group 1. Vinsonneau C, et al.: Lancet 2006, 368:379-385.
and the high-exposure group at days 28, 90 and hospital discharge were
19.6%, 8.8% and 12.4% versus 43.2%, 26.8% and 14.0% respectively (all
P <0.0001, except for hospital discharge P = NS). P370
Conclusion The preponderance of the available evidence suggests that The new dialysis method Mini-SLED is useful for dialyzing acute
CRRT is associated with a higher rate of renal recovery in AKI survivors brain stroke patients
compared with IRRT. F Taki, Y Komatsu
St Luke’s International Hospital, Tokyo, Japan
Critical Care 2012, 16(Suppl 1):P370 (doi: 10.1186/cc10977)
tissue osmolarity. For low clearance dialysis, CRRT, PD or low Qb HD of 7,464/8,268 (90.3%, 95% CI SEM 89.6 to 90.9). Therefore Hypothesis
were used but there are some complications. To dialyze these patients 2 is rejected.
more safely and simply, we modified a new dialysis method, Mini-SLED Conclusion The results above are encouraging, especially given the
(sustained low-efficiency dialysis). stringent definitions of instability used. By making multiple time-period
Methods We conducted a retrospective observational study from June comparisons the validity of the claims of haemodynamic stability are
2006 to October 2011. Maintenance HD patients who onset acute enforced, compared to previous papers. The number of sessions and
brain stroke, including hemorrhage and ischemic infarction, were measurement points combine to add weight to our findings, supported
observed. We divided patients into four groups by dialysis modality by robust confidence interval data.
and compared the clinical parameters. Determination of Mini-SLED was
Qb 200 ml/minute, QD 100 to 200 ml/minute, duration for 2 to 3 hours.
Results Sixty-one patients were observed in this study. Mean age 72.5 P372
years, 39 patients were male, 45 patients had diabetes. Major clinical Evaluation of microcirculation before and during continuous renal
parameters and outcomes are presented in Table 1. Patients treated replacement therapy and the impact of dose prescription
with Mini-SLED have lower risk of rebleeding compared to low Qb HD C Pipili1, CS Vrettou2, S Poulaki3, A Papastylianou3, M Parisi3, ES Tripodaki3,
or CRRT, and were more cost-effective than PD. Delivered Kt/V of Mini- S Ioannidou3, S Kokkoris3, E Douka3, S Nanas2
1
SLED was 0.72 ± 0.23. Modality difference did not affect mortality. Aretaieion University Hospital, Athens, Greece; 2National and Kapodistrian
University of Athens, Greece; 3Evaggelismos Hospital, Athens, Greece
Table 1 (abstract P370). Dialysis methods and clinical parameter Critical Care 2012, 16(Suppl 1):P372 (doi: 10.1186/cc10979)
CRRT PD Low Qb HD Mini-SLED
Introduction Microcirculation (MC) might provide evidence for the
(n = 25) (n = 3) (n = 21) (n = 12)
solute exchange taking place during the dialysis process. Near-infrared
NIHSS (score) 30.8 ± 17.2 34.6 ± 16.4 31.7 ± 20.8 32 ± 19.8 spectroscopy (NIRS) with combination of vascular occlusion technique
(VOT) allows evaluation of peripheral tissue oxygen utilization and
Rebleed (n, %) 6, 24% 1, 33% 4, 19.0% 0, 0% restoration mainly depending on integrity and functionality of
Mortality (n, %) 5, 20% 1, 33% 5, 23.8% 2, 16% vascular endothelium. Our purpose was to evaluate the acute effect of
continuous renal replacement therapy (CRRT) on the MC as assessed
Kt/V (daily) 0.68 ± 0.32 0.25 ± 0.16 0.86 ± 0.23 0.72 ± 0.23 by NIRS and VOT and to explore the impact of delivered CRRT dose on
Cost ($/1 treat) 498 ± 30.2 92.4 ± 22.6 82.5 ± 12.5 86.7 ± 14.3 MC alterations.
Methods A total of 43 critically patients who underwent CRRT were
eligible to participate in the study. The mean age of our population was
Conclusion Our Mini-SLED methods are effective and safe for dialyzing 66 ± 17 years and 40% were females. The APACHE II score was 20 ± 6,
acute brain stroke patients. the mean serum creatinine before the CRRT initiation was 2.6 ± 1.6
mg/dl and the mean CRRT delivered dose was 23 ± 6 ml/kg/hour. The
median value of dose was used to form groups of high (>22.5 ml/kg/
P371 hour) and low (≤22.5ml/kg/hour) delivered dose. NIRS parameters
Investigation into haemodynamic stability during intermittent were evaluated before CRRT initiation (H0), at 6 hours (H6) and at
haemodialysis in the critically ill 24 hours (H24) during the CRRT process. Tissue oxygen saturation
R Docking1, L Moss1, M Sim1, D Sleeman2, J Kinsella1 (StO2, %), defined as the percentage of hemoglobin saturation in the
1
University of Glasgow, UK; 2University of Aberdeen, UK microvasculature compartments, was measured with a probe placed
Critical Care 2012, 16(Suppl 1):P371 (doi: 10.1186/cc10978) on the thenar muscle. A 3-minute brachial VOT was applied to evaluate
the oxygen consumption rate (OCR, %/minute), the recovery slope (RS,
Introduction Studies that have reported cardiovascular (CVS) instability %/minute), and the hyperemia recovery area as the area (units/minute)
with haemodialysis (HD) are outdated and small. By analysing sessions under the StO2% curve above baseline values.
in detail it will be possible to identify the frequency and nature of Results Two-way repeated-measures ANOVA were performed for
CVS instability. Hypothesis 1: haemodialysis is associated with CVS StO2, OCR, RS and hyperemia recovery area at H0, H6 and H24. StO2
instability in the majority of sessions. Hypothesis 2: the majority of CVS correlated with RIFLE on admission and at the time of CRRT initiation
changes in unstable sessions will be harmful/potentially harmful. (r = 0.283, P = 0.03 and r = 0.45, P <0.0001 respectively). There was a
Methods Data were collected for 209 patients, identifying 1,605 significant decrease in OCR with time (hours on CRRT process) (within-
dialysis sessions. Analysis was performed on hourly records, classifying subjects ANOVA F = 4.83, P = 0.014) and especially between H0 and H24
sessions as stable/unstable by a cut-off >±20% change in baseline (–10.5 ± 9.4 vs. –12 ± 8.3, P = 0.008). Furthermore, a significant increase
physiology (HR/MAP). Data from 3 hours prior to and 4 hours after in RS was found in patients who received a high CRRT dose (between-
dialysis were included, and average and minimum values derived. subjects ANOVA F = 4.5, P <0.05), especially at H6 post CRRT initiation
Three time comparisons were made: pre-HD:during, during HD:post, (76 ± 117 vs. 86 ± 128, P = 0.05).
pre-HD:post-HD. If a session was identified as being unstable, then Conclusion Critically ill patients, receiving a dialysis dose higher than
the nature of instability was examined by recording whether changes 22.5 ml/kg/hour, showed improved MC. Further studies are needed to
crossed defined physiological ranges. The changes seen in unstable investigate the role of NIRS technology as a tool to assess the need for
sessions could be described as to their effects: being harmful/ CRRT initiation in acute renal failure.
potentially harmful, or beneficial/potentially beneficial.
Results Discarding incomplete data, 1,563 sessions were analysed. A
session was deemed to be stable if there was no change >±20% in P373
time-averaged or minimum MAP/HR across three time comparisons. Ultrafiltration during continuous hemofiltration in stabilized
In 1,563 sessions there was stability in 874 sessions (55.8%, 95% ICU patients is not associated with microcirculatory perfusion
CI for SEM 53.2 to 58.4). Hypothesis 1 is rejected. Each session had derangements
12 potential comparisons of MAP, HR and time, therefore in the B Scheenstra, G Veenstra, M Koopmans, WP Kingma, H Buter,
689 unstable sessions there were 8,268 potential changes ±20% HM Hemmelder, EC Boerma
(689×12). There were 804/8,268 harmful/potentially harmful changes, Medical Centre Leeuwrden, the Netherlands
922/8,268 beneficial/potentially beneficial changes and 6,542/8,268 Critical Care 2012, 16(Suppl 1):P373 (doi: 10.1186/cc10980)
opportunities for change where none occurred. Therefore, looking at
harmful/potentially harmful changes there were 804/8,268 (9.7%, 95% Introduction Ultrafiltration during intermittent haemodialysis has
CI for SEM 9.1 to 10.4). Looking at potentially beneficial changes this been associated with reduction in microcirculatory perfusion, as
occurred in 922/8,268 (11.2%, 95% CI for SEM 10.5 to 11.9), and if these observed with sidestream dark-field (SDF) imaging [1]. This technique
were combined with the nonsignificant changes this gave a proportion has also been useful in the evaluation of volume status in critically
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ill patients [2]. To date no data are available on the influence of with 25 to 30% hematocrit; correction of the blood coagulation system;
ultrafiltration during continuous venovenous hemofiltration (CVVH) on detoxication with the application of active methods of homeostasis
microcirculatory perfusion. correction; prevention and elimination of purulent and septic
Methods In this single-centre, prospective, observational study complications; primary surgical debridement and excision of necrotic
patients with acute renal failure on CVVH were included after mass areas carried out with general anesthesia, no excision conducted;
hemodynamic stabilization and written informed consent A fixed and transport immobilization before evacuation.
dose of net ultrafiltration was calculated for each patient, aiming at a Results Among all victims, hemodynamics stabilization was noted in
negative total fluid balance of 50 ml/hour. Microcirculatory perfusion 28 ± 6 hours, and dieresis increased up to 1,200 ± 100 ml/day in 18 ± 8
was observed with sublingual SDF imaging after 1 hour of zero balance hours. Acute renal failure cases were not noted. All victims in stable
CVVH (T1) and additionally after 1 hour of negative fluid balance condition were evacuated to specialized hospitals by helicopter. No
ultrafiltration (T2). The primary outcome was a change in microvascular mortality rate during medical aid rendering was noted.
flow index (MFI) between T1 and T2. Data are presented as median Conclusion MPPA application allows one to reduce the rate of compli-
(IQR). Differences are calculated with a nonparametric test for paired cations and mortality. MPPA application is the method of extra-
data. corporeal homeostasis correction option for victims with CS in a FH in
Results Eleven patients were eligible for the study; one denied emergencies.
informed consent. One patient could not be evaluated due to the
unavailability of the research team and in two patients we were unable P375
to obtain images of proper quality. The median APACHE II score was Degree of impaired kidney function at hospital discharge has
26 (21 to 29); at baseline LOS ICU was 5 (3 to 6) days and fluid balance a major impact on long-term survival of critically ill patients
+7.9 (5.1 to 14.2) l. Hemodynamic and microcirculatory variables are recovered from renal failure
depicted in Table 1. S Stads, G Fortrie, J Van Bommel, R Zietse, M Betjes
Erasmus MC, Rotterdam, the Netherlands
Table 1 (abstract P373). (Micro)circulatory variables during ultrafiltration Critical Care 2012, 16(Suppl 1):P375 (doi: 10.1186/cc10982)
T1 T2 P value
Introduction Renal replacement therapy (RRT) in critically ill patients
RR mean 71 (65 to 94) 66 (63 to 95) 0.87 with acute kidney injury (AKI) is associated with high mortality.
However, little is known about the prognosis of renal function after ICU
Heart rate 97 (78 to 126) 94 (75 to 123) 0.03 discharge and the effect of persisting impaired kidney function on long-
MFI 2.9 (2.7 to 3) 3 (3 to 3] 0.34 term survival. The objective of this study was to evaluate the overall
long-term mortality in a cohort of ICU patients with AKI necessitating
TVD 20 (18 to 22) 21 (17 to 23) 0.5 RRT. We hypothesized that both patient characteristics and the degree
of renal insufficiency at hospital discharge will influence long-term
Conclusion A negative net fluid balance of 50 ml/hour during ultra- mortality.
filtration in CVVH is not associated with microcirculatory perfusion Methods A retrospective cohort study was performed including all
alterations. patients older than 18 years admitted to the ICU of a tertiary-care center
References between 1994 and 2010, who underwent continuous RRT during their
1. Bemelmans et al.: Nephrol Dial Transplant 2009, 24:3487-3492. ICU stay (n = 1,220).
2. Pottecher et al.: Intensive Care Med 2010, 36:1867-1874. Results In-hospital mortality was 54.9%. After hospital discharge,
the overall mortality was 75.3% after a median follow-up of 8.5 years
(range 1 to 17 years). Univariate analysis showed that age, surgical or
P374 nonsurgical reason for ICU admission and kidney function at discharge
Plasmapheresis without apparatus in complex care of victims with were associated with overall survival. Multivariate Cox regression
crush syndrome during the first hours after extrication in a field analysis of the association of kidney function at hospital discharge with
hospital of EMERCOM of Russia in emergency areas patient survival was performed, adjusting for age, sex and surgical or
A Popov1, I Yakirevich1, A Skorobulatov1, V Shabanov2 nonsurgical admission type. The eGFR at hospital discharge remained
1
EMERCOM of Russia, Zhukovsky, Moscow Region, Russia; 2All-Russian Centre independently associated with long-term survival (P <0.001). Only 87
of Disaster Medicine, Moscow, Russia (15.8%) patients were discharged with an eGFR >90 ml/minute (using
Critical Care 2012, 16(Suppl 1):P374 (doi: 10.1186/cc10981) the MDRD formula). In this group 5-year and 10-year survival were
respectively 77.6% and 66.7%. The mortality risk increased for every
Introduction This is the generalization of the experience of increase in stage of chronic kidney disease (hazard ratio 1.25, P <0.001).
membranous plasmapheresis without apparatus (MPPA) application Patients discharged with an eGFR <30 ml/minute (CKD 4 to 5, 37.3% of
in the complex care of victims with crush syndrome (CS) in the field patients at hospital discharge) had a 5-year and 10-year survival of only
hospital (FH) of EMERCOM of Russia during elimination of medical 42.5% and 28.5%.
consequences of earthquakes (Pakistan, 2005; China, 2008; Haiti, 2010). Conclusion ICU patients with AKI who received CRRT have a high
Methods Thirty-eight victims with CS (19 males, 19 females, age 34.5 ± 4) mortality risk. This is more outspoken for patients who experience
were in the resuscitation department of the FH. Compound fractures incomplete recovery of renal function at hospital discharge. Impaired
of tubular bones and crushed tissues necrosis were observed. Joint kidney function at discharge has a major negative impact on their long-
movement was severely restricted and artery pulsation was uncertain. term survival. These results stress the importance of preserving kidney
Condition severity: according to the Glasgow Coma Scale 12 ± 1, function in ICU patients and the need for long-term nephrological
according to APACHE II score 29 ± 4. The tendency to hypotension and follow-up. Future research will have to identify possible determinants
tachycardia, increase of body temperature and dyspnea intensification in the period following hospital discharge that can be used to prolong
were observed, diurnal diuresis decreased. Plasmapheresis treatment survival in these patients.
was carried out by the MPPA method. A total of 2 ± 1 procedures
were conducted to each patient with the removal of 70 ± 10% of the P376
plasma circulation volume per session. Removed plasma volume was Long-term survival for ICU patients with acute kidney injury
calculated for each victim individually on the basis of average volume D Scott1, F Cismondi2, J Lee1, T Mandelbaum3, LA Celi1, RG Mark1, D Talmor2
1
before plasma exchange. The procedure frequency was once per day. MIT, Cambridge, MA, USA; 2Beth Israel Deaconess Medical Center, Boston, MA,
Substitution means: crystalloids, hydroxyethylized starch, proteins. The USA; 3Sheba Medical Center, Tel Hashomer, Israel
MPPA procedure time was from 60 to 120 minutes. MPPA was carried Critical Care 2012, 16(Suppl 1):P376 (doi: 10.1186/cc10983)
out in all victims during complex care for CS: elimination of painful
impact and stressful situation; restoration of acid–alkaline conditions Introduction A recently published study [1] validated the criteria
and water–electrolytic balance of blood, maintenance of hemodilution used in the Acute Kidney Injury Network (AKIN) definitions [2] of the
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three stages of acute kidney injury (AKI) using in-hospital mortality. immunoglobulins (κ-FLC) (23 kDa) and albumin (68 kDa) clearances
In the present study, we validate the clinical applicability of the AKIN were measured at 15 minutes, 1 hour, 4 hours, 12 hours, 24 hours and
classifications through long-term survival analysis of AKI patients. 48 hours. β2-M and κ-FLC were chosen as a middle molecular weight
Methods From over 17,000 adult ICU patients in the MIMIC II database marker. A linear mixed-effects model compared clearances between
[3,4] (V2.5), we excluded patients having end-stage renal disease and groups.
those with insufficient data and determined AKI stages for each patient. Results Twenty-four patients were included, 12 in the SHF-HD
Multivariate Cox regression was used to determine hazard ratios (HRs) group (32 sessions) and 12 in CVVH (30 sessions). κ-FLC and albumin
for 2-year survival, controlling for: age, sex, nonrenal Sequential Organ clearances were higher in the SHF-HD group over time. No difference
Failure Assessment (SOFA) score and selected co-morbidities. was observed for creatinine (P = 0.18) and β2-M (P = 0.98) clearances.
Results Among the final cohort of 14,525 patients, 43% had no AKI and Plasma albumin levels and the amount of albumin infused did not
39%, 14% and 4% developed AKI 1, 2 and 3 respectively. The results of differ between groups. See Figure 1.
the regression analysis show that AKI 1 (HR 1.12, P <0.05), AKI 2 (HR 1.10, Conclusion The removal of middle molecular weight molecules is
P = 0.05) and AKI 3 (HR 1.64, P <0.001) were significantly associated with higher with SHF-HD. Albumin loss was limited in both groups, even with
increased 2-year mortality. In addition, age (HR 1.04, P <0.001), gender SHF-HD. Therefore, SHF membranes seem to represent an alternative to
(M) (HR 0.93, P <0.05), nonrenal SOFA score (HR 1.05, P <0.001) and all high cut-off membranes for blood purification therapies.
co-morbidities were significant predictors. Adjusted and unadjusted
Kaplan–Meier curves for patients with AKI 3 are remarkably different
from each other, suggesting that in these most severely ill patients AKI P378
is only one aspect of their illness. Efficacy of continuous haemodiafiltration using a
Conclusion AKI stages 1, 2 and 3 are significant indicators of 2-year polymethylmethacrylate membrane haemofilter in the treatment of
mortality. The difference between AKI 1 and 2 is smaller than that sepsis and acute respiratory distress syndrome
between AKI 2 and 3 and it may be prudent to re-examine the criteria M Sakai
used to define AKI to provide better separation among the three Shintakeo Hospital, Takeo, Japan
classes. Critical Care 2012, 16(Suppl 1):P378 (doi: 10.1186/cc10985)
References
1. Mandelbaum T, et al.:, Crit Care Med 2011, 39:2659-2664. Introduction CHDF using a polymethylmethacrylate membrane is
2. Mehta RL, et al.: Crit Care 2007, 11:R31. currently widely applied for nonrenal indications in Japan; this tech-
3. Saeed M, et al.: Crit Care Med 2011, 39:952-960. nique is used in the treatment not only of patients with sepsis but also
4. MIMIC II databases [http://physionet.org/mimic2] of those with cytokine-induced critical illness such as acute respiratory
distress syndrome (ARDS) and pancreatitis. This study aimed to
investigate the clinical efficacy of continuous haemodiafiltration using
P377 a polymethylmethacrylate membrane haemofilter (PMMA-CHDF) in
Super high-flux continuous hemodialysis: an efficient compromise the treatment of patients with sepsis and ARDS.
for blood purification in sepsis Methods Thirty-five patients diagnosed with sepsis (ARDS (n = 10),
T Rimmelé, M Page, C Ber, F Christin, J Baillon, J Crozon, C Chapuis-Cellier, pyelonephritis (n = 5), cholangitis (n = 5), tsutsugami in Scrub typhus
R Ecochard, B Allaouchiche disease (n = 1), mamushi snake bite (n = 1), haemophagocytic syn-
Edouard Herriot Hospital, Hospices Civils de Lyon, France drome (n = 1), antineutrophil cytoplasmic antibody lung disease
Critical Care 2012, 16(Suppl 1):P377 (doi: 10.1186/cc10984) (n = 1), beriberi heart disease (n = 1) and unknown causes (n = 8)) were
enrolled in this study between August 2010 and November 2011.The
Introduction High cut-off membranes are proposed for blood purifi- common cause for ARDS in older patients was aspiration pneumonia.
cation therapy in septic shock. However, albumin loss related to these Our study group comprised 15 men and 20 women, aged 35 to 85 years
membranes is a major drawback limiting their clinical acceptance. (median age 68 years).
Super High-Flux membranes with an optimized cut-off may combine Results Before initiating treatment with the PMMA-CHDF, the
enhanced middle molecule clearances (inflammatory mediators) average APACHE score of these patients was 17.5 ± 3.6, whereas
with limited albumin loss. The aim of our study was to compare small, the average Sepsis-related Organ Failure Assessment score was
middle molecule clearances and albumin loss between continuous 6.5 ± 1.3. The duration of PMMA-CHDF treatment was 5.2 ± 2.3 days.
hemodialysis using a Super High-Flux membrane (SHF-HD) and Following initiation of PMMA-CHDF treatment, early improvement of
conventional continuous hemofiltration (CVVH). haemodynamics was observed, along with an increase in the urine
Methods After approval by the ethics committee, patients were enrolled output. The average survival rates of patients were 75.6%. The lowest
in a single-blind RCT. Patients with septic shock and acute kidney injury survival rate among diseases (35%) belonged to the unknown group.
received either SHF-HD (EMiC2® filter; Fresenius Medical Care) (cut- The highest survival rate for patients with ARDS was 95%. Moreover,
off = 40 kDa, dialysate flow rate of 40 ml/kg/hour) or conventional the urine output significantly increased in the survival group.
CVVH (cut-off = 30 kDa, UF flow rate of 40 ml/kg/hour). Each patient Conclusion The present study suggests that cytokine-oriented critical
received a maximum of three sessions of 48 hours each. Creatinine care using PMMA-CHDF might be effective in the treatment of sepsis
(113 Da), β2-microglobulin (β2-M) (11.8 kDa), kappa free light chain of and ARDS, particularly in the treatment of ARDS associated with
aspiration pneumonia in older patients.
P379
Possible adsorption mechanism of high mobility group box 1
protein on a polyacrylonitrile (AN69ST) membrane filter
O Nishida1, M Yumoto1, K Moriyama1, Y Shimomura1, T Miyasho2,
S Yamada3
1
Fujita Health University School of Medicine, Toyoake, Japan; 2Rakuno Gakuen
University, Ebetsu, Japan; 3Shino-Test Corporation, Sagamihara, Japan
Critical Care 2012, 16(Suppl 1):P379 (doi: 10.1186/cc10986)
P381
Polymyxin B-immobilized fiber column hemoperfusion has the
ability of endotoxin removal during 24 hours
C Mitaka, Y Ueda, Y Miyawaki, M Yamauchi, T Toyofuku, G Haraguchi,
T Kudo
Tokyo Medical and Dental University, Tokyo, Japan
Critical Care 2012, 16(Suppl 1):P381 (doi: 10.1186/cc10988)
P382 P383
Polymyxin B-direct hemoperfusion therapy could contribute to Clinical impact of enhanced cytokine clearance with sustained high-
hemodynamics and outcomes in emergency surgical patients efficiency daily diafiltration using a mediator-adsorbing membrane
M Yokota, T Goto, T Harada, M Takeda, R Moroi, M Namiki, A Yaguchi (SHEDD-fA) in patients with severe sepsis
Tokyo Women’s Medical University, Tokyo, Japan O Nishida1, T Nakamura1, N Kuriyama1, K Moriyama1, T Miyasho2,
Critical Care 2012, 16(Suppl 1):P382 (doi: 10.1186/cc10989) S Yamada3
1
Fujita Health University School of Medicine, Toyoake, Japan; 2Rakuno Gakuen
Introduction Polymyxin B-direct hemoperfusion (PMX-DHP) University, Ebetsu, Japan; 3Shino-Test Corporation, Sagamihara, Japan
(Toraymyxin®; Toray Medical Co., Tokyo, Japan) has been approved to Critical Care 2012, 16(Suppl 1):P383 (doi: 10.1186/cc10990)
treat patients with endotoxemia and/or severe sepsis due to Gram-
negative infection since 1994 in Japan. However, its efficacy and Introduction SHEDD-fA is an effective modality that makes the best
indication are still controversial. Recently, randomized controlled use of three principles in the treatment of severe sepsis: diffusion,
studies were performed in other countries. Our hypothesis is that convection and adsorption. We reported the efficacy of SHEDD-fA for
PMX-DHP may be useful for emergency-operated patients to eliminate the treatment of severe sepsis at the 31st ISICEM 2011 [1]. Here we
endotoxins from the systemic circulation after removal of the source present the blood clearance (CL) of seven important cytokines with
of infection. SHEDD-fA.
Methods From July 1994 to May 2011, all adult patients treated with Methods Ten critically ill patients were studied who were on SHEDD-
PMX-DHP in our ICU were included in this retrospective observational fA, at QB = 150 ml/minute, QF = 1,500 ml/hour (post dilution) and
study. Patients’ clinical and microbiological data were collected QD = 300 to 500 ml/minute as a nonrenal indication. In order to
from medical archives. The emergency postoperation patients and maximize cytokine adsorption efficiency, we used a large-size (2.1 m2)
the medical patients were compared for severity, mortality, and PMMA dialyzer. Blood samples were taken to measure the CL of plasma
hemodynamic status. Values are expressed as mean ± SD. Data were cytokines (HMGB-1, IL-6, IL-8, IL-10, G-CSF, MCP-1 and MIP-1) at 1 hour
analyzed by Mann–Whitney U test, chi-square test and Fisher’s exact and 3 hours after initiation (in one cytokine by 62 to 107 samples).
probability test. P <0.05 was considered statistically significant. Results The median values of CL with interquartile ranges of each
Results One hundred and sixty-six patients (98 men, 68 women; age cytokine (molecular weight: kDa) were: HMGB1 (30 kDa), 53.1 ml/
range 24 to 92 years (mean 64.7 ± 13.3)) were studied. The mortality rate minute (2.1 to 12.5); IL-6 (21 kDa), 39.9 ml/minute (12.4 to 70.6); IL-8
was 34.9% at 28 days after PMX-DHP. There were 129 (77.7%) emergency (8 kDa), 64.1 ml/minute (–0.5 to 82.0); IL-10 ml/minute (35 to 40 kDa),
surgical patients and 37 (22.3%) medical patients. The APACHE II score 45.6 ml/minute (0.5 to 88.3); G-CSF (19 kDa), 33.2 ml/minute (9.3 to
on the day of PMX-DHP was not significantly different between surgical 60.8); MCP-1 (8.7 kDa), 68.5 ml/minute (–14.4 to 125.4); and MIP-1 (7.8
and medical patients (20.3 ± 7.0 vs. 19.2 ± 8.1, P = 0.417). Mean arterial kDa), 66.5 ml/minute (18.6 to 100.0). In particular, CL of HMGB1 was
pressure (MAP) significantly improved in emergency surgical patients positively correlated with pre-SHEDD-fA blood levels, indicating the
before and after PMX-DHP therapy (73.7 ± 24.8 vs. 79.7 ± 26.0 mmHg, mechanism of HMGB1 removal was through adsorption. As a result of
P = 0.017), while MAP was not statistically different in medical patients enhancing the intensity of the dosage, CL (53 ml/minute) of HMGB1
(69.7 ± 24.2 vs. 76.7 ± 27.1 mmHg, P = 0.178). The inotropic score had was higher than that (25 ml/minute) of an in vitro experiment that we
no statistical difference between before and after PMX-DHP in both reported at the 31st ISICEM 2011. See Figure 1.
surgical and medical patients (13.2 ± 19.8 vs. 12.6 ± 19.2, P = 0.61; Conclusion Taking into account the fact that the creatinine CL of native
16.8 ± 27.3 vs. 13.8 ± 23.6, P = 0.65, respectively). The mortality rates at kidney function is 100 ml/minute, our findings suggest that SHEDD-fA
28 days, 90 days, 0.5 year and 1 year after PMX-DHP were significantly is a feasible adjusted modality for the treatment of patients with severe
different between surgical and medical patients (28.7 vs. 56.8, 43.8 vs. sepsis, with or without acute kidney injury. Considering our other
83.3, 52.2 vs. 85.7, 54.5 vs. 91.2%, P <0.0001, respectively). laboratory findings, deep filtration may enhance blood clearance.
Conclusion MAP increased in surgical patients but did not change Reference
in medical patients after PMX-DHP, and the inotropic score was not 1. Nishida O, et al.: Contrib Nephrol 2011, 173:172-181.
significantly different in both sets of patients. The mortality was
significantly lower in surgical patients than in medical patients.
Figure 1 (abstract P383). Correlation between clearance and blood level of cytokines.
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P385 Introduction The aim of this study was to investigate and compare
Mainz Emergency Evaluation Scoring in combination with Ranson criteria (RC) and RC + serum CRP levels as a feasible, practical
capnometry predicts outcome in trauma patients and precise method in acute pancreatitis (AP) cases admitted to the ICU
EH Hajdinjak1, ŠG Grmec2, MK Križmarić3, ET Torkar2, DB Buić-Rerečić2, in respect of length of stay (LOS) predicting severity of disease.
MZ Zelinka2, MŠ Škufca2 Methods This study was based on determination of RC scores in AP
1
Center for Emergency Medicine, University of Ljubljana, University of cases in a retrospective manner. On the other hand, this study included
Maribor, Maribor, Slovenia; 2Community Health Centre Ljubljana, University only the patients’ zero-time RC scores, not the 48-hour scores, for
of Ljubljana, University of Maribor, Ljubljana, Slovenia; 3Faculty of Medicine, the sake of more practical precision. Serum CRP levels were found to
University of Maribor, Slovenia have prognostic importance in AP, significantly more than 150 mg/l
Critical Care 2012, 16(Suppl 1):P385 (doi: 10.1186/cc10992) in necrotizing AP, at 50 mg/l in this study. Therefore, patients’ were
evaluated for RC and RC + CRP scores for comparison. However, RC had
Introduction This prospective study assessed the efficacy of the been etiologically modified for presence of gall bladder stones (GBS);
predicting power for mortality of two different prehospital scoring only the cases without GBS were included in order to prevent bias of
results. In addition, necrotizing cases were assumed to increase CRP and readmissions were excluded. Demographic characteristics, co-
levels more than predicted and were also excluded. After the exclusion morbidities and parameters included in severity scores (APACHE II,
of cases, 89 patients’ data were collected and compared for LOS in the SAPS II, SOFA) were studied. A Cox proportional hazard regression
ICU between 2005 and 2009. model was used to assess the effect of each variable on patient survival.
Results Statistical analysis of patients’ data for significance and receiver Results A total of 122 patients diagnosed with AP were admitted to our
operating curve (ROC) analysis to predict LOS, therefore pointing to ICU between January 2000 and December 2009 (68.9% men, mean age:
disease severity, was executed. All of the statistical comparisons were 60.5 ± 14 years); 43.4% were smokers and 41.8% alcohol consumers.
found significant for predicting LOS; RC (P <0.05), RC + CRP together The most frequent comorbidity was hypertension (41.8%), followed
(P <0.01) and CRP alone (P <0.04). Severity of the disease and therefore by dyslipemia (24.6%), cardiac disease (17.2%), DM and pulmonary
LOS were increased for RC score >3 and CRP levels >50 mg/l. ROC pathology (13.1%). Solid or hematologic malignancy (10.6%),
analysis resulted in RC (AUC 0.895), RC + CRP (AUC 0.901) and CRP (AUC chronic renal failure (9%) and hepatic pathology (5.7%) were other
0.823) for LOS. comorbidities. Biliary etiology was the most frequent (48.5%), followed
Conclusion AP cases usually require ICU care and treatment. There are by alcoholic AP (20.5%) and unknown etiology (17.2%); 3.3% were post-
some consented scoring systems such as RC, APACHE II and Glasgow biliary manipulation (surgery or ERCP) AP. The mean APACHE II score at
in predicting disease severity and guiding the physician’s approach. admission was 16.42 ± 7.64. In total, 56.6% patients needed mechanical
Although the most sensitive and specific method seemed to be ventilation, 50.8% vasopressors and 40.2% renal support during their
APACHE II scoring, it is time consuming and complex. On the other ICU stay. The ICU length of stay (LOS) was 16.55 ± 21.6, hospital LOS
hand, RC and Glasgow scorings need to be evaluated in 48 hours. In 45.39 ± 45.42 days. A total of 28.7% patients died in the ICU, and
the end, in the hardworking hours on the ICU, we need a more practical 38.5% during their hospital stay. We did not find any relation between
method of provision. In this study, we have found no priority of RC, RC comorbidities or AP etiology and outcome. Mortality predictors in
+ CRP and CRP alone in predicting AP outcome, excluding GBS disease AP patients were: PaFi relation (–0.007, P = 0.006), mean and systolic
and necrotizing cases. We conclude that, practically, ICU physicians arterial pressure (–0.39, P = 0.019 and –0.038, P = 0.001 respectively),
could substantially depend on CRP levels alone in the evaluation and pH (–5.641, P = 0.001), HCO3 (–0.081, P = 0.050), creatinine (0.347,
approach in these specific cases of AP. P <0.001), urea (0.008, P = 0.002), 24-hour diuresis (–0.001, P = 0.002)
and Glasgow Coma Scale (–0.312, P = 0.050).
Conclusion Comorbidities and AP etiology are not predictors of ICU
P387 mortality. Of the variables included in severity scores, only those
Number of failed organs and response to therapy determine related to organ dysfunction (hemodynamic – SAP, MAP, pH, HCO3–;
outcome in patients with acute pancreatitis requiring level 1 organ respiratory –PaFi relation; and renal – Cr, urea and 24-hour diuresis) are
support ICU mortality predictors in AP patients.
G Morris-Stiff, A Baker, A Breen, A Smith
Leeds Teaching Hospitals, Leeds, UK
Critical Care 2012, 16(Suppl 1):P387 (doi: 10.1186/cc10994) P389
System biology prediction model based on clinical data: highly
Introduction The aim of the study was to establish if the number of accurate outcome prediction in patients with acute-on-chronic liver
organs failing at admission to the ICU and the response to support had failure
a bearing on outcome in patients with severe acute pancreatitis (SAP). MJ McPhail, DL Shawcross, RD Abeles, T Chang, GL Lee, MA Abdulla,
Methods Only SAP patients requiring organ support were included C Willars, E Sizer, G Auzinger, W Bernal, JA Wendon
in the analysis. Gallstones (55%) and alcohol were the commonest King’s College Hospital, London, UK
aetiologies. The proportion of patients with one, two or three system Critical Care 2012, 16(Suppl 1):P389 (doi: 10.1186/cc10996)
failures at baseline, 24, 48, and 72 hours were calculated and related
to outcome. Introduction Present outcome prediction tools for patients with acute-
Results A total of 123 patients (85 male and 38 female) with a mean age on-chronic liver failure during critical illness are only of moderate
of 58 years met the study criteria. The numbers of patients presenting accuracy. Regression methods on latent variables (usually applied to
with one, two and three organ failures were 29, 70 and 24 respectively, top-down system biology applications with spectroscopic data) may
of which the mortality was six (21%), 29 (41%) and 14 (48%). Subsequent offer significant advantages over logistic regression techniques as
figures were 24, 57 and 39 with mortalities of four (17%), 19 (33%), and multiple cross-correlations are acceptable in this form of modelling.
24 (62%) at 24 hours; 21, 53 and 43 with mortalities of two (10%), 18 Methods Between 1 January 2000 and 31 December 2010 all patients
(34%), and 26 (60%) at 48 hours; and 17, 49 and 45 with mortalities of admitted to the Liver Intensive Therapy Unit (LITU) at King’s College
zero (0%), 16 (33%), and 28 (62%) at 72 hours. Hospital had daily prospective collection of demographic, biochemistry
Conclusion These data allow prognostication of patients with SAP and bedside physiology. Logistic regression modelling (LRM) and
requiring organ support. At 72 hours, the prognosis of patients with partial least-squares discriminant analysis (PLSDA), Model for End-
single organ failure is excellent and that of patients with three-organ stage Liver Disease (MELD) and APACHE II scores were compared using
failure remains poor. receiver operating characteristic (ROC) curve analysis.
Results A total of 986 patients (median age 52 (range 16 to 90) years;
603 (62%) male) with cirrhosis and emergency LITU admission were
P388 identified. The median APACHE II score was 21 (5 to 50) and the median
Mortality predictors in acute pancreatitis admitted to the ICU MELD score 23 (3 to 50). Overall LITU survival was 63% and survival to
P Vidal-Cortés1, P Lameiro-Flores1, A Aller-Fernández2, M Mourelo-Fariña2, hospital discharge 51%. Predictive accuracy at day 3 was improved
R Gómez-López1, P Fernández-Ugidos1, M Alves-Pérez1, in all models over admission values. The AUROC for LITU survival for
E Rodríguez-García1 MELD and APACHE scores on day 3 was 0.78 (95% CI 0.75 to 0.82,
1
CHU Ourense, Spain; 2CHU A Coruña, Spain sensitivity 72%, specificity 75%) and 0.83 (0.78 to 0.83, sensitivity 83%,
Critical Care 2012, 16(Suppl 1):P388 (doi: 10.1186/cc10995) specificity 63%) respectively. A LRM utilising nine variables had an
AUROC of 0.85 (95% CI 0.82 to 0.87, sensitivity 72%, specificity 83%).
Introduction Patients diagnosed with acute pancreatitis (AP) are Two-component PLSDA identified 30 variables with independent
usually admitted to our units. Despite using a lot of scores, none has prognostic significance. Performance in outcome prediction was
proved an acceptable yield to identify patients with higher mortality improved over logistic regression at day 3 – sensitivity 86%, specificity
risk. Our purpose is to identify mortality predictors of patients admitted 81%, AUROC 0.91 (0.89 to 0.93, P <0.001 for all comparisons) in a model
to our ICU diagnosed with AP. incorporating 30 variables. Cross-validation and permutation analysis
Methods We performed a retrospective study in which we analyzed confirmed the internal validity of this method.
patients diagnosed with AP admitted to a 24-bed ICU between January Conclusion This application of latent variable regression modelling
2000 and December 2009. Postcardiopulmonary bypass pancreatitis techniques to intensive care datasets demonstrates high accuracy of
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prediction. Liver-specific outcome schema based on logistic regression deranged LFTs (P <0.001) and clotting studies (P <0.001). ALD patients
may not fully describe the complex cross-correlating interactions that also had longer ITU stays (P <0.001) and higher mortality rates (45.45%
PLS techniques are designed to incorporate. Further validation in other ALD vs. 13.2% NALD). Receiver-operated curve analysis revealed that
centres and disease groups is warranted. current biochemical markers (ALT, PT, GGT, albumin) are not sensitive
and specific enough in detecting ALD. The prothrombin time yielded
the best area under the curve with 80.4% in ALD versus 71.7% in NALD.
P390 None of the markers was discriminatory for determining the type of
Prognostic relevance of arterial ammonia levels in different acute liver damage.
and acute-on-chronic liver diseases Conclusion Our results suggest that currently used markers of liver
V Fuhrmann, A Drolz, B Jaeger, M Wewalka, R Saxa, T Horvatits, disease are neither sensitive nor specific enough in patients with failure
T Perkmann, C Zauner, P Ferenci secondary to ALD. Research is needed to develop novel biomarkers to
Medical University Vienna, Austria better prognosticate outcome. Aetiology of acute-on-chronic liver
Critical Care 2012, 16(Suppl 1):P390 (doi: 10.1186/cc10997) failure plays a major role in determining outcome, and subgroups
of liver patients should be analysed individually. Studies [2,3] have
Introduction Increased levels of arterial ammonia in patients with shown that various markers are released depending on the type of
acute liver failure (ALF) are associated with increased mortality. There damage and differ in acute liver damage of different origin. Better
is a lack of data for prognostic impact of arterial ammonia in patients understanding of their role could prove useful in these patients.
with acute-on-chronic liver failure (AoCLF) and hypoxic hepatitis (HH). References
We evaluated arterial ammonia levels and their prognostic relevance 1. Thomson SJ, et al.: Alcohol Alcohol 2008, 43:416-422.
in patients with HH, ALF, AoCLF and without evidence for any liver 2. Antoine DJ, et al.: Keratin-18 and HMGB1 as predictive biomarkers for
disease. mode of cell death and clinical prognosis during acetaminophen
Methods One-hundred and ninety-seven critically ill patients were hepatotoxicity in man. J Hepatol 2012. [Epub ahead of print]
studied at the Medical University Vienna: 72 patients with HH, 22 with 3. Zhou RR, et al.: BMC Gastroenterol 2011, 11:21.
ALF, 58 with AoCLF and 45 critically patients without evidence for liver
disease. Arterial ammonia concentrations were assessed on a daily
basis in all patients and compared among the four study groups as well
as between 28-day survivors and nonsurvivors. P392
Results The 28-day mortality rates in HH, ALF, AoCLF and in the control Incidence, morbidity and mortality of admissions related to alcohol
group were 54% (n = 39), 27% (n = 6), 53% (n = 31) and 27% (n = 12), consumption on critical care: a single-centre experience
respectively. Peak arterial ammonia levels in patients with HH were A Retter, F Tait, M Stockwell
significantly higher in 28-day nonsurvivors compared to survivors St Helier Hospital, London, UK
(P <0.01). Cox regression identified peak arterial ammonia concentrations Critical Care 2012, 16(Suppl 1):P392 (doi: 10.1186/cc10999)
as an independent predictor for 28-day mortality (P <0.01). Peak arterial
ammonia levels in 28-day transplant-free ALF survivors were significantly Introduction Excessive alcohol consumption is a major challenge to
lower compared to ALF patients who died or underwent liver public health. In 2000 it accounted for 4% of the global disease burden.
transplantation (P <0.05). There was no association between outcome However, the relationship between alcohol and health is complex and
and arterial ammonia in AoCLF patients and in the control group. the burden it places on admissions to critical care is uncertain.
Conclusion Elevated arterial ammonia levels are frequently observed in Methods We conducted a retrospective analysis of prospectively
critically ill patients with liver injury but not in patients of comparable collected data on the influence of excess alcohol consumption on
severity of illness without hepatic impairment. They indicate poor the outcome of patients admitted from July 2009 to July 2011. The
prognosis in HH and ALF, but not AoCLF. admitting physician determined the relationship between alcohol use
and admission. No patients were excluded. All continuous data are
expressed as medians and were compared using the Wilcoxon Mann–
P391 Whitney U test. Categorical data were compared using the chi-squared
Liver failure secondary to alcoholic liver disease carries a worse test.
prognosis than other aetiologies of liver failure: retrospective Results A total of 1,150 patients were admitted, 129 cases (11.2%) were
analysis of routine biochemical markers in critically ill patients with identified as having excess alcohol consumption. Of these cases 34%
liver failure were women, whilst 48% of the controls were female. The median age
E McCarron, I Welters of the cases was 54 years versus 68 years for the controls (P <0.001).
Royal Liverpool University Hospital, Liverpool, UK The cases had a lower APACHE II score, 14.3 vs. 15.8 (P = 0.002). Twenty-
Critical Care 2012, 16(Suppl 1):P391 (doi: 10.1186/cc10998) four (18.6%) of the cases with excess alcohol consumption died on the
ICU compared to 141 controls (13.8%) (P >0.1). The hospital mortality
Introduction Patients with liver failure in the critical care unit frequently was similar between the two groups, 28 (21.7%) against 215 (21.1%)
provide physicians with problems about management and prognosis. controls (P >0.5). The cases spent longer on the ICU, median 3.95 days
Alcoholic liver disease (ALD) in particular is showing an increase in versus 2.9 in the controls (P <0.001). On admission the cases required
admission and mortality in the UK [1]. Current biochemical tests make a median of 2.0 organ supportive therapies compared to 1.8 in the
it difficult to differentiate between types and severity of liver damage control group (P <0.001). The cases were ventilated for a mean of
and fail to give a true idea about prognosis and outcome, often only 4.1 days compared to 2.4 days in the controls (P <0.001). There was
showing low-grade derangements before hyperacute decompensation no difference in the rate of sepsis between either group, 10% in the
of liver function. The aim of this study was to look at various liver cases and 9.8% in the controls. Twenty-six patients were admitted with
function tests (LFTs) routinely recorded in patients admitted to known alcoholic cirrhosis (0.23%), 10 with oesophageal varices and
critical care with liver failure, to see whether they differed between three with acute pancreatitis related to alcohol.
ALD and nonalcoholic aetiologies (NALD); that is, drug overdose and Conclusion To our knowledge this is the largest single-centre
nonalcoholic steatohepatitis, and so forth. We also aimed to assess assessment of the burden of excess alcohol consumption on patients
their prognostication value and relation to severity of disease scores. admitted to critical care. Eleven per cent of all admissions to the ICU
Methods A total of 119 patients admitted to the ITU with liver failure were complicated by excess alcohol consumption. The ITU mortality of
(66 ALD and 53 NALD) between 2008 and 20011 were included. Each these patients was increased when compared to the controls, despite
patient had admitting electrolytes, haematology, LFTs and clotting the patients having an equivalent APACHE score on admission and
studies along with APACHE II score, length of stay and ventilation and tending to be younger. The cases spent less time in hospital than the
vital organ support requirement. controls. This was due to a bimodal distribution of their survival curve.
Results ALD patients were found to have lower sodium (mean 135.56; Our study is limited by its retrospective design and the risk of selection
P = 0.004) and be hypocalcaemic (P = 0.015), as well as having more bias.
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Conclusion Older critically ill cirrhotics (over 60 years) undergoing liver Methods In this prospective, multicenter, observational study, all 3,902
transplantation have significantly worse post-LT outcomes. MELD and patients (mean age ± SD: 64.3 ± 15.7 years, 63.5% male) admitted to
SOFA scores do not appear to predict outcome post LT in this cohort. one of 24 medical or surgical ICUs between 3 April and 29 September
2006 were included.
Results Four hundred and forty-six of the patients had sepsis, including
P396 160 patients with severe sepsis (4.1%) and 145 patients (3.7%) with
Acute respiratory distress syndrome: analysis of incidence and septic shock. ICU mortality was 20% (n = 780) and median ICU length
mortality in a university hospital critical care unit of stay was 3 (1 to 9) days. ICU mortality was higher (41.3 vs. 17.2%,
JF Figueira, MO Oliveros, JL López, BC Civantos, LF Fernández P <0.001) and the median ICU LOS longer (15 (7 to 26) vs. 2 (1 to 7),
Hospital Universitario La Paz, Madrid, Spain P <0.001) in patients with sepsis than in those without sepsis. The
Critical Care 2012, 16(Suppl 1):P396 (doi: 10.1186/cc11003) mortality rate increased with the severity of sepsis (sepsis without
organ failure, severe sepsis, and septic shock: 19.9, 44.4, and 58.6%,
Introduction The aim was to determine the incidence of acute respectively). ICU-acquired sepsis was associated with higher ICU
respiratory distress syndrome (ARDS) in patients admitted to a mortality rates than sepsis occurring within 48 hours of ICU admission
university hospital ICU, analyse the ICU and the in-hospital mortality, (49.8 vs. 33.0%, P <0.001). In multivariate logistic regression analysis,
and evaluate the associated factors. the occurrence of severe sepsis (OR, 1.70 (1.06 to 2.72); P = 0.026) and
Methods A prospective study in an ICU from October 2008 to January septic shock (OR, 2.25 (1.49 to 3.49); P <0.001) were independently
2011. The ICU comprises 20 beds in a medical–surgical area, 10 in a associated with an increased risk of ICU death.
critical burns area. All patients who underwent mechanical ventilation Conclusion In this large multicenter cohort, severe sepsis and septic
(MV) during 48 hours or more and who fulfilled ARDS criteria as defined shock were independently associated with an increased risk of death.
by the 1994 American–European Consensus Conference on ARDS were Our data underscore the regional variability in the epidemiology and
included. All patients were ventilated following the protective MV outcome of sepsis syndromes and may be useful for resource allocation.
strategy recommended.
Results During this period 1,900 patients were admitted, 697 needed
MV for at least 48 hours and 108 fulfilled the ARDS criteria (5.6%
of those admitted, 17% of the group on MV); 63% were male. The P398
patients’ age was 52 ± 12. The APACHE II score on admission was 23 ± 7, Outcome of faecal peritonitis in the ICU
in survivors (S) 20 ± 7 and 24 ± 6 in nonsurvivors (NS) (P = 0.002). J Sayer, G Simpson, L Mccrossan, I Welters
ARDS was primary in 70% and secondary in 30%. The most common Royal Liverpool University Hospital, Liverpool, UK
aetiology was pneumonia (53%) followed by sepsis of intra-abdominal Critical Care 2012, 16(Suppl 1):P398 (doi: 10.1186/cc11005)
origin (15%). Duration of MV was 32.7 ± 30.2 days in S, 20.79 ± 20.73
in NS (P = 0.019). Survivors’ mean length of stay was 35 ± 24 days, Introduction Faecal peritonitis often leads to intensive care admission.
23 ± 20 for NS (P = 0.007). ICU mortality was 49% and in-hospital Anecdotally, patients with co-existing malignancy had an improved
mortality was 55%. Primary ARDS had an ICU mortality of 47%, an in- outcome. A retrospective analysis of all patients admitted to intensive
hospital mortality of 52%. Secondary ARDS had a 55% ICU mortality, care over 7 years was conducted to investigate this observation and
an in-hospital mortality of 64%. Duration of primary ARDS was longer, identify factors that are associated with outcome from faecal peritonitis
15.3 ± 12.2 versus 8.7 ± 79. Globally the main cause of death was in intensive care.
multiple organ dysfunction, predominantly respiratory failure (55%). In Methods A retrospective analysis of all cases of faecal peritonitis
primary ARDS the main cause of death was chiefly pulmonary (69%), admitted to the Royal Liverpool University Hospital ICU over 7 years.
while in secondary ARDS it was mainly multiple organ dysfunction Clinical records, laboratory results, histology reports and radiological
associated with septic shock (71%). Factors associated with increased data were accessed. Statistical analysis was performed using chi-
mortality were APACHE II score >23 and the presence of multiple organ squared and Student’s t tests.
dysfunction. Results A total of 133 patients were admitted to intensive care in
Conclusion Certain controversy remains regarding a decrease in ARDS- 7 years. Thirty-six patients had underlying malignancy. Predicted
related mortality. Despite the fact that its incidence is not very high, mortality, indicated by APACHE II score, was similar in both groups
it is still a clinical entity with a high mortality, and with a prognosis (malignancy: 17.1, nonmalignancy: 16.2). Inpatient mortality was lower
influenced not only by the degree of pulmonary involvement but by in patients with malignancy than those without (malignancy: 21.6%,
the association with multiple organ dysfunction. nonmalignancy: 38.1%, P <0.1) and shorter ITU stay (malignancy:
References 6.8 days, nonmalignancy: 12.7 days, P ≤0.0005). Cancer patients
1. Roca O, et al.: Estudio de cohortes sobre incidencia de SDRA en pacientes required a shorter period of TPN or NG feeding (malignancy: 4.29 days,
ingresados en UCIy factores pronósticos de mortalidad. Med Intensiva nonmalignancy: 7.7 days, P <0.05), and a shorter duration of inotropic
2006, 30:6-12 . support (malignancy: 2.54 days, nonmalignancy: 4.44 days, P <0.05).
2. Zambon M, Vincent JL: Mortality for patients with ALI/ARDS have Peak inflammatory markers are lower in patients with malignancy,
decreased over time. Chest 2008, 133:151-161 . notably neutrophil count (malignancy: 21.15, nonmalignancy: 24.9,
3. Frutos-Vivar et al.: Epidemiology of ALI and ARDS. Curr Opin Crit Care 2004, P <0.05).
10:1-6. The mean APACHE II score was significantly lower in cases who
survived, compared to those who did not (nondeaths: 15.3, deaths:
19.3, P <0.005). Mean albumin at admission was similar for patients
P397 who survived compared to those who did not (deaths: 18.2, nondeaths:
Epidemiology and outcome of sepsis syndromes in Italian ICUs: 18.6); however, minimum albumin during admission is significantly
a regional multicenter observational cohort lower in patients who died than those who survived (deaths: 10.33,
L Laudari1, Y Sakr2, C Elia1, L Mascia1, B Barberis3, S Cardellino4, S Livigni5, nondeaths: 13.24, P <0.005). Duration of feeding support (TPN or NG
G Fiore6, C Filippini1, VM Ranieri1 feeding) and time to commencement of feeding showed no difference
1
San Giovanni Battista-Molinette Hospital, University of Torino, Turin, Italy; between patients who survived and those who did not.
2
Friedrich Schiller University Hospital, Jena, Germany; 3Ospedale degli Infermi, Conclusion Underlying malignancy is associated with an increased
Revoli, Italy; 4Ospedale Cardinal Massaia, Asti, Italy; 5Ospedale Giovanni survival, shorter ITU stay, less requirement for inotropic support and
Bosco, Turin, Italy; 6Ospedale Santa Croce, Moncalieri, Italy decreased inflammatory markers potentially due to a less aggressive
Critical Care 2012, 16(Suppl 1):P397 (doi: 10.1186/cc11004) inflammatory response as a consequence of the presence of malig-
nancy. In this series, delay to introduction of nutrition and length of
Introduction We assessed the epidemiology of sepsis syndromes in nutritional support are not associated with outcome; however, low
patients admitted to ICUs of the Piedmont region in northern Italy and albumin is associated with a poor outcome, although it is not clear if
investigated the impact of sepsis on ICU mortality in these patients. this is secondary to nutrition or inflammation.
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P399 congestive heart failure cases died, 70% of them dead within 3 months.
HIV patients in the ICU: our experience Patients with CHF as compared to patients without CHF had a higher
V Nunes Velloso, L Calejman, E Canedo, M Deheza percentage of comorbidity disease (P <0.01) and poor performance
Hospital Rivadavia, Capital Federal, Argentina status (P <0.05). The majority of these patients (85.7%) who were older
Critical Care 2012, 16(Suppl 1):P399 (doi: 10.1186/cc11006) (P <0.001), and required a higher dose of dobutamine (P <0.0001),
had higher urine output (P <0.001) and prolonged INR (P <0.01) were
Introduction The objective was to describe characteristics of HIV- unable to care for self at 1 year of hospital discharge. Survivors with
positive patients admitted to the ICU. CHF who died (OR 4.7, CI 1.52 to 14.33) had higher dose of dopamine
Methods HIV-positive patients admitted between February 2000 (P <0.045) and poor performance status pre sepsis (P <0.028).
and February 2011, and demographic data, APACHE II score, cause of Conclusion About three-quarters of survivors of severe sepsis/septic
admission, days of internment, need for mechanical ventilation (MV), shock with congestive heart failure died after 1 year of hospital
previous antiretroviral therapy of high efficacy before admission discharge. Many of them (70%) died within 3 months of hospital
(HAART), viral load and CD4 count. discharge. The majority had poor performance status and only 14%
Results A total of 3,568 patients were admitted; 715 patients (20.03%) were able to carry on normal activity at 1 year after hospital discharge.
were HIV-positive, 413 patients (57.76%) were masculine and 302 These data highlight the need for different strategies to care for sepsis
patients (42.23%) feminine, and average age was 33 for men and survivors with congestive heart failure.
35 for women. The APACHE II average score was 13 versus 15.28 for
the general population. The most frequent cause of admission was
respiratory failure in 329 patients (46%), 57% due to Pneumocystis P401
jivoreci and bacterial pneumonias in 35%, the most frequent bacteria Predictive value of N-terminal pro-brain natriuretic peptide among
isolated were Streptococcus, Staphylococcus aureus and Haemophilus critically ill patients
influenzae. There were two cases of respiratory Kaposi sarcoma and M Cubrilo-Turek, N Maric, I Mikacic, N Tolj Karaula, N Budinski, M Mackovic
26 cases of Mycobacterium tuberculosis. Other causes were decrease Clinical Hospital Sveti Duh, Zagreb, Croatia
in mental state in 157 patients (22%), with the most frequent causes Critical Care 2012, 16(Suppl 1):P401 (doi: 10.1186/cc11008)
reported being toxoplasmosis, cryptococcus neoformans and brain
lymphoma, immediately post surgery in 79 patients (11%), COPD Introduction N-terminal pro-brain natriuretic peptide (NT-proBNP)
reagudization and asthma (9%), digestive bleeding in 36 patients (5%) represents a useful cardiac marker in evaluating heart failure. However,
and renal insufficiency in 50 patients (7%). From the 715 HIV-positive its role in the assessment of critically ill patients is not clear. The aim of
patients admitted, 479 required MV (67%). Regarding nationality, 276 this study was to evaluate survival of infected and noninfected patients
(38.6%) patients were Argentinean, and the other nationalities were according to the measurements of NT-proBNP.
Bolivian, Paraguayan, Peruvian and Korean. The average length of stay Methods Serum NT-proBNP measurements were done in 89 (46
was 10.5 days and the mortality was 43%. The viral load average was males/43 females, 68.20 ± 13.80 years) consecutive critically ill patients
inferior to 104 RNA/ml in just 44 known patients and the CD4 count was within 6 hours after admission to the ICU. NT-proBNP was determined
determined in 75 patients, from which the average was 400/mm3. The with a sandwich immunoassay on an Elecsys 2010 (Roche Diagnostics,
proportion of patients receiving HAART was just 26%. Mannheim, Germany). Logarithmic transformation of data was required
Conclusion HIV-positive patients have a high frequency of admission because of the skewed distribution of NT-proBNP.
to the ICU, and they have a lower risk score in comparison with non-HIV Results The median NT-proBNP (pg/ml) was 2,485.1 pg/ml (range 31.5
patients. The two main causes of admission where respiratory disease to 12,041 pg/ml) (log NT-proBNP mean 3.34 ± 0.71 pg/ml). Mean log NT-
and infectious CNS disease. Significant results were the prevalence of proBNP levels were higher at admission to the hospital in nonsurvivors
patients from limited countries, high mortality and prolonged stay in (3.73 ± 0.67 pg/ml) compared with survivors (3.12 ± 0.65 pg/ml), which
the ICU, and poor adherence to antiretroviral therapy. was statistically significant (P <0.0001). Higher concentrations were
found in proven infection (X ± SD) (3.43 ± 0.68) than in bacteriological
negative patients (3.30 ± 0.72), but it was statistically insignificant
(P <0.42). From 57 survivors seven were mechanically ventilated
P400 (12.28%) while 14 (43.75%) from 32 nonsurvivors were ventilated,
Impact of congestive heart failure on severe sepsis and septic shock which was statistically significant (P <0.001). More nonsurvivors were
survivors: outcomes and performance status after 1-year hospital taking vasoactive medications (n = 12 or 37.5%) than survivors (n = 3
discharge or 5.26%), which was statistically significant (P <0.001). NT-proBNP
M Alkhalaf1, N Abd-Aziz2, Y Arabi3, B Tangiisuran1 showed no correlation for any analyzed parameters (age, erythrocytes,
1
School of Pharmaceutical Sciences, Penang, Malaysia; 2University leucocytes, body temperature, systolic and diastolic blood pressure,
Technology MARA, Puncak Alam, Malaysia; 3National Guard Hospithal, C-reactive protein, fibrinogen, lactates or procalcitonin). The use of ROC
Riyadh, Saudi Arabia curve analysis reveals for serum NT-proBNP high sensitivity (75%), low
Critical Care 2012, 16(Suppl 1):P400 (doi: 10.1186/cc11007) specificity (57.9%) and low accuracy (64%) for discriminating survivors
from nonsurvivors.
Introduction The objective of this study was to evaluate the impact of Conclusion Our results showed that cardiac NT-proBNP levels can be
CHF on severe sepsis and septic shock survivor outcomes after 1 year elevated in critically ill patients and may also serve as markers of severity
of hospital discharge. and prognosis for survival. Mean baseline levels of log NT-proBNP were
Methods A retrospective cohort and cross-sectional study was different in critically ill patients with proved bacteriological infection
conducted at a tertiary-care hospital in Saudi Arabia. All patients than in patients without proven infection.
(≥18 years) with severe sepsis/septic shock admitted for more than
1 day to the medical–surgical and trauma ICU between April 2007
and March 2010 and alive at hospital discharge were included in the P402
study. Patients who died during admission, could not be contacted Low preoperative hepcidin concentration is a risk factor for
and with multiple ICU admission within the same hospitalization mortality but not for acute kidney injury after cardiac surgery
were excluded. Data were collected using the electronic ICU database, A Haase-Fieiltz1, P Mertens1, M Plaß2, M Westerman3, R Bellomo4, M Haase1
1
hospital information system and systematic review of medical records Otto-von-Guericke University, Magdeburg, Germany; 2German Heart Center,
to determine hospital outcomes and performance status pre sepsis. Berlin, Germany; 3IntrinsicLifeSciences, La Jolla, CA, USA; 4Austin Health,
Assessment of the vital status and performance at 1-year hospital Melbourne, Australia
discharge were performed via structured telephone interviews using Critical Care 2012, 16(Suppl 1):P402 (doi: 10.1186/cc11009)
the Karnofsky Performance Status Scale.
Results A total of 195 hospital survivors from 364 patients were included Introduction Hepcidin – expressed in renal proximal tubular cells – is a
in the final analysis. More than 70% of severe sepsis/septic shock with key regulator of iron homeostasis and was recently described as a renal
Critical Care 2012, Volume 16 Suppl 1 S144
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biomarker that early postoperatively predicts protection from acute a mean of 3.6 days, and 41% needed ARS for a mean of 3.8 days. See
kidney injury (AKI). Table 1.
Methods We studied 100 adult patients at increased risk of AKI Conclusion CC and hospital mortality was 17% and 33% respectively.
(RIFLE) after cardiac surgery. Plasma and urine were sampled before This study concurs with another which demonstrated that age is not
induction of anesthesia and hepcidin 25-isoforms were quantified by a good predictor of outcome post surgery [1]. These patients did not
competitive enzyme-linked immunoassay. Our objective was to assess have a significant impact on RRT or ARS resources or CC LOS.
the predictive indices of preoperatively measured urine and plasma Reference
hepcidin for the development of postoperative AKI and other patient- 1. Ford P, et al.: Determinants of outcome in critically ill octogenarians after
related outcomes, including the need for renal replacement therapy surgery. Br J Anaesth 2007, 99:824-829.
(RRT) and in-hospital mortality.
Results Preoperatively, patients not developing AKI presented with P404
nonsignificantly higher urine and plasma hepcidin concentrations Correlation between APACHE II score and quality of life among
compared to patients that developed AKI which did not translate into patients discharged from the ICU
a good predictive value for postoperative AKI (AUC-ROC <0.70 for L Zubek1, L Szabó1, L Horváth1, A Mesterházi2, J Gál1, G Élő1
1
both biomarkers). Also, the preoperative urine and plasma hepcidin Semmelweis University, Budapest, Hungary; 2Markusovszky Hospital,
concentrations as well as serum creatinine concentration did not Szombathely, Hungary
distinguish patients requiring postoperative RRT from those who did Critical Care 2012, 16(Suppl 1):P404 (doi: 10.1186/cc11011)
not require RRT (urine: AUC-ROC 0.62 (95% CI 0.38 to 0.86), plasma: AUC-
ROC 0.63 (95% CI 0.34 to 0.91), serum creatinine: AUC-ROC 0.61 (95% CI Introduction The goal of intensive therapy is not only saving the
0.22 to 0.99)). However, a low preoperative hepcidin concentration in patient’s life, but also to restore their quality of life. Based on expected
urine (median 5 ng/ml, 25th to 75th percentiles 4 to 15 ng/ml) and in quality of life improvement, a fair allocation of limited available
plasma (median 50 ng/ml, 25th to 75th percentiles 30 to 55 ng/ml) was resources can be provided. The assessment scores for the physical
a good predictor for postoperative mortality with an AUC-ROC for urine state of ICU patients, which correlate with survival, are widely known.
hepcidin of 0.89 (95% CI 0.73 to 0.99) (cut-off : 130 ng/ml, sensitivity However, it would be useful to know if these score systems also
73% and specificity 100%) and an AUC-ROC for plasma hepcidin of 0.90 correlate with the long-term quality of life. The aim of our study was to
(95% CI 0.80 to 0.99) (cut-off : 55 ng/ml, sensitivity 83% and specificity investigate the correlation between the APACHE II score and the long-
100%). Preoperative serum creatinine did not predict mortality (AUC- term quality of life after ICU treatment.
ROC 0.50 (95% CI 0.10 to 0.94). Patients who survived the hospital stay Methods We have collected data retrospectively from patients treated
had a median preoperative hepcidin concentration in urine of 330 ng/ in our department during the first quarter of 2008. The APACHE II score
ml (25th to 75th percentiles 140 to 760 ng/ml), and plasma of 115 ng/ was calculated for all patients, after which we examined the correlation
ml (25th to 75th percentiles 80 to 200 ng/ml). between this value and the survival of the patients. One year after
Conclusion Our findings suggest that low preoperative hepcidin ICU therapy, the Hungarian version of the EQ-5D questionnaire
concentration indicates mortality but not renal endpoints in patients (measurement consist of five dimensions: mobility, self-care, usual
undergoing cardiac surgery. Thereby, hepcidin may contribute to early activities, pain/discomfort, anxiety/depression and a visual analog
risk stratification. Findings should be validated in independent patient scale about health state) developed by EuroQol Group was sent out by
cohorts with a larger number of events. post. The correlation between the APACHE score and quality of life was
calculated, the Spearmann rank-order correlation was used.
Results During this period, 190 patients were treated in our department.
P403 The average of the APACHE II score was 13.23 (±6.99). In total, 25.3%
Outcomes and resource use for over 80 year olds admitted to a of patients died during treatment; 22.1% died during the first post-
UK critical care unit after an emergency laparotomy over a 3-year treatment year; 27.9% surely survived and 24.7% of patients were
period unattainable. In our cohort, every patient below 11 points survived
V Banks, C Scott and none above 24. The average APACHE score of patients completing
Northern General Hospital, Sheffield, UK the questionnaire was 9.30 (±3.85). They assessed their health as 66%
Critical Care 2012, 16(Suppl 1):P403 (doi: 10.1186/cc11010) at VAS, although correlation between this value and the APACHE
score could not be shown. However, we found statistically significant
Introduction There are few data on older people emergency surgical correlation between the APACHE score and the current mobility of
critical care (CC) admissions and the potential implications for future the patients (P = 0.021). Based on our data, 34% of the patients had
resource demands and service planning. problems with mobility, 36% with usual activity, 62% of patients
Methods Retrospective data were collected from a cohort of patients complained about pain or discomfort, 50% felt anxiety or depression
>80 years old admitted after emergency surgery between 2009 and and 18% had problems with self-care.
2011. CC and hospital information databases were used. Data included Conclusion ICU admission is associated with a high mortality, a poor
mortality, length of stay (LOS) and duration of renal replacement physical quality of life and low quality-adjusted life-years for 1 year
therapy (RRT) and advanced respiratory support (ARS). after discharge. We found that the APACHE II score did not show
Results A total of 118 patients were admitted; 52% female: mean age significant correlation with patient’s long-term quality of life, but we
85 years, male mean age: 84 years. In total, 69% were general surgical, detected significant correlation between the APACHE II score and the
22% vascular, and 9% hepatobiliary. Eleven per cent required RRT for current mobility of the patients.
P405 coefficient (SE) was 1.47 (0.001) for the whole cohort, 1.49 (0.001) after
Parameters that affect outcome in surgical ICU patients exclusion of cardiac surgery patients and 1.55 (0.006) after exclusion
A Vakalos, M Petkopoulou, D Jannussis of patients with an absolute difference in ROD >1% between the two
Xanthi General Hospital, Xanthi, Greece scores. Finally, the correlation between the APII and SAPS II scores was
Critical Care 2012, 16(Suppl 1):P405 (doi: 10.1186/cc11012) moderate (r2 = 0.63). The overall model was APII = 0.36×SAPS II + 4.4.
The APII/SAPS II coefficient (SE) was 0.36 (0.0003) for the whole cohort,
Introduction Surgical ICU patients have a lower severity illness score on 0.37 (0.0004) after exclusion of cardiac surgery patients and 0.39 (0.002)
ICU admission day. The aim of our study was to compare the length of after exclusion of patients with an absolute difference in ROD >1%.
stay (LOS), ventilation days (VD) and parameters that affect the APACHE Conclusion Simple and robust translational formulas can be developed
II–III scoring system between surgical patients who died in the ICU and to allow clinicians to compare illness severity in intensive care studies
surgical patients who survived and discharged from the ICU. of similar patients when such illness severity is expressed with different
Methods During November 2005 and May 2011, 310 patients were scoring systems.
admitted to our medical and surgical ICU. From these, 122 were surgical
patients (39.35%) and were included retrospectively in our study.
Mean age was 64 years, mean APACHE II score 14.5, actual mortality
rate 12.29%. The patients were separated into two groups. Group P407
A involved 107 surgical patients who survived the ICU and group Predicting hospital mortality: comparing accuracy of SAPS II and
B 15 surgical patients who died in the ICU. We looked for statistical clinical staff prognosis
significant difference (two-tailed P value) between the mean APACHE I Patrício1, M Marques1, A Costa-Pereira2, O Ribeiro2, I Aragão1, T Cardoso1
1
values at admission of group A and group B, using the unpaired Mann– Hospital Geral de Santo António, University of Porto, Portugal; 2Faculty of
Whitney test (nonparametric) or the unpaired t test Welch corrected Medicine, University of Porto, Portugal
(parametric), according to the normality test. Critical Care 2012, 16(Suppl 1):P407 (doi: 10.1186/cc11014)
Results The mortality rate of surgical patients was 12.29%. We detected
no statistical difference between the two groups according to age Introduction The purpose of this study is to compare the accuracy of
(P = 0.27), heart rate (P = 0.13), temperature (P = 0.57), Na (P = 0.44), K Simplified Acute Physiology Score (SAPS) II with the subjective opinion
(P = 0.18), WBC (P = 0.56), Ht (P = 0.7), PaO2 (P = 0.28), PaCO2 (P = 0.7), of clinical staff in predicting hospital mortality, in critically ill adult
albumin (P = 0.21), glucose (P = 0.68) and GCS (P = 0.26). We detected patients.
statistically significant higher group B values according to BUN Methods A prospective study in a mixed ICU, at a university hospital,
(P = 0.015), creatinine (P = 0.005), bilirubin (P = 0.0032), APACHE II using SAPS II to assess the risk of death. Patient outcome was also
score (P = 0.0018), LOS (P <0.0001) and VD (P <0.0001). We detected predicted subjectively by the clinical staff (consultants, residents and
statistically significant higher group A values according to mean nurses), including the possibility of return to prior physical activity. The
arterial pressure (P = 0.0052) and PH (P = 0.0027). subjective predictions were compared with SAPS II predictions using
Conclusion According to our data, surgical patients who died (group logistic regression analysis and receiver operating characteristic curve
B) had higher severity score on admission. Nevertheless, the main (ROC) measurement, as well as sensitivity and specificity analysis for
difference between surgical patients who died and who survived the each group of participants.
ICU was hemodynamic instability, which was severe enough to cause Results Over the study period 72 patients were included, with a
hypoperfusion, metabolic acidosis, early acute kidney injury and early mean age of 56.5 ± 16.8 years; 55% were male. The mean SAPS II was
multiple organ dysfunction. As a result, the length of stay and the 47.3 ± 15.4. Eighteen patients died in hospital (25%). Discriminations
ventilation days were higher in group B patients, assuming that early analysis showed the following areas under ROC: SAPS II 0.84 (95% CI:
and effective surgical management is important in order to avoid early 0.741 to 0.945); consultants 0.77 (95% CI: 0.632 to 0.908); residents 0.67
multiple organ dysfunction on ICU admission. (95% CI: 0.513 to 0.828); nurses 0.62 (95% CI: 0.453 to 0.777). See Figure 1.
Conclusion In our study, contrary to previous descriptions of similar
studies, SAPS II was more accurate in predicting hospital mortality
P406 than clinical staff opinion. Differences were also found between
Relationship between illness severity scores in the ICU different groups of clinical staff, partially related to previous ICU clinical
A Schneider1, M Lipcsey1, M Bailey2, D Pilcher3, R Bellomo1 experience.
1
Austin Health, Heidelberg, Australia; 2Monash University, Melbourne, References
Australia; 3ANZICS, Melbourne, Australia 1. Scholz N, et al.: Eur J Anaesthesiol 2004, 21:606-611.
Critical Care 2012, 16(Suppl 1):P406 (doi: 10.1186/cc11013) 2. Sinuff T, et al.: Crit Care Med 2006, 34:878-885.
P408 Results The last 50 patients were admitted between January 2004 and
Predictors of mortality in patients from a hematological ICU in August 2011. Overall the number of admissions increased throughout
Brazil this period, with only one admission in 2004, peaking at 10 in 2009.
OB Silva, L Correa, P Loureiro, E Araujo, D Teles, LA Vasconcelos, In 2011, patients with a hematological malignancy represented 0.5%
T Salvattori, P Schwambach, GT Henriques-Filho of all the ICU admissions. The commonest malignancies were acute
HEMOPE, Recife, Brazil myeloid leukemia (43%) and lymphoma (31%). The primary reason for
Critical Care 2012, 16(Suppl 1):P408 (doi: 10.1186/cc11015) admission was sepsis (61%), with pneumonia the commonest source
(27%) and 42% admitted with neutropenic sepsis. Compared to the
Introduction The study was designed to analyze the factors responsible 2010/11 cohort the patients admitted with a hematological malignancy
for increased mortality in an ICU specialized in hematological patients. had significantly higher mean APACHE II scores (24 (SD 8) vs. 15 (SD 6)
There are few ICUs specialized in hematological diseases, with reports P <0.0001), a longer mean ICU stay (10 days (SD 17) vs. 6 days (SD 10)
of high mortality rates (45 to 85%) [1], mostly related to severity P <0.0001) and greater ICU (50% vs. 27% P <0.0001) and hospital
of patients with blood cancer [2], mechanical ventilation (MV) and mortality (61% vs. 29% P <0.0001). However, the overall trend was a
multiple organ failure [2-4]. The most prevalent disease differs among considerable fall in mortality from 91% (2004 to 2007) to 36% (2008
studies [1-4] and acute leukemia seems to have the worst prognosis [2]. to 2011). The mean SOFA score on admission for the hematological
Methods A retrospective cohort was conducted at HEMOPE’s ICU. Data patients was 9 (SD 3). Twenty patients required two levels of organ
were collected from the medical records of patients admitted from support with only three patients receiving renal replacement therapy.
January 2006 to December 2009. No independent risk factors for outcome were identified.
Results Of the 576 admissions, 396 (68.75%) could be analyzed. The Conclusion The outcomes of patients with hematological malignancies
average age was 48.3 ± 19.4 years (11 to 88 years), 54% were female and admitted to the ICU are improving with rates approaching that of
there was no association between mortality and age or gender. Acute our general ICU population. Patients with hematological malignancy
leukemia occurred in 43% (65.3% acute myeloid leukemia). Sepsis was requiring ICU admission continue to increase and admission should
the major cause of admission (55.3%). The overall mortality rate was be based on their physiological derangement and overall prognosis.
57.5% and the specific one was 42.7%. The mean APACHE II score for Further prospective studies are required to investigate potential
this population was 13.4 ± 1.0 (7 to 43) and was statistically higher in predictors of outcomes in these patients.
the group that died (14.6 ± 0.7 vs. 11.8 ± 0.8; P = 0.013). Mean SOFA at Reference
day 1 (D1) and day 3 (D3) was 2.8 ± 0.2 and 2.1 ± 0.2 respectively, also 1. Hampshire P, et al.: Admission factors associated with hospital mortality in
significantly higher in those that died (D1 3.9 ± 0.3 and D3 2.9 ± 0.3; patients with haematological malignancy admitted to UK adult, general
P <0.0001). Almost 60% used vasoactive drugs (VAD) on admission and critical care units: a secondary analysis of the ICNARC Case Mix
had a higher mortality rate (P <0.0001). MV was used in 86% and 69% Programme Database. Crit Care 2009, 13:R137.
died (P <0.001). Of those with renal substitutive therapy (RST), 81.9%
died (OR = 3.12; 99% CI = 1.5 to 6.91). Mortality was also associated with
the completion of chemotherapy before ICU admission (P = 0.003) and P410
severe neutropenia (P <0.0001). In multivariate analysis, MV (RR = 13.1; Six-month survival of patients with lung cancer admitted to a
99% CI = 5.14 to 33.45) and a one-unit increase in SOFA D1 (RR = 1.26; medical ICU: a retrospective study
99% CI = 1.15 to 1.37) were associated with an increase in mortality. O Keller, GL Laplatte, H Lessire
Conclusion For this population, in univariate analysis mortality was CH Pasteur, Colmar, France
related to SOFA, RST, MV, use of VAD on admission, chemotherapy Critical Care 2012, 16(Suppl 1):P410 (doi: 10.1186/cc11017)
before ICU admission, and severe neutropenia. Although there
was a relation between APACHE II score and mortality, this score Introduction ICU admission of patients with lung cancer remains
underestimates it. In multivariate analysis, needing MV and a high SOFA debated because of the poor short-term prognosis. We evaluated the
D1 were independent predictors of death. duration of survival of patients admitted to our ICU and looked for
References factors associated with better survival.
1. Shelton BK: Crit Care Clin 2010, 26:1-20. Methods All patients with nonresectable lung cancer admitted to our
2. Kress JP, et al.: Am J Respir Crit Care Med 1999, 160:1957-1961. ICU between 1 January 2008 and 31 December 2010 were included in a
3. Taccone FS, et al.: Crit Care 2009, 13:R15. retrospective study. Postoperative patients were not included.
4. Thiéry G, et al.: J Clin Oncol 2005, 23:4406-4413. Results Twenty-two patients were included. Seventeen had nonsmall-
cell lung cancer (NSCLC). One had small cell lung cancer. Fifteen
patients (65%) had metastatic disease. Twelve patients were in
palliative therapy. The reason for ICU admission was acute respiratory
P409 failure in 12 patients (55%), hemorrhage in five patients (23%). Nine
Retrospective study of the outcomes of patients admitted to the patients (41%) had an infection. Fourteen patients (64%) needed
ICU with a hematological malignancy invasive mechanical ventilation. One-month survival was 45% (10/22).
H Lewis, J Patel, N Lonsdale Six-month survival was 13% (3/22). One-year survival was 0%. One-
Birmingham Heartlands Hospital, Birmingham, UK month survivors showed a nonsignificant trend to lower performance
Critical Care 2012, 16(Suppl 1):P409 (doi: 10.1186/cc11016) status and severity of disease. All 6-month survivors had metastatic
disease. Six-month survivors had nonsignificantly lower performance
Introduction The UK prevalence of haematological malignancy is status (1.7 ± 0.6 vs. 2.7 ± 1.2; P = NS). IGS II, SOFA score and duration
increasing. Seven percent of these patients become critically ill, necessi- of mechanical ventilation were significantly shorter in survivors (see
tating ITU care [1]. The past decade has seen significant advances in the Table 1).
treatment and outcomes of patients with hematological malignancies. Conclusion Prognosis of patients with nonresectable lung cancer
This has challenged the preconception that these patients are poor admitted to the ICU was poor. Metastatic disease did not influence
candidates for ICU admission. This study evaluated the trends in
admission and outcomes of patients admitted to a general ICU with a Table 1 (abstract P410)
diagnosis of hematological malignancy.
Methods A retrospective study of the last 50 consecutive admissions Number of
of patients with a hematological malignancy admitted to the ICU. IGS SOFA ventilation days
Patients were identified from the ICNARC database. Demographic data, Nonsurvivors 53.2 ± 6.5 5.6 ± 3.8 6.1 ± 6.4
APACHE II, SOFA scores on admission, baseline neutrophil count and
organ support data were collected. The primary outcome was ICU and 6-month survivors 36.3 ± 9.8 1.3 ± 2.3 0.7 ± 1.2
hospital mortality. Data were compared against the cohort of patients
P <0.05 P <0.05 P <0.01
admitted between April 2010 and April 2011.
Critical Care 2012, Volume 16 Suppl 1 S147
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survival in our survey. Patients admitted for a critical illness requiring total admissions). Sixty-eight percent were male, with a mean age of
more than a few days of mechanical ventilation were very unlikely to 60.21 ± 14.31 years and with an APACHE score of 22.21 ± 9.13. Solid
survive over 6 months. cancer was more frequent, 76.6% (urogenital 20%, lung 15.4% and
References low intestinal 15.4% were the most common). In the hematologic
1. Toffart AC, et al.: Use of intensive care in patients with nonresectable lung cancers (23.5%), the most frequent were non-Hodgkin lymphoma and
cancer. Chest 2011, 139:101-108. acute leukemia (both 7%). Active cancer (new diagnosis, recurrence or
2. Roques S, et al.: Six month prognosis of patients with lung cancer admitted progression) was presented in 75.3%. The main reason for admission
to the intensive care unit. Intensive Care Med 2009, 35:2044-2050. was respiratory failure (52.9%), shock (18.8%) or neurological impair-
ment (16.5%). The most common diagnoses were pulmonary sepsis
(23.5%), other sepsis (21.2%) and heart failure (8.2%). The ICU stay
P411 was 7.20 ± 12.32 days; with a mortality of 41.2% (hospital mortality
Health-related quality of life and survival of cancer patients 50.6%). The mortality was higher in the active disease (91% vs. 64%),
admitted to ICUs: results of the QALY study P <0.01. Patients who died developed more respiratory (88.6% vs. 48%),
AB Cavalcanti1, UV Silva2, KN Normílio-Silva1, AN Silva1, R Zancani1, hemodynamic (91.4% vs. 44%), renal (68.6% vs. 16%) or hematologic
MJ Giorgi1, AD Dias1, AT Simone1, PL Safra1, AC Figueiredo1, failure (45.7% vs. 16%), P <0.03. Septic patients were those with
G Tunes-da-Silva3, AC Lima3, LA Hajjar1, JO Auler1, J Eluf-Neto4, FR Galas1 higher ICU mortality (55.3% vs. 29.8%) and hospital mortality (63.2%
1
São Paulo State Cancer Institute, São Paulo, Brazil; 2Barretos Cancer Hospital, vs. 40.4%), P <0.05. By contrast, the patients with the longest survival
Barretos, Brazil; 3Instituto de Matemática e Estatística – Universidade de São were the neurological (90% vs. 54.7%) and cardiology patients (88.9%
Paulo, Brazil; 4Faculdade de Medicina da Universidade de São Paulo, Brazil vs. 55.3%), P <0.05. Patients who died needed more MV (88.6% vs.
Critical Care 2012, 16(Suppl 1):P411 (doi: 10.1186/cc11018) 52%), vasopressors (91.4% vs. 46%) or dialysis (34.3% vs. 4%), P <0.01.
The hematologic cancer had more cardiovascular (85% vs. 56.9%) or
Introduction Very limited data are available regarding postdischarge hematologic failure (65% vs. 16.9%) and neutropenia (45% vs. 9.2%)
health-related quality of life (HRQL) of cancer patients needing with P <0.03, but this is not reflected in more consumption of resources
intensive care. Our objective is to describe HRQL and survival in an or mortality.
unselected population of cancer patients who were admitted to ICUs. Conclusion The mortality was associated with organ failure and
Methods In this prospective cohort study conducted at two cancer greater need for resources. Hematologic cancer develops more organ
hospitals in Brazil, we enrolled a random sample of adult patients failure without affecting resource consumption or their outcome in
with cancer admitted to the ICUs. We collected data at ICU admission, our series. Septic patients have higher ICU and hospital mortality, and
including HRQL before the acute process that led to ICU admission, neurological patients lower.
and followed patients up on 15, 90 and 180 days after ICU admission
to assess HRQL and vital status. We determined HRQL with the EQ-5D
questionnaire, and the results were presented as summary measures P413
with values between –1 and 1, with 0 meaning HRQL similar to death Managing critically ill oncological patients in hospital: a survey
and 1 perfect HRQL. Summary measures were calculated using time- across all ICUs in the UK
trade-off value sets obtained from the UK population. Survival was C Gore, T Wigmore
calculated with the Kaplan–Meier estimator. Royal Marsden Hospital, London, UK
Results We enrolled 805 patients. Mean age was 61.4 ± 14.3 and 42.5% Critical Care 2012, 16(Suppl 1):P413 (doi: 10.1186/cc11020)
were female. Elective surgeries represented 52.2% of admissions,
urgent surgeries represented 5.0% and 42.8% were admitted due to Introduction The survival rates for oncology patients admitted to the
clinical reasons. Survival at 180 days was 51.2% (95% CI 47.4 to 54.9). ICU have improved significantly. The prognostic influence of the pre-
The HRQL summary measure (median (interquartile range)) before ICU admission oncological and treatment history is being questioned, the
admission was 0.64 (0.12 to 0.81), on the 15-day follow-up 0.73 (0.19 to most significant impact being related to acute physiological status. In
0.92), on the 90-day follow-up 0.73 (0.20 to 0.85) and on the 180-day
follow-up 0.70 (0.35 to 0.89).
Conclusion HRQL is, on average, moderately impaired before ICU
admission and through the 180-day follow-up in cancer patients
needing intensive care. Only about one-half of the patients were alive
after 180 days. However, there is large variability on both HRQL and
length of survival; thus, methods to estimate quality-adjusted life-years
on an individual basis are necessary.
P412
Characteristics, resource consumption and outcome of cancer
patients admitted to ICUs
R Garcia, L Terceros, I Saez, J Flordelis, L Colino, C Mudarra, S Temprano,
J Montejo
12 de Octubre Hospital, Madrid, Spain
Critical Care 2012, 16(Suppl 1):P412 (doi: 10.1186/cc11019)
Figure 1 (abstract P416). Calibration curves for customized APACHE II, SAPS II and SAPS 3.
Results A total of 880 patients were enrolled and a hospital mortality patients underwent study of endothelial vasodilating function using
rate of 57.4% was found. Community-acquired infections accounted for the method proposed by Celermajer and colleagues [1].
57.2% and 32.8% of patients had positive blood culture. The respiratory Results On 4 to 5 days after surgery, leg deep venous thrombosis was
tract was the most common site of infection (48.7%). The predicted found in 11 patients (8.8% of all patients after prosthetics). For decrease
mortality of all the scores was close to the observed mortality, with a of intraoperative blood loss the tourniquet was applied onto the middle
standardized mortality ratio (95% confidence interval) of 0.94 (0.86 to third of the leg in 77 patients (60.6%). In this group DVT was found in
1.02) for APACHE II, 1.01 (0.92 to 1.1) for customized APACHE II, 0.93 10.4% of cases. In the nontourniquet group (48 patients) DVT was
(0.85 to 1.01) for SAPS II, 1.07 (0.98 to 1.17) for customized SAPS II, 0.97 found in 6.25%. The differences in the complication frequency were not
(0.89 to 1.06) for SAPS 3 and 1.02 (0.93 to 1.11) for customized SAPS statistically valid. The data from duplex scanning showed that 43 patients
3. All six scores were well discriminated, with areas under the receiver (34.4%) before surgery had changes in the lower leg veins in view of
operating characteristic curves of 0.82, 0.813, 0.819, 0.815, 0.817 and varicose subcutaneous veins and post-thrombophlebitic syndrome
0.813, respectively. The Hosmer–Lemeshow goodness-of-fit showed combined with disorders of endothelial vasodilating function and low
good calibration in only the customized APACHE II (H-statistic 12.4, venous tone. Tourniquet use in patients with venous pathology resulted
P = 0.26). See Figure 1. in DVT in 30% (five of 15 patients). When a tourniquet was not used in
Conclusion In this study, the customized APACHE II was found to be patients with venous disease, DVT was found only in one of 28 patients
accurate in predicting hospital mortality in septic shock patients (3.5%). The test showed a significant difference in the frequency of
requiring ICU admission. thromboembolic complications in these groups (P <0.001).
Conclusion Therefore, using a tourniquet in patients with evident base
venous pathology in terms of varicose subcutaneous veins or post-
P417 thrombophlebitic syndrome in total knee joint endoprosthetics is a risk
Risk factors of venous thrombosis in knee joint endoprosthesis factor for venous thrombosis development.
SV Vlasov, IV Vlasova Reference
Scientific Clinical Center of Miner’s Health Protection, Leninsk-Kuznetsky, Russia 1. Celermajer DS, et al.: Non-invasive detection of endothelial dysfunction in
Critical Care 2012, 16(Suppl 1):P417 (doi: 10.1186/cc11024) children and adults at risk of atherosclerosis. Lancet 1992, 340:1111-1115.
anticoagulant and one-third received mechanical prophylaxis. Methods Fifty-seven patients with severe trauma were divided into
Thrombotic rates are higher in patients with HIT and suspected HIT two subgroups: 30 DIC patients and 27 non-DIC patients. The serum
than other patients. The frequent suspicion of HIT in critically ill patients levels of angiogenic factors were measured on admission (day 1), day
and initiation of other interventions may create a greater clinical and 3, and day 5. We compared serum levels of these angiogenic factors
economic burden than HIT itself. between with and without DIC groups and evaluated their predictive
value for organ dysfunction and outcome.
P424 Results DIC patients showed higher Sequential Organ Failure Assess-
Evaluation of iron, transferrin and ferritin serum levels in patients ment (SOFA) scores, soluble fibrin and lactate levels. The serum levels
with severe sepsis and septic shock of VEGF, Ang1, and the sTie2 levels were lower in the DIC patients than
M Missano Florido, M Assunção, B Mazza, M Jackiu, F Freitas, A Bafi, the non-DIC patients. The serum levels of sVEGFR1, Ang2 and the
F Machado Ang2/Ang1 ratio in the DIC patients were higher than in those without
UNIFESP, São Paulo, Brazil DIC. The sVEGFR2 levels showed no statistically significant difference
Critical Care 2012, 16(Suppl 1):P424 (doi: 10.1186/cc11031) between the patients with and without DIC. The levels of sVEGFR1,
Ang2 and the Ang2/Ang1 ratio correlated with the SOFA score. In
Introduction Iron metabolism is altered in critically ill patients leading particular, sVEGFR1 and Ang2 were independent predictors of an
to hypoferremia. Several studies related it to inflammatory response increase in the SOFA score. The lactate levels independently predicted
[1,2]. The present study aims to evaluate iron, transferrin and ferritin increases in the levels of sVEGFR1 and Ang2 and platelet consumption
serum levels in patients with severe sepsis and septic shock and its also independently predicted the increase in Ang2 levels in severe
association with severity of organ dysfunction. trauma patients with DIC.
Methods A prospective observational cohort study, unicentric, in Conclusion Angiogenic factors and their soluble receptors, particularly
a tertiary teaching hospital. From November 2010 to October 2011 sVEGFR1, play pivotal roles in the development of organ dysfunction in
patients over 18 years old with severe sepsis or septic shock with up DIC associated with severe trauma. The DIC-induced tissue hypoxia and
to 72 hours of organ dysfunction were included. Exclusion criteria were platelet consumption plays crucial roles in inducing sVEGFR1 and Ang2,
blood transfusion or iron supplementation in the last 90 days, previous and in determining the prognosis of the severity of organ dysfunction.
inclusion and pregnancy. After obtaining informed consent, blood
samples were taken at baseline and on day 7. Demographic and APACHE P426
II and SOFA data were also collected. Patients who were transfused with A simple blood-saving bundle reduces diagnostic blood loss in
red blood cells between the two periods were excluded from the day 7 mechanically ventilated patients
sample. Patients were followed until hospital discharge or death. R Riessen, M Behmenburg, G Blumenstock, D Guenon, S Enkel, M Haap
Results Thirty patients were included, with a mean age of 59.6 ± 19.3, University Hospital Tübingen, Germany
APACHE II score 19.1 ± 7.2, SOFA at baseline 8.5 ± 4.0, and most patients Critical Care 2012, 16(Suppl 1):P426 (doi: 10.1186/cc11033)
had septic shock (63.3%). Baseline iron and transferrin levels were low in
83.3% (14.0 (5.0 to 25.5)) and in 96.7% (94.1 ± 31.6) of the patients, while Introduction By introducing a blood-saving-bundle (BSB) consisting
ferritin was high in 63.3% (954.0 (508.4 to 5,394.0)). In the 19 patients of a closed-loop arterial blood sampling system, smaller tubes and an
where a day 7 sample was available, variation between baseline and day attempt to reduce the number of blood samples, we aimed to reduce
7 was statistically significant for transferrin (97.9 ± 37.5 to 132.7 ± 48.3, blood loss caused by diagnostic blood sampling and to minimize the
P = 0.013) and ferritin (478.0 (224.5 to 1,741.0) to 376.0 (187.0 to 886.7), development of anemia in a high-risk group of mechanically ventilated
P = 0.018), while iron levels showed a trend towards increasing levels intensive care patients.
at day 7 (17.0 (6.5 to 44.3) to 29.0 (21.0 to 54.0), P = 0.061). Baseline Methods Included were all patients from our medical ICU who were
SOFA score trends to be lower in hypoferrinemic patients (7.7 ± 3.8 vs. ventilated for more than 72 hours. Exclusion criteria were acute or
12.4 ± 1.9, P = 0.098). The Spearman test showed a weak correlation chronic anemia on admission, a bleeding episode during the ICU stay
only between SOFA and iron levels (P = 0.008; r2 = 0.48). or end-of-life therapy. The BSB was introduced in 2009 with training
Conclusion Septic patients have low iron and transferrin levels, and educational support. Patients treated in the year 2008 before the
associated with high ferritin levels, and those levels improved during introduction of the BSB served as a control group and were compared
the course of disease. Low iron levels might be associated with low to patients treated in 2010 after introduction of the BSB (BSB group).
SOFA scores. Daily blood loss was calculated on the basis of the documentation of
References blood samples and laboratory values in the patient data management
1. Lagan AL, et al.: Am J Physiol Lung Cell Mol Physiol 2008, 294:L161-L174. system and by using data from two representative study periods in
2. Quinlan GJ, et al.: Am J Respir Crit Care Med 1997, 155:479-484. which the sample volumes of all diagnostic blood tests were measured.
Results The control group comprised of 41 patients (614 observation
P425 days), the BSB group of 50 patients (559 observation days). Mean blood
Using angiogenic factors and their soluble receptors to predict loss per ICU day decreased from 43.3 ml (95% CI 41.2 to 45.3 ml) in
organ dysfunction in patients with disseminated intravascular the controls to 15.0 ml (14.3 to 15.7 ml) in the BSB group (P <0.001).
coagulation associated with severe trauma The introduction of a closed-loop arterial blood sampling system
T Wada1, S Jesmin2, S Gando3, S Zaedi2, H Yokota1 contributed most to this effect. Mean hemoglobin values showed
1
Nippon Medical School, Tokyo, Japan; 2National Center for Global Health a similar decrease in both groups during the ICU stay. However,
and Medicine, Tokyo, Japan; 3Hokkaido University Graduate School of hemoglobin values <9 g/dl were measured in 21.2% of observation
Medicine, Sapporo, Japan days in the controls versus 15.4% in the BSB group (P = 0.01). In the
Critical Care 2012, 16(Suppl 1):P425 (doi: 10.1186/cc11032) control group 31.7% (18.1 to 48.1%) of the patients received red blood
cell transfusions in contrast to only 8.0% (2.2 to 19.2%) in the BSB group
Introduction Disseminated intravascular coagulation (DIC) is observed (P = 0.006), while the hemoglobin concentration triggering transfusion
after not only sepsis but also trauma. DIC is associated with concomitant was not significantly different (8.2 vs. 7.8 g/dl). The mean number
activation of coagulofibrinolytic disorder and systemic inflammation of intubation days was 7.1 days (6.1 to 8.3 days) in the controls and
with endothelial dysfunction and microvascular permeability. The 7.5 days (6.6 to 8.5) in the BSB group (P = NS). However, patients in the
angiogenic factors, including vascular endothelial growth factor BSB group stayed with a mean of 9.8 days (8.6 to 11.3 days) significantly
(VEGF), angiopoietin (Ang), and their receptors, play crucial roles in shorter in the ICU than controls with 13.2 days (10.9 to 15.4 days)
angiogenesis and microvascular permeability. The aim of the study was (P = 0.014).
to assess: the relationship between angiogenic factors, their soluble Conclusion Our BSB could easily be implemented and was able to
receptors and organ dysfunction associated with DIC precipitated by reduce diagnostic blood loss by 65%. After introduction of the BSB
severe trauma; and the effects of DIC-induced platelet consumption, we observed less transfusions and a shorter ICU stay in mechanically
thrombin generation and tissue hypoxia on the expression of these ventilated patients; this, however, has to be interpreted with caution
factors and receptors. due to the longitudinal study design.
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P427 P429
Comparative assessment of invasive and noninvasive methods for Templating effect of clot structure can predict clot
detection of total hemoglobin in gynecological patients’ blood development and outcome in diluted blood: a comparison with
AV Pyregov, SV Petrov thromboelastography
Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia M Lawrence1, J Kaczynski2, S Stanford1, R Morris3, P Evans2
1
Critical Care 2012, 16(Suppl 1):P427 (doi: 10.1186/cc11034) Swansea University, Swansea, UK; 2ABMU LHB, Swansea, UK; 3UWIC, Cardiff, UK
Critical Care 2012, 16(Suppl 1):P429 (doi: 10.1186/cc11036)
Introduction Safety of patients is possible to increase applying
early detection of intraoperative and postoperative hemorrhage Introduction Treatment of major hemorrhage with colloids is known to
using the widening array of monitoring opportunities; not only the have an effect on clot outcome. However, determining both the rate and
hemodynamic parameters, but the detection of total hemoglobin. extent of these changes is difficult. Development of a new biomarker
Continuous noninvasive monitoring of total hemoglobin content is has shown that it can detect structural development earlier and
possible due to the Masimo Rainbow SET technology, using multiwave quantifies these changes to clot outcome accurately when compared
spectrophotometry. to other methods. This study compares the fractal dimension, Df [1],
Methods Seventy-eight patients aged 15 to 59 (35.9 ± 1.62) with found when the clot first forms to measures of mature clot firmness
laparoscopic gynecological operations were included in the research obtained from thromboelastography.
after permission of the ethics committee and signing the informing Methods Forty healthy blood samples were obtained; each sample
agreement. Total hemoglobin was detected by laboratory method was allocated a random dilution ratio (10%, 20%, 40%, 60%) and
invasively, discretely and delayed. Total hemoglobin was detected by diluted with gelofusine. These were matched with 40 healthy samples
another method oximetrically (SpHb) during the monitoring process that were undiluted. An oscillatory shear technique was applied to the
on the platform Rainbow SET technology noninvasive, continuous, and blood using an AR-G2 measuring Df (clot structure). Additionally the clot
promptly. SpHb was compared with total hemoglobin on the following development in terms of firmness was measured using a ROTEM analyser
stages of the research: before the operation, during the operation and measuring at 5, 10, 15 minutes and its maximum (A5, A10, A15, MCF).
in the early postoperative period. Statistical analysis was fulfilled by Results Df significantly decreases with increasing dilution. The decrease
comparing real and tabular (critical) criteria of reliability – Student test. in structural complexity indicates that gelofusine even at 40% dilution
Results During the detection of total hemoglobin by the laboratory is producing poor quality clots. See Table 1.
method, the mean value was 121.5 ± 17.28 g/l, while oximetrically it
occurred 118.6 ± 17.41 g/l. The real criterion of reliability (tr) was 0.85, Table 1 (abstract P429). Change in Df with dilution
the critical criterion of reliability (tcr) was 2.63.
Dilution % Df
Conclusion We did not discover statistically significant differences
of total hemoglobin determined by two different methods. Thereby, 0 1.74 (0.05)
noninvasive monitoring of total hemoglobin contention using
10 1.72 (0.04)
multiwave spectrophotometry by Masimo Rainbow SET technology
can serve as an appropriate replacement for the laboratory screening 20 1.70 (0.06)
of hemoglobin. 40* 1.63 (0.05)
60* 1.59 (0.06)
*Significant decrease from 0%.
Table 1 (abstract P430) Table 1 (abstract P431). Results of the fractal dimension obtained by
rheometry of fibrin clots
Mean Df Mean MCF (mm)
Thrombin (NIH) Fractal dimension
Pre enoxaparin 1.79 ± 0.08 68.0 ± 8.0
0.02 1.85
Post enoxaparin 1.64 ± 0.10 64.3 ± 4.2
0.1 1.95
0.3 2.13
Figure 1 (abstract P431). CLSM micrographs of formed fibrin clots at thrombin levels of 0.02, 0.1 and 0.3 NIH.
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site and severity of each bleeding event, which was reevaluated by two Conclusion Reducing frequent laboratory testing, and potential
independent blinded adjudicators. Patients with trauma, orthopedic phlebotomy complications, is a major concern in critical care medicine. If
surgery or neurosurgery were excluded. Major bleeding was defined as one could predict in advance whether a laboratory test would be normal
life threatening, occurring in critical sites, requiring ≥2 units of red blood or abnormal then that particular laboratory test may not be ordered,
cells or an invasive intervention, or associated with an unexplained and thereby reducing potential complications and costs. In this work we
decrease in systolic blood pressure (≥20 mmHg) or increase in heart present an artificial intelligence method for the classifying the likelihood
rate (≥20 beats/minute). We used Cox proportional hazard models of a blood test being normal or abnormal. Our results show acceptable
adjusting for age, APACHE II, reason for ICU admission, end-stage renal classification accuracy both in terms of sensitivity and specificity.
disease, drugs affecting coagulation, coagulation parameters and life-
support interventions to identify predictors of bleeding.
Results Among 3,746 patients, 208 had major bleeding (5.6%, 95% CI P437
4.9 to 6.3%). The commonest bleeding sites were: gastrointestinal tract Hemostasis system condition in infectious complication
(51.9%), surgical site (30.3%), respiratory tract (15.9%), retroperitoneal development in severe burned patients
(8.2%) and intracranial (3.4%). Independent predictors of major M Presnyakova, V Kuznetsova
bleeding (expressed as hazard ratio with 95% CI) were: prolonged Nizhny Novgorod Research Institute of Traumatology and Orthopedics,
activated partial thromboplastin time (aPTT) (1.10, 1.05 to 1.14 per Nyzhny Novgorod, Russia
10-second increase), thrombocytopenia (1.16, 1.09 to 1.24 per 50×109/l Critical Care 2012, 16(Suppl 1):P437 (doi: 10.1186/cc11044)
decrease in platelet count), therapeutic heparin (3.26, 1.72 to 6.17), anti-
platelet agents (that is, acetylsalicylic acid and/or clopidogrel) (1.38, Introduction Over the period of the history of combustiology one of
1.02 to 1.88), renal replacement therapy (1.75, 1.20 to 2.56) and surgery the main problems for treatment of patients with burns is infection,
in the preceding 3 days (1.64, 1.01 to 2.65). Prophylactic dalteparin in both local – bacterial pneumonia – and generalized – sepsis –
the preceding 3 days was not associated with bleeding. characterized by extremely severe course, complex diagnostics
Conclusion Major bleeding occurred in 5.6% of medical–surgical ICU and high lethality rate. However, the role of hemostasis disorders in
patients. Prolonged aPTT, thrombocytopenia, therapeutic (but not infectious complication development in severe burned patients is
prophylactic) heparin, anti-platelet agents and recent surgery are taken into consideration insufficiently. The aim of the study is to reveal
potentially modifiable and independent predictors of bleeding. the most relevant hemostasis system changes in sepsis and pneumonia
in patients with serious heat injury in an acute period of burn disease.
Methods Hemostasis and biochemical blood parameters were studied
in 169 patients with over 20% of the body burned, from the first to
P436 12th days after burn. Sepsis developed in 33 patients, 69 patients had
Reducing ICU blood draws with artificial intelligence pneumonia, and in 67 patients there were no complications of sepsis
FC Cismondi1, AS Fialho1, SM Vieira2, LA Celi1, SR Reti3, JM Sousa2, and pneumonia. Infectious septic complications were diagnosed
SN Finkelstein1 in the clinic on the basis of clinical and laboratory findings, as well
1
Massachusetts Institute of Technology, Cambridge, MA, USA; 2IST, Lisbon, as confirmed by morphological studies in casualties (44 from 102
Portugal; 3BIDMC, Brookline, MA, USA patients). Diagnosis of disseminated intravascular coagulation (DIC)
Critical Care 2012, 16(Suppl 1):P436 (doi: 10.1186/cc11043) syndrome was made based on standard criteria.
Results The analysis of findings showed both sepsis and pneumonia
Introduction Recent studies have demonstrated that frequent development in an acute period of burn disease to be accompanied by
laboratory testing does not necessarily relate to better outcomes. Our disorders of anticoagulant, fibrinolytic and procoagulant parts of the
aim is to reduce unnecessary blood draws for ICU laboratory tests by hemostasis system typical for DIC syndrome. The changes of hemostasis
predicting which tests are likely to return as normal or abnormal and system indices were not only the characteristic of infection in burned
therefore influence clinical management around gastrointestinal (GI) patients but they preceded the diagnosis of sepsis and pneumonia
bleeding. in the clinic on average by 2 to 4 days. In patients with pneumonia,
Methods An artificial intelligence tool, namely fuzzy systems, was relevant and statistically significant were the activity changes of XIIa-
applied to 1,092 GI bleed patients extracted from a large ICU database dependent fibrinolysis, from the second to sixth days. And on the
with over 32,000 patients. A classification approach for laboratory test third to seventh days there was reliable pneumonia development
outcome was utilized for a total of seven outcome variables shown in with decreased activity of antithrombin III. In patients with sepsis were
Table 1. The outcome for each test was binarized as normal or abnormal. revealed changes of XIIa-dependent fibrinolysis activity – from the
Input variables included 10 physiological variables such as heart rate, third to seventh days – and antithrombin III activity – from the third to
temperature and urine output, as well as further data on transfusions the sixth days.
for platelets, red blood cells and plasma. Conclusion The development of both local and generalized infection in
Results Classification accuracy of greater than 80% was achieved for an acute period of burn disease occurs against the background of DIC
all of the seven outcome variables (Table 1). Sensitivity and specificity syndrome induced by a serious heat injury. The indices of hemostasis
were satisfactory for all the outcomes. Input variables frequently system can be included into a complex of clinic and laboratory studies
selected as most predictive of normal or abnormal results include urine aimed at detecting infection and early intensive etiopathological
output and red blood cell transfusion. therapy.
Conclusion In our population of severely injured patients, the MTP was data regarding its impact on tissue metabolism. The aim of this study
not found to be beneficial in regards to mortality nor coagulopathy. was to explore the effect of RBC transfusion on microdialysis-assessed
Hypothermia and acidosis seem to be the main determinants for interstitial fluid metabolic parameters in septic patients.
mortality and should be among the priorities in caring for trauma Methods We conducted an observational, clinical study in a 25-
patients. bed, medical–surgical ICU of a university hospital. We analyzed the
Reference effect of transfusion of either 1 or 2 RBC units on interstitial fluid
1. Cotton BA, et al.: J Trauma 2009, 66:41-49. metabolic activity by means of a microdialysis (MD) catheter inserted
in the subcutaneous adipose tissue of the upper thigh. Samples were
collected before (T0) and after (T1a and T1b; spaced out by 4 hours)
P445 transfusion. Lactate, pyruvate, glycerol and glucose concentrations
Massive transfusion practice were measured with a bedside analyzer and the lactate/pyruvate (LP)
M Campbell, G Yakandawala, S Liddle, K Mehta, J Chooi ratio was calculated automatically.
BHR NHS Trust, London, UK Results We enrolled 37 patients with severe sepsis/septic shock
Critical Care 2012, 16(Suppl 1):P445 (doi: 10.1186/cc11052) requiring RBC transfusion. After transfusion, the mean arterial pressure
increased from 79 ± 9 to 82 ± 10 (T1a vs. T0: P <0.05) and 83 ± 10
Introduction Management of massive blood loss requires a multi- mmHg (T1b vs. T0: P <0.001). Besides a nonstatistically significant drop
disciplinary team approach. Current guidelines are varied and generic in arterial partial oxygen pressure, we observed no change in arterial
with a lack of adherence when it comes to management of massive blood gases and vital signs. Overall, RBC transfusion did not alter any
haemorrhage. The aim of our survey was to assess the transfusion of the MD-assessed parameters (that is, lactate, pyruvate, glycerol and
practice in the management of massive haemorrhage in a busy district glucose) or blood lactate, but it decreased the tissue LP ratio from (T0)
general hospital with a tertiary neurosurgical centre and the busiest 18.80 (interquartile range (IQR), 14.85 to 27.45) to (T1a) 17.80 (IQR,
obstetric unit in London. 14.35 to 25.20) (P <0.05) and (T1b) 17.90 (IQR, 14.45 to 22.75) (P <0.001).
Methods A retrospective analysis of cases requiring transfusion of The post-transfusion changes in LP ratio at T1a (r = –0.42; 95% CI, –0.66
more than 6 units of red blood cells (RBC), between January 2009 and to –0.098; P = 0.01) and T1b (r = –0.68; 95% CI, –0.82 to –0.44; P <0.001)
January 2010. Sixty-eight cases of massive transfusion were identified, were significantly correlated with the pre-transfusion LP ratio but not
and data collected included causes of the haemorrhage, patient’s with baseline demographic characteristics, vital signs, severity scores,
demographics and past medical background, investigations (FBC, hemoglobin level and blood lactate. Finally, 39.0% of the transfused
clotting), use of blood products and patient outcome. RBC units were leukoreduced and their median storage time was
Results There were 21 gastrointestinal, 17 vascular, 12 general surgical, 16 days (IQR, 11 to 24). RBC storage time and leukocyte reduction had
seven trauma, six obstetric, and five haematology–oncology patients. no influence on the tissue metabolic response to transfusion.
Thirty-one per cent of patients were 61 to 80 years old. Overall mortality Conclusion Tissue oxygenation is improved by red blood cell
was 35%, highest mortality among vascular patients. Average blood transfusion in critically ill septic patients. Monitoring of the tissue LP
products per patient: RBC 9 units, fresh frozen plasma (FFP) 4 units, ratio by microdialysis may represent a useful method for individual
platelets (PLT) 1.2 units, cryoprecipitate 0.67 units. Tranexamic acid was clinical management.
used in eight cases and factor VII in one case. At the time of haemorrhage,
FBC, clotting screen and fibrinogen levels were requested in 56% of P447
patients. In this group, FFP, PLTs and cryoprecipitate were used more Blood transfusion after cardiac surgery increases the hospital
frequently with mean use of blood products: RBC 9 units, FFP 5 units, length of stay in adult patients
PLT 1.5 units, and cryoprecipitate 1 unit. L Hajjar1, JL Vincent2, J Almeida1, F Jatene1, A Rodrigues1, J Fukushima1,
Conclusion Blood product use varied widely irrespective of speciality, R Nakamura1, C Silva1, E Osawa1, R Kalil1, F Galas1, J Auler Jr1
1
the dependent factor being individual doctors involved in patient Heart Institute, São Paulo, Brazil; 2Erasme Hospital, Université libre de
management. Due to difficulty of accessing and their complexity Bruxelles, Belgium
in emergency situations, it was noted that hospital guidelines Critical Care 2012, 16(Suppl 1):P447 (doi: 10.1186/cc11054)
were disregarded. FFP was the commonly used blood product
while cryoprecipitate and tranexamic acid were underused. Only Introduction Transfusion of allogeneic red blood cells (RBC) is a
56% of patients had FBC and clotting screen to guide transfusion recognized risk factor for adverse outcomes following cardiac surgery.
management. In these patients the ratio of cryoprecipitate and PLTs A potential endpoint to assess clinical complications and incremental
to RBCs was higher. This survey showed the need for revised, easily use of resources is the measurement of hospital length of stay (LOS).
accessible and user-friendly guidelines for the management of massive The primary objective of this study was to evaluate the relationship
haemorrhages. The results of this survey helped to establish point- between blood transfusion and increased hospital LOS after cardiac
of-care testing (thromboelastography) to provide a target controlled surgery.
therapy and make the use of blood and blood products cost-effective. Methods A prospective observational substudy that analyzed data
References from the overall 502 patients enrolled in the Transfusion Requirements
1. CRASH-2 Trial Collaborators et al.: Lancet 2010, 376:23-32. After Cardiac Surgery (TRACS) study [1]. Patients who received blood
2. Johansson PI, Stensballe J: Transfusion 2010, 50:701-710. transfusion during surgery or ICU stay were further categorized
3. Zink KA, Sambasivan CN, Holcomb JB, Chisholm G, Schreiber MA: Am J Surg according to the number of prescribed RBC units: nontransfusion
2009, 197:565-570. group, low transfusion requirement group (3 units or less), and high
4. Enriquez LJ, Shore-Lesserson L: Br J Anaesth 2009, 103(Suppl 1):i14–i22. transfusion requirement group (more than 4 units).
Results Patients who received any RBC unit had longer median LOS
than patients in the nontransfusion group: 15 days (95% CI, 12.66 to
P446 17.34) in high transfusion requirement group versus 10 days (95% CI,
Red blood cell transfusion improves microdialysis-assessed 9.1 to 10.9) in low transfusion group versus 8 days (95% CI, 7.4 to 8.6)
interstitial lactate/pyruvate ratio in critically ill septic patients in nontransfusion group (P <0.001). In a multivariate Cox proportional
P Kopterides, N Nikitas, M Theodorakopoulou, A Diamantakis, hazards model the following factors were considered predictive: age
D Vassiliadi, A Kaziani, S Assoti, F Drakopanagiotakis, A Antonopoulou, older than 65 years (hazard ratio (HR), 1.38 (95% CI, 1.11 to 1.73);
P Papadopoulos, E Mavrou, C Georgiadou, A Tsantes, A Armaganidis, P = 0.004), EuroSCORE 3 to 5 (HR, 1.44 (95% CI, 1.12 to 1.86); P = 0.005),
I Dimopoulou EuroSCORE higher than 5 (HR, 1.7 (95% CI, 1.26 to 2.28); P <0.001),
‘Attiko’ University Hospital, Haidari – Athens, Greece valvular surgery (HR, 1.57 (95% CI, 1.26 to 1.95); P <0.001), combined
Critical Care 2012, 16(Suppl 1):P446 (doi: 10.1186/cc11053) procedure (HR, 1.6 (95% CI, 1.03 to 2.46); P = 0.034), bypass duration
higher than 100 minutes (HR, 1.23 (95% CI, 1.01 to 1.51); P = 0.046),
Introduction Even though red blood cell (RBC) transfusion is a LVEF lower than 40% (HR, 1.69 (95% CI, 1.24 to 2.32); P = 0.001), LVEF
common intervention in the critical care setting, there is a paucity of 40 to 59% (HR, 1.36 (95% CI, 1.1 to 1.69); P = 0.004), RBC transfusion
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of 1 to 3 units (HR, 1.24 (95% CI, 1.01 to 1.53); P <0.001), and RBC controlled trials (RCTs) and observational studies comparing the effect
transfusion >3 units (HR, 1.96 (95% CI, 1.45 to 2.66); P <0.001). In an of two or more different PLT:RBC ratios in trauma resuscitation. We
adjusted model for age, EuroSCORE, type of surgical procedure, LVEF excluded studies using whole blood or systematically addressing the
and cardiopulmonary bypass time, the exposure to RBC transfusion use of hemostatic products. Two independent reviewers selected the
was associated with an elevated LOS. studies, extracted data using a standardized form, and assessed the
Conclusion Blood transfusion is an independent risk factor for risk of bias using the Newcastle–Ottawa scale and a checklist of key
prolonged hospital LOS after cardiac surgery. This finding can support methodological elements (for example, use of massive transfusion
the development of blood conservation strategies in order to avoid protocol, survival bias). Disagreements were solved by consensus or a
deleterious outcomes of blood exposure. third party. The primary outcome was mortality. Secondary outcomes
Reference were multiple organ failure (MOF), lung injury and sepsis. A meta-
1. Hajjar LA, Vincent JL, Galas FR, et al.: Transfusion requirements after cardiac analysis using random effects models was planned.
surgery: the TRACS randomized controlled trial. JAMA 2010, 304:1559-1567. Results From 6,123 citations, seven observational studies were included
(n = 4,230 patients). No RCT was identified. All studies were considered
to be at low risk of bias and addressed confoundings through
P448 multivariate regression or propensity scores. Four studies (n = 1,978)
Transfusion of blood stored for longer periods of time does not alter reported a decrease in mortality with higher PLT:RBC ratios in patients
the reactive hyperemia index in healthy volunteers requiring massive transfusion and one study observed no mortality
A Coppadoro1, L Berra2, B Yu2, C Lei2, E Spagnolli2, AU Steinbicker2, difference (n = 1,181) in nonmassively transfused patients. Two studies
KD Bloch2, T Lin2, HS Warren2, FY Sammy2, BO Fernandez3, M Feelisch3, reported on the implementation of a massive transfusion protocol with
WH Dzik2, CP Stowell2, WM Zapol2 higher PLT:RBC ratios; only one revealed a survival benefit (n = 211).
1
University of Milan-Bicocca, Monza, Italy; 2Massachusetts General Hospital, Of the three studies accounting for survival bias, two demonstrated
Boston, MA, USA; 3University of Warwick, Coventry, UK a survival benefit (n = 1,300). Among two studies reporting on the
Critical Care 2012, 16(Suppl 1):P448 (doi: 10.1186/cc11055) secondary outcomes (n = 854), one observed an increase in MOF with
higher PLT:RBC ratios. Clinical heterogeneity between studies and
Introduction The purpose of this study is to investigate the effects methodological limitations precluded the use of a meta-analysis.
of transfusing human packed red blood cells (PRBC) after prolonged Conclusion There is insufficient evidence to strongly support the use of a
storage, as compared to short storage. Retrospective data suggest that specific PLT:RBC ratio for acute trauma resuscitation, especially considering
transfusion of PRBC stored for over 2 weeks is associated with increased survival bias and nonmassively transfused patients. RCTs examining both
mortality and morbidity. During storage, PRBC progressively release safety and efficacy of liberal PLT transfusions are warranted.
hemoglobin, which avidly binds nitric oxide (NO). We hypothesized
that the NO-mediated hyperemic response following ischemia would P450
be reduced after transfusion of PRBC stored for 40 days. Impact on early trauma mortality of the adoption of the Updated
Methods We conducted a cross-over randomized interventional study, European Guidelines on the management of bleeding
enrolling 10 healthy adults. Nine volunteers completed the study; E Cingolani1, G Nardi2, G Ranaldi2, C Siddi2, S Rogante2, A Ciarlone2
1
one volunteer could not complete the protocol because of anemia. Azienda Ospedaliera San Camillo Forlanini, Roma, Italy; 2S.Camillo Hospital,
Each volunteer received 1 unit of 40-day and 1 unit of 3-day stored Roma, Italy
autologous leukoreduced PRBC, on different study days according to Critical Care 2012, 16(Suppl 1):P450 (doi: 10.1186/cc11057)
a randomization scheme. Blood withdrawal and reactive hyperemia
index (RHI) measurements were performed before and 10 minutes, Introduction Post-traumatic bleeding is the leading cause of potentially
1 hour, 2 hours, and 4 hours after transfusion. preventable death among trauma patients. The Updated European
Results The change of RHI after transfusion of 40-day stored PRBC Guidelines (UEG), published at the beginning of 2010, were aimed to
did not differ as compared to 3-day stored PRBC (P = 0.67). Plasma provide an evidence-based multidisciplinary approach to improve the
hemoglobin and bilirubin levels were higher after transfusion of 40-day management of the critically injured bleeding trauma patients. The aim
than after 3-day stored PRBC (P = 0.02 and 0.001, respectively). Plasma of this study is to evaluate the impact of the implementation of UEG
levels of potassium, LDH, haptoglobin, cytokines, as well as blood recommendations on early hospital mortality for severe trauma in a
pressure, did not differ between the two transfusions and remained high-flow trauma center.
within the normal range. Plasma nitrite concentrations increased after Methods S. Camillo Hospital is a level 1 trauma center based in
transfusion of 40-day stored PRBC, but not after transfusion of 3-day downtown Rome, with a catchment population of 2.5 million people.
stored PRBC (P = 0.01). UEG recommendations were formally adopted and implemented since
Conclusion Transfusion of 1 unit of autologous PRBC stored for longer 1 April 2010. The pre-existing hospital guidelines were modified as
periods of time is associated with increased hemolysis, an unchanged follows: immediate pelvic ring closure for all unstable patients with
RHI and increased levels of plasma nitrite in healthy volunteers. a suspected pelvic fracture; early administration of plasma with a
higher rate of plasma/blood units; early use of thromboelastometry
to monitor bleeding patients; and early use of antifibrinolitics for all
P449 bleeding patients. Data on trauma admissions and early hospital (6
Liberal use of platelet transfusions in the acute phase of trauma hours) mortality before (2009) and after the adoption of the UEG were
resuscitation: a systematic review collected using the hospital registry, and were subsequently analysed.
J Hallet1, F Lauzier1, O Mailloux2, V Trottier1, P Archambault2, Results A total of 1,617 patients met the criteria for full trauma team
R Zarychanski3, AF Turgeon1 activation (551 in 2009, 528 in 2010 and 538 during the first 11 months
1
CHA-Hôpital de l’Enfant-Jésus, Université Laval, Québec, Canada; 2Université of 2011). There were no differences for gender, age, mechanism of
Laval, Québec, Canada; 3University of Manitoba, Winnipeg, Canada injury and average ISS. In 2009 21 patients died within the first 6 hours
Critical Care 2012, 16(Suppl 1):P449 (doi: 10.1186/cc11056) versus 17 in 2010 and 12 in 2011; P = 0.3, P for trend = 0.1 Hemorrhage
was the most important cause of death within this time-span. All early
Introduction With the recognition of early trauma coagulopathy, trauma deaths occurred in the operating room or in the emergency
trauma resuscitation has recently shifted towards early and aggressive room during the initial stabilization.
transfusion of platelets (PLTs). However, the clinical benefits of this Conclusion This is a retrospective cohort study based on the data of the
strategy remain controversial. This systematic review examined the S. Camillo Hospital registry and the emergency department electronic
impact of an aggressive approach (higher PLT:RBC ratios) compared to shift. With the limitations of all retrospective studies, our data suggest
restrictive PLT transfusions (lower PLT:RBC ratios) in the acute phase of that the implementation of the European Guidelines recommendations
trauma resuscitation. might contribute to a relevant reduction in early trauma mortality.
Methods We systematically searched Medline, Embase, Web of Science, Reference
Biosis, Cochrane Central and Scopus to identify relevant randomized 1. Rossaint et al.: Crit Care 2010, 14:R52.
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P451 outcome measures were in-hospital mortality and time to death. The
Hemodynamics in the severely injured patient with significant secondary endpoint was to identify the effect of chronic medication
hemorrhage on mortality. Categorical variables were compared by chi-squared test
G Nardi, D Piredda, A Cossu, E Cingolani, M Cristofani, I Ghezzi and continuous variables by Student’s t/Mann–Whitney tests. Multiple
S. Camillo Hospital, Roma, Italy logistic regression analysis was used to predict mortality. P <0.05 was
Critical Care 2012, 16(Suppl 1):P451 (doi: 10.1186/cc11058) considered statistically significant.
Results The inclusion criteria were met by 261 patients. Age average was
Introduction Very little is known about the hemodynamic impairments 75.57 years (SD 5.7). Male gender was more prevalent (58.5%) for all age
induced by trauma and severe hemorrhage. The aim of this study is groups. The median ISS was 17. The most frequent trauma mechanism
to contribute to a better understanding of this topic. A recent paper was low-energy type (58.2%). Patients with chronic ACT numbered 41
has shown that about 50% of the hemorrhagic patients receive (15.7%). The mean ICU stay was 12.8 days (SD 2.8). Global mortality was
vasopressors [1] together with fluids, blood and plasma. Fluids and 34.1%. Age >78 years and ISS >18 were predictive of mortality (P <0.05)
vasopressors are aimed to restore patients’ hemodynamics; however, with a HR of 6.0 (CI 2.5 to 14.6) and 1.01 (CI 1.01 to 1.05) respectively.
they might be detrimental. Furthermore, the time to death was found to be earlier in both of the
Methods The setting was a 10-bed trauma ICU in a level 1 trauma latter groups (P <0.05). GCS <4 or bilateral mydriasis was associated
center with a catchment population of over 2.5 million people. This is with 100% mortality. About 15% of patients with low-energy trauma
a retrospective cohort study based on the data of the ICU electronic (LET) underwent ENS compared to 7.8% with high-energy trauma. For
shift. During a 24-month period (2009 and 2010), 780 patients with the same ISS category, ACT increases the risk with HR 2.7 (CI 1.2 to 6.3)
major trauma (ISS >15) were admitted to the hospital; 410 of them of ENS compared with nonanticoagulated patients.
were subsequently admitted to the shock and trauma ICU. All patients Conclusion LET accounted for most of the older trauma patients
with ISS >15, who had received ≥5 blood units before ICU admission, admitted to our ICU and had increased risk of death, especially with ACT.
and who were submitted to semi-invasive hemodynamic monitoring Although this is not necessarily secondary to alarming mechanisms.
(PICCO), were entered into the study. Reference
Results Thirty patients (mean age 42.7 ± 17, mean 37.5 ± 12) met the 1. Spaniolas et al.: Ground level falls are associated with significant mortality
study criteria. At the time of insertion of the PICCO catheter (T0) the 30 in elderly patient. J Trauma 2010, 69:821-825.
patients had already received an average of 8,760 ml fluids (3,239 ml
blood, plasma and platelets, 4,870 ml crystalloids and 685 ml colloids). P453
Systemic blood pressure, central venous pressure and heart rate at T0 Outcomes in older blunt chest wall trauma patients: a retrospective
were, as an average, in the normal range. Nevertheless, six patients study
(20%) had a Cardiac Index lower than 2.5 l/minute, and 76% had a DO2 C Battle, H Hutchings, PA Evans
significantly lower than the normal range. In the subsequent 24 hours Swansea University, Swansea, UK
following the information of the PICCO, these patients received, Critical Care 2012, 16(Suppl 1):P453 (doi: 10.1186/cc11060)
as an average, an additional 6,070 ml fluids, blood and plasma. All
vasopressors were discontinued, but 40% of the patients received Introduction Blunt chest wall trauma accounts for over 15% of all
dobutamine. Within 24 hours (T24), oxygen transport (DO2) and lactate trauma admissions to emergency departments in the UK and has high
were back to the normal values in all patients but one. ICU mortality morbidity and mortality rates [1]. Reported risk factors for morbidity
and hospital mortality were respectively 13.3% and 16%. and mortality in blunt chest trauma patients include patient age,
Conclusion A high percentage of the severely injured patients who pre-existing disease and three or more rib fractures [2]. No guidelines
received ≥5 units of PRC have a low oxygen transport at the time of exist for management of this patient group unless the patient has
ICU admission. A high percentage of them is treated with vasopressors. severe immediate life-threatening injuries. The aim of this study was
However, as 20% of the patients in our study had a low cardiac index to investigate whether blunt chest wall trauma patients aged 65
in spite of a normal blood pressure and a highly positive fluid balance, years or more have higher rates of mortality, morbidity (respiratory
vasopressors might be harmful. In our experience, hemodynamic complications), ICU admissions and hospital length of stay (HLOS) than
monitoring with PICCO allowed the early recognition of inappropriate patients aged less than 65 years.
oxygen transport and a goal-directed treatment. Our data do not Methods A retrospective study was completed in which the notes of
support the use of vasopressors to increase blood pressure in trauma 1,056 blunt chest wall trauma patients who presented in 2010 to the
patients. emergency department of a large regional trauma centre in Wales were
Reference examined. A total of 94 out of the 1,056 (9%) patients were admitted to
1. J Trauma 2011, 71:17-19. hospital in 2010 with blunt chest wall trauma. Data were recorded for
each of the admitted patients including patient age, severity of injury,
P452 morbidity, mortality, ICU admission and HLOS. Patients were grouped
Critical older trauma patients according to age; group one included all blunt chest wall trauma
M Irazábal, S Yus, L Fernández patients aged 65 years or more and group two included all patients
Hospital La Paz, Madrid, Spain aged less than 65 years. Pearson’s chi-square analyses were performed
Critical Care 2012, 16(Suppl 1):P452 (doi: 10.1186/cc11059) to determine whether any differences existed between the two groups
and significance set at P <0.05.
Introduction The aim of this study was characterize the older injured Results There was no significant difference in severity of injury between
patient in our setting and identify risk factors that might predict the groups. The mortality rate and HLOS in the patients aged 65 years
mortality. Trauma is the fifth leading cause of death over the age of or more were significantly higher (P <0.05) than in the younger patient
65. In Spain, it has become a major public health problem as a result group. There were no significant differences between the morbidity
of the increase of this population. It represents 30% of the trauma rates and number of ICU admissions.
admissions to our ICU. Geriatric patients may have comorbidities, Conclusion Blunt chest wall trauma patients have a significantly higher
limited physiologic reserve, may be taking chronic medication and the rate of mortality and hospital length of stay if aged 65 years or more
injury pattern is different [1]. when compared to those patients aged less than 65 years. Older blunt
Methods We retrospectively analyzed trauma patients aged 65 years chest wall trauma patients should be considered for a higher level of
and older admitted to our ICU from January 2000 through December care on admission to hospital from the emergency department.
2010. Three groups were formed on the basis of age: 65 to 70, 71 to 78 References
and older than 78 years. The Injury Severity Score (ISS) was categorized 1. Trauma Audit and Research Network: Blunt Chest Trauma Admissions in the UK
into three ranges: >12, 12 to 18 and >18. Variables studied include: in 2010. TARN; 2011. (Kindly provided by Tom Jenks.)
age, gender, mechanism of injury, anticoagulant therapy (ACT), ISS, 2. Blecher GE, Mitra B, Cameron PA, et al.: Failed emergency department
Glasgow Coma Scale (GCS) or presence of pupillary abnormalities disposition to the ward of patients with thoracic injury. Injury 2008,
and need for emergent neurosurgery (ENS) at admission. Primary 39:586-591.
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P454 Conclusion The uptake of this checklist has not been optimal, but the
Mortality trend alteration of thoracic injury after rapid response MSC provides an excellent tool for clear documentation of C-spine
trauma team establishment status. During this initial trial phase, October 2010 to December 2011,
K Chittawatanarat, C Ditsatham, K Chandacham, T Jirapongchareonlap, the MSC has been consultant-only. Further action will involve rolling-
N Chotirosniramit out the checklist to critical care trainee doctors to improve the rate of
Chiang Mai University, Chiang Mai, Thailand documentation of C-spine status and improve patient safety in this
Critical Care 2012, 16(Suppl 1):P454 (doi: 10.1186/cc11061) area of significant clinical risk [1].
Reference
Introduction The Department of Surgery, Faculty of Medicine, Chiang 1. Morris CG, et al.: BMJ 2004, 329:495-499.
Mai University established a rapid response trauma team (RRTT) in July
2006. The aims of this study were to verify mortality rate alteration after
setting up the RRTT. P456
Methods We retrospectively collected data between January 2004 and Effect of instrumented spinal fixation on outcome in polytrauma
September 2009. The month before July 2006 was defined as before patients in the ICU
RRTT and after July 2006 as after RRTT. The monthly mortality rate, G Simpson, C Menakaya, A Bidwai, R Pillay, M Dematas
severity injury score (ISS) and demographic data were collected. Royal Liverpool University Hospital, Liverpool, UK
Results A total 951 patients were included (427 (30 months) before Critical Care 2012, 16(Suppl 1):P456 (doi: 10.1186/cc11063)
RRTT and 524 (39 months) after RRTT). Of these, 83 patients (8.8%)
were dead after admission and analyzed for characters of mortality. Introduction Spinal injuries in polytrauma patients carry high
The average age of mortality patients was 38.7 ± 16.3 years. Male was morbidity and mortality often necessitating intensive care admission.
the predominant gender. The most common mechanism of injury A review of polytrauma patients admitted to the ICU at The Royal
was a motorcycle accident. Although there were no differences of Liverpool University Hospital was undertaken to investigate the effect
character and mechanism of injuries between the two periods, patients of spinal instrumentation on outcome in the ITU.
associated with maxillofacial injury had significant lower mortality Methods A retrospective review of all polytraumatized patients
after RRTT (28.5% vs. 10.5%; P = 0.04). However, the after RRTT group admitted to the RLUH ICU over 3 years with a thoraco-lumbar spinal
had significantly higher occurrence of urinary complication and acute fracture. Clinical records, laboratory results and radiological records
renal failure. The average adjusted monthly mortality rate was lower were accessed. Patients were grouped according to the use of
after RRTT (9.0 ± 6.1 vs. 6.9 ± 4.0%). Time series analysis between two instrumented spinal fixation versus conservative management and
periods demonstrated a decrease trend in monthly mortality after outcomes compared.
RRTT (coefficient (95% CI) = –0.61 (–1.13 to –0.23); P <0.01)). Results Fourteen polytrauma patients with spinal fractures were
Conclusion Rapid response trauma team establishment could decrease admitted to the ICU over 3 years, five managed conservatively with a
the mortality trend. A protective effect was predominant in patients TLSO brace and nine managed operatively with instrumented spinal
associated with maxillofacial injury. fixation. The degree of injury as graded by the Injury Severity Scale
(ISS) was lower in the nonoperative group (mean: 27, range: 14 to
59) compared to the operative group (mean: 36.1, range: 14 to 57).
P455 Mortality was significantly higher in patients conservatively managed
Trauma patients and cervical spine protection in critical care: the (nonoperative: 60%, operative: 0%) (P <0.01). The intubation time
impact of a spinal checklist on clinical care and documentation was lower in patients who underwent spinal instrumentation (mean:
A Chick, C Scott, H Ellis, A Tipton 12.3 days, range: 1 to 27 days), when compared to conservative
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK management (mean: 16 days, range: 11 to 27 days), and similarly the
Critical Care 2012, 16(Suppl 1):P455 (doi: 10.1186/cc11062) ITU length of stay was reduced in the operative group (operative:
mean 20.6 days, nonoperative: 32.25 days). Development of respiratory
Introduction In October 2010 a specific online proforma for cervical failure was decreased in patients treated with instrumented fixation
spine (C-spine) assessment in the context of trauma was introduced in (operative 33.3%, nonoperative: 71%).
critical care in a large UK teaching hospital. The aim of this study is to Conclusion Surgical stabilization of spinal fractures avoids restrictive
assess the impact of the Metavision Spinal Checklist (MSC) on clinical spinal braces and permits mobilization. Surgical fixation of spinal
care and documentation. Prior to October 2010, the documentation of fractures appears to decrease mortality and ITU stay and has a
C-spine status on admission to critical care was incomplete or unclear beneficial effect on respiratory function, with regards to degree of
in over 40% of these patients. ventilatory support and development of respiratory failure.
Methods Patients were identified from a comprehensive critical care
database. Inclusion criteria: age >16; polytrauma or traumatic brain
injury; other trauma where mechanism of injury suspicious for C-spine P457
injury; admission date after 1 October 2010, before 30 November 2011. Whole body computed tomography scanning for severe blunt
Exclusion criteria: pre-existing spinal injury; mechanism of trauma not polytrauma: analysis of Trauma Audit and Research Network
consistent with C-spine injury. Clinical and MSC details were recorded, database 2005 to 2010
including sequential forms for individual patients where the C-spine PA Hunt1, F Lecky2, O Bouamra2
1
status changed (for example, C-spine cleared and hard collar removed). James Cook University Hospital, Middlesbrough, UK; 2Hope Hospital, Salford,
Results A total of 62 patients met the inclusion criteria; 47% of these UK
had been transferred from a district hospital. In patients with an MSC Critical Care 2012, 16(Suppl 1):P457 (doi: 10.1186/cc11064)
completed, there was 100% documentation of time, date and name of
the completing critical care consultant. Seventy-five per cent of initial Introduction There is growing evidence to recommend the use of
MSCs indicated the name of the responsible consultant spinal surgeon. whole body computed tomography (WBCT) scanning in the early
Seventy-nine per cent of patients with a completed MSC required their management of severe blunt polytrauma patients. One recent study
C-spines to be cleared after critical care admission. When completed, reported a survival advantage when using WBCT compared to a
the initial MSC allowed clearance of C-spine and immediate removal conventional imaging approach [1]. A number of UK NHS institutions
of hard collar in 67% of those patients. There were clearly documented already utilise WBCT protocols based upon either injury mechanism-
instructions for C-spine care from a spinal consultant in 92% of patients related or physiological factors, or a combination of these. However, the
with a completed MSC. Overall, an MSC was completed for only 39% of UK Royal College of Radiologists is yet to provide recommendations on
patients, despite 53% of patients having sustained a spinal fracture at the use of WBCT in polytrauma. We present the results of our analysis
some level (for example, lumbar, thoracic or cervical). The median time of a large retrospective case series from 2005 to 2010 taken from the
from critical care admission to MSC completion was 36 hours (range 3 Trauma Audit and Research Network (TARN) database. We believe this
hours to 12 days, mean 48 hours). is the first analysis of its kind involving UK trauma cases and provides
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important evidence to support the use of WBCT and guide best clinical of maximal CPK levels (15,780 to 52,600 U/l), but more severe acidosis
practice. (lowest pH 7.0 to 7.2, maximum lactate: 7.5 to 28 mmol/l, acidosis
Methods We utilised retrospective, multicentre data of severe blunt duration: 72 to 84 hours). This acidosis turned out to be due to intra-
polytrauma (ISS >15) direct ED admissions aged >15 years recorded abdominal complications: post-traumatic pancreatitis and mesenteric
in the UK TARN database to compare survival at 30 days between two ischemia. The vital prognosis of post-traumatic crush injury was good
groups of patients: those who underwent WBCT scans, and those who but the sequelae of the compartment syndrome were major. The need
received a focused CT scan approach as part of their initial management for RRT was not linked to CPK levels but rather to acidosis due to intra-
in the emergency department. A total of 12,792 cases were included in abdominal complications.
the final dataset. References
Results A total 2,822 (22%) of 12,792 cases underwent WBCT from the 1. Bagley WH, Yang H, Shah KH: Rhabdomyolysis. Intern Emerg Med 2007,
ED. The median ISS for the WBCT group was 22 (IQR 14 to 33) compared 2:210-218.
to 16 (IQR 9 to 25) for the focused CT group. The calculated crude 2. Bosch X, Poch E, Grau JM: Rhabdomyolysis and acute kidney injury. N Engl J
mortality rate for the WBCT group was 10.1% compared to 8.7% in the Med 2009, 361:62-72
focused CT group (P = 0.0124). Multivariate analysis with adjustments
for potential confounding factors demonstrated an OR of 1.313 (95%
CI = 1.083 to 1.592, P = 0.006) in favour of survival in the WBCT group. P459
Conclusion Despite the crude mortality rates appearing to demonstrate Exertional rhabdomyolysis in female amateur triathletes
a poorer outcome in the WBCT group, correcting for confounding V Meighan
factors revealed an around 30% improvement in survival for the Galway University Hospital, Galway, Ireland
WBCT group. However, when also correcting for the potential effect Critical Care 2012, 16(Suppl 1):P459 (doi: 10.1186/cc11066)
of clustering, the benefit of WBCT is less clear, with an around 20%
improvement in survival and a lower level of significance (P = 0.084). Introduction Multisport endurance events are becoming increasingly
This effect may, in part, be due to differing trauma systems and popular in Ireland. Overexertion, especially in the heat, of overweight
logistical organisation between institutions. Overall, the results of our or poorly conditioned athletes increases the risk of rhabdomyolysis.
investigation appear to suggest a potential survival benefit from the This study presents a case series of three female amateur triathletes
use of WBCT in severe blunt polytrauma. presenting with acute abdominal pain caused by rhabdomyolysis.
Reference Methods The medical case notes of three female athletes presenting to
1. Huber-Wagner S, et al.: Lancet 2009, 373:1455-1461. the emergency department were reviewed.
Results All three patients presented with abdominal pain after triathlon
training. On admission, creatinine kinase levels were over 30,000 in all
P458 three cases and all required acute hospital admission for pain relief and
Post-traumatic rhabdomyolysis: an observational study in seven intravenous fluids to prevent renal failure.
patients Conclusion Exertional rhabdomyolysis is not rare, but rarely do such
M Alezrah, A Berger, P Bentzinger, C Sassot, L Profumo, B Saumande, patients present to the emergency department with acute abdominal
O Collange, A Meyer, B Calon pain. Whilst triathlon training is popular among amateur sports
réanimation chirurgicale, Strasbourg, France people, awareness must be raised to train appropriately under proper
Critical Care 2012, 16(Suppl 1):P458 (doi: 10.1186/cc11065) conditions.
Results In placebos, very high levels of cytokines appeared almost No patients fulfilling the inclusion criteria required re-intubation or
immediately in the echars and circulation, persisting 7 days post burn. emergency intubation.
In the estrogen group, cytokines, including tissue and circulating IL-6, Conclusion Extended periods of mechanical ventilatory support are
the greatest predictor of MOF, remained suppressed at all time points, known to be associated with poorer outcomes in the severely burnt
even day 7 (Figure 1). patient. Guidance on minimising ventilator dependency through
Conclusion Early single-dose parenteral estrogen can dramatically introduction of a protocol has led to improved outcomes of such
suppress both the local and systemic massive proinflammatory patients within a regional burns centre. This study suggests that many
responses in severe burns. Based on these data, estrogen may not only burns patients are overtreated through routine ventilation.
be an inexpensive, simple, adjunctive therapy in burn management, it Reference
may obviate the need for many subsequent interventions altogether. 1. Mackie D, Spoelder E, Paauw R, et al.: Mechanical ventilation and fluid
References retention in burn patients. J Trauma 2009, 67:1233-1238.
1. Crit Care Med 2010, 38:S620-S629.
2. J Neuroinflamm 2009, 6:30-36.
P467
Cardiopulmonary exercise testing and elective open abdominal
P466 aortic aneurysm surgery over a 6-year period in a UK teaching
Reducing the indication of ventilatory support in the severely hospital
burnt patient and improving outcomes: results of a new protocol AH Raithatha, S Smith, K Chakrabarti, A Tridente, K Kerr
approach within a regional burns centre Sheffield Teaching Hospitals NHS Trust: Northern General Hospital, Sheffield,
J Gille1, H Taha2, R Blankenburg1, T Raff1, A Sablotzki1 UK
1
St Georg Hospital, Leipzig, Germany; 2Royal Devon & Exeter Hospital Critical Care 2012, 16(Suppl 1):P467 (doi: 10.1186/cc11074)
Foundation Trust, Exeter, UK
Critical Care 2012, 16(Suppl 1):P466 (doi: 10.1186/cc11073) Introduction A reduced oxygen uptake at anaerobic threshold (AT) and
an elevated ventilatory equivalent for carbon dioxide (VE/VCO2) have
Introduction Initial management of the severely burnt patient often been shown to be predictors of outcome after major surgery [1]. We
includes sedation and mechanical ventilatory support as routine. report the demographic and outcome data of patients undergoing
Conversely it is documented in the literature that nonjudiciously elective open abdominal aortic aneurysm (AAA) surgery who
applied mechanical ventilatory support can itself lead to poorer underwent cardiopulmonary exercise testing (CPET) testing within our
patient outcomes [1]. Exploring means to reduce this iatrogenic risk, a unit and examine the relationship between age, AT and VE/VCO2 on
standardised in-house five-point protocol offering clinical guidance on survival outcomes.
the use and duration of ventilation was introduced, analysed and the Methods A retrospective observational analysis of our unit’s CPET Excel
impact on outcome assessed. database was conducted to identify patients who underwent CPET
Methods A clinical observation study, approved by the local ethical testing for elective open AAA repair over a 6-year period. Demographic
committee, was designed and executed. Criteria for early spontaneous data and survival at 30 days, 90 days and 1 year were extracted. Logistic
breathing were defined. These were formulated into a protocol for regression analysis was undertaken using STATA statistical software to
the management of severely burnt patients and trialled over 2 years determine if age, AT or VE/VCO2 were predictors of survival at 30 days,
in clinical practice on all admitted patients (group A). The ventilation 90 days or 1 year.
period, complications and final outcomes were recorded and compared Results CPET was performed in 259 patients who subsequently
with a retrospective control group of patients (group B) collated prior underwent an elective open AAA repair. Outcome data were available
to implementation of the protocol. Initial study analysis revealed high for 185 patients from a potential 222 in whom 1-year follow-up was
inclusion rates of superficial burns in the intervention group. To achieve available (83%). Baseline demographics included AT ≤10.9 ml/kg/
comparability these were excluded and further analysis was conducted minute in 39% and >10.9 ml/kg/minute in 61% of patients with
only for patients with an abbreviated burn severity index (ABSI) ≥7. respective median ages in these groups being 73 and 72. Regression
Results In total 118 patients were included. The demographics and analysis demonstrated that AT was the only predictor of survival
injury characteristics of both groups were similar. Patients of group at 30 days, 90 days and 1 year. Age and AT remained independent
A (n = 61) had fewer ventilator days in the time course of treatment predictors of survival at 90 days and 1 year following multivariate
(3.9 ± 11.7 vs. 17.1 ± 19.6 days, P <0.01). Affiliation to group A correlated analysis. Of note, 87 patients underwent elective endovascular
with a shorter time of ventilation after admission (P <0.01); 61.1% of aneurysm repair and CPET, median age 76, during the period analysed.
these patients were extubated within 6 hours after admission (vs. 14.3% In particular, 26.4% were older than 80 years old, versus 14.7% in the
in group B). Group A showed lower mortality rates (1 (1.4%) vs. 8 (14%), AAA group. See Figure 1.
P = 0.01), shorter total hospital stay (34.2 ± 23.9 vs. 50 ± 38.4, P = 0.014) Conclusion Our data support existing evidence that AT can be used as
and lower incidence of sepsis (24 (39.3%) vs. 39 (68.4%), P <0.01). a predictor of survival in open elective AAA surgery. In addition, age at
CPET also predicted 90-day and 1-year survival; however, VE/VCO2 was Methods This nonrandomized single-centre control trial was
not a predictor of survival in this cohort. prospectively conducted on 65 patients who were subjected to
Reference coronary artery bypass surgery followed by stay in the Open Heart
1. Carlisle J, et al.: Mid-term survival after abdominal aortic aneurysm surgery Intensive Care Center of the Police Authority Hospital, in the period
predicted by cardiopulmonary exercise testing. Br J Surg 2007, 94:966-969. from July 2009 to January 2010. Patients were divided into two groups;
group A, 25 patients underwent surgery using cardiopulmonary
bypass pump (on coronary artery bypass pump (ONCAB)); and group
P468 B, 40 patients underwent surgery without using cardiopulmonary
Perioperative evaluation of elective surgical patients: is it possible bypass pump (off-pump coronary artery bypass (OPCAB)). All of the
to plan ICU admission? demographic, operative and postoperative data were prospectively
LM Mozzoni, FR Ruggeri, MN Nastasi collected and analyzed statistically. Six months later, the patients
Ospedale Ceccarini Riccione, Italy underwent coronary angiography.
Critical Care 2012, 16(Suppl 1):P468 (doi: 10.1186/cc11075) Results There was no significant difference between both groups
intraoperatively concerning arrhythmias, blood transfusion, and
Introduction The aim of the study is to evaluate the possibility to hemodynamic support. Off-pump patients had a significantly higher
predict ICU admission in elective surgical patients, studying the mean number of constructed grafts than in the ONCAB group
perioperative period variables. (mean, 3.30 ± 0.88 vs. 2.84 ± 0.80, P = 0.02). There were no significant
Methods This is a prospective, nonintervention study concerning differences between off-pump and on-pump regarding postoperative
207 patients, who have been operated on under elective conditions blood loss, blood transfusion, length of the ICU and the hospital
from January to October 2011. The group we studied was affected by stay, the ventilation time, the use of intraaortic balloon pump, renal
thoracic (n = 78) or abdominal (n = 129) cancer. Mean age was 67.8 (SD complications, respiratory complications, and reopening. However,
11.3; limits 24 to 91). ASA score III concerned 107 patients (51.7%) and graft occlusion, MI, raised cardiac enzymes, ventricular tachycardia,
score II 98 patients (47.3%). A senior anesthetist screened all patients cardiogenic shock, and disturbed conscious level were significantly
before operation, assigning them to one of these three possible higher in the OPCAB group. The postoperative mortality rate was
groups: G0 (patient who does not need ICU admission), G1 (patients significantly higher in the OPCAB group than in the ONCAB group
who could need ICU admission), G2 (patients who definitely need ICU (15% vs. 0%, P = 0.046). Follow-up angiograms in 40 patients out of
admission). Scheduling of patients into groups was made considering 65 (61.5%) who underwent 124 grafts revealed that no significant
medical history, laboratory data, physical evaluation and type of difference between off-pump and on-pump groups regarding the
surgery. Patients were studied from surgical intervention to discharge. overall rate of graft patency (83.5% vs. 84.4%, P = 0.84). No mortality
All data were analyzed using IBM SPSS statistics v19 (SPSS Inc.), using was reported in both groups at 6-month follow-up.
adequate test and accepting P <0.05. Conclusion There was a higher incidence in postoperative
Results Sixty-six patients (31.9% of all patients) were in G0, 70 (33.8%) complications and mortality in the off-pump procedure than the on-
in G1 and 71 (34.3%) in G2. The ASA score can distinguish patients in pump. At 6-month follow-up, no significant differences between both
G0 and G2, but not in G1 (P <0.05). The decision to schedule patients techniques were found in graft patency and mortality. Hence, longer-
in a group arises mainly from the coexistence of both cardiovascular term mortality from randomized trials of off-pump versus on-pump
and respiratory diseases [1]. Ninety patients (43.5%) entered the ICU; CABG is needed.
30 (42.8%) of these were in G1 and 34 (47.9%) in G2; 26 (39.4%) were Reference
in G0. Distribution in the three groups of ICU-admitted patients was 1. Shroyer AL, Grover FL, Hattler B, et al.: On-pump versus off-pump coronary-
similar (P = NS) and there was no significant relationship between the artery bypass surgery. N Engl J Med 2009, 361:1827-1837.
ASA score (and its distribution in the three groups) and ICU admission
(P = NS). Patients admitted had undergone surgery of longer duration
or had problems in the theater (low output syndrome, difficult P470
weaning at the end of procedure, bleeding) or organizational problems Aortic aneurysm disease versus aortic occlusive disease: differences
(P <0.05). ICU-admitted patients show a lower number of postoperative in postoperative ICU requirements after open elective abdominal
complications as arrythmias and wound infections (P <0.05). Four aortic surgery
patients died, all had been hospitalized in the ICU. The mortality rate J Bisgaard1, HK Jørgensen1, T Gilsaa1, E Ronholm1, P Toft2
1
was 1.9% (75% were in G2). Patients with complications requiring Littlebaelt Hospital Kolding, Denmark; 2Odense University Hospital, Odense,
further surgery were 15 (7.2%), seven of which had been hospitalized Denmark
in the ICU. Critical Care 2012, 16(Suppl 1):P470 (doi: 10.1186/cc11077)
Conclusion Preoperative evaluation does not appear to be a significant
predictor for ICU admission, which is determined by intraoperative Introduction Open elective abdominal aortic surgery is a high-
or organizational factors. The ICU admission reduces the incidence of risk procedure involving clamping of the aorta. Indications include
postoperative complications; mortality is mainly due to the immediate abdominal aortic aneurysm (AAA) or aortic occlusive disease (AOD)
perioperative period. causing lower limb ischaemia. These patients are often regarded as
Reference one entity in postoperative study settings. However, previous studies
1. Rhodes A, et al.: Intensive Care Med 2011, 37:1466-1472. indicate that risk profiles, inflammatory activity, and haemodynamic
capacity may differ between these groups [1,2]. The aim of this study
was to evaluate postoperative ICU requirements after open elective
P469 abdominal aortic surgery, hypothesising that AAA patients had longer
Cardiac-specific biomarkers and life-threatening complications of ICU stays and needed more mechanical ventilation or acute dialysis
off-pump versus on-pump coronary bypass surgery in Egyptian than did patients with AOD.
patients Methods This cohort study was based on prospectively registered data
H Elabd1, A Alsherif2, T El Gohary2, M Hagras2, S Salah Eldin2 from the Danish National Vascular Registry and the Danish ICU Database
1
Student Hospital, Cairo University, Giza, Egypt; 2Kasr Alaini Hospitals, Cairo, between 1 January 2007 and 1 May 2010. The study population
Egypt comprised all patients (n = 1293) undergoing open elective, primary
Critical Care 2012, 16(Suppl 1):P469 (doi: 10.1186/cc11076) aorto-iliac bypass, or aorto-femoral bypass procedures (n = 363) or
abdominal aortic aneurysm repair (n = 930) in the eight hospitals
Introduction Coronary artery bypass grafting (CABG) has traditionally performing these procedures in Denmark. The primary endpoints
been performed with the use of cardiopulmonary bypass (ONCAB). were: ICU stay >24 hours, mechanical ventilation, and acute dialysis.
This study aims to compare between on-pump and off-pump surgery Results Patients in the AAA group were older (70 ± 7 vs. 62 ± 9 years,
concerning postoperative morbidity and mortality, and also to evaluate P <0.001), predominantly males (80 vs. 49%, P <0.001), with a higher
6-month graft patency in Egyptian patients. prevalence of preoperative cardiac co-morbidity (34 vs. 24%, P = 0.001),
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and malignant disease (2.7 vs. 0.6%, P = 0.02). In contrast, AOD patients P472
had a higher prevalence of smoking (95 vs. 86%, P <0.001), and diabetes Predictors of prolonged mechanical ventilation after heart
(16 vs. 9%, P <0.001). AAA patients had larger intraoperative blood transplantation
losses (1,610 (1,000 to 2,500) vs. 1,200 (750 to 1,800) ml, P <0.001), M Turker, P Zeyneloglu, A Pirat, A Sezgin, G Arslan
but duration of surgery was shorter (161 (130 to 205) vs. 194 (160 to Baskent University, Ankara, Turkey
240) minutes, P <0.001). Postoperatively, more AAA patients had ICU Critical Care 2012, 16(Suppl 1):P472 (doi: 10.1186/cc11079)
stays >24 hours (62 vs. 45%, P <0.001), tended to need mechanical
ventilation more often (16 vs. 12%, P = 0.08), and more needed acute Introduction Several studies have reported that prolonged mechanical
dialysis (3.8 vs. 0.9%, P <0.03). ventilation is associated with high mortality and morbidity rates, length
Conclusion Compared to the AOD group, more AAA patients had ICU of hospital stay, and costs after coronary artery and valvular surgeries.
stays >24 hours and more often needed acute dialysis. Distinguishing However, no study has focused on the incidence and risk factors of
between these two diseases may be useful in planning and distribution prolonged mechanical ventilation after heart transplantation. The
of ICU resources. Furthermore, considering these two patient groups as aim of this study was to determine the incidence and predictors of
different pathological entities may be advised in future studies. prolonged mechanical ventilation after heart transplantation.
References Methods We retrospectively analyzed the records of 38 out of 45
1. Shteinberg D, et al.: Eur J Vasc Endovasc Surg 2000, 20:462-465. patients who underwent heart transplantation from February 2003 to
2. Johnston WE, et al.: Anesthesiology 1987, 66:386-389. November 2010 at our center. Patients under 12 years of age and those
who died before extubation were excluded. We defined prolonged
mechanical ventilation as mechanical ventilation longer than 36
hours. Preoperative, intraoperative, and postoperative variables were
collected.
Results The mean age of the patients (71% male) was 31.5 ± 16.8
P471 years and the incidence of prolonged mechanical ventilation was 40%.
High postoperative blood levels of macrophage migration Compared with patients who did not require prolonged mechanical
inhibitory factor are associated with less organ dysfunction in ventilation, those who did had significantly lower preoperative
patients after cardiac surgery hemoglobin levels (12.0 ± 1.5 vs. 13.7 ± 2.4 mg/dl, P = 0.03), higher
C Stoppe1, G Grieb1, D Simons1, R Rossaint1, J Bernhagen1, S Rex2 intraoperative lactate levels (7.14 ± 4.13 vs. 3.5 ± 1.82 mmol/l,
1
University Hospital of the RWTH, Aachen, Germany; 2University Hospital P = 0.006), higher postoperative day 1 serum creatinine levels (2.2 ± 0.9
Gasthuisberg, KU Leuven, Belgium vs. 1.2 ± 0.7 mg/dl, P = 0.002), and longer cardiopulmonary bypass
Critical Care 2012, 16(Suppl 1):P471 (doi: 10.1186/cc11078) times (143.0 ± 24.2 vs. 122.8 ± 29.1 minutes, P = 0.005). Binary logistic
regression revealed that the postoperative day 1 serum creatinine level
Introduction Macrophage migration inhibitory factor (MIF) is a was an independent risk factor for prolonged mechanical ventilation
structurally unique inflammatory cytokine [1] that exerts protective after heart transplantation (OR: 5.109; 95% CI: 1.362 to 19.159, P = 0.016).
effects during ischemia and reperfusion [2]. We hypothesized that Length of hospital stay was significantly longer in patients with PMV
elevated MIF levels in the early postoperative time course might be than those who did not require prolonged mechanical ventilation
inversely associated with postoperative organ dysfunction as assessed (36.4 ± 30.4 vs. 21.8 ± 12.7, P = 0.049). The respective mortality rates
by SAPS II and SOFA score in patients after cardiac surgery. for patients with prolonged mechanical ventilation and those without
Methods Fifty-two cardiac surgical patients (mean age (± SD) 67 ± 10 prolonged mechanical ventilation were 60% versus 40%, P = 0.15.
years; EuroSCORE: 7 (2 to 11)) were enrolled in this monocenter, Conclusion Prolonged mechanical ventilation occurred in 40% of our
prospective, observational study. Serum levels of MIF and clinical data patients after heart transplantation. A higher creatinine level during
were obtained after induction of anesthesia, at admission to the ICU, 4 the first 24 hours after the surgery was associated with prolonged
hours thereafter and at the first and second postoperative day (POD). mechanical ventilation in this study.
Patient outcome was assessed using the SAPS II at POD1 and SOFA Reference
score for the first 3 days of the eventual ICU stay. 1. Cislaghi F, et al.: Minerva Anestesiol 2007, 73:615-621.
Results MIF_AUC, the computed area under the curve of MIF serum
levels from admission until POD1, was inversely correlated with SAPS
II and SOFA score on POD1 (Table 1). MIF at admission (r = 0.296; P473
P = 0.041) and MIF at 4 hours (r = 0.367; P = 0.012) correlated inversely Atrial fibrillation following major noncardiac thoracic surgery:
with the paO2/FiO2 ratios at POD1. Moreover, postoperative MIF values significance and impact on morbidity
were inversely correlated with SAPS II (r = 0.528; P = 0.044) and SOFA H Michalopoulou, PS Stamatis, M Michaloliakou, N Baltagiannis,
scores during the early postoperative stay (Table 1). In addition, MIF D Stamatis
values on POD1 were related to the calculated Cardiac Power Index ‘Metaxa’ Hospital, Athens, Greece
(r = 0.420; P = 0.009). Critical Care 2012, 16(Suppl 1):P473 (doi: 10.1186/cc11080)
Table 1 (abstract P471) Introduction Atrial fibrillation (AF) is a common complication after
noncardiac thoracic surgery. Its impact on overall mortality has not
MIF level SOFA 1. POD SOFA 2. POD SOFA 3. POD
yet been fully assessed and few data are available on the effects of the
ICU admission r = –0.2; P = 0.18 r = –0.4; P = 0.11 r = –0.6; P = 0.05 noncardiac post-thoracotomy AF on clinical outcomes.
Methods From July 2006 to July 2011, 226 consecutive patients
4 hours later r = –0.4; P = 0.40 r = –0.5; P = 0.05 r = –0.8; P = 0.01 undergoing lung resection for lung cancer were studied retrospectively.
MIF_AUC r = –0.4; P = 0.01 r = –0.2; P = 0.55 r = –0.4; P = 0.19 Preoperative data and serial electrocardiograms were evaluated.
Hypertension, dyslipidaemia, diabetes mellitus, smoking and advanced
1. POD r = –0.3; P = 0.08 r = –0.6; P = 0.03 r = –0.7; P = 0.02 age (>75 years) were considered as risk factors. Patients (n = 97) who
had structural heart disease or ≥2 risk factors were considered a high-
Conclusion Elevated postoperative MIF levels are inversely correlated risk group whereas those with <2 risk factors constituted the low-risk
with organ dysfunction in patients after cardiac surgery. group.
References Results Thirty-two patients (14.16%) experienced new-onset post-
1. Calandra T, et al.: Macrophage migration inhibitory factor: a regulator of operative AF. The high-risk group had a 58% incidence of AF compared
innate immunity. Nat Rev Immunol 2003, 3:791-800. with 23% in the low-risk group (P <0.001). Moreover, following
2. Koga K, et al.: Macrophage migration inhibitory factor provides β-blocker administration, more of the high-risk group required
cardioprotection during ischemia/reperfusion by reducing oxidative antiarrhythmic treatment with amiodarone than did the low-risk group
stress. Antioxid Redox Signal 2011, 14:1191-1202. (67% vs. 35% respectively, P = 0.02). Patients who developed AF had
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a significantly longer hospital stay (P <0.01). The 30-day mortality rate Table 1 (abstract P474). Postoperative complications by achievement of an
was significantly higher in the high-risk group (11% vs. 2%; P = 0.03) oxygen delivery index of 600
but AF was not an independent risk factor for death. In the multivariate
DO2I >600 DO2I <600 P value
analysis, major resection (pneumonectomy) and advanced age
were identified as independent risk factors for the development of Number of patients 16 (43%) 21 (57%) –
postoperative AF (P = 0.004 and P = 0.008 respectively).
Conclusion Atrial fibrillation occurrence after lung resection does not Complications 13 (29%) 32 (71%) P = 0.003
independently affect the short-term mortality but is associated with a Mortality 0 (0%) 4 (100%) P = 0.12
prolonged length of hospital stay.
P475
P474 Transfer delays in patients referred for neurosurgical intervention
Oxygen delivery index during goal-directed therapy predicts with traumatic brain injury
complications and hospital length of stay in patients undergoing L Smith1, B Jordan2, J Paddle1
1
high-risk surgery Royal Cornwall Hospital NHS Trust, Truro, UK; 2Derriford Hospital, Plymouth, UK
M Cecconi, N Arulkumaran, R Suleman, D Shearn, M Geisen, J Mellinghoff, Critical Care 2012, 16(Suppl 1):P475 (doi: 10.1186/cc11082)
D Dawson, J Ball, M Hamilton, M Grounds, A Rhodes
St George’s Hospital, London, UK Introduction National guidance for patients presenting to the emergency
Critical Care 2012, 16(Suppl 1):P474 (doi: 10.1186/cc11081) department (ED) with a traumatic head injury advises that head computed
tomography (CT) should be performed and reported within 1 hour [1].
Introduction The aim of this study was to evaluate the efficacy of a The operative intervention or injury to knife time should be within 4 hours
goal-directed therapy (GDT) protocol designed to augment the oxygen [2]. With more than 50% of patients requiring neurosurgical intervention
delivery index (DO2I) and to assess the relationship between DO2I in the UK taken to hospitals without onsite neurosurgical services [3],
measurements and postoperative complications and length of stay. secondary transfer is necessary prior to definitive intervention. Are we
Methods A single-centre retrospective cohort study assessing the data achieving timely transfers in rural England?
obtained during an 8-hour post-operative GDT protocol in consecutive Methods The Royal Cornwall Hospital is a district general hospital
major surgical patients admitted to the ICU. serving a population of 300,000. The regional neurosurgical unit is
Results Thirty-seven patients were included. The median DO2I increased 100 km away. All patients undergoing transfer to the neurosurgical
over the 8-hour protocol from a baseline level of 407 ml/minute/m2 to unit during 2009 were identified. A notes review was undertaken of all
a maximum of 537 ml/minute/m2 (P <0.0001) (Figure 1). Twenty-one these patients transferred to the care of neurosurgeons. The operative
(57%) patients developed a postoperative complication. Patients who logs were also reviewed. Time lines were created of their care from
developed zero or one complication had a higher maximum oxygen ambulance call to neurosurgical intervention.
delivery index DO2I than patients who had more than one complication Results Ten patients in total were transferred for neurosurgical
(602 vs. 477 ml/minute/m2, P = 0.018) (Table 1). The proportion of intervention. Two of these patients required two transfers as they were
patients with a length of stay greater than 2 weeks was less in patients initially seen in satellite minor injury units. No patient had CT within
who achieved a DO2I of at least 600 ml/minute/m2 (P = 0.035). 1 hour of arriving in the ED. The median time was 2 hours 56 minutes.
Conclusion Postoperative GDT was able to increase DO2I in the The CT report was available at a median of 3 hours 17 minutes. None
postoperative period. Patients who achieved a DO2I of 600 ml/minute/ of these patients arrived in the tertiary referral centre within 4 hours of
m2 were less likely to suffer postoperative complications and have a their injury. The fastest time to intervention was 8 hours 29 minutes,
significantly reduced length of hospital stay. median 22 hours 59 minutes after injury.
Conclusion We are not meeting targets for CT head acquisition and
transfer for neurosurgical intervention. Prompt transfer of a trauma
patient from a rural district general hospital in the UK to a tertiary
referral centre for neurosurgical intervention is a multifactorial problem.
The introduction of trauma centres and of protocols for direct admission
to tertiary centres by paramedics may reduce the delays that our audit
has highlighted.
References
1. Head Injury Triage: Assessment, Investigation and Early Management of
Head Injury in Infants, Children and Adults, Methods Evidence and
Guidance. Commissioned by the National Institute for Health and Clinical
Excellence. [http://guidance.nice.org.uk/CG56/NICEGuidance/pdf/English]
2. Better Care for the Severely Injured. Joint Report. Royal College of Surgeons
of England and British Orthopaedic Association. [http://www.rcseng.ac.uk/
publications/docs/severely_injured.html]
3. Trauma: Who Cares? Report. National Confidential Enquiry into Patient
Outcome and Death. [http://www.ncepod.org.uk/2007report2/Downloads/
SIP_report.pdf ]
P476
Performances of ventilator at simulated altitude
E Forsans1, L Franck1, T Leclerc1, M Bensalah1, J Tourtier1, Y Auroy1,
C Bourrilhon2
1
HIA Val-de-Grâce, Paris, France; 2Institut de Recherche Biomédicale des
Armées, Brétigny sur Orges, France
Critical Care 2012, 16(Suppl 1):P476 (doi: 10.1186/cc11083)
Figure 1 (abstract P477). Influenza admissions into critical care in winter 2010/2011.
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supervision (physical proximity of supervising ICU fellow: distant, prompting critical decisions in mass casualty drills. In the beginning the
immediately available, direct). In-person and telephone interactions average time to complete the VR scenario was higher than the LS. This
between participants were recorded and transcribed. We conducted an could be due to the fact that on day 1 very detailed VR victims created
inductive thematic analysis of anonymized transcripts using constant a higher challenge for untaught students. However, the higher triage
comparison within and between scenarios. Distributed cognition accuracy recorded at the end of day 3 in VR could be explained by a
theory was used as a framework to guide analysis. lower stress level compared to the LS, which could be creating a more
Results Both distant and direct levels of supervision resulted in stressful environment in taught students.
variable involvement of residents in patient care. A shift of control
over patient care from residents to fellows often occurred regardless
of the physical distance of the fellow. Direct supervision did not always P480
result in decreased resident contributions. Fellows were found to Utilization of iPad in the system of emergency demand and
facilitate more elaborated cognitive contributions from the residents acceptance
during direct supervision. In addition, practicing in the presence of K Yamada1, Y Sakamoto1, Y Enjiyouji2
1
a supervisor was more likely to lead to timely feedback. However, Saga University, Saga, Japan; 2Saga Prefectural Government, Saga, Japan
a presence at the bedside allowed fellows to influence the nature of Critical Care 2012, 16(Suppl 1):P480 (doi: 10.1186/cc11087)
resident involvement by delegating specific tasks such as technical
procedures. During distant supervision, fellows had to use residents as Introduction This study reports that the transportation time by
proxies to obtain information about patients and to deliver care, with ambulance was shorter following the introduction of iPad (Apple,
potentially serious consequences: when residents’ interpretations of Inc.) to the current system of emergency demand and acceptance in
the clinical information were problematic, the quality of fellows’ clinical Saga Prefecture, Japan. There were about over 5,000,000 ambulance
decisions was negatively affected. Higher cognitive work required of dispatches in Japan, and the time for transportation is increasing
fellows during distant supervision appeared to limit their ability to (the national average: 36.1 minutes) [1]. The administration has made
invest cognitive resources in teaching. various efforts nationwide that did not achieve any positive results.
Conclusion Level of clinical supervision was not the main determinant Although the information system of medical institutions and the
of resident engagement in patient care. Both distantly and directly emergency medical service (99 Saga Net) was established in 2003 in
supervised scenarios presented learning opportunities for residents. Saga, it has been underutilized. The Saga prefectural government
Given the observed negative effects of distant supervision on patient renewed the previous system as the real-time system of emergency
care, strategies to optimize unique learning opportunities offered by demand and acceptance for the first time in Japan in April 2011.
direct supervision should be investigated. Methods Cloud computing has provided new system to facilitate
Internet access from ambulances. In addition, iPads were put into all
ambulances (about 55) and emergency medical technicians can get
P479 the picture of acceptable hospitals in real time. Emergency personnel
Virtual reality and live scenario simulation: options for training who arrive on the scene select the patient’s symptoms with an iPad,
medical students in mass casualty incident triage and this new system displays an up-to-date list of acceptable hospitals.
PL Ingrassia, L Ragazzoni, L Carenzo, FL Barra, D Colombo, G Gugliotta, The data that the emergency personnel entered into the system from
F Della Corte the iPad are uploaded to 99 Saga Net immediately. Therefore, both
CRIMEDIM Research Center in Disaster and Emergency Medicine, Novara, Italy the emergency personnel and medical staff in the hospital share the
Critical Care 2012, 16(Suppl 1):P479 (doi: 10.1186/cc11086) information of where the emergency occurred, the transportation and
the medical institutes to which patients were transferred in real time.
Introduction Multicasualty triage is the process of establishing the Results The transportation time by ambulance was shorter for the first
priority of care among casualties in disaster management. Recent mass time since statistics were first kept in 1999, the mean time was 33.7
casualty incidents (MCI) revealed that health personnel are unfamiliar minutes in 2009 and 33.2 minutes in April 2011. Furthermore, the new
with the triage protocols. The objective of this study is to compare the system is expected to reduce the operational costs by 40,000,000 yen a
relative impact of two simulation-based methods for training medical year. The data on the transportation time by ambulance are continually
students in mass casualty triage using the Simple Triage and Rapid stored in the system and analyses are continuing.
Treatment (START) algorithm. Conclusion The introduction of iPad to the new 99 Saga Net has
Methods A prospective randomized controlled longitudinal study. three beneficial points. First, the utilization of information and
Medical students enrolled in the emergency medicine course were communication technology is useful for a realistic emergency medical
randomized into two groups (A and B). On day 1, group A students setting. Second, the situation of a realistic emergency medical setting
were exposed to a virtual reality (VR) scenario and group B students is visualized in real time. Finally, both the emergency personnel and
were exposed to a live scenario (LS), both exercises aiming at triaging the medical staff in the hospital share the information in an emergency
10 victims in a limited period of time (30 seconds/victim). On day medical setting by eliminating vertically divided administrative
2 all students attended a 2-hour lecture about medical disaster functions. Medical personnel will work with local governments in the
management and START. On day 3 group A and B students were future to analyze the data from this new system.
exposed to a LS and to a VR scenario respectively. The vital signs and Reference
clinical condition of the 10 victims were identical in the two scenarios. 1. Fire and Disaster Management Agency: White Paper on Fire and Disaster (2010) [in
Ability of the groups to manage a simulated triage scenario was then Japanese]. [http://www.fdma.go.jp/html/hakusho/h22/h22/html/2-4-5_4.html]
compared (times and triage accuracy).
Results Groups A and B were composed of 25 and 28 students
respectively. During day 1 group A LS triage accuracy was 58%, while P481
the average time to assess all patients was 4 minutes 28 seconds. The Mass evacuation of victims from emergency areas by medical
group B VR scenario triage accuracy was 52%, while the average time to modules aboard the aircraft of EMERCOM of Russia
complete the assessment was 5 minutes 18 seconds. During day 3 the I Yakirevich, A Popov
triage accuracy for group A VR simulation was 92%, while the average EMERCOM of Russia, Zhukovsky, Moscow Region, Russia
time was 3 minutes 53 seconds. Group B triage accuracy during the LS Critical Care 2012, 16(Suppl 1):P481 (doi: 10.1186/cc11088)
was 84%, with an average time of 3 minutes 25 seconds. Triage scores
improved significantly during day 3 (P <0.001) in the two groups. The Introduction During elimination of medical consequences of various
time to complete each scenario decreased significantly from day 1 to emergencies the issues concerning victims’ mass evacuation to a
day 3. specialized hospital base are constantly brought up. The physicians of
Conclusion The study demonstrates that the training course generates the Central Airmobile Rescue Service of EMERCOM of Russia and the
significant improvement in triage accuracy and speed. It also reveals specialists of Kazan Helicopter Plant ‘Zarechye’ developed two types
that VR simulation compared to live exercises has equivalent results in of modules. The Medical Airplane Module (MMS) is used for medical
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evacuation of four victims aboard Ilyushin 76 aircraft. The Medical Conclusion Our triage system shows a good interrater reliability and
Helicopter Module (MMV) is used for medical evacuation of two victims validity in predicting resource consumption. To our knowledge, this is
aboard an MI 8 helicopter. MMS and MMV advantages are: mobility the first prospective Italian study that tests the relationships between
– the possibility of installation in various aircraft cabins types; and the triage category assigned by the nurses (using a four-level triage
versatility – the possibility of any required equipment installation for method) and resource consumption.
the treatment of victims with various trauma severity, safe fixation of
medical equipment straight on the module, equipment operation off-
line as well as using the aircraft power supply network.
Methods From December 2008 until now 28 medical evacuations
were carried out using MMS aboard Iluyshin 76 aircraft: traffic accident
victims, terrorism act victims and manmade catastrophes. In total, P483
198 patients were evacuated (including 12 children), 55 victims with Coordination of emergency resources after Lorca’s earthquakes
artificial lung ventilation (ALV). Medical evacuation of severely injured L Escobar1, A Ferrández2, J Jimenez1, A Peláez1, A Corbatón3, R Alvaro4
1
children and adults from regional hospitals to Moscow specialized Hospital Rafael Méndez, Lorca, Spain; 2Gerencia 061, Murcia, Spain; 3Hospital
hospitals in order to provide efficient and modern medical aid was Clínico San Carlos, Madrid, Spain; 4Área II Servicio Cantabro de Salud,
carried out using MMV. In total, 27 patients were evacuated (including Santander, Spain
five children), five patients with ALV. The majority of victims were in Critical Care 2012, 16(Suppl 1):P483 (doi: 10.1186/cc11090)
severe and extremely severe conditions with associated multisystem
trauma. Closed craniocerebral injury was observed in 75% of victims Introduction This work’s purpose is to describe the coordination
with mass affection of locomotor apparatus, mine and explosion of different medical resources after Lorca’s 2011 earthquakes. They
trauma, gunshot wounds, burn shock and burn disease. Constant caused 11 deaths, including two pregnant women and their babies,
monitoring, oxygen therapy, ALV, analgesia and sedation, intensive and many injured, moderate or severe damage to 80% of the buildings, and
anti-shock care as well as wound dressing were carried out in flight. more than 30,000 people without shelter.
The victims’ general condition was evaluated according to the Glasgow Methods A descriptive study of the files of Murcia’s Emergency
Coma Scale, APACHE II and SOFA scales. Coordination Center (ECC) on the activation of resources after the
Results MMS and MMV application in case of mass evacuation in flight earthquakes.
ensures spare victims’ transportation, total monitoring and treatment Results Time 17:06 hours: first call. Local resources and city emergency
continuity. It enables one to carry out anesthetic and resuscitation plan are activated. Four medical teams (UME) are pre-activated. 18:49
treatment, intensive care, monitoring and treatment of all the victims. hours: incoming calls alert of buildings crumbling, dead among the
Conclusion The quality of mass medical evacuation of extremely injured rubble, and hundreds of injured. 18:55 hours: seven UME from five cities
victims has considerably improved and the time of transportation are sent to Lorca. 19:00 hours: telephone communications collapse. The
from emergency area to specialized hospitals to render them efficient ECC uses its internal network. An Advanced Command Point (ACP) is
medical aid has reduced. established with a field hospital. 19:10 hours: Rafael Mendez Hospital
(225 patients) has to be evacuated. Medical personnel of the hospital,
private ambulances and UMEs begin the evacuation. The emergency
P482 service of the hospital continues to be operative in the building until
Reliability and validity of an Italian four-level emergency triage system evacuation is completed and in a field hospital later. 19:20 hours: the
N Parenti1, G Rastelli2, C Ferri2, V Serventi1, R Lazzari3, L Sarli1 Military Emergencies Unit is required for activation. 19:30 hours: the
1
University of Parma, Bologna, Italy; 2Ospedale Fidenza, Italy; 3University of military and emergency services field hospitals are sent to Lorca. 19:50
Modena, Italy hours: Virgen del Alcázar Hospital has to be evacuated (145 patients).
Critical Care 2012, 16(Suppl 1):P482 (doi: 10.1186/cc11089) 20:25 hours: at the ACP field hospital of the Red Cross, Civil Protection
and Emergency Services are being set. 20:30 hours: 11 hospitals in six
Introduction The goal of this study is to assess the reliability and provinces are contacted to relocate evacuated patients. 20:40 hours:
validity of a four-level emergency triage system (Urgency Category all buildings in Lorca are have been evacuated. Thirty thousand people
(UC) 1 = immediate response; UC 2, 3 and 4 assessment within 20, 60 need shelter. Ten camps with tents are set throughout Lorca by the Red
and 120 minutes respectively) used in an Italian large urban hospital Cross, Emergency Services and Civil Protection to give shelter to 16,000
with 60,000 emergency department (ED) visits annually. people. See Figure 1.
Methods Three triage nurses, using our triage system, independently Conclusion Coordination of the different medical and emergency
assigned, at the same time, triage scores to each patient admitted to the services by the ECC made possible correct use of resources and
ED from June to August 2011. We collected demographic and clinical fast attention to the population that minimized the effects of the
characteristics, nurse triage category, resources used for each triage catastrophe.
code (for example, laboratory tests, EKG, radiographs, procedures),
admission status and site, nurse triage forms that included presenting
complaint, vital signs, and pain score. For each scenario, the most
frequent UC (the mode) has been considered as true triage. Weighted
kappa (K) was used to calculate inter-rater reliability. Validity was
evaluated by studying the relationships between the triage category
assigned by the nurses and resource consumption.
Results A total of 315 patients admitted to the ED were included in the
study randomly (35 were excluded for incomplete data). Mean age was
47 years. Five patients were admitted to the ICU, 48 to nonintensive
units. Trauma was the most frequent symptom at triage (44%). The
mean time of rating was 2 minutes. The UCs assigned were: 14%
with UC 4, 60% UC 3, 25.7% UC 2, 0.3% UC 1. We found 2/315 (0.6%)
cases with a marked discordance (2 or more points), 69/315 (21.9%)
cases with partial agreement (2/3) and 244/315 (77.5%) cases with a
complete agreement (5/5) among nurses who used the triage method.
Interrater reliability among the three nurses was K = 0.71 (CI: 0.58 to
0.84). Hospital admission by our triage system was as follows: 1 (100%),
2 (30%), 3 (12%), 4 (2%). The mean of resources used for each triage Figure 1 (abstract P483). Thirty thousand people need shelter after the
code was: 4.5 (SD 2.2) for UC 2; 3.2 (SD = 1.67) for UC 3; 1.89 (SD 0.84) earthquakes.
for UC 4.
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P484 factor analysis to analyze responses with regard to factors such as face
Lightning injuries in a lightning city: a district hospital experience wash, toilets, sleep, clothes, and food.
in Singapore Results The overall response rate was 59.5% (n = 47/79); the response
Y Mok, P Tan, R Jagadesan rate was 38.3% (n = 18/47) for medical doctors, 36.2% (n = 17/47) for
Changi General Hospital, Singapore nurses, and 25.5% (n = 12/47) for logisticians. The mean length of
Critical Care 2012, 16(Suppl 1):P484 (doi: 10.1186/cc11091) career was 16.5 years (standard deviation, 9.75). Descriptive statistics
revealed that the participants reported high satisfaction with regard
Introduction Tropical Singapore’s meterological profile makes it one of to the command system and consistent satisfaction with regard to
the world’s lightning capitals. This study aims to assess the profile of membership. However, some were unsatisfied with the deployment
the at-risk patient, and possibly identify factors predicting the length of length. Almost all participants wanted to be part of a relief team if given
hospital stay in patients with lightning injuries over a period of 11 years. an opportunity again. Factor analysis derived one factor (eigenvalue
Methods This is an 11-year retrospective study of patients who were shows 3.48 (one factor), 0.33 (two factors), 0.17 (three factors), and
admitted to Changi General Hospital, the only hospital located in 0.13 (four factors)) as comfort. Face wash (–0.95) contributed the most
eastern Singapore, from 2000 to 2011 with the diagnosis of lightning satisfaction compared to other factors such as toilets (–0.86), sleep
injuries. (–0.81), clothes (–0.74), and food (–0.69).
Results There were a total of 27 subjects, with 25 (95.6%) males Conclusion Almost all participants were satisfied with their level of
and two (7.4%) females in the sample. Their age ranged from 17 to comfort, and the influence of factors responsible for this comfort in
62 years; 63% of the subjects were between 20 and 40 years old. All descending order were face wash, toilets, sleep, clothes, and food.
except three subjects had no comorbidities, with the latter having References
only hypertension or hyperlipidemia. Most of the events occurred 1. Singh G, et al.: Psychiatry Clin Neurosci 2003, 57:333-336.
during two periods, March to April and October to December, which 2. Kondo Y, et al.: Jpn J Reanimatol 2011, 30:77-81.
is consistent with previously observed seasonal peaks. The length of
hospital stay ranged from 1 to 10 days for all patients, except one who
stayed for 78 days and one who was transferred to another hospital. Six P486
patients (22.2%) required admission to the ICU or high dependency. Nuclear disaster and the medical problems during the earthquake
There were three mortalities, all found in asystole at the incident site in Japan, 2011
and also suffered hypoxic ischemic encephalopathy (HIE). Seventeen Y Haraguchi, Y Tomyasu, H Nishi, M Sakai, E Hoshino, M Hoshino,
(63%) events were occupation related with all occurring either at the T Takeda-Nozawa
airbase or open construction sites. Although there were reportedly Japanese Compendium Team for Disaster Medicine, Kawasaki, Japan
six mechanisms of lightning injuries (direct strike, contact injury, side Critical Care 2012, 16(Suppl 1):P486 (doi: 10.1186/cc11093)
flash, ground current, upward streamer and blast injury) this study only
established two types of mechanisms – direct strike and contact injury Introduction The roles of medicine including intensivists against
– amongst our patients. Clinical and biochemical parameters that were natural mega-disaster followed by artificial disaster are discussed.
studied included cardiovascular morbidity, rhabdomyolysis, otologic Methods The Higashinihon earthquake caused more than 2,000 deaths
injuries, burns, acute kidney injury and neurological complications. or missing, which was followed by the Fukushima Daiichi nuclear plant
The small numbers limited a statistical analysis for any correlations explosion. This study was mainly studied based upon on the actual
between clinical factors and prognosis as well as hospital length of experience in and around the nuclear station.
stay. Nevertheless, it is notable that all three deaths had asystole arrest Results Many medical teams, rescue teams and public officials worked
at presentation, developed HIE, and a trend towards a higher serum hard. However, many serious problems are revealed, even if they are
creatinine on admission. limited to the medical fields, which are as follows: inappropriate basic
Conclusion The results of this study add to the small but increasing preparedness against the largest degree of mega-disaster; lack of
literature on lightning injuries and may serve to increase physician official education for medical teams against special disaster, such as
awareness in this medical niche. nuclear disaster (that is, most members of the Japan DMAT or disaster
References medical assistance team seemed to be laypersons); incorrect standard/
1. Chao TC, et al.: A study of lightning deaths in Singapore. Singapore Med J rules of Japan DMAT, which were thought to be excessively focused
1981, 22:150-157. upon the cure of the injured patients and a planned short period or
2. Feng Z, et al.: Lightning city. The Straits Times, 22 November 2011, B1. nearly 48 hours; and insufficient consideration for the weak people or
CWAP: children, (pregnant) women, aged people, and the poor people/
sick patients. Many CWAP seemed not to have survived.
P485 Conclusion In order to cope with the mega-disaster, it became evident
Satisfaction survey among medical staff involved in relief that it is insufficient to take makeshift measures or use cheap tricks.
operations following the Great East Japan Earthquake and Tsunami Working out the systematization of disaster medicine, based upon the
Y Kondo1, T Abe2, S Deguchi3, Y Kuba4, H Mitsunaga5, H Sekiguchi1, academic viewpoints and philosophy/reliability, is essential to protect
K Kohshi1, I Kukita1 the people and the nation too.
1
University of the Ryukyus, Nishihara, Japan; 2Mito Kyodo General Hospital,
University of Tsukuba, Mito, Japan; 3Graduate School of Health Sciences, Meio
University, Nago, Japan; 4Medical Corporation Kariyushi Heart-Life Hospital, P487
Nishihara, Japan; 5Tokyo Institute of Technology, Tokyo, Japan Stressors in the ICU: different perceptions of patients, relatives and
Critical Care 2012, 16(Suppl 1):P485 (doi: 10.1186/cc11092) staff members
M Umbrello1, G Mistraletti1, B Cerri1, E Carloni1, V Mariani2, A Di Carlo1,
Introduction We conducted an attitude survey regarding satisfaction F Martinetti1, L D’Amato1, S Miori1, G Iapichino1
1
among medical staff involved in relief operations following the Great Università degli Studi di Milano, Milan, Italy; 2AO San Paolo – Polo
East Japan Earthquake (magnitude 9.0) and Tsunami, which struck Universitario, Milan, Italy
Japan on 11 March 2011. The damage was enormous and a number Critical Care 2012, 16(Suppl 1):P487 (doi: 10.1186/cc11094)
of medical relief teams visited the affected area to rescue victims. Our
Okinawa medical relief team visited Otuchi, Iwate, on 15 March and Introduction The high-risk critically ill are exposed to significant
provided medical support to the victims for 2.5 months. stressors, along with difficulties in communicating them to relatives
Methods We conducted an anonymous paper survey using self- and members of the staff. The aim of this study was to compare the
developed questionnaires. The 79 participants included medical perception of stressors as reported by patients (P), relatives (R) and ICU
doctors, nurses, and logisticians from medical relief teams involved in staff members (S).
rescuing victims of the 2011 Great East Japan Earthquake and Tsunami. Methods A validated questionnaire [1] was used to quantitatively
Data were analyzed using descriptive statistics. We also performed assess discomforts related to the ICU stay. Items were clustered into
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P488
Role of ICU nurses in the confrontation of post-traumatic stress
disorder in relatives of ICU patients in a general hospital of Athens,
Greece
M Kourti1, T Katostaras2, G Kallergis2, E Christofilou1, I Floros1, G Fildisis2
1
Laiko General Hospital, Athens, Greece; 2University of Athens, Faculty of
Nursing, Athens, Greece
Critical Care 2012, 16(Suppl 1):P488 (doi: 10.1186/cc11095)
Figure 1 (abstract P489). Preferences for care at the end of life after
Introduction This study was planned to assess post-traumatic stress family meetings.
disorder (PTSD) in relatives of ICU patients and to evaluate the role of
ICU nurses in the confrontation of these symptoms. Conclusion Withholding intubation and withdrawal therapy are
Methods The Impact of Event Scale – Revised (IES-R) was translated and uncommon in Thai people. However, most Thai families prefer not to
distributed to the family members of patients that were hospitalized in escalate therapy including CPR. All of them died peacefully and the
the ICU from August 2008 to September 2010. Two measurements took families were satisfied with the care at the end of life.
place: the first one 7 to 10 days from the admission of the patient to the Reference
ICU and the second one (to the same relative) after 15 to 20 days from 1. Truog RD, et al.: Crit Care Med 2001, 29:2332-2348.
the admission. The maximum IES-R score is 88 (0 to 4 for each one of the
22 questions that constitute the scale). Scores over 33 were interpreted P490
as severe cases of PTSD. Patients’ health condition was evaluated with Influence of burnout on attitudes of ICU doctors and nurses towards
the APACHE II score before each measurement. liberalization of visiting polices
Results From the first measurement it occurred that 66.7% of the A Giannini1, G Miccinesi2, E Prandi1, M Audisio3, A Bencivinni4, E Biagioni5,
relatives faced severe symptoms of PTSD (scores >33) and from the E Castenetto6, I Laganà7, R Oggioni4, V Porta8, R Salcuni9, A Sarti10,
second measurement it occurred that 70% of family members were MG Visconti11, C Borreani12
1
identified as cases of severe stress symptoms too. No correlation Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy;
2
was found between these symptoms and APACHE II score (P >0.05), Istituto per lo Studio e la Prevenzione Oncologica, Florence, Italy; 3Ospedale
indicating that such symptoms exist in family members during the di Ciriè, Italy; 4Ospedale Nuovo del Mugello, Borgo San Lorenzo, Italy; 5Azienda
whole patient’s stay in the ICU, regardless of the seriousness of the Ospedaliera Universitaria di Modena, Italy; 6Ospedale Civico, Chivasso, Italy;
7
patient’s condition. Azienda Ospedaliera ‘G. Salesi’, Ancona, Italy; 8Ospedale Civile, Legnano, Italy;
9
Conclusion Relatives of ICU patients seem to suffer from symptoms of Ospedale di Ivrea, Italy; 10Ospedale S. Maria Nuova, Florence, Italy; 11Ospedale
PTSD. Nurses who work in the ICU, and have direct and longer contact ‘A. Uboldo’, Cernusco sul Naviglio, Italy; 12Istituto Nazionale per lo Studio e la
with patients and relatives too, need to recognize, evaluate and Cura dei Tumori, Milan, Italy
minimize these symptoms in order that further disorders and damage Critical Care 2012, 16(Suppl 1):P490 (doi: 10.1186/cc11097)
to the relatives’ mental health be prevented.
References Introduction The staff working in the ICU have a complex and stressful
1. Azoulay E, et al.: Am J Respir Crit Care Med 2005, 171:987-994. job and are at risk of burnout [1]. We conjectured that the presence
2. Azoulay E, et al.: Am J Respir Crit Care Med 2001, 163:135-139. of a burnout profile may also influence the views of ICU doctors and
3. Horowitz MJ, et al.: Psych Med 1979, 41:209-218. nurses regarding the liberalization of visiting policies. We investigated
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this issue in the course of a survey about the impact on ICU staff of with the development of severe BOS. These results confirm previous
liberalization of visiting policies. findings and highlight that strategies to decrease BOS in ICU clinicians
Methods We administered an anonymous closed-question question- are urgently warranted.
naire to nurses and doctors at eight ICUs that were about to increase
the daily visiting time to at least 8 hours, soliciting their views on P492
policy changes in their unit. The ICU staff were asked to fill in the same Opening the ICU: views of ICU doctors and nurses before and after
questionnaire a year after implementation. On both occasions we also liberalization of visiting policies
administered the Maslach Burnout Inventory (a 22-item self-completed A Giannini1, G Miccinesi2, E Prandi1, M Audisio3, A Bencivinni4, E Biagioni5,
questionnaire) to survey the incidence of burnout. E Castenetto6, I Laganà7, R Oggioni4, V Porta8, R Salcuni9, A Sarti10,
Results The first response rate was 91% (234/258), the second 76% MG Visconti11, C Borreani12
1
(197/258). Most doctors and nurses gave a favourable opinion Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy;
2
regarding changes to visiting policy in both the first (72%) and the Istituto per lo Studio e la Prevenzione Oncologica, Florence, Italy; 3Ospedale
second survey (71%). In both phases of the study, the percentage di Ciriè, Italy; 4Ospedale Nuovo del Mugello, Borgo San Lorenzo, Italy; 5Azienda
of respondents presenting a profile compatible with burnout was Ospedaliera Universitaria di Modena, Italy; 6Ospedale Civico, Chivasso, Italy;
7
36% and 41% respectively. In subjects without burnout there was Azienda Ospedaliera ‘G. Salesi’, Ancona, Italy; 8Ospedale Civile, Legnano, Italy;
9
a marked predominance of a favourable opinion (80% vs. 61%), Ospedale di Ivrea, Italy; 10Ospedale S. Maria Nuova, Florence, Italy; 11Ospedale
and this favourable attitude was also maintained a year after the ‘A. Uboldo’, Cernusco sul Naviglio, Italy; 12Istituto Nazionale per lo Studio e la
implementation of policy change (79% vs. 59%). Cura dei Tumori, Milan, Italy
Conclusion The presence of burnout has a strong influence on the Critical Care 2012, 16(Suppl 1):P492 (doi: 10.1186/cc11099)
opinion of doctors and nurses regarding liberalization of visiting
policies in the ICU. A favourable opinion predominates among ICU staff Introduction Italian ICUs still impose restrictive visiting policies (with
members without burnout symptoms. In preparing for and assisting a median visiting time of about 2 hours/day); however, a revision of
the opening of ICUs it is important also to be aware of this aspect and current policies is underway [1-3]. No data are available on the views
to offer nurses and physicians appropriate support. of Italian ICU teams following an at least partial liberalization of visiting
Acknowledgments The study was supported by Associazione per il policies. We investigated this issue in the course of a survey about the
Bambino Nefropatico (Milan, Italy). impact on ICU teams of the liberalization of visiting policies.
Reference Methods We administered an anonymous closed-question question-
1. Embriaco N, et al.: Curr Opin Crit Care 2007, 13:482-488. naire to nurses and doctors at eight ICUs that were about to increase
daily visiting time to at least 8 hours, soliciting their views on policy
P491 changes in their unit. The ICU staff were asked to fill in the same
Prevalence, risk factors and impact of severe burnout syndrome in questionnaire a year after implementation.
12 Uruguayan ICUs Results The first response rate was 91% (234/258), the second 76%
G Burghi1, J LAmbert2, M Chaize2, C Quiroga3, G Pittini4, M Cancela5, (197/258). In the first instance, 83% of doctors and 67% of nurses
H Bagnulo1, S Chevret2, E Azoulay2 expressed a favourable opinion regarding the change in visiting policy.
1
Hospital Maciel, Montevideo, Uruguay; 2Saint Louis Hospital, Paris, France; After 1 year a positive opinion was expressed by 84% of doctors and 63%
3
Hospital Español, Montevideo, Uruguay; 4CAAMEPA, Pando, Uruguay; of nurses. Both phases of the study show a significant predominance of
5
Hospital de Clínicas, Montevideo, Uruguay positive opinions among doctors (P = 0.032 and 0.005).
Critical Care 2012, 16(Suppl 1):P491 (doi: 10.1186/cc11098) Conclusion Most ICU staff members view the opening of the unit
positively, and on the whole maintain this opinion 1 year after the
Introduction Burnout syndrome (BOS) is defined as a state of emotional policy change. Overall, the attitude of doctors is more favourable than
fatigue that leads to a loss of motivation, usually progressing towards that of nurses. It is essential to build up a picture of the difficulties
feelings of inadequacy and failure. Severe BOS is relevant as it leads to that liberalizing visiting could create for ICU staff (and particularly
loss of psychological well-being, increased absenteeism and turnover, for nurses), and to explore the causes and extent of such difficulties,
and deterioration in the quality of care provided to patients. The in order to identify possible solutions and offer nurses and doctors
objective was to determine the prevalence of BOS among Uruguayan appropriate support.
ICU clinicians. To evaluate personal or organization characteristics Acknowledgments The study was supported by Associazione per il
associated with the development of severe BOS. Bambino Nefropatico (Milan, Italy).
Methods A survey was conducted in 12 Uruguayan adult ICUs. The level References
of BOS was evaluated on the basis of the Maslach Burnout Inventory 1. Giannini et al.: Intensive Care Med 2008, 34:1256-1262.
(MBI score). ICU, patient, and clinician characteristics were assessed for 2. Giannini et al.: Intensive Care Med 2011, 37:1890.
their association with the prevalence of severe BOS (that is, highest MBI 3. Giannini et al.: Pediatr Crit Care Med 2011, 12:e46–e50.
scores). All variables with P <0.2 in univariate analysis were included
in a model of ordinal regression. P <0.05 was considered statistically P493
significant. A family-based satisfaction survey on the ICU
Results A total of 364 questionnaires were evaluated, including 282 D Moult, R Breeze, A Molokhia
nurses and 82 ICU physicians. The prevalence of severe BOS was 51% University Hospital Lewisham, London, UK
among ICU physicians and 42% in nursing staff. For ICU nurses, factors Critical Care 2012, 16(Suppl 1):P493 (doi: 10.1186/cc11100)
independently associated with lower MBI scores were the following:
work on fixed days (OR 0.6; 95% CI 0.3 to 0.9; P = 0.01), integrated Introduction We conducted a prospective survey to determine
in-ICU working groups (OR 0.6; 95% CI 0.3 to 0.9; P = 0.02), good satisfaction amongst relatives of patients on our ICU. Patient-reported
relationships with physicians (OR 0.8; 95% CI 0.7 to 0.9; P = 0.008) and outcome measures have become widely used and accepted in the
good relationships with supervisors (OR 0.8; 95% CI 0.7 to 1; P = 0.05). pursuit of improved quality of care [1]. However, assessing patient
In contrast, at least one death over the last week was associated with satisfaction is difficult on the ICU, an environment where we more
higher MBI score (OR 2; 95% CI 1.2 to 3.2; P = 0.008). For ICU physicians, commonly communicate with the family of patients regarding the
not being partnered was independently associated with higher MBI care of their relative. Therefore, a more family-centred approach is
scores. Conversely, good relationships with colleagues was associated indicated, for which family satisfaction questionnaires have already
with lower MBI scores (OR 0,5; 95% CI 0.3 to 0.8; P = 0.004). Interestingly, been validated [2].
this study confirms that clinicians with severe BOS had increased Methods We utilised a 35-point questionnaire-based survey of relatives
burden such as sleep disorders, libido troubles, lack of memory, of patients in our ICU over 10 weeks. Questionnaires were distributed
inadequate money management as well as the wish to leave the ICU. to family members when the decision to discharge from the ICU was
Conclusion The prevalence of severe BOS is very high among ICU made. We limited this to two family members per patient who were in
workers in Uruguay. We have identified different risk factors associated the ICU for more than 48 hours.
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Results We received 29 completed questionnaires. Relatives of 24 of the to provide some history as a surrogate to patient interview. We think
respondents had survived to ICU discharge. Responses were linearly the care we provide should encompass both the patient and their
transformed to give percentage scores. Higher values represented a family. This is already accepted practice in the paediatric ICU setting
greater degree of satisfaction. Overall care in the ICU, 88.8%. Courtesy, [2]. Communication between family and clinical staff, ideally on a daily
respect and compassion to the patient (93.8%), to relatives (92.2%); basis, is clearly imperative and a systematic approach to improve this
assessment and treatment of pain (94.4%), breathlessness (92.9%), is good practice. Increasing insight into relatives’ perceptions and
agitation (88.9%); emotional support (89.4%); care from nurses (92.0%), expectations will aid the delivery of high-quality care. We believe that
doctors (95.5%); frequency of communication nurses (92.9%), doctors involving relatives in the ward round will be of benefit for us in our
(89.7%). Overall decision-making, 91.3%. Willingness of staff to answer professional relationships with them and improve their understanding
questions (90.5%); honesty (90.5%), completeness (91.4%), consistency during an extremely difficult time.
of information (90.5%); inclusion in decision-making, 78.7%; support Methods This was a prospective study over 2 months formally inviting
during decision-making, 78.7%; time to think about information given, up to four families per day to be present for that part of the ward round
96.2%. involving their relative. Subsequently they were asked to complete a
Conclusion Family satisfaction with our ICU is high, with satisfaction questionnaire anonymously on the experience.
high in both care and decision-making domains. Appropriate inclusion Results The results that reflected 31 ward round attendances
with and support during the decision-making process were areas with were unanimous: every family agreed that their attendance had a
lower satisfaction scores. The structuring of options for answering positive impact, alleviating misconceptions about the intensive care
these questions may have been a confounding factor in this finding. environment and clarifying the processes involved in the care of their
However, this may represent genuine lower levels of satisfaction and relative. The survey also revealed that attendance at the ward round
steps should be taken to improve this. In response to these findings provided an excellent opportunity to have their questions answered
we have invited families to join their relatives’ part of the consultant by consultants. All those invited wished to attend and all respondents
ward round to improve inclusion and support in decision-making. We said the experience was valuable and they would like to attend again.
are currently repeating the survey with these changes in place and will Comments included: ‘Explanations very helpful to deal with the
present our findings in the future. stress of the situation’ and ‘Reassuring to have information delivered
References professionally and compassionately’.
1. Dodek et al.: Crit Care Med 2004, 32:1922-1927. Conclusion In this single-centre survey we have demonstrated that
2. Wall et al.: Crit Care Med 2007, 35:271-279. inviting families to ICU ward rounds is feasible and we believe that
this intervention could improve family satisfaction on the ICU. We
P494 are investigating the impact of this intervention with a detailed
Immediate needs and level of anxiety of families with traumatic comparative survey, which we will present in the future.
brain injury patients admitted to ICUs References
S Gholamzadeh, R Abdoli, F Shariff, R Gholamzadeh, 1. Patient Satisfaction [www.patientsatisfaction.co.uk]
A Maraghian Mohammadi 2. Aronson et al.: Paediatrics 2009, 124:1120-1125.
Shiraz University of Medical Sciences, Shiraz, Iran
Critical Care 2012, 16(Suppl 1):P494 (doi: 10.1186/cc11101) P496
Family satisfaction in an interdisciplinary ICU: a quality audit
Introduction Meeting the needs of family members of patients in the UM Schmid, R Alpiger, T Rizzo, CK Hofer
ICU is an important criterion in assessment of quality of care in the ICU. Triemli City Hospital, Zurich, Switzerland
Therefore this study was conducted to determine the immediate needs Critical Care 2012, 16(Suppl 1):P496 (doi: 10.1186/cc11103)
and level of anxiety of families with traumatic brain injury patients
admitted to ICUs in Shiraz, Iran in 2008. Introduction The quality of intensive care medicine depends on
Methods In this descriptive cross-sectional study, a convenience sample multiple indicators [1,2]. Meeting relatives’ needs in the challenging
of 60 family members was recruited over a period of 4 months. On the situation of ICU visits is crucial. The aim of this audit was to assess next
second day of ICU admission, one family member for each patient who of kin’s satisfaction and influencing factors.
met the study criteria were asked to complete three questionnaires, Methods With institutional approval, questionnaires were distributed
consisting of the Critical Care Family Need Inventory (CCFNI), the State- to family members of ICU patients. The survey included two visual
trait Anxiety Inventory (STAI) and a demographic data sheet. analogue scale ratings (VAS 1: patient care, VAS 2: decision-making)
Results The mean ages of the subjects were 32.2 years. A total of 10 and 24 questions with four dimensions D1 to D4 (general impression,
needs statements in the CCFNI were rated to be important or very treatment and patient care quality, professional quality) on a five-point
important needs by 50 of the 60 families (83.3%); seven were needs Likert scale, transformed into values 1 to 100. Patient-specific and
for assurance, two were needs for information, and one of them was relatives’ sociodemographic data were recorded. Data are presented
needs for proximity. The mean of CCFNI satisfaction scores were as the mean ± SD, median (Q.5), interquartile range (IQR) and range
low (16.5 ± 1.5) for needs to comfort, and high for needs to support (minimum/maximum). Subgroup analysis (relative’s and patient’s
(38.1 ± 4.7). Also the mean score of state anxiety (56.75 ± 5.7) and trait age, sex, education, marital status, length of stay, visit frequency and
anxiety score (52 ± 6.2) was higher than previous studies. mortality) was performed using the Mann–Whitney U test.
Conclusion A needs-based education program can decrease the level Results Questionnaires of 159 patients were analyzed (patients: age =
of family anxiety and increase the level of satisfaction. 66.1 ± 13.0 years, 64% female, SAPS = 38.8 ± 17.5, LOS = 13.5 ± 11.8
days, mortality = 16.5%; relatives: age = 44.5 ± 26.9 years, 63.7% female, Methods A retrospective analysis of all patients that were treated in the
13% medical/25.5% higher education). High satisfaction (VAS 1/2, D1 medical ICU of a large German university hospital in 2009 and 2010 and
to D4) was observed (Table 1). Significant differences within subgroups died during their hospital stay.
were found: relatives with healthcare education showed higher D1 to Results During the observation period 3,401 patients were treated in
D4 satisfaction than the ones with a graduate degree only. Higher VAS our ICU. The ICU mortality was 15% (n = 501), hospital mortality was 19%
scorings were observed from next of kin with high visit frequency (≥5×/ (n = 658). The mean predictive mortality derived from the SAPS 2 score
week). was 29% for all patients (standardized mortality ratio 0.67), deceased
Conclusion Relatives of ICU patients were in general highly satisfied. patients had a predictive mortality of 56%. Of all deceased, 232 (35%)
The educational status and ICU visit frequency of the next of kin were had received CPR, 170 of those (73%) outside the ICU. Of all patients
revealed to be influencing factors. who died in the hospital, 126 (19%) had received unlimited therapy.
References Life support was withdrawn in 245 patients (37%) and life support was
1. Intensive Care Med 2007, 33:1913-1920. withheld in 241 patients (36%). In 46 patients (7%) palliative care was
2. Intensive Care Med 2009, 35:2051-2059. instituted right from the beginning of the ICU stay. In 104 cases (16%)
the patients themselves made the EOL decision, in 78 cases (12%) an
P497 advance directive was present. A legally designated healthcare proxy
Incidence of post-traumatic stress, anxiety and depression was involved in 8%. In 541 cases (82%) the relatives were integrated
symptoms in patients and relatives during the ICU stay and after in EOL decisions with the objective of finding a broad consensus;
discharge however, in these cases the assessment of the medical indication and
R Fumis, P Martins, G Schettino the prognosis by the medical team was of particular importance. Cases
Hospital Sirio-Libanes, São Paulo, Brazil in which relatives were not involved in EOL decisions were in 76% cases
Critical Care 2012, 16(Suppl 1):P497 (doi: 10.1186/cc11104) with short unsuccessful maximal therapy, for example CPR (median
ICU stay 5 hours). The rate of life support withdrawal was highest (60%)
Introduction To study the incidence and predictors of post-traumatic in patients with CNS diseases. We did not experience any serious or
stress, anxiety and depression symptoms in medical and surgical patients unsolvable conflicts with relatives. Involvement of a law court was
and relatives during the ICU stay and at 30 and 90 days post ICU discharge. necessary in none of the cases.
Methods A prospective study of 72 patients and 99 family members Conclusion EOL policies were applied in 81% of our intensive care
that completed the Hospital Anxiety and Depression Scale during the patients who died during their hospital stay. The new German law
ICU stay and at 30 and 90 days after discharge. The Impact of Event regulations served as a practical and realizable basis for EOL policies
Scale at 30 and 90 days after ICU discharge was used to evaluate post- in our medical ICU.
traumatic stress disorder (PTSD).
Results The prevalence of symptoms of anxiety, depression or both
in patients during the ICU stay was 10%, 2.8% and 6.9% respectively. P499
Among family members prevalence was 17.3%, 6.5% and 14.4% Effect of a full moon on mortality of patients admitted to the ICU
respectively, and was significantly higher compared to patients R Nadeem1, A Nadeem1, E Madbouly1, J Molnar2, J Morrison2
1
(P = 0.034). PTSD symptoms were present in 39.8% and 32.7% of Captain James A. Lovell Federal Healthcare Center, North Chicago, IL, USA;
2
family members respectively at 30 and 90 days after discharge. Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
Among patients symptoms were significantly lower (P <0.001). Factors Critical Care 2012, 16(Suppl 1):P499 (doi: 10.1186/cc11106)
associated with symptoms of anxiety and depression during the ICU
stay in a multivariate model included patient-related factors as SAPS 3 Introduction The effect of the full moon (the lunar effect) on human
(OR 1.1, 95% CI 1.01 to 1.24) and length of family member stay in the behaviour has occupied researchers for centuries. We aim to determine
ICU (OR 1.39, 95% CI 0.89 to 2.16) and family-related factors as female such a lunar effect on mortality among patients admitted to the ICU.
gender (OR 5.43, 95% CI 0.67 to 43.8) and oncologic diagnosis (OR 0.25, Methods We analyze the electronic medical records of patients
95% CI 0.05 to 1.31). The multivariate model also identified patient age admitted to the ICU. The subjects were divided into two groups:
(OR 0.97, 95% CI 0.93 to 1) and oncologic diagnosis (OR 0.27, 95% CI patients who died on full moon days (14th,15th, and 16th days of the
0.09 to 0.79) associated with symptoms of post-traumatic stress after lunar month) and the patients who died on other days of the lunar
discharge among family members. month. The mortality rates were calculated for patients in both groups.
Conclusion At least one-third of family members visiting patients Parameters including age, gender, acute physiology and chronic health
in the ICU suffer from symptoms of anxiety, depression or both. The evaluation (APACHE) III scores, predicted mortality, type of ICU, and
level of post-traumatic stress symptoms in family members was high actual mortality were compared between the two groups. Student’s t
after ICU discharge. Depression, anxiety and post-traumatic stress test was performed to determine whether there were any differences
symptoms were higher among family members compared to patients. between the groups.
Female gender and oncologic diagnosis were strongly associated Results Data from 4,387 patients who were followed for 23 months
with depression and post-traumatic stress. Further actions might be were analyzed. Overall, 297 patients died during this period, including
adopted to diminish the incidence of these disorders. 31 patients on full moon days and 266 patients on the other days of
References the month. Both groups were similar in terms of age (73 vs. 71 years,
1. Myhren H, et al.: Crit Care 2010, 14:R14. P = 0.39), APACHE III scores (82.06 vs. 76.52, P = 0.28), and predicted
2. Pochard F, et al.: Crit Care Med 2001, 29:1893-1897. mortality (0.405 vs. 0.370, P = 0.48). There was no difference in the
3. Fumis R, et al.: Intensive Care Med 2009, 35:899-902. frequency of death between the full moon days and the other days
(10.33 vs. 9.85, P = 0.81). See Table 1.
P498 Conclusion The full moon does not seem to affect the mortality of
Application of a new German law as a basis for end-of life decisions patients admitted to the ICU.
in a medical ICU
R Riessen, C Bantlin, M Haap Table 1 (abstract P499). Characteristics of patients who died on full moon
University Hospital Tübingen, Germany days versus other days
Critical Care 2012, 16(Suppl 1):P498 (doi: 10.1186/cc11105) Full moon Other days P value
Introduction In 2009 a new German law came into effect that clarified Age 73.6 ± 14.59 71.07 ± 16.1 0.39
issues regarding end-of-life decisions, especially the role of patient
Male/female 15/16 133/133 0.86
autonomy and the importance of a medical indication in the course
of treating patients with terminal illness. In this study we analyzed APACHE III 82.06 ± 24.1 76.52 ± 27.4 0.28
the end-of-life (EOL) policies in our medical ICU with a focus on the
practicability of this law. Mortality 0.405 ± 0.249 0.370 ± 0.268 0.48
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Results A total of 3,629 admissions during a 4-year period pre ICON Results The number of MET calls initially increased from 34 to 56 and then
(August 2004 to August 2008) and 1,446 admissions during 18 months decreased to 39 calls/1,000 admissions/year. Most of the calls were from
post ICON (August 2009 to February 2011) were audited. Following the the emergency department and less from medical and surgical wards.
introduction of ICON the percentage of unplanned admissions fell from The number of ICU admissions did not increase (Figure 1). During the
36.68% to 22.9%. These patients also had a lower mortality rate (14.57% period of study there was a reduction of observed mortality compared to
vs. 9.36%) and the SMR decreased from 1.55 to 1.35. that predicted from SAPS II score, especially in surgical patients (Figure 2).
Conclusion Our data show that the mortality rate has decreased Finally, there was an increase of ICU length of stay (LOS) from 11.5 to 13.7
since the introduction of ICON although a confounding factor could days and a reduction of hospital LOS from 24 to 23.1 days.
be a concurrent decreased crude mortality rate (5.5% in 2003 to 2004 Conclusion The implementation of RRS could result in a temporary
vs. 4.2% 2008 to 2010) in all paediatric intensive care patients in the increase of MET calls but not of ICU admissions; moreover, it could lead
UK [2]. Despite this we believe that ICON is a significant contributing to a reduction of mortality and hospital LOS, but not of ICU LOS.
factor in identifying and rescuing patients on the wards before further References
significant deterioration requiring intensive care. Further ongoing 1. Acutely Ill Patients in Hospital: Full Guideline [http://guidance.nice.org.uk/
audit is required. CG50/Guidance]
References 2. DeVita MA, et al.: Crit Care Med 2006, 34:2463-2478.
1. FO Odetola, et al.: Do outcomes vary according to the source of admission
to the PICU? Pediatr Crit Care Med 2008, 9:20-25. P507
2. Paediatric Intensive Care Audit Network [http://www.picanet.org.uk/] Medical emergency team admittance to intensive care versus
conventional admittance: characteristics and outcome
G Jäderling, M Bell, CR Martling, A Ekbom, M Bottai, D Konrad
P506 Karolinska Institutet, Stockholm, Sweden
In-hospital rapid response system: effects on outcome and Critical Care 2012, 16(Suppl 1):P507 (doi: 10.1186/cc11114)
workload
D Liberti, C Di Maria, P De Luca, M Alberico, C Popa, O Sagliocco, Introduction The purpose of the medical emergency team (MET) is to
MR Scalzulli, E De Blasio find and treat deteriorating ward patients. Suboptimal care and delays
Hospital G. Rummo, Benevento, Italy on general wards before admission to intensive care have an effect on
Critical Care 2012, 16(Suppl 1):P506 (doi: 10.1186/cc11113) mortality [1] and patients admitted from general wards have a worse
outcome than from the operating room (OR) or emergency department
Introduction The implementation of an in-hospital rapid response (ED) [2]. MET patients have a high rate of ICU admissions but whether their
system (RRS) could improve the outcome of a deteriorating patient outcome differs from other patients admitted from the wards has not been
but could increase the medical emergency team (MET) and ICU staff studied before. We evaluated characteristics and outcome of ICU patients
workload [1,2]. based on mode of admittance, via the MET versus the conventional way.
Methods A retrospective analysis of the years pre, during and post Methods An observational prospective study of patients admitted
implementation of a RRS in a 480-bed hospital with a mean of 17,500 from general wards to the central ICU at Karolinska University hospital,
admissions/year. Stockholm, Sweden in 2007 to 2009. Two groups were identified:
admissions directly following a MET call or the conventional way,
usually on request from the ward physician. Patients were analyzed
for age, gender, co-morbidities, length of stay, severity scoring system
(APACHE II) and mortality.
Results Of 2,571 ICU admissions, 694 admissions in 643 patients came
from the wards. In total, 355 were admitted by the MET and 339 were
conventional admissions. Median age was 65 years in the MET group
versus 58 years in the conventional group, hospital LOS prior to ICU
admission was median 3 days versus 1 day and APACHE II score was a
mean of 26 versus 21. They did not differ as to proportion of invasive
ventilator treatment or dialysis but MET patients more often received
noninvasive ventilation, 57.2% versus 29.2% (P <0.01). ICU mortality
was 14.5% versus 8.9% (P = 0.04) and 30-day mortality 27.0% versus
19.1% (P = 0.02). MET patients also had a higher proportion of co-
morbidities, with a prevalence of heart failure in 17.3% versus 11.7%
Figure 1 (abstract P506). MET calls and ICU admission before, during (P = 0.0.4) and malignancy in 45.3% versus 35.1% (P <0.01) as well as
and after the RRS implementation. a higher proportion of limitation of medical treatment (LOMT), 23.0%
versus 15.7% (P = 0.02). When LOMT patients were excluded, mortality
rates were no longer significantly different, ICU mortality then being
5.7% versus 3.3% (P = 0.2).
Conclusion Two distinct groups of patients with intensive care needs
are found in general wards. Those admitted by the MET are older, have
more severe co-morbidities and have been in hospital longer. We find
the MET to be an important tool to identify patients with multiple
problems and at high risk of an adverse outcome.
References
1. McQuillan et al.: BMJ 1998, 316:1853-1858.
2. Goldhill et al.: Crit Care Med 1998, 26:1337-1345.
P508
Factors affecting critical care admission to a UK university hospital
A Tridente1, A Chick1, S Keep1, S Furmanova2, S Webber1, DC Bryden1
1
Sheffield Teaching Hospitals, Sheffield, UK; 2University Hospital Wales, Cardiff, UK
Critical Care 2012, 16(Suppl 1):P508 (doi: 10.1186/cc11115)
Figure 2 (abstract P506). Hospital mortality predicted and observed
before, during and after the RRS implementation. Introduction Access to critical care is limited, with disparity existing
between availability and demand. Guidance to inform triage decisions
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has been published but may no longer reflect current pressures [1,2]. Table 1 (abstract P509). Distribution of intensive care services in 2010
We aimed to identify a set of criteria able to reliably predict likelihood
Total Total Case mix
of admission to a critical care unit in a large UK tertiary care centre.
National data, number number index
Methods Consecutive patient referrals were prospectively enrolled in a
2010 of units of beds (mean ± SD) P value
review cohort. Data were collected using a predefined case report form
(CRF). The CRF included information on the referral, acute physiological University hospitals (level III) 10 412 7.67 (± 4.06) 0.204
parameters, hospital length of stay (LOS), demographic and functional
status, dependency and comorbidities. Logistic regression was County hospitals (level II) 30 584 8.08 (± 2.89) 0.376
performed to identify factors predicting admission, employing STATA [3]. City hospitals (level I) 39 280 6.05 (± 1.97) 0.093
Results Between 17 July and 27 November 2011, 201 patients were
referred to critical care, of whom 85 (42.7%) were declined. Median
age (interquartile range) was 67 (54 to 79) years, 121 (60.8%) were P510
male, median LOS (interquartile range) was 1 (1 to 3) day. Age, gender, Data acquisition for the UK Critical Care Minimum Data Set:
ethnic origin, LOS, referral reason, and markers of acute physiological validation of a computer model for automatic calculation from an
derangement did not impact on likelihood of admission to critical care. electronic patient record
Odds ratios (95% CIs) for admission were 3.1 (1.72 to 5.56) for exercise A Clarke, M Thomas, T Gould, C Bourdeaux
tolerance >100 yards (P <0.001), 3.03 (1.56 to 5.89) for self-caring status Bristol Royal Infirmary, Bristol, UK
(P = 0.001), 0.38 (0.2 to 0.71) for house-bound status (P = 0.003), 0.28 Critical Care 2012, 16(Suppl 1):P510 (doi: 10.1186/cc11117)
(0.1 to 0.76) for wheelchair-bound status (P = 0.013), 0.41 (0.23 to
0.74) for cardiovascular (P = 0.003), 0.36 (0.18 to 0.72) for renal system Introduction This study reports the accuracy of a computer and a
(P = 0.004), 0.34 (0.14 to 0.85) for malignant (P = 0.021), and 0.49 (0.25 to manual system at collecting data for the UK Critical Care Minimum
0.94) for neurological (P = 0.033) comorbidities, respectively. Data Set (CCMDS). This is required by the Department of Health to
Conclusion Our data suggest that critical care admission decisions are compare performance, to facilitate funding and to plan future resource
made based mainly on the assessment of patients’ pre-morbid state provision. There are 14 data fields in the mandatory dataset, and
and functional capacity, rather than on the extent of acute physiological the full compliment extends to 34 fields. At present this is collected
derangement. This behaviour is more consistent with the application of manually, which is laborious and subjective. We use an electronic
a prioritization model, defining those patients who will benefit most patient record (Innovian, Draeger, Germany) to store all the measured
from critical care admission (Priority 1) to those who will not benefit at patient observations and laboratory results. We have written a program
all (Priority 4) and consistent with pressured resources, rather than an to interrogate Innovian for the CCMDS data, thereby reducing the
objective parameters model or a diagnostic model [1]. administrative time.
References Methods A stratified sample of 50 patients’ data (elective and
1. Guidelines for intensive care unit admission, discharge, and triage. emergency surgical and medical patients) was analysed. Both manual
ACCCM, SCCM. Crit Care Med 1999, 27:633-638. and computer systems collected the mandatory 14 items of the CCMDS.
2. Fair allocation of intensive care unit resources. ATS. Am J Respir Crit Care This consists of six demographic variables (for example, admission
Med 1997, 156:1282-1301. date, discharge date, date of birth) and eight organ support variables
3. STATA 10.1. College Station, TX: StataCorp. (for example, duration of either advanced or basic cardiovascular,
respiratory, renal or neurological support or duration of level 2 or 3
support). Where the computer and manual systems returned different
P509 values, a blinded physician analysed the patient records and created a
Intensive care services in Hungary 2000 to 2010: an analysis of bed gold standard value. The frequency of these differences was analysed.
numbers, occupancy rates, case mix and economics Results Both computer and manual systems returned all the required
A Csomos1, B Fulesdi2, M Gresz3 data, giving a total of 700 data variables. Different values were returned
1
Semmelweis University, Budapest, Hungary; 2University of Debrecen, for 183 (26%) variables. The systems had good concordance in the
Hungary; 3National Institute for Quality and Organisational Development in demographic variables, with only 4/300 (1.3%) discrepancies between
Healthcare, Budapest, Hungary the computer and manual systems. In the organ support variables,
Critical Care 2012, 16(Suppl 1):P509 (doi: 10.1186/cc11116) there were 179/400 (45%) discrepancies. Days of renal support had
most concordance, with discrepancies in 3/50 patients (6%). Days of
Introduction The purpose of this study is to describe the changes in level 2 support had least concordance, with discrepancies in 37/50
pattern of intensive care (ICU) use over a 10-year period in Hungary. patients (76%). Overall, the computer method returned the correct
We attempt to analyze national data in order to improve resource use. variable for 544 (78%) variables, where the manual system returned the
Methods A retrospective analysis of national data provided by the correct variable on 591 (84%) variables.
hospitals for reimbursement of care to the National Healthcare Fund of Conclusion This study shows that both computer and manual data
Hungary between 2000 and 2010. collection methods could be improved, but at present both have
Results The total number of active hospital beds decreased by 33.4% similar accuracy. This may be because the criteria for some organ
(from 65,532 to 44,300); however, the number of ICU beds increased support can be subjective (for example, risk of deterioration), which
by 9.8% (from 1,189 to 1,306) between 2000 and 2010. As a result, can be interpreted in different ways between manual data collectors
the percentage of ICU beds to hospital beds increased from 1.89% in but not by a computer. We plan to rewrite the computer program,
2000 to 2.95% in 2010. The ICU bed occupancy rate ranged between aiming for >95% concordance with the gold standard.
58.43% and 63.78%; it showed no correlation with the case mix index
(r2 = 0.2799). The number of ventilator days increased from 28.9% to
66.1%; it showed good correlation with the case mix index (r2 = 0.9125). P511
Analysing 2010 data, we found significantly lower mortality in level III To admit or not to admit? The suitability of critical care admission
units (30 ± 18%) compared to level II (51 ± 20%) and level I (56 ± 19%) criteria
care (P = 0.001 and 0.003), without significant differences in case mix D Marriott, Z Turner, N Robin, S Singh
index (Table 1). The mean ICU bed occupancy rate was 59.5% (SD ±12%), Countess of Chester Hospital, Chester, UK
and length of hospital stay was 12.3 (SD ±3.0) in 2010. Geographic Critical Care 2012, 16(Suppl 1):P511 (doi: 10.1186/cc11118)
distribution of ICU beds per 100,000 population ranged between 7.3
and 27.4 (nationwide 12.9/100,000); it showed no correlation with Introduction During the 2010/2011 winter the H1N1 influenza
regional gross domestic product values (r2 = 0.4593). pandemic placed increased demand on critical care services,
Conclusion Our data suggest that intensive care beds are not utilized; prompting our department to devise a modified triage tool for the
a progressive level of care does not function and also there are ICU to be implemented at a time of exceptional bed crisis [1]. Scoring
unnecessary regional differences in intensive care provision in Hungary. systems such as APACHE or Sequential Organ Failure Assessment
Critical Care 2012, Volume 16 Suppl 1 S182
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(SOFA) have been used to predict mortality and optimize critical care when medical staffing levels on the wards are highest. The SICS define
service utilization [2]. This audit aimed to validate our triage tool for the out-of-hours period based on the time of handover to nightshift.
patients admitted to the ICU. For discharges at this time, there was no increase in mortality. In our
Methods We retrospectively examined patient notes for all admissions hospital, evening ward cover is the same as overnight. For an out-
to our adult ICU during December 2010 and January 2011. Patient of-hours period of 17:00 to 07:59, there was a significant increase in
admission criteria (SpO2 <90% on FiO2 >85%, respiratory acidosis mortality following out-of-hours discharge.
pH ≤7.2, respiratory failure or airway compromise, systolic pressure Conclusion Our data show increased mortality following ICU step-
<90 mmHg, SOFA score ≥7) or refusal criteria (SOFA score ≥12, severe down in the evening as well as at night. Discharge was most often
trauma, unwitnessed or non-VF arrest, severe life-limiting condition) delayed due to a lack of ward beds. To reduce mortality, efforts must
were recorded with outcome data. therefore be made to improve bed management and ensure discharge
Results We analysed 27 sets of notes. Twenty-two patients (81%) from the ICU before 17:00.
fulfilled at least one admission and no refusal criteria. Two patients Reference
(7%) had documented refusal criteria. The first of these had a severe 1. Scottish Intensive Care Society Audit Group: Audit of Critical Care in Scotland
life-limiting condition, staying 29 days in the ICU and a further 65 days 2011, Reporting on 2010; 2011. Edinburgh: ISD Scotland.
in hospital. The second was admitted post non-VF arrest, dying after
2 days in the ICU. Three patients (11%) met no admission criteria. These P513
patients stayed between 4 and 6 days in critical care with total hospital Delayed discharges revisited: impact of a liaison post on patients’
stays of 18 to 98 days, one requiring 30 days of rehabilitation. transition from ICU to ward care
Conclusion The proposed admission criteria concurred with clinical J Mellinghoff, P O’Shea, D Dawson, J Ball, A Rhodes, M Grounds
decision-making in 81% of admissions. The patients that met refusal St George’s Healthcare NHS Trust, London, UK
criteria required either prolonged hospital stay or had short survival Critical Care 2012, 16(Suppl 1):P513 (doi: 10.1186/cc11120)
times and may not represent optimal utilization of critical care facilities
during a time of increased demand. Those patients not meeting the Introduction This audit reviewed the discharge process of patients
admission criteria had short critical care stays illustrating that rigid from an adult general ICU to the general wards before and after the
admission requirements may exclude patients who could benefit from introduction of a liaison nurse post over a 3-year, 3-month time period.
critical care. A standardized set of admission criteria may supplement Methods The audit utilised routinely collected retrospective data from
decision-making during times of increased critical care demand and a 17-bed ICU. We examined the impact of a liaison post on the length
strengthen documentation of those decisions. However, no set of of delays on discharge of patients from the ICU to the general wards.
criteria can replace clinical judgement in critical care admission. Results The study period was from April 2008 until June 2011 with the
References start date of the liaison nurse post in January 2010. Overall, there were
1. Christian MD, et al.: Development of a triage protocol for critical care 4,327 patient discharges to hospital wards (before group = 2,063, after
during an influenza pandemic. CMAJ 2006, 175:1377-1381. group = 2,264). The odds of experiencing a delay in discharge >4 hours
2. Ling CY, et al.: Outcome scoring systems for acute respiratory distress were 3.2-fold higher in the before group compared to the after group
syndrome. Shock 2010, 34:352-357. (95% CI = 2.808 to 3.717, P <0.0001). Accumulated discharge delays
decreased by 23% from 1,116 (before group) to 864 days (after group)
despite an increase in patient turnover of 10% (n = 201). The median
P512 delay time was 7.2 hours (IQR 5.0 hours, 10.4 hours) in the before group
Out-of-hours discharge from the ICU: defining the out-of-hours and 5.3 hours in the after group (IQR 2.7 hours, 9.0 hours). See Figure 1.
period and its effect on mortality Conclusion Our analysis suggests that the introduction of a liaison
YL Bramma, R Allan, R Sundaram nurse post within intensive care significantly reduced the length of
Royal Alexandra Hospital, Paisley, UK delays in the discharge process despite an increase in patient turnover.
Critical Care 2012, 16(Suppl 1):P512 (doi: 10.1186/cc11119)
P514
Introduction Out-of-hours discharge from the ICU is associated with Assessing demand for intensive care services: the role of
increased mortality. In Scotland, approximately 15% of discharges readmission rates
occur out of hours [1]. The aim of this study was to determine the RA O’Leary, B O’Brien
reasons behind out-of-hours discharges in our hospital and the effect Cork University Hospital, Cork, Ireland
this has on mortality. Critical Care 2012, 16(Suppl 1):P514 (doi: 10.1186/cc11121)
Methods We carried out a retrospective analysis of all patients admitted
to our ICU over a 3-year period. Patients who died during their ICU stay, Introduction Irish ICUs typically have bed occupancy rates approaching
patients <16 years, patients transferred to another ICU, and those with 100%, with 75 to 80% being the recommended level [1]. Detection
missing data were excluded. Data collected: patient demographics, of excessive demand from simple databases can thus be difficult:
APACHE II score, time of discharge from the ICU, reason for out-of-hours expedited turnover and cancellations of elective surgery often ensue,
discharge, and hospital mortality. The out-of-hours period was defined leaving occupancy rates unchanged. We hypothesised that excessive
as per the Scottish Intensive Care Society (SICS) as 20:00 to 07:59 hours, demand would produce higher readmission rates, thus illustrating the
then later re-defined as 17:00 to 07:59 hours. strain imposed on ICU resources during the H1N1 influenza pandemic.
Results A total of 766 patients were included: 607 discharged between Methods The GICU database was examined from 1 March 2010 to 1
08:00 and 19:59 hours, 159 discharged between 20:00 and 07:59 hours. March 2011. The H1N1 pandemic was recognised as a period of strain
Data are expressed as mean values (SD) or percentages, ‘in hours’ versus on the ICU and this period was estimated as 24 December 2010 to
‘out of hours’. Both groups were similar: age 51.9 (18.1) versus 54.0 21 January 2011. All ICU readmissions during the same hospital stay
(17.7) years, males 48.9% versus 50.9%, APACHE II score 15.8 (8.7) versus were noted. Transfers between GICU, cardiac ICU and theatre recovery
17.4 (8.0). Hospital mortality following ICU discharge was 9.9% (55/607 were excluded as patients were still being treated by the intensive care
deaths) versus 10.0% (16/159 deaths), RR 1.11 (95% CI 0.66 to 1.88). team. Patients readmitted after transfer for extracorporeal membrane
Discharge was delayed due to a shortage of ward beds in 28.5% versus oxygenation (ECMO) were also excluded.
43.4% of cases. No early discharges were recorded. With the out-of- Results The number of GICU admissions during the period was 422.
hours period re-defined: 393 patients were discharged between 08:00 There were 19 readmissions (readmission rate of 4.6%). However, this
and 16:59 hours, 373 between 17:00 and 07:59 hours. Both groups were rate increased to 8.6% during the period of high activity encompassing
similar: age 51.0 (18.4) versus 53.8 (17.5) years, males 49.9% versus the H1N1 pandemic (Figure 1). Hospital mortality was 36.8% in the
48.8%, APACHE II 14.9 (8.7) versus 17.4 (8.2). Hospital mortality was readmission group, higher than the average, 24.6%, for the whole GICU
7.7% (28/393 deaths) versus 11.5% (43/373 deaths), RR 1.62 (95% CI population. This is in keeping with previous research showing up to an
1.03 to 2.55). Discharge was delayed due to a shortage of ward beds in 11-fold increase in relative risk of mortality in patients readmitted to
22.7% versus 41.0% of cases. ICU step-down is most safely performed the ICU [2].
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Conclusion The annual readmission rate for our unit was acceptable P515
[3]. A clear spike was noted during the period of the H1N1 pandemic. Management of cardiac drugs in a critical care setting
Whilst this is a pattern we hope to address, it is a useful indicator of M Mallick1, J Walkington1, A Gratrix1, R Pretorius2
1
increased demand. Our study suggests that readmission trends Hull Royal Infirmary, Hull, UK; 2York Teaching Hospital, York, UK
in a single institution may be helpful when analysing the severity Critical Care 2012, 16(Suppl 1):P515 (doi: 10.1186/cc11122)
of epidemics, planning staffing needs, and comparing periods of
heightened demand. Introduction ICU admissions may lead to discontinuation of
References longstanding evidence-based therapies. A recent study demonstrated
1. Intensive Care Society: Standards for Intensive Care Units. London: ICS; 1997. how such medications have been discontinued for patients even after
2. Rosenberg AL, et al.: Crit Care Med 2001, 29:511-551. their ICU stay [1]. Evidence has shown the beneficial role of β-blockers
3. Rosenberg AL, et al.: Chest 2000, 118:492-502. in the perioperative period [2], and roles for other drugs such as
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angiotensin-converting enzyme inhibitors (ACE-I) and statins have unindicated SUP use; and reduction in inappropriate i.v. administration
been demonstrated. The aim of the current study was to examine 30- (23.1% vs. 0%, P = 0.0024).
day mortality and complication rates in the critical care population who Conclusion Emphasis on the guidelines for SUP to all members of the
were on cardiac medications and did not receive these medications team, especially the pharmacist, improves compliance. Inclusion in
during their ICU stay. SUP prescriptions of the intended discontinuation date may further
Methods We looked retrospectively at the last 80 patients admitted to reduce excessive duration of treatment. Re-audit will occur after
the ICU or HDU in York, 2011. The patients’ case notes were examined implementation of new guidelines which acknowledge the diminishing
to assess if they were on cardiac medications and if those drugs were benefit from SUP and the not-insignificant risks associated with its use.
omitted during their admission. The cardiac medications assessed Reference
were β-blockers, ACE-I and statins. We also reviewed any cardiac 1. Cook DJ, et al.: Crit Care 2001, 5:368-375.
complications incurred during their stay, alongside 30-day mortality.
Results A total of 29.6% of patients on β-blockers received them,
whilst 67.8% did not. Complication and mortality rates for medications P517
given versus not given were 12.5% versus 68.4% and 0% versus 42.1% Healthcare workers’ experience when using an electronic medical
(P = 0.003 and P = 0.007) respectively. A total of 17.6% of patients on order entry and bar-code technology in an ICU
ACE-I received them, whilst 82.3% did not. Complication and mortality R Fumis, I Souza, V Pizzo, G Schettino
rates for medications given versus not given were 0% versus 9.0% Hospital Sírio-Libanês, São Paulo, Brazil
and 0% versus 35.7% (P = 0.004 and P = 0.055) respectively. A total Critical Care 2012, 16(Suppl 1):P517 (doi: 10.1186/cc11124)
of 31.6% of patients on statins received them, whilst 68.4% did not.
Complication and mortality rates for medications given versus not Introduction Medication errors are frequent in the ICU and may occur
given were 25.0% versus 42.3% and 8.3% versus 38.5% (P = 0.256 and during medical ordering, transcription or administration of drugs. A
P = 0.02 respectively). The global complication and mortality rates for system consisting of a computerized physician order entry (CPOE) with
medications given versus not given were 28% versus 55.2% and 11.5% bar-code verification of medications (TASY; Web Sistemas, Brazil) has
versus 51.7% (P = 0.0648 and P = 0.0039) respectively. Omission of been described as a tool to improve medication safety [1], but few data
β-blockers resulted in significantly higher complication and mortality are available about the satisfaction of healthcare workers with the use
rates. Omission of ACE-I resulted in higher complication rates and of of this new technology in the ICU.
statins in higher mortality rates. Omission of cardiac medications Methods We conducted a survey to evaluate the satisfaction of
resulted in a significantly higher mortality rate. healthcare workers when using a CPOE with bar-code verification of
Conclusion The study does highlight a trend associated with patients medications in a tertiary 40-bed adult ICU in Sao Paolo, Brazil 6 months
who are on medications who do not receive them to either develop after implementing the system. A satisfaction questionnaire which
higher complication rates or higher mortality rates or both. Further consisted of items in a numeric scale type from 1 (low satisfaction) to 10
research involving larger numbers is required to produce validated (high satisfaction) was filled out by physicians (n = 42), nurses (n = 58),
opinions. nurses technicians (n = 84) and other professionals (n = 66).
References Results Most subjects were female (66%), below 36 years of age (69%)
1. Bell CM: JAMA 2011, 306:840-847. and used the computer daily at home (81%). On average, respondents
2. 2009 ACCF/AHA focused update on preoperative beta blockade: a report were satisfied with the CPOE system (score 5.74 ± 2.14) and believed
of the American College of Cardiology Foundation/American Heart it improved safety (score 7.64 ± 2.42). Satisfaction was lower among
Association task force on practice guidelines. Circulation 2009, physicians (score 4.62 ± 1.79) when compared to other professionals
120:2123-2151. (score 5.97 ± 2.14; P <0.0001). The ease to place the first medical order
and to copy the order form the previous day scored 5.41 ± 2.05 and
P516 6.39 ± 1.93. The visualization of the medical order with the bar-code
Pharmacists and fastidiousness improve compliance with verification of drugs administration scored 5.95 ± 2.51 by the nurses.
guidelines for stress ulcer prophylaxis On average, physicians found the system less user-friendly (score
S Sanders, KC Shelley, AJ Marsh 3.88 ± 1.85) than other professionals (6.40 ± 2.29; P <0.0001).
Frenchay Hospital, Bristol, UK Conclusion Although most of the ICU staff believe that the CPOE
Critical Care 2012, 16(Suppl 1):P516 (doi: 10.1186/cc11123) and bar-code has the potential to improve medication safety and the
quality of care for critically ill patients, our survey showed a low level of
Introduction This audit assessed compliance with guidelines for the satisfaction 6 months after implementing the system, particularly for
use of stress ulcer prophylaxis (SUP) in our mixed general/neurosurgical physicians who consider the system unfriendly.
ICU. These patients are at increased risk of gastrointestinal bleeding Reference
with clinically important bleeding occurring in about 3.5% of patients 1. Poon EG, et al.: N Engl J Med 2010, 362:1698-1707.
ventilated for 48 hours or more [1]. SUP guidelines: all patients at risk
of stress ulceration (coagulopathy/IPPV >48 hours/nasogastric (n.g.)
feed not absorbed) or already on ant acids should receive ranitidine, P518
enterally where possible. Exceptions are patients on a proton pump Safer ICU trainee handover: a service improvement project
inhibitor (PPI) prior to ICU admission. PPIs should continue enterally if E Godfrey1, I Hassan1, A Carson-Stevens2, AG Saayman1
1
possible as lanzoprazole, or as omeprazole i.v. University Hospital of Wales, Cardiff, UK; 2Cardiff University, Cardiff, UK
Methods Data were collected from May to August 2010 (Period 1). Critical Care 2012, 16(Suppl 1):P518 (doi: 10.1186/cc11125)
Results from this were discussed and the following interventions
adopted prior to further data collection (Period 2: August to November Introduction Quality handover between team members within the ICU
2011): prescription of SUP in all ventilated patients on admission is vital for patient safety. Critically ill patients are at high risk of medical
to the ICU; discontinuation of SUP after 48 hours if n.g. feeding errors; these complex patients are exposed to high-risk interventions,
tolerated; documented daily review of SUP including consideration of medical and procedural [1]. Distractions are known to be particularly
discontinuation, drug, route and dose used; and the presence of the prevalent within critical care [2]. This can compromise handover
ICU pharmacist on ward rounds, briefed specifically to prompt correct efficiency, interrupt information-giving and may ultimately lead to
SUP use. poorer patient outcomes [3]. We sought to demonstrate the capability
Results Period 1 (n = 86) revealed excess use of SUP, excess use of of junior physicians to lead change to their practices that benefit
PPIs when ranitidine was indicated, unnecessary i.v. administration the quality of patient care in a large critical care unit. We present an
and failure to discontinue prophylaxis appropriately. Period 2 (n = 71) improvement project that has transformed handover quality in our ICU.
demonstrated: no fall in SUP use in those with indications (93% vs. Methods Participant observation of handover practices took place
97%, P = 0.65); increased prescription accuracy in terms of drug, dose within a high-occupancy 33-bed adult ICU. Quantitative assessment
and administration route (40% vs. 84%, P = 0.0001); no increased of handover criteria as per Royal College of Anaesthetists guidelines
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Methods We conducted a prospective audit on implementation of a confidence in its use, a similar proportion to the original audit. Eighty
care bundle after audit approval. We collected data for 101 patient days per cent would have an ODP for unplanned intubations. One hundred
from all patients admitted to Hull Royal Infirmary ICU during the month per cent were airway trained. Outcomes A designated consultant
of November 2011. We collected information regarding stress ulcer was assigned to teach difficult airway management at quarterly
prophylaxis, deep vein thrombosis (DVT) prophylaxis, ventilator care departmental induction sessions which included equipment location
bundle, blood glucose control, daily assessment of need for a central and algorithms. Trainees and consultants underwent simulation and
line, sedation score assessment and delirium score assessment at least mannequin training, including tracheostomy and surgical airway
twice a day. management. Regular updates and case-based teaching sessions were
Results All patients received stress ulcer prophylaxis. At least 95% of implemented. Airway proficiency assessments were conducted at
patients received DVT prophylaxis, adequate blood glucose control induction.
and appropriate sedation need assessment. There was further scope Conclusion This audit highlights our variable workforce. The
for improvement in areas of sedation hold practice and assessing daily presence of junior, nonairway-trained staff on the ICU calls for regular,
need for a central line. Poor clinical practice was identified in delirium compulsory airway teaching sessions for all, regardless of grade.
score assessment and head elevation to reduce VAP. See Table 1. Airway competency must be formally assessed at the start of an ICU
attachment. Airway instructions for challenging patients should be
Table 1 (abstract P524) clearly documented with advice on access to senior assistance for
emergencies.
Intervention in eligible patients Adherence, n (%)
Reference
Stress ulcer prophylaxis 101/101 (100) 1. Jeanrenaud P, et al.: Difficult airway trolleys for the critical care unit. JICS
2010, 11:98-103.
DVT/PE prophylaxis 94/97 (97)
Head elevation 30% in ventilated patients 62/75 (83)
P526
Daily sedation hold 28/32 (88) A new patient mobilization scoring system in the ICU: what is the
Blood glucose control 96/101 (95) degree of similarity in scores between assessors in daily use?
M Vogel, CW Casteleijn, P Bruins, AJ Meinders
Need for central line assessed 73/85 (86) St Antonius Ziekenhuis, Nieuwegein, the Netherlands
Critical Care 2012, 16(Suppl 1):P526 (doi: 10.1186/cc11133)
Sedation score assessment 98/101 (97)
CAM-ICU score at least twice a day 29/101 (28) Introduction Inactivity and immobility in ICU patients have significant
deleterious physiologic effects, including atelectasis, pressure ulcers,
Conclusion It is very challenging to implement care bundles despite and increased susceptibility to aspiration and pneumonia. A new
evidence showing that they improve outcome. A recent study suggests trend on the ICU is early mobilization of critically ill adult patients.
that doing a daily quality rounds checklist (QRC) will improve long-term However, evidence of when to start mobilization is missing. Casteleijn
compliance, thereby reducing potential complications for intensive developed a new scoring system, the Patient Mobilization Frame (PMF),
care patients [1]. We have implemented QRC in our practice and will be to improve early mobilization in the ICU. The framework is based on
re-auditing in 6 months to ensure continued adherence. a multidisciplinary agreement. The aim of this study was to evaluate
Reference interobserver agreement using the PMF.
1. DuBose et al.: Measurable outcomes of quality improvement in the trauma Methods A prospective observational study in 47 critically ill
intensive care unit: the impact of a daily quality rounding checklist. J patients in the ICU was performed. The PMF categorizes patients
Trauma 2008, 64:22-29. into one of three stages of possible training using a scoring system
based on 14 items. Various factors influencing individual stage are
used including circulation, respiration, infection, kidney function,
P525 wounds and neurology. Stage A (critically ill) permits only passive
Awareness of difficult airway equipment on the ICU physical examination. Whereas stage B (stable) and stage C (nearly
A Wozniak, A Iyer recovered) permit (guided) active mobilization and functional training,
Royal Liverpool University Hospital, Liverpool, UK respectively. Two staff members and one resident obtained 47
Critical Care 2012, 16(Suppl 1):P525 (doi: 10.1186/cc11132) independent observation series of the PMF. All observations were at
the same date and time and were compared.
Introduction It is widely recognised that critically ill patients can be Results Interobserver reliability of observers 1, 2 and 3 proved to be
difficult to intubate, requiring the use of advanced airway skills and adequate. Kappa for observers 1 and 2 was 0.9. Kappa for observers 1
equipment. The range of airway equipment necessary for patients on the and 3 was 0.6. Kappa for observers 2 and 3 was 0.6. The value of kappa
ICU has recently been recommended [1]. Our ICU has a comprehensive can range from 0 (disagreement) to 1 (perfect agreement). Kappa
difficult airway trolley (DAT) which is regularly maintained. With a high larger than 0.6 was regarded as substantial agreement.
turnover of trainees, we were keen to determine if there was a training Conclusion Casteleijn’s PMF proved to be a reliable scoring system as
need to be met regarding airway management in ICU patients. The both resident and staff members had comparable results for staging
objectives were to determine awareness of the DAT, assess knowledge the physical abilities of the critically ill patient in the ICU.
of its contents and ascertain confidence in its use.
Methods We audited against previously described standards [1]
using a short questionnaire, disseminated to trainees and consultants P527
working on the ICU in November 2010: 100% of clinicians should be Motor and respiratory intensive rehabilitation in bedridden
aware of the location and contents of the DAT; 100% of anaesthetists patients
should have had difficult airway equipment training. E Canedo, V Nunes Velloso, L Calejman, N Leidi
A re-audit was conducted in June 2011 to complete the audit cycle. Hospital de Infecciosas F.J. Muñiz, Buenos Aires, Argentina
Results One hundred per cent of clinicians were aware of the DAT. Only Critical Care 2012, 16(Suppl 1):P527 (doi: 10.1186/cc11134)
35% had read the folder detailing its contents with instructions. Ninety
per cent could confidently name the equipment which should be readily Introduction Inability to play significant social roles due to a pattern
available for difficult intubations but only 70% were confident to use of motor disability affects the quality of a person’s life, and is where
it unaided. Fifty per cent would request the presence of an operating the motor and respiratory rehabilitation process takes fundamental
department practitioner (ODP) for an unplanned intubation on the importance. This disability prevents one to function independently in
ICU. Twenty-eight per cent were not airway trained. Re-audit showed basic tasks such as dressing and feeding and in more complex tasks
100% of respondents were aware of the equipment. Sixty per cent had such as handling in public and/or work. It can also be a constraint for the
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dependent patient in personal care activities. The objective of a motor 4. Mohammadi B, et al.: J Neurol 2008, 255:265-272.
rehabilitation plan is to reduce the impact caused by this alteration of 5. Latronico N, et al.: Lancet Neurol 2011, 10:931-941.
motor ability, facilitating the restoration of functional patient capacity 6. Bolton CF, et al.: Crit Care Med 1996, 24:1408-1416.
so they can effectively engage in occupations, reaching the highest
level of functional independence possible.
Methods A cross-sectional retrospective descriptive and observational P529
study of rehabilitation of bedridden patients in hospital from January Muscle strength assessment of critically ill patients is associated
2010 to June 2011. The programme is implemented in Section 30 (21, 9, with functional ability and quality of life at hospital discharge
and 20 rooms). The inclusion criteria for the rehabilitation programme G Sidiras, I Patsaki, M Dakoutrou, E Karatzanos, V Gerovasili, A Kouvarakos,
were patients of both sexes, without age limit, inpatient of Hospital A Kardara, K Apostolou, S Dimopoulos, V Markaki, S Nanas
F.J. Muñiz coming from the ICU, in bedridden condition (limitation or University of Athens, Greece
motor disability in which the patient cannot move or perform activities Critical Care 2012, 16(Suppl 1):P529 (doi: 10.1186/cc11136)
of daily living and must depend on the care of others), with Barthel
scale value 0 to 35 with total or severe dependence and stability Introduction Patients with critical illness after hospital discharge often
hemodynamics. exhibit poor functional ability and quality of life as a consequence
Results We included patients who met the inclusion criteria. The of acquired muscle weakness. The Medical Research Council (MRC)
program presented an intensive character in terms of the frequency of strength score and hand-grip dynamometry (HGD) are reliable and
weekly sessions as the number of exercises implemented in the form valid methods to detect clinically significant muscle weakness.
was specified according to the pathology of the patient. Ninety percent The objective of this study is to examine the correlation of these
of patients were male. The median age was 41 years. The predominant instruments to functional ability and quality-of-life questionnaires at
infectious pathology was pulmonary tuberculosis (90%), cerebral hospital discharge.
toxoplasmosis (50%), spastic paraplegia (6%), bilateral pneumonia Methods Two hundred and sixty-six consecutive patients who had
(6%), and fumigares aspergillosis (6%). The profit was 100% of kinesic been discharged from the ICU were evaluated and 37 of them were
treatment adherence, 94% of cases won full independence valued eligible (inclusion criteria: in mechanical ventilation >72 hours, a
on the Barthel scale with a value of 100, and a single case achieved cognitive status that allows assessment) for the study (mean ± SD: age
independence moderated by the presence of spastic paraplegia. 55 ± 15; APACHE 14 ± 5; SOFA 8 ± 3; length of ICU stay 22 ± 22 days;
Conclusion The intensive rehabilitation programme presented a great duration of mechanical ventilation 17 ± 19 days). Muscle strength was
benefit for hospitalized patients; taking them from being bedridden to evaluated with the MRC score and HGD every 7 days until discharge
total independence in the AVD, the outpatient had better social and from the hospital. The Functional Independence Measure (FIM) was
labor conditions. used to evaluate the functional ability while health-related quality of
life was assessed by the Nottingham Health Profile (NHP).
Results At hospital discharge the MRC scale and HGD were significantly
P528 correlated with FIM (r = 0.69, P <0.001 and r = 0.58, P <0.001,
Severity of electrophysiological alterations correlates with severity respectively). There seems to be a good correlation of the MRC scale
of illness in the early phase of critical illness polyneuropathy (r = –0.57, P <0.001) with the section of mobility of the NHP. There is
R Nemes, Z Fülep, B Fülesdi also certain association among the domain of mobility and energy
University of Debrecen, Hungary of the NHP with the FIM (r = –0.88, P <0.001 and r = –0.61, P <0.05,
Critical Care 2012, 16(Suppl 1):P528 (doi: 10.1186/cc11135) respectively).
Conclusion The significantly reduced muscle strength of critically ill
Introduction We aimed to investigate the early characteristics of critical survivors could have detrimental effects on their mobility and quality
illness polyneuropathy in surgical patients in a 5-day follow-up setting. of life. By this study it was shown that muscle strength assessment was
Methods Twenty critically ill patients were enrolled showing signs well associated with functional ability. We assume that this might be a
of systemic inflammatory response, sepsis or multiorgan failure possible significant prognostic role.
featuring APACHE II score ≥12 on admittance aged 26 to 86 years.
Routine noninvasive nerve conduction study of bilateral median and
ulnar nerves was performed on a two-channel portable Keypoint P530
Medtronic apparatus. Nerve conduction studies were performed on Functional dependency in the direct post-ICU phase in patients
five consecutive days starting within at most 2 days after admittance, with prolonged mechanical ventilation
then weekly follow-up was carried out. Electrophysiological findings S Vossenberg1, I Drogt2, N Bruins2, C De Jager2, EC Boerma2, M Tijkotte1
1
were compared to age-matched control group parameters. Zorggroep Noorderbreedte, Leeuwarden, the Netherlands; 2Medical Centre
Results On first examination, within 2 days following admission 17 Leeuwarden, the Netherlands
of 20 (85%) patients showed signs of axonal type sensory-motor Critical Care 2012, 16(Suppl 1):P530 (doi: 10.1186/cc11137)
polyneuropathy. Medians of compound muscle action potential (CMAP)
and sensory nerve action potential (SNAP) amplitudes of all nerves Introduction Prolonged mechanical ventilation and length of stay
showed a significant decrease compared to control values (P <0.001). (LOS) in the ICU is associated with long-term impaired functional
During the 5-day study period four patients showed improvement. capacity. However, little is known about functional dependency in the
Sensory nerve fibres were less severely affected than motor fibers. The direct post-ICU phase. Therefore the timing and location for optimal
consecutive measurements revealed negative correlation with the post-ICU rehabilitation programs remain to be established.
severity of peripheral interstitial oedema determined by circumference Methods In this single-centre observational study we aimed to quantify
of the elbow. Changes in CMAP and SNAP amplitudes also showed a functional dependency at three different time points: discharge from
negative correlation with daily rated APACHE II and SAPS II severity ICU (DI), discharge from hospital (DH) and discharge from nursing home
scores, and thus with patients’ general condition. rehabilitation unit (DR). To this end we retrospectively assed Barthel
Conclusion Electrophysiological alterations appear early after the scores (BS) for individual patients [1], with a duration of mechanical
development of critical illness [1-4]. Early electrophysiological ventilation >48 hours. Data are presented as median (IQR). Comparison
investigations are advisory although results should be evaluated between time points was performed with nonparametric tests for
cautiously, as it is hard to differentiate between definitive lesions and paired data and repeated measurements. P <0.05 was considered
temporary disorder caused by bioenergetic failure [3,5-6] of the nerve significant.
which tend to improve with normalisation of patients’ condition. Results Thirty-four patients were included. Baseline characteristics:
References APACHE II score 20 (17 to 25), age 68 (55 to 73) years, LOS ICU 22 (8 to
1. Tennilä A, et al.: Intensive Care Med 2000, 26:1360-1363. 36) days, mechanical ventilation 8 (2 to 17) days, LOS hospital 21 (14
2. Khan J, et al.: Neurology 2006, 67:1421-1425. to 30) days, LOS rehabilitation unit 53 (31 to 85) days. Median BS at DI
3. Latronico N, et al.: Crit Care 2007, 11:R11. was 2 (1 to 3), indicating total functional dependency. In comparison
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