Revitalising the medical emergency team call

Critical Care, Mar 2015

KP Verma, S Jasiowski, K Jones

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Revitalising the medical emergency team call

35th International Symposium on Intensive Care and Emergency Medicine P 0 2 4 5 7 9 10 12 17 18 20 22 23 25 27 29 30 32 34 New real-time bowel sound analysis may predict disease severity in septic patients JGoto 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 KMatsuda 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 NHarii 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 TMoriguchi 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 MYanagisawa 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 DHarada 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 HSugawara 1 2 4 6 7 9 11 12 17 19 20 22 24 25 28 29 31 32 34 OSakata 0 2 4 5 7 9 10 12 17 18 20 22 23 25 27 29 30 32 34 0 University of Yamanashi , Kofe , Japan Critical Care 2015, 19(Suppl 1):P2 (doi: 10.1186/cc14082) 1 University of Yamanashi School of Medicine , Chuo , Japan 2 P1 Cerebral autoregulation testing in a porcine model of intravenously administrated E. coli induced fulminant sepsis L Molnar 3 Institute of Biomedicine, University of Gothenburg, Sweden Critical Care 2015 , 19(Suppl 1):P6 (doi: 10.1186/cc14086) 4 P6 Systemic symptoms as markers for severity in sepsis J Edman-Waller 5 Skaraborg Hospital , Skovde , Sweden 6 Sodra Alvsborg Hospital , Boras , Sweden 7 P5 Audit of strategies to improve sepsis management in emergency departments CE Thakker 8 Swedish Medical Center, Trauma Research , Engelwood, CO, USA Critical Care 2015, 19(Suppl 1):P24 (doi: 10.1186/cc14104) 9 P24 Time course of redox potential and antioxidant capacity in patients undergoing cardiac surgery C Stoppe 10 RWTH Aachen University, University Hospital , Aachen , Germany 11 RWTH Aachen University , Aachen , Germany 12 P23 Sublingual leukocyte activation in patients with severe sepsis or septic shock BK Fabian-Jessing 13 University of Pittsburgh , PA, USA Critical Care 2015, 19(Suppl 1):P23 (doi: 10.1186/cc14103) 14 University of Alabama at Birmingham , AL , USA 15 Aarhus University Hospital , Aarhus , Denmark 16 Doctoral School of Sciences and Technology, Platform of Research and Environmental Sciences , Beirut , Lebanon 17 P35 Expression of apolipoproteins L in neutrophils during sepsis I Akl 18 Institut Jules Bordet, Universite Libre de Bruxelles , Belgium 19 CHU de Charleroi-Hopital Andre Vesale , Montigny-Le-Tilleul , Belgium 20 P34 Serial change of C1 inhibitor in patients with sepsis: a preliminary report T Hirose 21 Institute of Medicine and Molecular Biology IBMM , Charleroi, Belgium Critical Care 2015, 19(Suppl 1):P35 (doi: 10.1186/cc14115) 22 P537 Predictors of 30-day mortality in cancer patients with septic shock E Osawa , C Park, F Bergamin, B Pileggi, J Almeida, R Nakamura, I Duayer, G Queiroz, F Galas, J Ribeiro, I Bispo, J Fukushima , L Hajjar Institute of Cancer of University of Sao Paulo , Brazil Critical Care 2015, 19(Suppl 1):P537 (doi: 10.1186/cc14617) 23 Duke University Medical Centre , Durham, NC, USA Critical Care 2015, 19(Suppl 1):P536 (doi: 10.1186/cc14616) 24 CHU Pontchaillou , Rennes , France 25 P536 Liver dysfunction is associated with long-term mortality in septic shock N Nesseler 26 University of Liverpool, UK Critical Care 2015 , 19(Suppl 1):P547 (doi: 10.1186/cc14627) 27 Royal Liverpool University Hospital , Liverpool , UK 28 Institute of Ageing and Chronic Disease , Liverpool , UK 29 P547 Developing a laboratory-based score to predict mortality in patients admitted to the ICU A Iqbal 30 School of Health , Amsterdam , the Netherlands 31 Academical Medical Center , Amsterdam , the Netherlands 32 P558 Physiotherapy in the ICU: an evidence-based , expert-driven, practical statement J Sommers 33 Gelre Hospital , Apeldoorn, the Netherlands Critical Care 2015, 19(Suppl 1):P558 (doi: 10.1186/cc14638) 34 P570 Evaluation of screening criteria for palliative care in an emergency department ICU S Ribeiro, R Carvalho , P Ayres, D Barros , D Roger Hospital das Clinicas School of Medicine, University of Sao Paulo , Brazil Critical Care 2015, 19(Suppl 1):P570 (doi: 10.1186/cc14650) P3 Usefulness of sepsis screening tools and education in recognising the burden of sepsis on hospital wards EJGaltrey, CMoss, HCahill Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK Critical Care 2015, 19(Suppl 1):P3 (doi: 10.1186/cc14083) - Introduction To assess cerebral hemodynamics in an experimental sepsis model. Methods Nineteen juvenile female Hungahib pigs were subjected into control group (n= 9) or septic group (n= 10). Under general anesthesia in animals of the sepsis group, Escherichia coli culture (2.5 105/ml; strain: ATCC 25922) was intravenously administrated in a continuously increasing manner as follows: 2 ml in the first 30 minutes, then 4 ml in 30 minutes and afterwards 16 ml/hour for 2 hours (so a total of 9.5 106 E. coli within 3 hours). In the control group the anesthesia was maintained for 8 hours, infusion was administered as a similar volume of isotonic saline solution and no other intervention was made. Hemodynamic monitoring of all animals was performed by PiCCo monitoring system. The middle cerebral artery of the pigs was insonated through the transorbital window and cerebral blood flow velocity (MCAV) and pulsatility index was registered. Results In the septic group, as expected, all animals developed fulminant sepsis and died within 3 to 7hours two animals in 3 to 4hours, and three in 6 to 7hours). In the septic animals the heart rate rose and mean arterial pressure dropped, their ratio increased significantly compared with both the base values (at the 6th hour: P <0.001) and the control group (P = 0.004). The control animals showed stable condition over the 8-hour anesthesia. MCAV significantly decreased during the development of sepsis (from 23.66.6 cm/s to 16.03.9 cm/s, P <0.01) and pulsatility indices increased (from 0.68 0.22 to 1.37 0.58, P <0.01), indicating vasoconstriction of the resistance vessels. A significant relationship was fund between percent change of the MAP and the pulsatility index in septic animals (R2= 0.32) referring to maintained cerebral autoregulation. Conclusion Cerebral autoregulation is preserved in the pig model of experimentally induced fulminant sepsis. Introduction Healthy bowel function is an important factor when judging the advisability of early enteral nutrition in critically ill patients, but long-term observation and objective evaluation of gastrointestinal motility are difficult. We developed a non-invasive monitoring system capable of quantifying and visualizing gastrointestinal motility in real time. In the study gastrointestinal motility was performed in patients with severe sepsis using this developed bowel sound analysis system, and the correlation between bowel sounds and changes over time in blood concentrations of IL-6, which is associated with sepsis severity, was evaluated. Methods The study was a prospective, observational pilot study conducted in our hospital. Consecutive adult patients with severe sepsis, on a mechanical ventilator with an IL-6 blood concentration 100pg/ml in the acute phase, defined as being up to the 28th day of illness in the ICU, were entered in this study between June 2011 and December 2012. Subjects were divided into those who were treated with steroids (steroid treatment group) and those who were not (nosteroids group) during the target period, because steroids strongly affect IL-6 blood levels. Results The subjects were five adult patients in the acute phase of severe sepsis on a mechanical ventilator. Gastrointestinal motility was measured for a total of 62,399 minutes: 31,544 minutes in three subjects in the no-steroids group and 30,855minutes in two subjects in the steroid treatment group. In the no-steroids group, the bowel sound counts were negatively correlated with IL-6 blood concentration (r = 0.76, P <0.01), suggesting that gastrointestinal motility was suppressed as IL-6 blood concentration increased. However, in the steroid treatment group, gastrointestinal motility showed no correlation with IL-6 blood concentration (r= 0.25, P=0.27). The IL-6 blood concentration appears to have decreased with steroid treatment irrespective of changes in the state of sepsis, whereas bowel sound counts with the monitoring system reflected the changes in the state of sepsis, resulting in no correlation. Conclusion The new real-time bowel sound analysis system provides a useful method of continuously, quantitatively, and non-invasively evaluating gastrointestinal motility in severe patients. Furthermore, this analysis may predict disease severity in septic patients. tool and electronic order set (EPR alert) alongside an education programme to improve delivery of the SSC bundle. Previous audits showed only 43% full bundle compliance in those that were alerted, and this raised concerns regarding the burden of unalerted sepsis. We sought to estimate the number of unalerted sepsis episodes to assess the efficacy of our screening tool and improve early recognition. Methods All referrals to our critical care response team with a diagnosis of sepsis over a 3-month period (September to November 2014) were investigated to determine how many had an EPR sepsis alert comprising a prompt for blood cultures, serum lactate measurement, fluid challenge if hypotensive, and antibiotics within 1hour. Results Only 25/174 (14%) patients with a diagnosis of sepsis had an EPR sepsis alert. There was no significant difference between acute and nonacute ward areas in their likelihood of using the screening tool or alert, in contrast to previous audits of the alerted population which showed that acute areas such as A&E and medical acute admission wards had higher utilisation and bundle completion rates. Conclusion Despite these interventions, most patients still do not receive the full recommended treatment bundle. These findings have prompted a point prevalence audit at ward level, which will examine all patients notes for the preceding 24 hours to ascertain if sepsis is truly unrecognised or whether it is simply that our current tool is not a helpful adjunct to care. With national guidelines expected within the year, we will redesign and re-launch our screening tools and education programme to improve awareness and management of this common medical emergency. References 1. Dellinger R, et al. Crit Care Med. 2013;41:580-637. 2. 3. 4. Introduction An elevated body temperature is one of the four criteria in diagnosing systemic inflammatory response syndrome (SIRS), and is often used at the bedside to trigger diagnostic investigations for infection. Standard intermittent temperature measurement may, however, delay the detection of an elevated temperature or miss this altogether. The aim of the study is to compare intermittent noninvasive versus continuous invasive body temperature measurement as a tool to detect an elevated body temperature. Methods This was a secondary analysis of a prospective study in 25 critically ill patients comparing different measurement techniques. Temperature was measured intermittently with an axillary digital thermometer every 4hours, and a urinary bladder thermistor catheter was used for continuous temperature measurement; the latter was considered the reference method. Fever (core temperature 38.3C) episodes occurring within 60minutes after each other were classified as one episode. We compared the fever detection rate of both methods and calculated the difference in timing between both techniques. Results Twenty-nine episodes of fever were detected in 10 patients (seven male) with a median APACHE II score of 10 (IQR 3 to 24) and a median SOFA score of 10 (IQR 8 to 11). Median duration of a fever episode was 1hour 24minutes (IQR 47minutes to 2hours 59minutes) and median maximum temperature was 38.4C (IQR 38.3 to 38.7). Median axillary temperature was 0.7C (IQR 0.3 to 0.9) lower than core temperature. Using intermittent, non-invasive measurement, 27 out of 29 fever episodes (93.1%) remained undetected. Conclusion Intermittent, non-invasive temperature measurement failed to detect most of the fever episodes as measured by a bladder thermistor catheter and should not be used to screen for elevated body temperature in critically ill patients. Introduction Severe sepsis results in ~36,800 UK deaths each year [1]. Prior studies demonstrate the benefit of early recognition and treatment of sepsis in reducing mortality [2]. The Sepsis Six [1] bundle aims to optimise the first hour of sepsis management. We assessed the proportion of emergency department (ED) patients with severe sepsis receiving the Sepsis Six bundle and whether this was improved by a combination of staff education and use of Sepsis Six management stickers in patient notes. Methods A closed loop audit was completed in the ED at Ipswich Hospital, UK. Each cycle was 14 days with interventions made in a 4-week period between the two cycles. The interventions consisted of: Sepsis Six management stickers and posters placed in the ED; two training sessions for all ED nurses on sepsis recognition and management; a teaching session for all middle-grade doctors; and a trolley in the ED with equipment required for the Sepsis Six. The notes of all patients with lactate 2 mmol/l were retrospectively reviewed. Those with 2 systemic inflammatory response syndrome criteria and a documented suspicion of infection were deemed to have severe sepsis. The times at which these patients had each of the Sepsis Six completed were recorded, as were the final diagnosis and 7/28day mortality. Results In Cycle 1, 31/106 patients met the criteria for severe sepsis, compared with 36/120 in Cycle 2. The delivery of the Sepsis Six interventions was highly variable. In Cycle 1 lactate levels and i.v. access had the highest 60-minute completion rates (90.3%, 83.9% respectively). Blood cultures and i.v. fluid resuscitation were completed for 61.3% and 64.5% of patients within 60minutes. Only 38.7% of septic patients were given i.v. antibiotics within 60 minutes. In total, 58.9% of patients received antibiotics in accordance with trust guidelines. High flow oxygen, catheters and fluid balance charts had the lowest 60-minute completion rates (35.5%, 6.5%, 6.5% respectively). In Cycle 2, post intervention, there was no significant change in the percentage of patients receiving the Sepsis Six bundle. Conclusion The low rates of Sepsis Six completion require improvement to meet the targets set out by the College of Emergency Medicine. Our results suggest that simple interventions are ineffective in increasing Sepsis Six completion and thus lend support to the case for integrated interventions such as electronic recording and alert systems. References 1. Daniels et al. Emerg Med J. 2011;28:507-12. 2. Kumar et al. Crit Care Med. 2006;34:1589-96. Introduction The objective of this study was to evaluate six general symptoms as markers for severe sepsis in patients with suspected bacterial infections. Severe sepsis is a common cause of death and morbidity. Early detection and treatment is critical for outcome. Clinical presentation varies widely and no single test is able to discriminate severe sepsis from uncomplicated infections or non-infectious emergencies. Apart from local symptoms of infection, the systemic inflammatory reaction itself may give rise to general symptoms such as muscle weakness and vomiting. Methods We present an observational, consecutive study. Data from ambulance and hospital medical records were analyzed. The survey included 290 patients (mean age: 70.6 years; median age: 74 years; male: 47%) who were admitted to a 550-bed secondary care hospital, receiving intravenous antibiotics for suspected community-acquired infections. General symptoms (fever/shivering, dyspnea, muscle weakness, gastrointestinal symptoms, localized pain, altered mental status) that were part of the reason the patient sought medical care were registered. Additionally, age, sex, vital signs, C-reactive protein, and blood cultures were registered. Patients that within 48hours from admission fulfilled any criteria for severe sepsis were compared with patients that did not. Odds ratios for severe sepsis were computed using univariable as well as multivariable logistic regression, controlling for age and gender as confounders. Results Severe sepsis criteria were fulfilled in 31% (n = 91) of the patients. These were older (median age: 79 years vs. 71 years) and experienced more symptoms (mean: 2.2, SD 0.9 vs. mean: 1.4, SD 0.7) than patients without severe sepsis, while there was no difference in C-reactive protein levels (OR per 50 mg/l: 1.07, 95% CI: 0.96 to 1.20). Among individual symptoms, altered mental status (OR: 4.4, 95% CI: 2.2 to 9.0), dyspnea (OR: 3.5, 95% CI: 2.1 to 5.9), and muscle weakness (OR: 2.2, 95% CI: 1.0 to 4.4) were significantly related to severe sepsis. Adjusting for age and sex, altered mental status (adj. OR: 4.1, 95% CI: 2.0 to 8.4) and dyspnea (adj. OR: 3.1, 05% CI: 1.8 to 5.3) remained significant. Conclusion General symptoms, especially altered mental status and dyspnea, appear to be more common in severe sepsis than in milder infections. These symptoms might be utilized as a diagnostic aid for severe sepsis in the clinical setting, complementing vital signs and laboratory tests. P8 Clinical scores and blood biomarkers for prediction of bacteremia in emergency department patients: Bacteremia Assessment in Clinical Triage (BACT) study SLaukemann1, NKasper1, NKasper1, AKutz1, SFelder1, SHaubitz2, BMller1, PSchuetz1 1Kantonsspital Aarau, Switzerland; 2University Hospital, Bern, Switzerland Critical Care 2015, 19(Suppl 1):P8 (doi: 10.1186/cc14088) Introduction Collection of blood cultures is routinely performed in patients with suspicion of infection in the emergency department (ED) despite a low yield of positive culture results. To increase sensitivity, different clinical prediction rules and blood biomarkers have been put forward. Herein, we validated the performance of different promising clinical prediction rules alone and in combination with novel blood biomarkers to predict blood culture positivity. Methods This is an observational cohort study including consecutive medical patients with suspected infection and collection of ED admission blood cultures. Five clinical prediction rules were calculated and admission concentrations of procalcitonin (PCT), C-reactive protein, neutrophillymphocyte count ratio (NLCR), lymphocyte count, white blood cell count, and red blood cell distribution width were measured. True blood culture positivity was assessed by two independent physicians. We used logistic regression models with area under the curve (AUC) to establish associations between clinical prediction rules and blood culture positivity. Results Of 1,083 included patients, 106 (9.8%) cultures were positive. Of the clinical prediction rules, the Shapiro rule performed best (AUC 0.733) followed by the Metersky rule (AUC 0.609). The best biomarkers were PCT (AUC 0.796), NLCR (0.692) and lymphocyte count (AUC 0.671). Combination of the Shapiro rule and PCT showed the best combination result (AUC of combined model 0.822). Limiting blood cultures to either the Shapiro rule 4 points or PCT >0.11 g/l would reduce negative sampling by 25.6% while still identifying 100% of positive cultures. Using a Shapiro rule 3 points or PCT >0.25 g/l limit would reduce negative sampling by 42.1% while still identifying 96.2% of positive cultures. Conclusion Combination of clinical parameters combined in the Shapiro rule together with admission levels of PCT allows reduction of unnecessary blood cultures with minimal false negative rates. References 1. Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med. 2008;35:255-64. 2. Mller F, Christ-Crain M, Bregenzer T, Krause M, Zimmerli W, Mueller B, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138:121-9. P9 Assessment of specific risk scores for patients admitted to the ICU for severe community-acquired pneumonia CJoya-Montosa, MDDelgado-Amaya, ETrujillo-Garca, ECuriel-Balsera Hospital Regional de Mlaga, Spain Critical Care 2015, 19(Suppl 1):P9 (doi: 10.1186/cc14089) Introduction The aim of the study is to evaluate the calibration and discrimination of two specific risk scores for community-acquired pneumonia (CAP) in patients with this illness who required ICU admission. Methods A retrospective descriptive study of patients with severe CAP admitted to the ICU between January 2008 and September 2013. We analyzed clinical and epidemiological variables and APACHE II, SAPS III, CURB-65 and Pneumonia Severity Index (PSI) that were recorded in the first 24hours. We used the Student t test to compare means and the chi-square test for univariate analysis. The standardized mortality ratio (SMR) and HosmerLemershow test were calculated to analyze the calibration and ROC curve analysis for discrimination of different scores. Results We analyzed 111 patients aged 57.517.7years, with 63.1% (70) males. The APACHE II score at admission was 19.817.7 and SAPS III was 60.616.7. ICU mortality was 29.7% (33). There was association between the four scores and mortality. The SMR for APACHE II was 0.87 and 0.85 for the SAPS III. Figure 1 shows the ROC curve for the four scores, the best observed discrimination obtained was for SAPS III score (AuC 0.79) and the worst was obtained for CURB-65 score (AuC 0.7). The HosmerLemeshow test showed acceptable calibration for the four predictive systems (P>0.05). Conclusion The four analyzed scores presented good calibration, but discrimination seems better in SAPS III. Given the difficulty of calculating PSI, and its low discrimination (similar to CURB-65), we prefer to use the CURB-65 score in routine clinical practice. Introduction The aim of our study was to investigate perioperative risk factors associated with deep sternal wound infections in complicated cardiac surgery. Methods A total of 1,017 patients underwent cardiac surgery in a 2-year period. We investigate the correlation between deep sternal wound infection with the following 14 preoperative characteristics and perioperative parameters: age >75, female gender, diabetes mellitus (DM), insulin dependence, body mass index (BMI) >30, current smokers, COPD, cardiopulmonary bypass time (CBP) >120minutes, use of steroids, emergency operation, prolonged mechanical ventilation (>48 hours), reintubation, transfusion with more than 3 units of red blood cells, and the postoperative use of non-invasive ventilation (NIV). The chi-square test was used for statistical analysis. Results A total of 35 patients (3.44%) were complicated by deep sternal wound infections. No statistical correlation was found with age >75, gender, DM, BMI >30, steroids, emergent operation, prolonged ventilation, CBP time >120minutes, reintubation and NIV. Factors with statistical significant correlation are presented in Table1. Conclusion Postoperative deep sternal wound infections have statistical significant correlation with the following parameters: transfusion with >3 red blood cell units, history of COPD, insulin dependence and when the patient is a current smoker. Also there is a tendency for correlation with CBP time >120minutes (P=0.056). References 1. Diez C, et al. Risk factors for mediastinitis after cardiac surgery a retrospective analysis of 1700 patients J Cardiothor Surg. 2007;2:23. 2. Schimmer C, et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial. Ann Thorac Surg. 2008;86:1897-904. Introduction Blood culture is a critical procedure for detecting potentially life-threatening bloodstream infections (BSI). At the same time, early diagnosis and appropriate treatment of BSI are the key factors in order to improve prognosis. The purpose of the current analysis was to identify risk factors for bacteremia in adult febrile patients in emergency settings. Methods We conducted a retrospective casecontrol study within a population of adult patients visiting the emergency department at a community hospital (St Lukes International Hospital, Tokyo, Japan) and who underwent two sets of blood culture testing between 2003 and 2012. Among a total of 13,582 patients, 1,322 (10%) were detected as bacteremia. We included in this study 179 randomly selected patients from the bacteremia group and 321 randomly selected patients from the negative blood culture group to serve as the comparison group. Multivariate logistic regression was used to evaluate the relationship between clinical characteristics factors and bacteremia. Results In a multivariate logistic regression model, a statistically significant independent effect was found for body temperature (BT) >38C (OR = 2.58, 95% CI, 1.76 to 3.79, P <0.001), systolic blood pressure (SBP) <100mmHg (OR= 1.72, 95% CI, 1.11 to 2.65, P=0.01), CRP>10mg/dl (OR= 3.03, 95% CI, 2.05 to 4.49, P<0.001) and PaCO2 <32mmHg (OR= 2.3, 95% CI, 1.57 to 3.37, P<0.001). Receiver operating characteristic curve analysis revealed an area under the curve value of 0.725 for differentiating patients with bacteremia from negative culture. Conclusion BT >38C, SBP <100 mmHg, CRP >10 mg/dl and PaCO2 <32 mmHg are independently associated with bacteremia. These factors might be useful to know whether or not adult febrile patients have bacteremia. References 1. Hoenig M, et al. Procalcitonin fails to predict bacteremia in SIRS patients: a cohort study. Int J Clin Pract. 2014;68:1278-81. 2. Hoeboer SH, et al. Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever: a case for procalcitonin. J Infect. 2012;64:484-93. P12 Pre-exposure to mechanical ventilation and endotoxin influence bacterial growth and immune response during experimental ventilator-associated pneumonia JSperber1, ANyberg1, MLipcsey2, ALarsson2, JSjlin2, MCastegren2 1Centre for Clinical Research Srmland, Uppsala University, Uppsala, Sweden; 2Uppsala University, Uppsala, Sweden Critical Care 2015, 19(Suppl 1):P12 (doi: 10.1186/cc14092) Introduction Overproduction of nitric oxide (NO) is correlated with adverse outcomes in sepsis. NO is additionally a central part of the innate immune system defense against pathogens causing ventilatorassociated pneumonia (VAP), which can complicate the clinical course during mechanical ventilation (MV). We hypothesized that pre-exposure to MV and systemic inflammation from endotoxin each would influence bacterial growth in lung tissue, based on an altered immune response in experimental pneumonia. We used a porcine Pseudomonas aeruginosa VAP model with ventilatory and inflammatory pre-exposures before inoculation to evaluate bacterial growth, development of lung damage, total NO production and inflammatory cytokine response. Methods Three groups of mechanically ventilated pigs were subjected to experimental VAP for 6 hours with intrapulmonary 1 1011 CFU P. aeruginosa at baseline. Two groups were pre-exposed to MV for 24 hours before bacterial inoculation: MV + Etx (n = 6, received endotoxin 0.063gkg1hour1) and MV (n= 6, received saline in equivalent volume). One group, Un (n = 8), started the experiment unexposed to both MV and endotoxin, directly from the initiation of VAP. Postmortem lung tissue samples rendered bacterial cultures. NO production was measured with urinary nitrate levels over 6 hours of VAP. Results The animals pre-exposed to endotoxin (MV + Etx) displayed higher bacterial growth (CFUg1) (P<0.05), lower PaO2/FiO2 (P<0.05) and lower nitrate levels (P <0.01) than the unexposed animals (Un). Plasma TNF levels were higher in Un than in both pre-exposed groups MV + Etx and MV (P <0.01). There were no significant differences between the two pre-exposed groups. Conclusion Mechanical ventilation for 24 hours with concomitant endotoxin exposure enhances bacterial growth and lung damage during P. aeruginosa VAP, compared with inoculation without any preexposure to MV or endotoxin. The greater bacterial clearance in the unexposed animals was associated with higher NO production and higher levels of pro-inflammatory cytokines. Introduction Cervical necrotizing fasciitis (CNF) is a rapidly evolving and life-threatening condition. Therefore, it is important for physicians to evaluate the severity of illness and to predict clinical outcome exactly in the early phase. We focused on extension of acute fluid collection along the deep cervical space by CT findings. The purpose of this study was to produce the CT grade and to analyze whether our CT grade is related to the clinical features and the responses to treatment of CNF. Methods Between June 2004 and December 2012, 42 patients diagnosed and treated for CNF in two institutions were included in this study. Cervical spaces were subdivided into three components according to the concept of interfascial planes. The extension of acute fluid collection in cervical spaces was classified into three grades: Grade I, fluid collection confined to one component; Grade II, fluid collection spreading into two or three components; and Grade III, fluid collection spreading into four components or mediastinum. We analyzed association with CT grades and severity of illness (SOFA score, APACHE II score, CRP). All patients underwent percutaneous catheter drainage either ultrasonography guided or CT guided. We compared treatment outcome of CNF with CT grades. Results According to elevation of CT grades, severity of illness was significantly associated with high score (APACHE II: 10.5 to 4.0, 12.8 to 4.2, 16 to 4.2, SOFA: 2.6 to 1.5, 2.9 to 1.9, 6.8 to 3.7, CRP: 17.8 to 10.6, 22.4 to 10.1, 33.3 to 11.9) and also duration of mechanical ventilation and length of hospital stay were longer (duration of mechanical ventilation: 10.9 to 6.6, 11.5 to 6.7, 15.8 to 7.2, length of hospital stay: 23.4 to 10.6, 27.9 to 21.4, 48.7 to 36.2). Conclusion Novel classification of CNF based on CT findings showing the extension of fluid collection is a useful indicator of the disease severity and predicting clinical outcome. These findings may influence the strategy for the success of percutaneous catheter drainage. Introduction The aim of the study was to evaluate the difference in mortality rates between those admitted to the ICU with and without sepsis, and to assess the proportion of patients who had sepsis. Septic patients are one of the key groups of patients admitted to ICUs around the world. Septic patients have an extremely poor prognosis with published mortality rates ranging from 20.7% (severe sepsis) to 45.7% (septic shock) [1]. With septic patients making up roughly 21% of patients admitted to ICUs, it is important to assess whether these rates of mortality hold true to a district general ICU and to assess the extent of the difference in prognosis between patients with and without sepsis [2]. Methods We performed a retrospective case note review, looking at a sample of 5,954 patients 18years or older who were admitted to East Surrey Hospital (ESH) ICU, which has an elective admissions rate of 3%, between 1 January 2005 and 31 October 2014. The total number of patients with sepsis was 941 compared with 5,013 without sepsis. We looked at mortality rates, APACHE II scores and length of stay on the unit. Results From the beginning of 2005 to the end of October 2014, mortality rates in septic patients were 44.6% compared with 26.2% in nonseptic patients. Fishers two-tailed test showed a significant difference (P<0.0001) between the mortality in septic and nonseptic patients. There was a significant difference (MannWhitney) between APACHE II scores, with median scores of 18 and 13 in septic and nonseptic patients respectively. Septic patients had longer lengths of stay, with the mean and median 8.73 and 3.89 days respectively, compared with 4.90 and 2.5 in nonseptic patients. Septic patients made up 15.8% of all patients admitted to the ICU. Conclusion Patients with sepsis admitted to ESH ICU made up a significant minority of patients admitted to the ICU. Septic patients had a 70% relative higher mortality rate compared with nonseptic patients. The mortality rate of 44.6% fits with previously quoted mortality rates in septic shock. Patients with sepsis had a significantly higher predicted mortality, recorded by their APACHE II score, which was statistically significant. This also meant they needed longer ICU care, with the average length of stay almost doubled. References 1. Estaban A, et al. Crit Care Med. 2007;35:1284-9. 2. Alberti C, et al. Intensive Care Med. 2002;28:108-21. Introduction The aim of this study was to evaluate the effect of the Surviving Sepsis Campaigns on mortality rates, before and after the second surviving sepsis publication, and to assess whether patients with sepsis being admitted to the ICU had a lower APACHE II score on admission. Patients with sepsis, who require ICU care, have an extremely poor prognosis. It has been shown that the mortality rates range from 20.7% (severe sepsis) to 45.7% (septic shock) [1]. The surviving sepsis campaign was initiated in 2002. The first, second and third publications were published in 2004, 2008 and 2012 respectively [2]. Methods A retrospective case note review was performed, looking at a sample of 5,954 patients who were 18years or older who had been admitted to East Surrey Hospital (ESH) ICU between 1 January 2005 and 31 October 2014. The total number of patients with sepsis was 941. We compared results before and after the second publication of the surviving sepsis campaign, looking at mortality rates, age of patients, admission length prior to ICU transfer, APACHE II score and the length of stay on the ICU. Results From the beginning of 2005 to the end of 2008, the mortality rates for septic patients was 51.9% compared with 41.3% from the beginning of 2009 to end of October 2014. Fishers two-tailed test showed a significant difference (P=0.003) between the mortality before and after the second publication. The median ages before and after 2009 were 63.9 and 64.8years. The time in hospital before admission to the ICU was greater before 2009 (6.15days) compared with after 2009 (5.53 days). There was no significant difference (MannWhitney test) between the APACHE II scores, with the mean and median score the same at 17.6 and 18 for both groups. The mean length of stay was 1day longer after 2009 (8.07days compared with 9.07days). Conclusion Patients with sepsis admitted to ESH ICU had a 20% relative decrease in mortality after the second publication of surviving sepsis guidelines. The original aim of the campaign was to reduce mortality from sepsis by 25% in 5years [3]. This decrease was not due to a significant difference between the sets of patients. The decreased time to admittance to ICU may be due to improved recognition of the need for ICU care. Overall the surviving sepsis campaign has had a significantly beneficial effect on mortality rates in patients with sepsis. References 1. Estaban A, et al. Crit Care Med. 2007;35:1284-9. 2. Dellinger RP, et al. Crit Care Med. 2013;41:580-637. 3. Slade E, et al. Crit Care. 2003;7:1-2. Introduction The purpose of this study was to examine long-term mortality, 5 years after severe infection, and to identify independent risk factors associated with it. Methods A prospective cohort study developed at a tertiary care university-affiliated 600-bed hospital including all patients with severe infection admitted into intensive care, medical, surgical, haematology and nephrology wards, over a 1-year period (2008/2009). The outcome of interest was mortality 5 years following hospitalisation and its association with specific risk factors was studied through logistic regression. Results There were 1,013 patients included in the study. Hospital mortality rate was 14% (n= 137) and 5-year mortality was 37% (n= 379). Factors independently associated with 5-year mortality were (adjusted odds ratio (95% confidence interval)): age= 1.04 per year (1.03 to 1.05), cancer = 8.00 (3.06 to 20.88), chronic hepatic disease = 3.06 (1.06 to 8.87), chronic respiratory disease = 2.21 (1.06 to 4.62), haematologic disease= 3.40 (1.64 to 7.04), Karnovsky Index <70= 2.56 (1.63 to 3.71), infection by an ESKAPE pathogen= 1.65 (1.02 to 2.66) and severity of infection (reference is infection without SIRS): sepsis= 1.14 (0.7 to 1.83), severe sepsis = 1.18 (0.73 to 1.93), septic shock = 3.69 (1.78 to 7.65). The final model had a very good discrimination for long-term mortality with an area under the ROC curve of 0.78 (Figure1). Conclusion The authors identified several factors that were significantly associated with increased long-term mortality in patients with severe infection. This information will help clinicians in the discussion of individual prognosis and clinical decision-making. Introduction Costs of severe sepsis care from middle-income countries are lacking. This study investigated direct ICU costs and factors that could affect the financial outcomes. Methods A prospective cohort study was conducted in the medical ICU of a tertiary referral university teaching hospital in Thailand over a 4-year period. Results A total of 897 patients, with 683 (76.1%) having septic shock. Overall ICU mortality was 38.3%. The median (interquartile range) ICU length of stay (LOS) was 4 (2 to 9) days. Community, nosocomial and ICU-acquired infection were documented in 574, 282 and 41 patients, respectively. The median ICU costs were 2,067.2 (986.3 to 4.084.6) per patient and 456.6 (315.3 to 721.8) per day. The ICU costs accounted for 64.7% of the hospital costs. In 2008 to 2011, the ICU costs significantly decreased by 40% from 2,695.7 to 1,617, whereas the daily ICU costs decreased only 3.3% from 463.9 to 448.7 (Figure 1). The average ICU costs of patient with nosocomial and ICU-acquired infection were significantly higher than patients with community-acquired infection. By multivariate logistic regression analysis, age, nosocomial or ICU infection, admission from emergency department, number of organ failures, ICU LOS, and fluid balance in the first 72 hours were independently associated with total ICU costs. Conclusion The ICU costs of severe sepsis management significantly declined in Thailand. However, the ICU costs were a financial burden accounting for two-thirds of the hospital costs. It is essential for Figure1 (abstract P17). Median ICU costs per patients and ICU cost per day according to study years. intensivists to contribute a high standard of care within a restricted budget. The cost-effectiveness analysis should be evaluated in sepsis care cases. Introduction Survivors of sepsis report persistent problems that can last years after hospital discharge. The main aim of this study was to investigate long-term health-related quality of life in survivors of SIRS and sepsis compared with Welsh normative data, controlling for age, length of stay and pre-existing conditions. The second aim was to investigate any differences in long-term health-related quality of life specifically with the patients categorised into three groups: SIRS, uncomplicated sepsis, and severe sepsis/septic shock. Methods A prospective study design was used in order to investigate all sepsis patients either presenting to the emergency department or admitted to the ICU of a regional trauma centre. A total of 106 patients were recruited and all patients were considered eligible as per the SIRS and sepsis criteria [1]. The Sepsis-related Organ Failure Assessment score was determined over the first 24hours to assess organ function. Patients were assigned to groups as follows: sterile SIRS; uncomplicated sepsis; severe sepsis or septic shock as per the criteria. Assignment into groups was blinded and performed by an intensive care specialist independent of the study. Baseline demographics, clinical characteristics and outcomes were collected and surviving patients were sent a SF-12v2 survey at between 6 months and 2 years post hospital discharge. Results A total of 106 patients were included in the study. A mortality rate of 34% was recorded, leading to a final response rate of 72% by the end of the data collection period. Quality of life was significantly reduced in all patients when compared with local normative data (all P <0.0001). Reductions in the physical components of health-related quality of life were more pronounced in severe sepsis/septic shock patients when compared with uncomplicated sepsis and SIRS patients. Conclusion This is the first observational study to specifically focus on the different groups of SIRS and sepsis patients to assess long-term quality of life. Local population norms were used for comparison, rather than wide geographical norms that fail to reflect the intricacies of a countrys population. Significant reductions in quality of life were found in severe sepsis/septic shock patients compared with in uncomplicated sepsis and SIRS patients, when controlling for age, preexisting conditions, hospital and ICU length of stay. Reference 1. Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS. International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-6. P19 Analysis of the mortality rate in patients admitted to the ICU for severe community-acquired pneumonia CJoya-Montosa, MDDelgado-Amaya, HMolina-Diaz, ECurielBalsera Hospital Regional de Mlaga, Spain Critical Care 2015, 19(Suppl 1):P19 (doi: 10.1186/cc14099) Introduction The aim of the study was to analyze the factors associated with hospital mortality in patients with severe community-acquired pneumonia (CAP) who required ICU admission. Methods An observational, retrospective study of patients with severe CAP admitted to the ICU between January 2008 and September 2013. We analyzed clinical, epidemiological and outcome variables. Quantitative variables were expressed as the mean and standard deviation. Qualitative variables are expressed as the percentage and absolute value. We applied the MannWhitney and Fishers exact test, as needed, with an alpha error of 5%. Results We analyzed 111 patients, 57.517.7years old, with 63.1% (70) males and APACHE II score on admission of 19.817.7. ICU mortality was 29.7% (33) and in-hospital mortality was 32.4% (36). Ten percent of patients met criteria for medical care-associated pneumonia (HCAP); there were no significant differences in mortality between HCAP and CAP (P = 0.075). Patients chronically taking immunosuppressive therapy had a significantly higher mortality compared with the rest of the patients (47.8% vs. 28.4%, P=0.07). The mortality rate was also higher in patients in whom NIV fail in the first 24 hours (42.9% vs. 17.6% with P=0.09). Patients who required intubation and mechanical ventilation in the first 24hours had a higher mortality rate (47.2% vs. 19%, P=0.002). Regarding the etiology of pneumonia, in 11 patients the viral origin of infection was confirmed (10 patients had H1N1 pneumonia and one patient CMV pneumonia), with a mortality rate significantly lower than in patients with bacterial pneumonia (3.6% vs. 35.3%, P = 0.06). The use of the right antibiotic therapy at admission was associated with mortality (P=0.0001). Conclusion Patients admitted to the ICU with severe CAP and immunosuppressive therapy have higher mortality, with no differences between HCAP and CAP. The delay in intubation as well as bacterial and inappropriate antibiotic treatment are factors that increase mortality. Introduction Sepsis is a high-prevalence disease in ICUs, associated with high mortality and high costs, mainly in developing countries. The aim of this study is to demonstrate the ICU costs, in a private hospital, in patients admitted with severe sepsis and septic shock. Methods A retrospective, observational, single-center study of patients admitted from November 2013 to March 2014 with severe sepsis and septic shock. The records data were taken from the Software Epimed, MV System, and IBM SPSS Statistics 21. The classification was based on the Surviving Sepsis Campaign 2012. We included all 50 beds of an adult ICU, clinical and surgical. All patients older than 18years with severe sepsis and septic shock were included. We evaluated the costs of patients during their ICU stay, and its relation to clinical presentation (severe sepsis and septic shock), antibiotic start time, permanence of ICU stay, and mortality. Only the first episode per patient was recorded. Results From November 2013 to March 2014 were included 82 patients with criteria for severe sepsis and septic shock. The mean age of patients was 62.521.8years, divided equally between the genres. The overall mortality rate was 34.15%. The SAPS 3 was 56.43, with death probability set to Latin America 38.83%. Patients with severe sepsis had a mortality of 23.2% and those with septic shock had a mortality rate of 58%. The average total cost during ICU admission per patient was US$17,834 and the average daily cost was US$1,641. The daily cost in patients with severe sepsis and septic shock was US$1,263 and US$2,465 (P = 0.002), respectively, and in survivors and nonsurvivors was US$1,189 and US$2,512 (P=0.001). The length of stay of patients in the ICU was 11.09days, being 11.3days in patients with severe sepsis and 10.7days in patients with septic shock (P=0.785). The beginning of the antibiotics in nonsurvivors was 73.7 minutes and in survivors was 64.7 minutes (P = 0.757), with the earliest onset in patients with septic shock than in patients with severe sepsis (38.5 vs. 81.5minutes, P=0.141). Conclusion Severe sepsis and septic shock are conditions that consume large amounts of resources. Nonsurvivors had higher average spending than survivors. Patients admitted with septic shock had higher mortality than patients with severe sepsis with high mortality in relation to the prognostic indices adopted. The beginning of the antibiotics was longer in the nonsurvivors. We should adopt measures aimed at recognizing and earlier treatment of sepsis. If we improve our treatment, especially in septic shock, we will prevent deaths and decrement costs. P21 Global burden of sepsis: a systematic review CFleischmann1, AScherag1, NKAdhikari2, CSHartog1, TTsaganos3, PSchlattmann1, DCAngus4, KReinhart1 1Jena University Hospital, Jena, Germany; 2University of Toronto, ON, Canada; 3University of Athens, Greece; 4University of Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P21 (doi: 10.1186/cc14101) Introduction Sepsis is a global healthcare challenge. However, comprehensive information on sepsis morbidity and mortality across the world is scarce. We aimed to estimate the global burden of sepsis and to identify knowledge gaps based on available evidence from observational epidemiological studies. Methods We searched 15 international and national citation databases for population-level estimates on incidence rates of sepsis or severe sepsis per 100,000 person-years and case fatality rates in adult populations using consensus criteria and published in the last 40years. No language or publication restrictions were applied. Studies were stratified into four subgroups (setting: hospital or ICU for sepsis and severe sepsis) and meta-analyzed using metaprop of the R 3.0.2 package. Heterogeneity of the underlying effects across studies was expressed by the estimated , the square root of the between-study variance. Results The search yielded 1,553 reports from 1979 to 2013, of which 37 met our criteria and 33 provided data for meta-analysis. The included studies were from 15 high-income countries in North America, Europe, Asia, and Australia. For these countries, the population incidence rate was 256 (95% CI, 182 to 360, = 0.43) hospital-treated sepsis cases and 151 (95% CI, 94 to 242, = 0.98) hospital-treated severe sepsis cases per 100,000 person-years, with large between-study heterogeneity. Restricted to the last decade, the incidence rate was 427 (95% CI, 281 to 648, = 0.24) sepsis cases and 331 (95% CI, 207 to 530, = 0.59) severe sepsis cases per 100,000 person-years. Hospital mortality was 15% for sepsis and 25% for severe sepsis during this period of time. There were no population-level sepsis incidence estimates from lower income countries. A tentative extrapolation from high-income-country data suggests global estimates of 30.7 million sepsis and 23.8 million severe sepsis cases, with potentially six million deaths each year. Conclusion Our analyses underline the urgent need to implement global strategies to monitor sepsis morbidity and mortality especially in low-income and middle-income countries. For further epidemiological studies, more consistent and standardized methodological approaches are needed to reduce between-study heterogeneity. In particular, further research on sepsis coding using administrative data seems necessary to derive sensitive and specific sepsis case identifications. P22 Disparities in acute sepsis care: a systematic review DYamane, NHuancahuari, PHou, JSchuur Brigham and Womens Hospital, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P22 (doi: 10.1186/cc14102) Introduction Disparities in the incidence and outcomes of sepsis have been documented in observational studies but little is known about how these occur and how we might prevent them. Our objective is to identify disparities by race, language, gender, socioeconomic status, insurance status and geography in acute sepsis care in emergency department (ED) or ICU settings in the published literature. Methods We performed a systematic review of disparities in sepsis care. The search strategy and inclusion and exclusion criteria were defined a priori. A medical librarian searched the entire MEDLINE (PubMed), EMBASE and Cinahl databases prior to 2013. One author reviewed all abstracts and a second author reviewed 10% of all abstracts for agreement. Both reviewers independently reviewed each included article using an explicit study review tool. We included studies that met the following inclusion criteria: ED or ICU setting; disparities due to race, language, gender, socioeconomic status, insurance status or geography; process of care measures (antibiotics, lactate, i.v. fluid resuscitation, central line placement, vasopressor use) or outcome measures (mortality, length of stay, complications, costs). We excluded studies involving organ-specific infectious conditions, pediatric populations, case reports, and review articles. Results We identified 778 abstracts; yielding 31 for inclusion (k= 0.95), 26 of 31 studies were excluded due to quality issues. Five articles met our inclusion criteria. Only one of the studies [1] contained data on process of care measures, showing that central venous monitoring was less likely to occur in older patients. Three studies [2-4] showed that Black patients had a higher incidence of sepsis, a higher hospitalization rate, and higher mortality rate. Plurad and colleagues [5] reported that Asian patients had increased incidence of post-traumatic sepsis. Overall, Black patients with sepsis were younger, had lower socioeconomic status and were more likely to be cared for in urban settings compared with their cohorts. Conclusion We found little published data addressing whether disparities due to race, language, gender, socioeconomic status, insurance status or geography exist in the acute care of sepsis. As sepsis is a leading cause of in-hospital mortality, future research should determine whether such disparities exist. Specifically, prospective studies of the process of care in sepsis management may further elucidate additional factors that may contribute to these disparities. References 1. Lagu T, Rothberg MB, Nathanson BH, et al. Variation in the care of septic shock: the impact of patient and hospital characteristics. J Crit Care. 2012;27:329-36. 2. Barnato AE, Alexander SL, Linde-zwirble WT, Angus DC. Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics. Am J Respir Crit Care Med. 2008;177:279-84. 3. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Occurrence and outcomes of sepsis: influence of race. Crit Care Med. 2007;35:763-8. 4. Mayr FB, Yende S, Linde-zwirble WT, et al. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. JAMA. 2010;303:2495-503. 5. Plurad DS, Lustenberger T, Kilday P, et al. The association of race and survival from sepsis after injury. Am Surg. 2010;76:43-7. Introduction The objective of this study was to compare the number of rolling and adhered leukocytes in patients with severe sepsis/septic shock with non-infected controls. Microcirculatory flow alterations and endothelial cell dysfunction are elements of sepsis pathophysiology. Traditionally, microcirculatory emphasis has been on red blood cell vessel perfusion. However, assessment of interactions between white blood cells and endothelial cells may be another early diagnostic modality. Methods We included adult (age >18 years) ED patients presenting with severe sepsis/septic shock (sepsis with elevated lactate (>4 mmol/l)) or hypotension) from the prospective clinical ProCESS trial. We studied a subset of patients with microcirculatory videos obtained along with non-infected control patients. Using a sidestream dark-field videomicroscope, we obtained image sequences from the sublingual mucosa and used video stabilization and frame averaging techniques to visualize slowly-moving leukocytes. We quantified the number of rolling and adhered leukocytes present per 1 mm1 mm visual field in a standardized 3-second clip. Furthermore, we extracted the total length of vessels candidate for counting of rolling/adhered leukocytes (vessels with an adequate focus). We report sample means with standard deviation and compare them with Students t test. Results We included a total of 64 patients with severe sepsis/septic shock and 32 non-infected controls. The mean number of adhered leukocytes per field in the sepsis group was 2.1 (SD 2.3) compared with 0.4 (SD 0.8) in the non-infected group (P <0.001). This corresponded to a mean number of adhered leukocytes per unit vessel length of 0.16/mm (SD 0.22) and 0.03/mm (SD 0.06) for sepsis and non-infected groups, respectively (P<0.001). For the rolling leukocytes, we observed a mean number of 27.8 (SD 19.4) in the sepsis group and 12.0 (SD 8.7) in the non-infected group (P<0.001) per field. This corresponded to a mean number of rolling leukocytes per unit vessel length of 2.00/mm (SD 1.67) and 0.75/mm (SD 0.55), respectively (P<0.001). Conclusion Our results show a higher number of rolling and adhered leukocytes in patients with severe sepsis/septic shock when compared with non-infected controls. This also applies when taking the total vessel length in the field of view into consideration. This may hold potential as a useful tool in sepsis assessment. Introduction Cardiac surgery regularly provokes inflammation and oxidative stress which contribute to the development of organ failure and mortality of patients. While the assessment of single markers does not reflect a comprehensive investigation of redox status, the measurement of oxidationreduction potential (ORP) provides a reliable measure to assess the balance between total prooxidant and antioxidant balance in the blood. The aim of the present study was to investigate the overall redox potential in patients undergoing cardiac surgery. Methods This is a prospective observational study in patients scheduled for elective cardiac surgery. Serum samples were drawn prior to surgery, after connection to cardiopulmonary bypass (ischemia), after opening of cross-clamp (reperfusion) and after termination of surgery. The redox status of patients was measured using the bedside point of care RedoxSYS Diagnostic System (Luoxis, USA). Simultaneously the antioxidant capacity in serum samples were calculated in all perioperatively obtained serum samples. Results All patients sera (n= 17) demonstrated a significant increase of ORP upon start of myocardial ischemia (141.04.8 mV vs. 157.94.9 mV; P = 0.002) and compared with reperfusion (141.0 4.8 mV vs. 158.6 4.9mV; P <0.001, Figure 1A). In parallel, the antioxidant capacity significantly decreased during surgery (0.505 0.190 C vs. 0.3840.120 C; P=0.022) corresponding to the increase of oxidative stress (Figure1B). Conclusion This preliminary study is the first to highlight the time course of overall redox potential and antioxidant capacity in cardiac surgery patients. Further studies are underway to evaluate the clinical significance on outcome in cardiac surgery patients. Figure1 (abstract P24). (A), (B) Perioperative time course of oxidative stress and antioxidant capacity. Introduction Change in fatty acid composition of erythrocytes and blood plasma in cases of various pathological conditions is evidence of lipid metabolism disorder and can indicate the reasons for and the degree of these disorders [1]. The aim of this study was to assess the FA composition of plasma and erythrocytes in patients with multiple organ dysfunction syndrome (MODS). Methods The objects of study were 19 people with MODS (37.6 8.3 years) of various etiologies. The blood of 17 healthy volunteers aged 38.43.3years served as control. The FA analysis was conducted using capillary gasliquid chromatography. Quantitative evaluation of individual FA content was made as a mass percentage of their total (C14:0 to C22:6). Statistical analysis was performed using the MannWhitney U test (P<0.05). Results Our data indicate that changes in blood plasma FA composition in patients with MODS are mainly caused by activation of lipolysis in fat depots and are accompanied by an increase of monounsaturated fatty acids, a decrease in saturated stearic acid and polyunsaturated fatty acids in the ratio. In conditions of increased level of monounsaturated palmitoleic (C16:1) and oleic (C18:1) FA in blood plasma (2.530.40% vs. 1.550.29%, P<0.001 and 25.182.15% vs. 16.551.17%, P<0.001, respectively), only the level of palmitoleic (C16:1) acid is increased in erythrocytes (0.56 0.12% vs. 0.16 0.12%, P <0.001). Despite the high content of oleic (C18:1) acid in blood plasma in case of MODS, in erythrocytes its relative level is not changed as compared with the control group. The disorder of lipid composition constancy in erythrocyte membranes is also manifested by change in the content of saturated palmitic (C16:0) and polyunsaturated linoleic (C18:2) fatty acids. In the test group of patients, as compared with the control group there was an elevated level (27.12 0.78% vs. 25.80 0.77%, P<0.05) of saturated palmitic (C16:0) acid combined with the reduced (11.460.52% vs. 13.951.09%, P<0.001) level of linoleic (C18:2) acid. Conclusion The changes revealed in fatty acid composition of erythrocytes may indicate systemic modifications of cell membranes in MODS. Reference 1. Kremmyda LS, et al. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155:195-218. P26 Lower platelet mitochondrial function in severe septic patients than in controls LLorente1, MMartin2, JBlanquer3, JSol-Violn4, LLabarta5, CDaz6, AJimnez1, ELpez-Gallardo7, JMontoya7, ERuiz-Pesini7 1Hospital Universitario de Canarias, La Laguna, Tenerife, Spain; 2Hospital Universitario Nuestra Seora Candelaria, Santa Cruz, Tenerife, Spain; 3Hospital Clnico Universitario de Valencia, Spain; 4Hospital Universitario Dr Negrn, Las Palmas de Gran Canaria, Spain; 5Hospital San Jorge, Huesca, Spain; 6Hospital Insular, Las Palmas de Gran Canaria, Spain; 7Universidad de Zaragoza, Spain Critical Care 2015, 19(Suppl 1):P26 (doi: 10.1186/cc14106) Introduction The oxidative phosphorylation system (OXPHOS) in septic patients has been scarcely analyzed in studies of small sample size and the results are apparently inconsistent. Previously, including 96 severe septic patients, we found that nonsurviving severe septic patients showed lower platelet respiratory complex IV (CIV) activity than surviving patients at the moment of severe sepsis diagnosis and during the first week of sepsis diagnosis. However, we did not examine this enzyme activity in normal individuals. Thus, the objective of this study was to compare the CIV activity between severe septic patients and healthy control individuals in a larger series of patients (including 198 severe septic patients). Methods This was a prospective, multicenter, observational study in six Spanish ICUs. We obtained blood samples from 198 severe septic patients at days 1, 4 and 8 of the severe sepsis diagnosis and from 96 sex-matched and age-matched healthy control individuals and determined platelet CIV activity/protein quantity. The endpoint of the study was 30-day mortality. Results We found that severe septic patients showed lower CIV activity/ protein quantity than controls at day 1 (P <0.001), day 4 (P <0.001) and day 8 (P<0.001) of severe sepsis diagnosis. Survivor severe septic patients (n = 130) showed lower CIV activity/protein quantity than controls at day 1 (P<0.001), day 4 (P<0.001) and day 8 (P<0.001) of severe sepsis diagnosis. In addition, nonsurvivor severe septic patients (n = 68) showed lower CIV activity/protein quantity than controls at day 1 (P<0.001), day 4 (P<0.001) and day 8 (P<0.001) of severe sepsis diagnosis. Besides, nonsurvivor severe septic patients showed lower CIV activity/protein quantity than survivor ones at day 1 (P<0.001), day 4 (P<0.001) and day 8 (P<0.001) of severe sepsis diagnosis. Conclusion The major finding of our work, that represents the largest series of severe septic patients with data on OXPHOS function, was that survivor and nonsurvivor severe septic patients showed lower platelet CIV activity than healthy controls during the first week of severe sepsis diagnosis. P27 Influence of genetic variants in the susceptibility and outcome of influenza virus infection JSole-Violan1, MLpez-Rodrguez1, EHerrera-Ramos1, JRuiz-Hernndez1, JHorcajada2, LBorderas3, JBlanquer4, JFerrer1, ORajas5, JAspa5, FRodrguezdeCastro1, CRodrguez-Gallego1 1Hospital GC Dr Negrn, Las Palmas de Gran Canaria, Spain; 2Hospital del Mar, Barcelona, Spain; 3Hospital San Jorge, Huesca, Spain; 4Hospital Clnico, Valencia, Spain; 5Hospital de la Princesa, Madrid, Spain Critical Care 2015, 19(Suppl 1):P27 (doi: 10.1186/cc14107) Introduction The role of genetic variability in the susceptibility and outcome of influenza virus infection (IVI) remains largely unknown. We have previously demonstrated that variants at SFTPA2 influence the severity of H1N1pdm infection. We have now studied genetic variants at different genes, some of them previously associated with infections by influenza and/or other viruses. The purpose of this study was to analyze the role of genetic variants in the susceptibility and outcome of IVI. Methods In total, 136 white Spanish patients developed IVI (80.3% of them by H1N1pdm virus). The general population group consisted of 1,466 unrelated healthy volunteers. Patients and controls were analyzed for different polymorphisms at 13 genes (FCGR2A, FCGR3A, FCGR3B, IL1RN, IL6, LTA, TIRAP, TLR1, TLR2, TLR3, TLR4, CCR5, IGHG2). IVI was detected in nasopharyngeal swabs using real-time PCR. The HardyWeinberg equilibrium was analyzed by Haploview v. 4.2. The comparisons of genotypes distribution based on susceptibility and severity were performed using the chi-squared test or Fishers exact test when needed. The relationship between severity in hospitalized patients and genotypes was evaluated by binary logistic regression models. Results No associations were found between the different genetic variants and susceptibility or severity of IVI. Variants at LTA, FCGR2A, IGHG2, TLR3 and CCR5, previously associated with severity of IVI were not replicated in our study. Conclusion Our study does not suggest that polymorphisms at LTA, FCGR2A, IGHG2, TLR3 and CCR5 genes are associated with susceptibility or severity of IVI. P28 Phenotypic factors associated with outcome in 977 intensive care patients with faecal peritonitis: analysis of trends in the GenOSept cohort ATridente, GClarke, AWalden, AGordon, PHutton, JChiche, PHolloway, GMills, JBion, FStuber, CGarrard, CHinds, GenOSeptInvestigators St Helens and Knowsley, Liverpool, UK Critical Care 2015, 19(Suppl 1):P28 (doi: 10.1186/cc14108) Introduction Patients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment that require close collaboration between surgical and intensive care teams [1]. We aimed at establishing whether dynamic assessment of trends in selected variables may be associated with outcomes, and therefore inform medical decision-making. Methods We analysed trends in all 35 variables available for the first week of ICU stay in 977 patients from 102 centres across 17 countries. The primary study outcome was 6-month mortality. Secondary outcomes were ICU, hospital and 28-day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and gender, were performed for each endpoint. Trends found to be significant in these analyses, after Bonferroni correction for multiple testing, were entered into a multivariate Cox PH model, to determine independent associations with mortality. Results The trends over the first 7days of ICU stay (primary analysis) retained as independently associated with 6-month outcome were worsening thrombocytopaenia (mortality HR= 1.02, 95% CI= 1.01 to 1.03, P<0.001) and changes in renal function (total daily urine output HR= 1.02, 95% CI= 1.01 to 1.03, P<0.001; renal SOFA subscore HR= 0.87, 95% CI= 0.75 to 0.99, P=0.047), highest recorded level of bilirubin (HR= 0.99, 95% CI= 0.99 to 0.99, P=0.02) and GCS SOFA subscore (HR= 0.81, 95% CI= 0.68 to 0.98, P=0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA and worsening thrombocytopaenia were also independently associated with secondary outcomes. Dynamic trends over the first 7days of ICU stay in all other measured laboratory variables, physiological parameters or radiological findings failed to be retained as independently associated with outcome on multivariate analyses. Furthermore, changes in respiratory support, renal replacement therapy and inotropic and/or vasopressor requirements appeared not to be independently associated with any of the primary or secondary outcomes. Secondary post hoc analyses on trends over the first 3 and 5days corroborated these findings. Conclusion Only deterioration in renal function, thrombocytopaenia and hyperbilirubinaemia over the first 7 days of ICU stay were consistently associated with mortality at all endpoints. Reference 1. Tridente A, et al. Intensive Care Med. 2014;40:202-10. Introduction Platelets are now considered to be immune and inflammatory agents as well as key cells in coagulation, and as such have been implicated in the pathophysiology of sepsis [1]. Thrombocytopenia is associated with sepsis severity and poor prognosis, and hyperactivated platelets probably contribute to microvascular thrombosis and organ failure. In the present study, we evaluated platelet activation markers as potential predictive markers of sepsis and of mortality among four commonly encountered populations of patients admitted to ICUs. Methods Ninety-nine non-infected ICU patients were prospectively screened at day 1 (T1) and day 3 (T2) of admission after elective cardiac surgery, trauma, acute neurologic dysfunction or prolonged ventilation (>48hours). A third sample was drawn when infection was diagnosed (Tx). We evaluated platelet activation by measuring the expression of P-selectin (CD62P) and fibrinogen binding on the cell surface before and after stimulation with major platelet agonists (ADP, collagen, and TRAP) through flow cytometry. Clinical scores were obtained at admission. Results Patients who developed sepsis (n = 18) presented with significantly higher platelet fibrinogen binding at T1 compared with patients who did not get infected (basal: P=0.0014, upon stimulation: P<0.0035). At T1, ROC AUC for association of basal fibrinogen binding with the occurrence of sepsis was 0.79 (95% CI: 0.68 to 0.89). Elevated basal CD62P expression level was associated with increased 90-day mortality (P = 0.042, ROC AUC = 0.78 (0.64 to 0.88)). KaplanMeier survival curves illustrated that mortality was significantly higher after stratification based on T1 basal CD62P level (cutoff MFI >31.56, HR = 13.6, P = 8.23 106). Multivariate logistic regression analysis using clinical scores (SOFA, APACHE II, SAPS II, SAPS III) indicated that addition of CD62P level or of bound fibrinogen level significantly improved prediction of mortality (odds ratio 1.078, P = 0.003) and sepsis (odds ratio 1.033, P=0.0012), respectively. Conclusion Predisposition to severe infection in selected critically ill medico-surgical adults can be identified on day 1 of admission based on circulating basally activated platelets. Levels of activated platelets may add incremental prognostic information to clinical scoring. Reference 1. de Stoppelaar SF, van t Veer C, van der Poll T. The role of platelets in sepsis. Thromb Haemost. 2014;11:666-77. P30 Antiplatelet therapy does not influence outcome or host response biomarkers during sepsis: a propensity-matched analysis MAWiewel1, SFDeStoppelaar1, LAVanVught1, JFFrencken2, AJHoogendijk1, PMKleinKlouwenberg2, JHorn1, MJBonten2, MJSchultz1, AHZwinderman1, OLCremer2, TVanderPoll1 1Academic Medical Center, University of Amsterdam, the Netherlands; 2University Medical Center Utrecht, the Netherlands Critical Care 2015, 19(Suppl 1):P30 (doi: 10.1186/cc14110) Introduction Sepsis is a life-threatening condition, during which triggering of inflammatory and coagulation cascades, together with endothelial damage, invariably leads to activation of platelets. Although platelets are essential components of primary hemostasis, uncontrolled platelet activation during sepsis may contribute to organ failure. The aim of this study was to investigate whether chronic antiplatelet therapy impacts on the presentation and outcome of, and the host response to, sepsis. Methods We performed a prospective observational study in patients admitted with sepsis to the mixed ICUs of two hospitals in the Netherlands between January 2011 and July 2013. Cox proportional hazards regression was used to estimate the effect of antiplatelet therapy on mortality. To account for indication bias, a propensity score was constructed, and used to match antiplatelet therapy users to nonusers. Plasma biomarker levels, providing insight into hallmark host responses to sepsis, including activation of endothelial cells and the cytokine network, were determined during the first 4days after ICU admission. Results Of 1,070 sepsis patients, 297 (27.8%) were on antiplatelet therapy, including acetylsalicylic acid, clopidogrel and dipyridamole, prior to ICU admission. Antiplatelet users and nonusers differed significantly with regard to several baseline characteristics, such as age, gender and cardiovascular disease. Antiplatelet therapy was not related to sepsis severity at presentation, the primary source of infection, causative pathogens, the development of organ failure or shock during ICU stay, or mortality up to 90 days after admission, in either the unmatched or propensity-matched analyses. Antiplatelet therapy did also not modify plasma concentrations of biomarkers. Conclusion Pre-existing antiplatelet therapy does not influence clinical disease severity at presentation, nor the host response or outcome following sepsis. Acknowledgement This research was performed within the framework of CTMM, the Center for Translational Molecular Medicine (http://www., project MARS (grant 04I-201). P31 Perioperative programmed death-1 expression on CD4+ T cells predicts the incidence of postoperative infectious complications following gastrointestinal surgery SOno1, TIkeda1, TKubo2, HTsujimoto2, MKinoshita2, TUeno1 1Hachioji Medical Center, Tokyo Medical University, Hachioji, Tokyo, Japan; 2National Defense Medical College, Tokorozawa, Saitama, Japan Critical Care 2015, 19(Suppl 1):P31 (doi: 10.1186/cc14111) Introduction Programmed death-1 (PD-1) has been reported to be an immunoinhibitory receptor expressed by chronically stimulated T cells after T-cell activation. The present study was designed to evaluate the relationship between perioperative PD-1 expression on CD4+ T cells and the incidence of postoperative infectious complications in patients undergoing gastroenterological surgery. Methods This was a prospective observational study. The subjects of this study included 101 patients with gastroenterological disease who underwent elective abdominal surgery via laparotomy at the National Defense Medical College Hospital. Blood samples were taken on the preoperative day (Pre) and the first postoperative day (POD1). We calculated CD4+ T-cell count and PD-1 expression on CD4+ T cells by flow cytometer. The occurrence of postoperative infectious complications was defined according to a combination of clinical findings and the results of laboratory and other tests. The postoperative infectious complications in this study included incisional surgical site infections (SSIs), organ/space SSIs, enterocolitis, urinary tract infections, and pneumonia. Incisional and organ/space SSIs were diagnosed according to the definitions stated in the guidelines issued by the Center for Disease Control and Prevention. Results Postoperative infectious complications occurred in 30 of the 101 patients. CD4+ T-cell count was significantly lower in the patients who developed postoperative infectious complications at POD1 compared with those from the patients who did not. In addition, PD-1 expression on CD4+ T cells was significantly higher at Pre or POD1 in patients who developed postoperative infectious complications. Those results were similar for the incidence of organ/space surgical site infection. Preoperative PD-1 expression on CD4+ T cells tended to be higher in males than in females. We found there was a significant negative correlation between preoperative PD-1 expression on CD4+ T cells and CD4+ T-cell count. Conclusion Perioperative CD4+ T-cell count or PD-1 expression on CD4+ T cells could be an early predictive marker for the development of postoperative infectious complications. P32 Mitochondrial dysfunction and ischemia in critical illness: anadipose tissue microdialysis study in 203 ICU patients MTheodorakopoulou, SApollonatou, NNikitas, DVassiliadi, ADiamantakis, VTsagkari, FFrantzeskaki, IDimopoulou University Hospital of Athens, Greece Critical Care 2015, 19(Suppl 1):P32 (doi: 10.1186/cc14112) Introduction Ischemia and mitochondrial dysfunction have been implicated in critical illness. The potential of MD to diagnose and separate ischemia and mitochondrial dysfunction in ICU patients remains currently unknown. Methods A retrospective, observational study of 203 mechanically ventilated patients studied over a 6-year period with MD including medical, surgical and trauma patients. Sepsis stages: SIRS (n = 24), severe sepsis (n= 46) and septic shock (n= 133). Median age 67years (range: 17 to 92 years). Mortality was 53%. All subjects had a MD catheter placed in femoral adipose tissue upon admission to the ICU. Interstitial fluid samples were collected six times per day, for 3 consecutive days, and were analyzed for glucose, lactate, pyruvate, and glycerol levels. The lactate to pyruvate (LP) ratio was calculated. Blood lactate was measured. Ischemia was defined as LP ratio >30 and pyruvate level <70mmol, while mitochondrial dysfunction was defined as LP ratio >30 and pyruvate >70mmol. Results Analysis during the course of the 3-day period revealed three distinct patterns: no ischemia/mitochondrial dysfunction (n = 150 or 74%), ischemia (n= 27 or 13%) and mitochondrial dysfunction (n= 26 or 13%). On day 1, median blood lactate was higher in mitochondrial dysfunction (2.2 mmol/l) compared with both ischemia (1.3 mmol/l) and with no ischemia/mitochondrial dysfunction (1.3 mmol/l) (P=0.004). Again on day 1, median interstitial fluid lactate was higher in mitochondrial dysfunction (8.4mmol/l), in comparison with ischemia (1.4 mmol/l) and with the group without ischemia/mitochondrial dysfunction (2.5mmol/l) (P<0.001). Similar results were obtained with interstitial fluid glycerol levels (P=0.009). Median LP ratio was higher in ischemia (LP=36), and mitochondrial dysfunction (LP=33) compared with those without ischemia/mitochondrial dysfunction (LP = 17) (P <0.001). Median interstitial fluid glucose was lower in ischemia (2mmol/l) compared with both mitochondrial dysfunction (4mmol/l) and with no ischemia/mitochondrial dysfunction (5mmol/l) (P<0.001). ICU mortality was 77% in mitochondrial dysfunction, 52% in ischemia and 49% in the group without ischemia/mitochondrial dysfunction (P=0.033). Conclusion Bedside subcutaneous adipose tissue MD is possible to diagnose and separate ischemia and mitochondrial dysfunction in general ICU patients. These two conditions are not so common; however, mitochondrial dysfunction seems to be associated with higher mortality rates. P33 Pyruvate dehydrogenase levels are low in sepsis ENuzzo, XLiu, KBerg, LAndersen, MDoninno Beth Israel Deaconess Medical Center, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P33 (doi: 10.1186/cc14113) Introduction Pyruvate dehydrogenase (PDH) is a key component of aerobic metabolism. Multiple rodent studies have shown that PDH levels are low in sepsis. This leads to a shift to anaerobic metabolism, resulting in increased lactic acid. Alteration in PDH levels during sepsis, however, has never been studied in humans. The aim of this study was to identify whether PDH levels (activity and quantity) were altered in humans in sepsis. Methods We conducted a casecontrol study at a single urban tertiary care center. We compared PDH levels between sepsis and healthy control subjects by measuring PDH levels in peripheral blood mononuclear cells via a novel assay. We measured PDH levels in control subjects at baseline and in sepsis subjects at 0, 24, 48 and 72hours. Results There were 39 sepsis (age 6714years, MSD) and 19 control (age 50 12 years) subjects of similar gender (56% and 63% female, respectively) and race (79% and 68% Caucasian, respectively). PDH levels in the sepsis group were significantly lower than the control group at all time points (Figures 1 and 2). After controlling for age, gender, race, and assay plate via multivariable linear regression, the effect of treatment group remained significant. We were unable to control for comorbid illness, which was exclusively concentrated in the sepsis group. Conclusion PDH levels are significantly lowered in humans during sepsis when compared with healthy controls, even when controlling for age, race and gender. Further research is needed to determine whether this finding persists after adjustment for comorbid disease, and whether lower PDH levels are associated with clinical outcomes. Introduction C1 inhibitor (C1INH), belonging to the superfamily of serine protease inhibitors, regulates not only complement system, but also the plasma kallikreinkinin system, fibrinolytic system and coagulation system. The biologic activities of C1INH can be divided into the regulation of vascular permeability and anti-inflammatory functions. In recent years, hereditary angioedema (HAE), caused by an inherited deficiency of C1INH, has been focused. During HAE attacks, vascular permeability was markedly increased, which leads to angioedema. In sepsis, significant endothelial hyperpermeability is similarly observed systemically, but the role of C1INH has not been clarified in the pathogenesis. The serial change of C1INH in patients with sepsis is not clear. The objective of this study was to clarify the serial change in C1INH in patients with sepsis and evaluate the impact of C1INH on their clinical course. Methods We serially examined C1INH activity values (normal range 70 to 130%) and quantitative values (normal range 160 to 330g/ml) in patients with sepsis during the period between December 2012 and February 2013. We also analyzed their clinical course: prognosis, volume of infusion, body weight, urine volume, catecholamine administration, and steroid administration. Results The serial change of C1INH was evaluated in five patients with sepsis (three male and two female; four survivors and one nonsurvivor; mean age, 68 11 years). In the nonsurvivor, C1INH activity on admission value was 97.2% (normal range), and quantitative value was 133.1 g/ml (below normal). In the patient with severe sepsis requiring fluid resuscitation, catecholamine and steroid administration to maintain hemodynamics, C1INH activity value on admission was 94.4% (normal range), and quantitative value was 126.7g/ml (below normal range). His general condition was improved on day 6, and C1INH activity value and quantitative value increased (139.9%; above normal range, 250.1g/ml; normal range). In the other three patients with sepsis not requiring steroid administration, C1INH activity value on admission was 130.68.7% (above normal range), and quantitative value was 21526.5g/ml (normal range). Conclusion In the nonsurvivor or the severe patient with sepsis requiring steroid administration, the enhancement of C1INH activity was not observed, and the C1INH quantitative values were low. Further evaluation of the serial change of C1INH and the validity of C1INH replacement therapy in patients with septic shock may lead to a new strategy for management in sepsis. Introduction Sepsis is characterized by a strong systemic inflammatory reaction. The pathogenesis is driven by alterations in the immune system and is associated with high neutrophil counts related to a specific delay in apoptosis [1]. The apolipoproteins L (ApoLs) family comprises six members in humans (ApoL1 to ApoL6). In light of their deregulated expression in several pathologies, they are likely to be important molecular players of programmed cell death [2]. We analyzed ApoL expression in cohorts of septic and nonseptic ICU patients and healthy volunteers in order to test whether ApoLs could be involved in the neutrophil apoptotic program. Methods By means of magnetic cell sorting, peripheral neutrophils were purified from 20 healthy volunteers and 40 ICU patients with (n= 20) or without sepsis (n = 20). ApoL expression was analyzed at the mRNA and protein levels by real-time PCR and western blot analysis respectively. Apoptosis of purified neutrophils was assessed using flow cytometry following 4 and 24 hours of in vitro incubation. We monitored the expression of C-reactive protein (CRP), an inflammatory marker, and its correlation with ApoL expression in PMNs was studied by linear regression analysis. Results Our results showed a significant downregulation in mRNA expression of ApoL1 (P<0.0001), ApoL2 (P=0.0009), ApoL3 (P<0.0001) and ApoL6 (P=0.0003) in purified PMNs from ICU patients as compared with the healthy individuals. This downregulation was also validated at the protein level for ApoL1 and ApoL2, whereas ApoL 6 was upregulated in septic patients. We could not detect ApoL3 protein in any of the cohorts. This was accompanied by a significant delay in PMN apoptosis in septic patients as compared with healthy volunteers (P<0.05) at 4 and 24hours. We also showed a strong negative correlation in the three mixed groups between CRP and ApoL1 (R= 0.607), ApoL2 (R= 0.651), ApoL3 (R= 0.578) and ApoL6 (R= 0.506). Conclusion The altered apoptotic fate of neutrophils in sepsis was correlated with the modification of the expression profile of ApoLs, a family of proteins thought to be involved in the apoptotic process. The role of these proteins in the sepsis-associated phenotype of neutrophils remains to be further elucidated. References 1. Grgl P, et al. Crit Care. 2011;15:R20. 2. Vanhollebeke B, et al. Cell Mol Life Sci. 2006;63:1937-44. Introduction The primary aim of this study was to determine the differences in ex vivo generation of neutrophil extracellular traps (NETs) by neutrophils from septic and nonseptic patients. We further sought to examine plasma levels of cell-free DNA (cf-DNA) and histones to assess in vivo NET formation. Methods We isolated neutrophils from consecutive patients with sepsis (n= 17) and without sepsis (n= 18) admitted to the ICU. Neutrophils were activated by incubation with phorbol myristate acetate to induce release of NETs and NET formation was assessed by measuring the extracellular DNA level. Immunolabeling and fluorescence imaging were also performed. Extracellular killing of bacteria by NETs was studied by co-culture of Escherichia coli and neutrophils in the presence of the phagocytosis inhibitor cytochalasin D. To assess in vivo NET formation, plasma levels of cf-DNA and histones were measured. Results The condition of the nonseptic patients was significantly less severe than that of the septic patients. The SOFA score of septic patients and the nonseptic patients was 6 (3 to 18) and 2.5 (1 to 8), respectively (median (IQR), P = 0.02). The overall mortality rate was 29%. After stimulation with PMA, neutrophils isolated from septic patients released 4.08 1.02% of their total DNA, whereas neutrophils from nonseptic patients released 29.06 2.94% (P <0.0001). Immunofluorescent staining of released DNA, elastase, and myeloperoxidase also revealed similar results. Neutrophils from nonseptic patients showed effective extracellular killing of E. coli through NETs, whereas neutrophils from septic patients did not (P<0.001). Plasma levels of cf-DNA and histones were higher in septic patients than in nonseptic patients (P<0.001). Conclusion The increase of the immature PMN count and immature/ total PMN ratio confirmed recruitment of immature neutrophils from the bone marrow into the circulation. The ex vivo generation of NETs is downregulated in neutrophils isolated from patients with sepsis. However, it is unclear whether in vivo NET formation is also impaired during sepsis, so further investigation is necessary. Introduction The inflammatory response of sepsis is developed in two phases, an inflammatory phase (SIRS) and a phase more variable in frequency and intensity (CARS): this balance has an important effect on morbidity and mortality. Lymphopenia affects particularly T cells, and correlates inversely with outcome. The aim of the study was to identify phenotypic and functional early markers of T cells and NK cells related to prognosis in the septic patient population. Methods We collected peripheral blood mononuclear cells from 47 patients with severe sepsis or septic shock at ICU admission (T0) and from 50 healthy controls. On these subjects we evaluated frequency and absolute numbers of CD4+ and CD8+ T cells and of NK and B lymphocytes, the rates of regulatory CD4+CD25+Foxp3+ T cells (Tregs), the cytotoxic potential of CD4+, CD8+ T cells and of NK cells by evaluation of perforin (PER) and granzyme (GRA) expression and production of effector cytokines (namely IL-2, IL-17, IL-4, TNF, IFN) by CD4+, CD8+ T cells and NK cells upon polyclonal stimulation. The markers were compared in patients with different outcome. Results Septic patients, compared with healthy donors, were characterized by global lymphopenia; we found increased frequencies of CD4+ T cells producing IL-2 (P=0.0000000003), increased percentage of CD8 T cells producing IFN (P = 0.03), and reduced proportion of CD4+ T cells (P=0.00007) and NK cells (P=0.002) producing IFN. We also noticed an increased frequency of CD8+ T cells expressing PER (P=0.00000025) and GRA (P=0.01); moreover, the proportion of NK cells expressing GRA was also significantly increased (P = 0.000019). To establish the prognostic value of these biological markers, we compared the cytokine expression by lymphocytes in septic patients that survived with those that died (D). We found that CD4+ and CD8+ TNF-producing T cells were significantly increased in D (P = 0.01 and P = 0.0001 respectively); similarly the percentage of CD8+ T cells producing IFN was more elevated in D (P = 0.006). The same was observed for IL-17 production by CD4+ T cells (P = 0.03) in D. On the contrary we observed a tendency to the reduction of circulating CD4+CD25+foxp3 (Tregs) in D (P=0.08). Conclusion Septic patients are characterized by a peculiar immunophenotype which includes global lymphopenia and a specific pattern of cytokines. Some of the evaluated markers seem to individuate those with worse outcome; in particular, this group showed an inflammatory phenotype with a higher expression of IFN, TNF, IL17 and a tendency to a reduction of Tregs. P38 Reduced responsiveness of blood leukocytes to lipopolysaccharide does not predict nosocomial infections in critically ill patients LAVanVught, MAWiewel, AJHoogendijk, BPScicluna, HBelkasim, JHorn, MJSchultz, TVanderPoll Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P38 (doi: 10.1186/cc14118) Introduction Critically ill patients show signs of immune suppression, which is considered to increase vulnerability to nosocomial infections. Whole blood stimulation is a frequently used functional test for immune suppression. We here aimed to assess the association between whole blood leukocyte responsiveness to lipopolysaccharide (LPS) and the subsequent occurrence of nosocomial infections in critically ill patients admitted to the ICU. Methods All consecutive critically ill patients admitted to the ICU between April 2012 and June 2013 with two or more systemic inflammatory response syndrome criteria and an expected length of ICU stay of more than 24 hours were enrolled. Age-matched and gender-matched healthy individuals were included as controls. Blood was drawn the first morning after ICU admission and stimulated ex vivo with 100 ng/ml ultrapure LPS for 3hours. Tumor necrosis factor (TNF), interleukin (IL)-1 and IL-6 were measured in supernatants. Results Seventy-three critically ill patients were included, 10 of whom developed an ICU-acquired infection. Compared with healthy subjects, whole blood leukocytes of patients were less responsive to ex vivo stimulation with LPS, as reflected by strongly reduced TNF, IL-1 and IL-6 levels in culture supernatants. However, results were not different between patients who did and those who did not develop an ICUacquired infection (Figure1). Conclusion The extent of reduced LPS responsiveness of blood leukocytes in critically ill patients on the first day after ICU admission does not relate to the subsequent development of ICU-acquired infections. Figure1 (abstract P38). Similarly reduced responsiveness of whole blood leukocytes to lipopolysaccharide. P39 Cell-culture model to study endothelial activation in sepsis TEichhorn1, SRauscher2, CHammer2, BFhrer2, MGrger2, VWeber1 1Danube University Krems, Austria; 2Core Facility Imaging, Medical University of Vienna, Austria Critical Care 2015, 19(Suppl 1):P39 (doi: 10.1186/cc14119) Introduction The endothelium is a complex organ influenced by circulating mediators, adjacent cells, physico-chemical factors, and shear stress. During systemic inflammation and sepsis, excessive and sustained activation of the endothelium result in the loss of its anticoagulant and anti-adhesive characteristics as well as in a loss of endothelial barrier function. We set up a cell-culture model to study endothelial activation induced by lipopolysaccharide (LPS) or by plasma from septic patients and studied the effect of adsorbent-based mediator modulation on endothelial activation. Methods Human whole blood was stimulated with LPS (100 ng/ ml) from Escherichia coli for 4 hours. The stimulated blood or plasma from septic patients was treated in vitro with 10 vol% polystyrene divinylbenzene (PS-DVB)-based polymers (CG161, mean pore size 16 nm; CG300, mean pore size 30 nm) or left untreated. After adsorption, the plasma was separated and diluted with cell culture medium. The resulting conditioned medium was used to stimulate human umbilical vein endothelial cells (HUVEC) for 16 hours. HUVEC activation was assessed by the release of interleukin (IL)-1, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF), plasminogen activator inhibitor-1 (PAI1), as well as the expression of intercellular adhesion molecule (ICAM)1 and E-selectin. HUVEC were cultured at a shear stress of 5 dyne/ cm2 using the Ibidi perfusion system. Adhesion of monocytic THP-1 cells to HUVEC was studied after 4 hours of HUVEC stimulation with conditioned media. THP-1 cells were perfused over HUVEC at 1 dyne/ cm2 for 15minutes, and adhering THP-1 were quantified over time. Results The adsorbents CG161 and CG300 substantially decreased levels of TNF, IL-1, IL-6, IL-8 and IL-10 in LPS-stimulated blood. TNF, a key stimulus for HUVEC, was reduced to 12% and 8% of the initial concentration by CG161 and CG300, respectively. Stimulation of HUVEC with the adsorbent-treated plasma resulted in significantly diminished release of IL-6, IL-8, PAI-1 and decreased ICAM-1 and E-selectin expression, indicating reduced HUVEC activation. THP-1 adhesion was substantially decreased when HUVEC were stimulated with CG300-treated plasma as compared with untreated controls. Conclusion The flow model allows to study the effect of cytokine modulation on endothelial activation and to assess the interaction of activated endothelial cells with blood cells. Modulation of inflammatory mediators with porous polystyrene-based polymers attenuates endothelial activation and reduces monocyte adhesion. Introduction Extracellular heat shock proteins (HSP) act as inducers of interleukins (IL) and stimulants for immune cells during systemic inflammatory response syndrome (SIRS). Little is known about the alarming roles of extracellular HSP72 and HSP90 in the acute phase [1] of sepsis (S) or severe sepsis (SS). We determined serum HSP90, HSP72 and neutrophil CD64 expression, IL-6, IL-8, IL-10, and TNF in children with S or SS compared with SIRS (brain injury) or healthy children (H). Methods Critically ill children with S (n= 16), SS (n= 15) or SIRS (n= 18) and H (n= 21) were enrolled in the study. ELISA was used to evaluate HSPs, chemiluminescence to measure ILs, and flow cytometry to evaluate nCD64 expression (IRB approved). Results Patients in both septic groups had elevated HSP90 (P<0.0001), HSP72 (P <0.05), IL-6 (P <0.0001), IL-8 (P <0.02) and IL-10 (P <0.05) levels compared with H, whereas SS had increased HSP72, IL6 and TNF compared with SIRS (P<0.05). SIRS patients presented increased HSP90, IL-6 and IL-8 compared with H (P <0.05). Both HSPs were dramatically increased among nonsurvivors. In a logistic regression model, only HSP90 was independently associated with mortality (P<0.0001). HSP90 related positively (P<0.001) to nCD64, IL-8, IL-10, CRP, PRISM, PELOD, TISS, and LOS and negatively to HDL (P<0.001) and LDL (P<0.02). HSP72 also related negatively to HDL (P<0.001). Conclusion Extracellular HSP72 and HSP90 are alarmingly elevated in critically ill children, especially in severe sepsis. HSP90 levels are independently associated with mortality, related to CD64, IL-8, IL-10, severity of illness, and outcome. Both HSPs are inversely related to the low LDL/low HDL septic metabolic pattern [2]. Acknowledgements This research has been co-financed by the European Union (European Social Fund) and Greek national funds through the Operational Program Education and Lifelong Learning of the National Strategic Reference Framework Research Funding Program: THALES. Investing in knowledge society through the European Social Fund. P41 Early heat shock protein 72 and 90 intracellular and extracellular responses in patients with severe sepsis or systemic inflammatory response syndrome KApostolou1, KVardas1, EBriassouli1, KPsara1, DGoukos1, EMageira1, SNanas1, CRoutsi1, GBriassoulis2 1Evangelismos Hospital, National and Kapodistrian University of Athens, Greece; 2University Hospital, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P41 (doi: 10.1186/cc14121) Introduction Heat shock proteins (HSPs) have intracellular cytoprotective actions, while they act extracellularly as inducers of cytokines and stimulants for immune cells during stress. Their induction constitutes a highly conserved cellular defense mechanism against all kinds of stress. Our objective was to determine the intracellular as well as extracellular levels of HSP72 and HSP90 in patients with severe sepsis (SS) or systemic inflammatory response syndrome (SIRS) admitted to a general ICU, compared with those of healthy individuals; to correlate their expression with severity of illness. Methods Eighty-two consecutively admitted patients in the ICU (35 SIRS, 47 SS) as well as 35 healthy controls (H) were finally enrolled in the study. Patients demographic characteristics, laboratory examinations and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded on admission. HSP levels were determined intracellularly using four-color flow cytometry. Mean fluorescence intensity (MFI) values for each HSP were measured and analyzed. Extracellular levels of HSPs were determined via ELISA. Results HSP expression differed significantly between groups (KruskalWallis), both intracellularly (HSP72 lower in SS, P <0.001), and extracellularly (higher levels of HSP90 (P <0.001) and HSP72 (P = 0.003) in SS). HSP72 and HSP90 intracellular expression was inversely correlated to severity of illness, as expressed by APACHE II score (Spearmans, P=0.003 and P=0.025 respectively). Intracellular HSP72 was correlated to mortality when confounding factors were excluded from the analysis (logistic regression, P=0.05). Extracellular HSP90 levels correlated with prolonged PT (P = 0.021) and INR (P=0.008). Finally, in the SIRS group, intracellular levels of HSP90 were higher in nonsurvivors (P<0.001). Conclusion SS is characterized by high levels of extracellular HSPs. Intracellular HSP72 is highly expressed during the acute phase of stress in SIRS, while being downregulated in SS. HSP72 and HSP90 intracellular expression and extracellular level variations correlate with severity of illness and mortality. Acknowledgements This research was co-financed by the European Union (European Social Fund) and Greek national funds through the Operational Program Education and Lifelong Learning of the National Strategic Reference Framework Research Funding Program: THALES. P42 Heat shock proteins 70/90 and associations with immunosuppression along with sepsis: preliminary data PPapadopoulos1, APistiki2, TChristodoulopoulou1, MTheodorakopoulou1, VTsagkari1, AArmaganidis1, STsiodras2, IDimopoulou1, GBriassoulis3, GBriassoulis3 1University Hospital of Athens, Greece; 2University Hospital ATTIKON, Athens, Greece; 3University Hospital, University of Crete, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P42 (doi: 10.1186/cc14122) Introduction CD14/HLADR is an index of immune suppression. Heat shock proteins (hsp) regulate cell response to oxidative stress. We evaluated the relationship of CD14/HLADR and hsp70/90 in patients with SIRS and severe sepsis versus healthy volunteers. Methods We evaluated 31 patients with SIRS or severe sepsis against a group of sex-matched healthy volunteers. Demographic data were obtained for all patients. APACHE score was calculated upon admission. Blood samples were collected upon diagnosis of SIRS or severe sepsis. To evaluate the %HLA-DR expression on monocytes, the fresh whole blood was stained with anti-CD14-FITC, anti-HLA-DR-PE and CD45PC5 while staining with anti-CD33-PE, anti-CD45-PC7, anti-hsp70-FITC and anti-hsp90-PE allowed evaluation of the MFI expression of hsps on CD33+ monocytes. Cells were then analyzed using flow cytometry. ANOVA with post hoc tests was used to compare CD14/HLADR cell counts and hsp70 and hsp90 levels among the three groups. Results Nineteen controls, six SIRS patients and 25 severe sepsis patients were studied. The percent expression of HLADR on CD14+ monocytes was significantly different between the three groups showing progressive decrease from controls (mean 90.5 3.8%) to SIRS (mean 61.25.9%) to severe sepsis (mean 39.25.5%) patients (controls vs. severe sepsis, P <0.001; controls vs. SIRS, P = 0.006; SIRS vs. severe sepsis, P = 0.03). hsp70 and hsp90 MFI were significantly different between controls (mean 49.54.9 and 33.53.4 respectively), SIRS (mean 69.916.5 and 46.55.7 respectively) and severe sepsis patients (mean 33.3 4.5 and 21.7 2.7 respectively) (P <0.05 for all comparisons). Notably, the hsp level rose from controls to SIRS and fell from SIRS to severe sepsis patients. APACHE score increased significantly (P=0.023) in septic patients compared with SIRS. Conclusion There were a significant difference in CD14/HLADR, a marker of immune paralysis, between controls and patients with SIRS or severe sepsis. hsp70 and hsp90 showed an initial stimulation followed by exhaustion as sepsis progressed. Acknowledgements This research was co-financed by the European Union (European Social Fund) and Greek national funds through the Operational Program Education and Lifelong Learning of the National Strategic Reference Framework Research Funding Program: THALES. This abstract is part of the study Heat Shock Proteins and Glutamine Alterations Related to Hormonal, Immunological, Inflammatory and Molecular Response to Sepsis: A Combined Clinical and Experimental Study. Introduction Rethinking the hosts defense mechanisms during severe infection has led to the use of flow cytometry (FCM) and to the current concept of sepsis-induced immunosuppression. However, organ dysfunctions that develop in the period preceding severe sepsis as a consequence of surgery, trauma or burn might also trigger immune reprogramming predisposing to overwhelming infection. Our aim was to look for correlation of specific phenotypes among four commonly encountered populations of patients and the later occurrence of severe sepsis and septic shock. Methods In total, 114 non-infected patients were prospectively screened via FCM on days 1 (T1) and 3 (T2) of elective cardiac surgery, trauma, acute neurologic dysfunction and prolonged ventilation (>48hours). A third sample was drawn when infection was diagnosed (Tx) and 7 days later (Tx + 7). Exclusion criteria included use of immunosuppressive agent(s). The broad panel of cell-specific antibodies focused on B, T lymphocytes (Tregs, Th17, NKT), NK cells, monocytes and neutrophils. Plasmatic levels of IL-2/IL-6/IL-7/TNF/ IFN were also determined. Results Ninety-nine patients were included in the final analysis. Eighteen patients developed severe sepsis or septic shock. They presented with significantly higher levels of intermediate (CD14++/16+) and CD62L monocytes and lower IL-2 levels at T1 compared with patients who did not get septic. ROC AUC for association of these parameters with the occurrence of sepsis were 0.78 (95% CI: 0.63 to 0.91), 0.72 (0.62 to 0.82) and 0.73 (0.65 to 0.82), respectively. High counts of these monocytic cells were also associated with increased 90day mortality (P<0.01, ROC AUC= 0.87 (0.77 to 0.95), 0.79 (0.66 to 0.9)). KaplanMeier survival curves showed significantly higher mortality after stratification based on these cell counts at T1 (CD14++CD16+: cutoff >236.8 cells/l, HR= 23.6 (P=1.24105); CD62L: cutoff >95.4 cells/l, HR= 6.67 (P=7.6104)). Multivariate logistic regression analysis using clinical scores indicated that addition of IL-2 levels at T1 significantly improved prediction of sepsis (OR= 0.834, P=0.02). Conclusion Predisposition to sepsis in selected critically ill medicosurgical adults can be identified on day 1 of admission based on high counts of circulating intermediate and CD62L monocytes and low levels of IL-2 (the latter provide incremental prognostic information). High counts of these specific monocytes correlate with higher 90-day mortality. P44 Macrophage phenotype in sepsis immunosuppression ETheodorakis, EDiamantaki, CTsatsanis, DGeorgopoulos, KVaporidi University of Crete, School of Medicine, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P44 (doi: 10.1186/cc14124) Introduction Sepsis is followed by profound, yet poorly characterized, innate immune system suppression. While low monocyte HLA-DR expression is observed in septic patients, its clinical significance has not been established [1]. In vitro, repeated LPS stimulation induces a tolerant or M2 macrophage phenotype, characterized by decreased cytokine production [2], which could contribute to sepsis immunosuppression. The present study examines macrophage phenotype in a mouse model and in patients with sepsis immunosuppression. Methods Sepsis was induced in C57Bl6 mice by cecal ligation and puncture (CLP) followed by intratracheal instillation of Pseudomonas aeruginosa. Bronchoalveolar lavage fluid (BALF), cells and serum, collected 12hours after lung infection, were analyzed for bacterial load, cytokine levels and the classical M1 marker, iNOS. Peripheral blood monocytes isolated from septic adult patients admitted to the ICU on the 1st and 7th day after admission were analyzed by flow cytometry for the expression of HLA-DR and CD86 (co-stimulatory molecule and M1 marker), and for the M2 markers, CD163 and CD206. Additional blood samples from patients and healthy volunteers were exposed ex vivo to LPS prior to isolation and analysis of monocyte markers. Results CLP-induced sepsis resulted in immunosuppression in mice, indicated by higher BALF bacterial load after infection in CLP than in sham-operated mice, and more severe injury on histology. Serum cytokines TNF and MIP2 were greater in CLP than in sham-operated mice. Although recruitment of CD11c+ alveolar macrophages post infection was threefold greater in CLP than in sham-operated mice, those macrophages expressed 40% lower levels of iNOS. Evidence of sepsis immunosuppression was present in most patients on the 7th day after ICU admission. Low expression of CD86 and/or HLA-DR was observed in 71% of patients, and increased expression of M2 markers in 15% of patients. Upon LPS stimulation the normal decrease in M2 markers was absent in all patients on day 1, and partially restored in 50% of patients on day 7. Conclusion Sepsis is associated with decreased monocyte expression of M1 markers and increased expression of M2 markers in septic mice and critically ill patients. Therefore, in addition to decreased HLA-DR expression, M2 macrophage polarization appears to be a component of sepsis-induced monocyte dysfunction, and should be considered for immune monitoring and targeted intervention. Acknowledgement Supported by GSRT research grant ExcellenceII-4620. References 1. Gomez H, et al. Crit Care Med. 2014;42:771. 2. Porta C, et al. Proc Natl Acad Sci U S A. 2009;106:14978. Introduction Decreased monocyte surface HLA-DR (mHLA-DR) measured by flow cytometry (FCM) is an independent marker of immunosuppression in sepsis. In a previous report we demonstrated that septic patients display a strong correlation between mHLA-DR and mRNA-levels of HLA-DRA in whole blood [1]. mRNA-based HLADR monitoring by PCR would improve the clinical usage and facilitate conduction of multicentre studies. The primary focus in this study was to evaluate the correlation between mHLA-DR and HLA-DRA at different time points during sepsis. In addition, we assessed the dynamic expression of both mHLA-DR and HLA-DRA, in relation to sepsis severity. Methods Study patients (n = 54) were included at day 1 to 2 after hospital admission if blood cultures turned positive. Repeated sampling at days 1 to 2, 3, 7, 14 and 28 was performed. mHLA-DR was monitored by FCM and HLA-DRA by quantitative RT-PCR. Mixed models for longitudinal data were used after logarithmic transformation to calculate the interactional effects of time and severity on HLA-DR expression. Figure2 (abstract P45). Box plots of HLA-DRA, measured by qRT-PCR. Results Correlation between mHLA-DR(FCM) and HLA-DRA(PCR) at day 1 to 2 (R= 0.78) and day 14 (R= 0.27). Both HLA-DR markers increased linearly on a log scale over time. The linear association was significantly different between the severe (n = 16) and nonsevere septic patients (n= 38) when measuring either mHLA-DR(FCM) or HLA-DRA(PCR). By pairwise comparison of means between the two severity groups, at every time point, the differences between groups were shown to be significant at days 1 to 2 and 3 when monitoring mHLA-DR(FCM) and at days 1 to 2, 3 and 7 for HLA-DRA(PCR) (Figures 1 and 2). Conclusion The correlation between flow cytometry and PCR-based HLA-DR monitoring is stronger in the early phase of sepsis. However, the linear associations over time, in relation to sepsis severity, display similar results for both HLA-DR markers. HLA-DRA(PCR) as a biomarker could be an alternative approach in monitoring immune status in sepsis but needs to be evaluated in relation to clinically relevant immunosuppression. Reference 1. Cajander S, et al. Crit Care. 2013;17:R223. P46 HLA-DR monocyte antigen expression as predictors of outcome in patients with community-acquired infections presenting with fever DLogothetis, EGiourou, IStarakis, ALekkou, GTheodorou, MLeotsinidis, MKarakantza, CGogos University of Patras, Patra, Greece Critical Care 2015, 19(Suppl 1):P46 (doi: 10.1186/cc14126) Introduction The aim of the present study was to evaluate the prognostic value of HLA-DR antigen expression in monocytes, in patients with community-acquired infections presenting with fever, as possible markers for the patients final outcome. Methods A total of 81 patients (males= 46; females= 35) presenting with fever >38C to the emergency room (ER) of the Department of Internal Medicine of the Patras University Hospital were enrolled in the study during a period of 12 months. Sera for monocyte HLA-DR expression were obtained from the patients on admission (day 1) and on days 3, 7 or discharge/death. Results were expressed as percentages of HLA-DR-positive monocytes, calculated by the coexpression of CD14 and HLA-DR antigens in the total CD14+ population. Additionally, the patients were evaluated using the Simplified Acute Physiology Score (SAPS-II), the Sequential Organ Failure Assessment (SOFA) and the Mortality in Emergency Department Sepsis (MEDS) score on the same days while all the indicated clinical, laboratory and imaging procedures as required for fevers differential diagnosis were followed. A questionnaire regarding demographic characteristics, comorbidities, medications used and patients survival was also completed. All statistical analyses were performed using SPSS v.21. Results Lower mean HLA-DR monocyte antigen expression percentages were significantly correlated to lower Glasgow Scale scores on all days of measurement. HLA-DR expression was significantly negatively correlated to MEDS, SOFA and SAPS-II scores whereas patients who developed sepsis, severe sepsis, septic shock and MODS had significantly lower HLA-DR values compared with the ones who did not. HLA-DR expression on day 1 was lower in patients who would develop SIRS and/or sepsis on days 3 and 7 (P<0.01). Additionally, HLADR expression was significantly decreased in nonsurvivors (n = 33) compared with survivors (n = 48), whereas lower HLA-DR expression was correlated to longest duration of hospital stay at all time points (P<0.01). Conclusion Monocyte HLA-DR appears to be an early indicator for survival and infection progression and therefore it can be used as a predictive marker for the final outcome of patients presenting in ER departments with fever. Introduction The idea of using the eosinophil count (EC) as a diagnostic marker for clarifying the nature of systemic inflammatory response syndrome (SIRS) belongs to K Abidi, who showed that EC could be Cutoff (EC, Sensitivity Specificity cells/mm3) (%) (%) used as a diagnostic criterion of sepsis. There are no published data to define the role of dynamic control of EC in the process of intensive therapy as a prognostic marker and indicator of severity condition in critically ill patients. The aim was to determine the informative value of EC in the development of SIRS as a biomarker of sepsis and indicator of the severity condition and prognosis of outcome in the pathological process. Methods A total of 143 patients were enrolled in this study who were admitted to the ICU and had SIRS. All patients were divided into a septic group patients with community-acquired pneumonia, complicated by sepsis and two SIRS groups of noninfectious genesis patients who had an acute cerebrovascular accident (CVA) and an acute myocardial infarction (AMI). The absolute EC was measured at admission and in the dynamics on days 3 to 5 of stay. Results The median EC was 75 cells/mm3 in septic patients on admission, which was significantly lower than in patients with CVA (120 cells/mm3) and AMI (130 cells/mm3). Comparison of EC in septic patients between survivors and those who died showed significant differences (Table1). Receiver operating characteristic (ROC) analysis determined a value less than 80 cells/mm3 as the optimal diagnostic cutoff value with a high level of confidence in the comparison of septic and noninfectious groups. Area under the ROC curves was 0.94, sensitivity of 80.8%, specificity of 95.6%, P<0.0001. There was a significant increase of EC in survivors, while the EC did not change significantly among those who died in the dynamics. ROC analysis determined the cutoff values of EC, which indicated a high risk of an adverse outcome in septic patients (Table2). Table2 (abstract P47). Informational value of eosinophil count in assessment of disease outcome On the 3rd to 5th days Conclusion EC may be an additional diagnostic marker which characterizes the nature of SIRS. Eosinopenia associated with prognosis of outcome in critical conditions. Introduction The endotoxin activity (EA) assay is a useful test to risk stratify critically ill patients and assess for Gram-negative (GN) infection. However, the prevalence and significance of early high levels of EA in patients with septic shock (SS) has yet to be elucidated. Methods We designed a prospective observational study including adult patients with clinically diagnosed SS. EA was measured on arterial blood by a chemiluminescent assay within the first 24 hours from SS diagnosis. The finding of an EA value 0.6 was used as the cutoff for test positivity, as described elsewhere. In addition, laboratory, microbiological and clinical data were collected at inclusion. In-hospital follow-up was also conducted. Results A total of 107 consecutive patients were included. The overall median EA was 0.56 (0.44 to 0.71), with 46/107 (43%) patients testing positive for elevated EA (0.6). GN species were identified in microbial cultures as the infective etiology in 49/107 (46%) patients, of which 28 (57%) developed bacteremia. GN infections were associated with higher levels of EA compared with other microbial causatives (0.61 (0.52 to 0.77) vs. 0.52 (0.38 to 0.64), P = 0.021). Patients with EA 0.6 showed significantly higher lactate levels (2 (1 to 3) vs. 3.8 (1.7 to 6.4), P=0.01), Sequential Organ Failure Assessment (9 (6 to 12) vs. 10 (8 to 14), P=0.04) and inotropic score (20 (5 to 50) vs. 50 (16 to 100), P=0.003) at inclusion. See Figure1. Conclusion Elevated EA is a common finding in SS patients. In patients developing SS from a GN infection, higher levels of endotoxin activity could be measured within 24 hours. Furthermore, in our study, EA 0.6 identified a subgroup of subjects at greater risk for worse clinical outcomes. We therefore propose use of the EA assay for the early identification and risk stratification of SS patients. Introduction The purpose of this study was to evaluate the diagnostic and prognostic value of the endotoxin activity assay (EAA) of sepsis in patients with systemic inflammatory response syndrome (SIRS) and organ failure in ICU setting. Methods In total, 76 patients with SIRS and organ failure or who were suspected of sepsis during critical care were included. According to the levels of EAA, all patients were classified into three groups (groupL, EAA <0.4; group M, EAA 0.4 or EAA <0.6; group H, EAA 0.6). In order to evaluate the severity of illness, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score and catecholamine (CA) index were recorded. Blood samples were obtained to measure EAA levels, inflammatory markers (procalcitonin, C-reactive protein and white blood cells), serum lactate level as an indicator of tissue hypoxia, and for blood culture. All patients were followed up for 6 months. APACHE II score, SOFA score, CA index, inflammatory markers, serum lactate levels and blood culture results were examined for diagnosis of sepsis, severe sepsis, septic shock and for prognosis of 30-day mortality. Each value was also compared with EAA levels. Results Patient age was 699.9years (male: n= 48, female: n= 25). The total number of samples was 106 (group L/group M/group H: 35/35/36). Twenty-seven specimens were obtained from nonseptic patients and 83 specimens were obtained from septic patients. APACHE II score was highly correlated with SOFA score (P <0.05). In group H, the APACHE II score was significantly higher (22.20.8) than that in group M (18.40.87) (P=0.01). The SOFA score in group H was significantly higher (9.9 0.5) than that in group M (7.5 0.6) and group L (7.90.6) (P=0.006). EAA levels were significantly increased in septic patients (septic patients: 0.56 0.03, nonseptic patients: 0.42 0.05) (P = 0.011) and in the positive blood culture group (positive group: 0.660.05, negative group: 0.480.03) (P=0.006). There was no relationship between EAA levels and other inflammation markers or 30-day mortality. Conclusion In patients with suspected sepsis and positive blood culture, EAA levels were significantly increased and had strong correlation with severity of disease. This result suggests that EAA indicates the state of sepsis regardless of the possibility of infection in patients with SIRS with organ failure. Introduction Sepsis is a common reason for admission to ICUs throughout the world. During the past two decades, the incidence of sepsis in the USA has tripled and is now the 10th leading cause of death. As sepsis continues to impact negatively on critically ill patients, it is clear that early diagnosis and effective management could improve patient morbidity and mortality. Numerous studies have attempted to examine biomarkers and their ability to diagnose and prognosticate septic patients. Despite multiple efforts, currently there are no reliable markers that can effectively improve our clinical effectiveness in diagnosing and managing septic patients. The purpose of our systematic review was to evaluate the diagnostic and prognostic value of various biomarkers used in septic patients. Methods A systematic search of the literature was performed with MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases using terminology selected for biomarkers (through to and including November 2013). All articles involving neonates and not in English were excluded. Inclusion was agreed on by two independent reviewers of abstracts or full text. Assessment was based on the biomarkers ability to diagnose septic patients and its ability to predict mortality. Results Of 5,257 articles identified, all abstracts were screened, and 750 full-text articles were selected for review. These included primarily randomized controlled trials, cohort studies and postmortem studies. Of 49 biomarkers examined, 72% of the studies examined procalcitonin. Comparing the serum of septic patients with that of controls, most biomarkers were elevated in septic patients, even though only a few had high sensitivity (>85%) and high specificity (>80%). It was often difficult to compare study group with control group as the control group patients were usually not healthy controls. Conclusion Overall the heterogeneity of studies, small sample size and the lack of true healthy controls influenced the ability to use the biomarker for prognostication of a septic patient. Furthermore, the lack of healthy control raises the question of redefining selection criteria in order to better study septic patients. P51 C-reactive protein and hemogram parameters for the nonsepsis SIRS and sepsis: what do they mean? BGucyetmez1, HKAtalan2, MBerktas3, EOzden4, NCakar5 1International Hospital, Istanbul, Turkey; 2Atasehir Memorial Hospital, Istanbul, Turkey; 3Kappa Consulting, Istanbul, Turkey; 4Antalya Memorial Hospital, Antalya, Turkey; 5Acibadem University, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P51 (doi: 10.1186/cc14131) Introduction The aim of this study was to investigate the laboratory parameters as an indicator of sepsis. Sepsis is one of the most common reasons of mortality and morbidity in the ICU [1]. Thus, it is important to distinguish sepsis from nonsepsis SIRS. CRP and hemogram parameters may be fast, easy and affordable alternatives in distinguishing sepsis from nonsepsis SIRS. Eosinophil count (EoC), lymphocyte count (LymC) and neutrophillymphocyte count ratio (NLCR) are used as sepsis indicators [1,2]. Methods A total of 2,777 patients admitted to the ICU of two centers between 2006 and 2013 were evaluated retrospectively. The patients were diagnosed as SIRS(), nonsepsis SIRS or sepsis at ICU admission by the consensus of two doctors in accordance with 1992 sepsis guidelines [3]. The patients who were under 18years old, readmitted, immunosuppressive, SIRS() and whose laboratory values and outcomes were unknown were excluded. In total, 1,302 patients were divided into two groups as the nonsepsis SIRS group and the sepsis group. The patients age, gender, diagnoses (medical, elective and urgent surgery), APACHE II, SOFA, CRP, WBC, neutrophil count (NeuC), LymC, NLCR, EoC, platelet, mean platelet volume, length of ICU stay and mortality were recorded by a third doctor. In the fully adjusted model, WBC, CRP, LymC, NeuC, NLCR and EoC were entered into the model. Results A total of 1,302 patients were categorized as nonsepsis SIRS (816, 62.7%) and sepsis (486, 37.3%). In the sepsis group, age, APACHE II, SOFA, mortality, length of ICU stay, CRP, NLCR and EoC were higher; LymC was lower than in the nonsepsis SIRS group (P<0.001 for each). Likelihood of sepsis (reference to nonsepsis SIRS) increased 2.62 (2.05 to 3.34), 2.02 (1.42 to 2.88) and 1.88 (1.36 to 2.60) times (OR (95% CI)) by the values of CRP >4.4 mg/dl, LmyC <500/mm3 and NLCR >15.7 respectively in mutually adjusted multivariate logistic regression (P<0.001 for each). Conclusion CRP, LymC and NLCR may distinguish sepsis from nonsepsis SIRS. Thus, CRP and hemogram parameters may contribute to early diagnosis of sepsis. References 1. Abidi K, et al. Crit Care. 2008;2:R59. 2. Castelli GP, et al. Minerva Anestesiol. 2006;1-2:69-80. 3. Bone RC, et al. Chest. 1992;101:1644-55. Introduction Early diagnosis of systemic inflammation, a generalised response to noxious stimuli, is fundamentally important for effective and goal-directed therapy. Various inflammation biomarkers have been used in clinical and experimental practice. However, a definitive diagnostic tool for an early detection of systemic inflammation remains to be identified. Acetylcholine (Ach) has been shown to play an important role in the inflammatory response. Serum cholinesterase (butyrylcholinesterase (BChE)) is the major Ach hydrolyzing enzyme in plasma. The role of this enzyme during inflammation has not yet been fully understood. Here, we describe a correlation between the BChE activity and the early systemic inflammatory response upon traumatic injury. Methods We measured BChE activity in patients with traumatic injury admitted to the emergency room using a point-of-care-test (POCT) system. In addition, we measured levels of routine inflammation biomarkers during the initial treatment period. We used the Injury Severity Score to assess the trauma severity. Data were statistically analyzed using the Friedman test. Correlation analysis was performed using Spearmans rank correlation test. P <0.05 was considered statistically significant. Results Reduced BChE activity correlated with trauma severity and the resulting systemic inflammation. Compared with serum levels of routinely measured inflammatory biomarkers, changes in the BChE activity were detected significantly earlier, suggesting that the BChE activity might serve as an early indicator of systemic inflammation. Conclusion Our results suggest that BChE activity, measured using a POCT system, might play an important role in the early diagnosis of trauma-induced systemic inflammation. Introduction The apoptotic process, in which cells are actively eliminated by a programmed pathway, is increased in sepsis. Extrinsic and intrinsic apoptotic death cell pathways activate caspase-3, which leads to cell apoptosis. Cytokeratin 18 (CK-18), a protein present in most epithelial and parenchymal cells, is cleaved by the action of caspases and released into the blood as caspase-cleaved CK (CCCK)-18 during apoptotic death. The novel objectives of this study were to determine whether there are associations between serum caspase-3 levels, serum CK-18 levels and mortality in septic patients. Methods A prospective, multicenter, observational study in six Spanish ICUs, including 216 patients with severe sepsis. We collected blood samples at the severe sepsis diagnosis moment to determine serum levels of caspase-3 (to assess the main executor of apoptosis) and CCCK18 (to assess the apoptosis level). The endpoint was 30-day mortality. Results We found that nonsurvivor (n= 76) in comparison with survivor (n= 140) septic patients showed higher serum levels of caspase-3 (0.41 ng/ml (0.14 to 0.52) vs. 0.11 ng/ml (0.10 to 0.25); P<0.001) and CCCK18 (448 (310 to 723) vs. 319 (236 to 445); P <0.001). Multiple logistic regression showed that serum caspase-3 levels >0.25 ng/ml were associated with mortality at 30days (odds ratio= 6.51; 95% confidence interval= 3.32 to 12.77; P<0.001), controlling for SOFA score and age. KaplanMeier survival analysis showed a higher risk of death in septic patients with serum caspase-3 levels >0.25 ng/ml than in patients with lower levels (hazard ratio= 3.80; 95% CI= 2.35 to 6.15; P<0.001). We found a positive association between serum levels of caspase-3 and CCCK-18 (= 0.32; P<0.001). Conclusion The novel findings of our study were that there is an association between serum caspase-3 levels, serum CK-18 levels and mortality in septic patients. There has been reported decreased apoptosis and increased survival in septic rats with the administration of caspase inhibitors; thus, it may be interesting to explore those agents in septic patients. Acknowledgements Funded by Grant FIS-PI-14-00220 from Instituto de Salud Carlos III (Madrid, Spain) and co-financed by Fondo Europeo de Desarrollo Regional (FEDER). Introduction During sepsis a leading symptom is capillary leakage caused by endothelial damage, followed by multiorgan dysfunction. Sphingosine-1-phosphate (S1P) is a bioactive lipid with multiple functions. Cellular reactions depend on the S1P concentration in the blood and its binding to five specific G-protein coupled receptors. S1P-regulated functions include: control of endothelial permeability; lymphocyte migration across microvessels depending on an S1P gradient; and control of vascular tone [1]. This clinical study will address the question of whether S1P blood concentrations are associated with sepsis severity. Methods Following ethical approval we enrolled patients fulfilling the ACCP/SCCM sepsis criteria into three groups (Group A: sepsis; Group B: severe sepsis; Group C: septic shock). A group of 20 healthy donors served as controls. Serum blood samples, laboratory data and clinical parameters are presented for day 1. The primary outcome variable was serum S1P concentration (g/l) quantified by mass spectrometry (Agilent). The SOFA score was used to describe disease severity. Results We included 87 patients (32 Group A, 25 Group B, 30 Group C). The serum concentration of S1P (meanSD) in the control group was 484.6 152.6 g/l and significantly higher compared with Group A 239.4 61.3 g/l, Group B 248.6 93.7 g/l and Group C 141.646.3g/l. We observed a negative correlation between S1P and SOFA score (Pearson r = 0.45, P <0.001, R2 = 0.2). The median SOFA score in our cohort was 6. We divided the cohort into two groups: SOFA score <6; and SOFA score >6. We tested the sensitivity and specificity of S1P to indicate disease severity by ROC analysis. In our cohort the area under the curve (AUC) for S1P was 0.77 (CI 0.670 to 0.870) and therefore higher when compared with common markers of inflammation (PCT, IL-6, CRP with AUC of 0.68 (0.560 to 0.796), 0.68 (0.554 to 0.786) and 0.67 (0.571 to 0.794), resp.). Conclusion Our findings suggest that S1P is a novel marker for severity of sepsis with severe sepsis and septic shock being associated with low levels of S1P. Moreover, blood concentrations of S1P might play a key role in sepsis pathophysiology. Acknowledgements MSW and AN are equal contributors. Reference 1. Maceyka M, et al. Sphingosine-1-phosphate signaling and its role in disease. Trends Cell Biol. 2012;22:50-60. P55 Diagnostic accuracy and clinical relevance of an inflammatory biomarker panel in early sepsis in adult critical care patients PBauer, RKashyap, SLeague, JPark, DBlock, NBaumann, AAlgeciras-Schimnich, SJenkins, CSmith, OGajic, RAbraham Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P55 (doi: 10.1186/cc14135) Introduction Low awareness, late recognition and delayed treatment of sepsis are still common. CD64 is a marker of the innate immune response upregulated in sepsis. The primary goal of this prospective, double-blind study was to compare the diagnostic accuracy of neutrophil CD64 and other cellular markers, along with C-reactive protein (CRP) and procalcitonin (PCT) levels, in early sepsis. Methods Adult ICU patients, between 2012 and 2014 were eligible. The eight-color flow cytometric biomarker panel included CD64, CD163, HLA DR, CD15 and others. Diagnostic test results were compared with infection as the reference standard and sepsis as the target condition, using receiver operating characteristic curve analyses. Multivariable logistic regression was used to assess the relationship of sets of markers with the probability of sepsis, adjusting for other patient characteristics. Results A total of 219 patients were enrolled, 120 with sepsis, 99 served as controls. APACHE IV (median 70 vs. 57), SOFA (8 vs. 7), ICU (2 vs. 1) and hospital length of stay (6 vs. 4) were higher in the sepsis group. Mortality was not different. After adjustment for APACHE IV, CRP and PCT, CD64 molecules/neutrophil measure remained a significant predictor of sepsis (OR= 1.852 for one-unit increase on the log scale, 95% CI= 1.083 to 3.168, P=0.02, AUC= 0.90). See Table1. Table1 (abstract P55). Area under the curve (AUC) for individual biomarkers P56 Validation of BRAHMS PCT direct, a new sensitive point-ofcare testing device for rapid quantification of procalcitonin in emergency department patients: a prospective multinational trial AKutz1, PHausfater2, MOppert3, CAlonso4, CWissmann4, BMueller1, PSchuetz1 1Kantonsspital Aarau, Switzerland; 2Hpital Piti-Salptrire and UnivParis 06, Paris, France; 3Klinikum Ernst von Bergmann, Potsdam, Germany; 4BRAHMS GmbH, Hennigsdorf, Germany Critical Care 2015, 19(Suppl 1):P56 (doi: 10.1186/cc14136) Introduction Procalcitonin (PCT) is increasingly the standard in the emergency department (ED) for the diagnostic and prognostic workup of patients with suspected infections. Recently, BRAHMS PCT direct, a new high-sensitive point-of-care test, has been developed for fast PCT measurement on capillary or venous blood samples with a measuring range of 0.1 to 10.0g/l. Methods This is a prospective, comparative international study conducted in three European EDs. Consecutive patients with suspicion of bacterial infection were included. Duplicate determination of PCT was performed on two distinct BRAHMS PCT direct test devices on capillary (fingertip) and venous whole blood (EDTA), and compared with the reference method (BRAHMS PCT sensitive Kryptor or Elecsys BRAHMS PCT, respectively). The diagnostic accuracy was evaluated by correlation and concordance analyses. Results A total of 303 patients were included over a 6-month period (60.4% male, median age 65.2years). The correlation between capillary or venous whole blood and the reference method was excellent: r2= 0.96 and 0.97, sensitivity 88.1% and 93.0%, specificity 96.5% and 96.8%, concordance 93% and 95% respectively at a 0.25 g/l threshold. No significant bias was observed (0.04 and 0.02 for capillary and venous whole blood) although there were 6.8% and 5.1% outliers, respectively. BRAHMS PCT direct had a shorter time to result as compared with the reference method (25 vs. 147minutes, difference 122minutes, 95% CI= 110 to 134minutes, P<0.0001). Conclusion This study found a high diagnostic accuracy and a faster time to result of the PCT direct in the ED setting. The BRAHMS PCT direct may allow a more widespread use of PCT tests in outpatient clinics and smaller institutions. Introduction Endotoxin, a key component on the outer membrane of Gram-negative bacteria, is considered to be the most important toxin Results A total of 420 patients poisoned by wild mushrooms were studied. The male/female ratio was 1/1.5. The age of patients changed from 18 to 92 and mean age was 46 years. MP constituted 13.3% of all intoxication cases. The time when the first symptom occurred after mushroom intake was a mean 2 (0.17 to 2.15) hours. Of the patients, 47.6% lived in villages, 38.6% in towns and 13.8% in city centers. Admissions were mostly made in autumn, with 57.6%. Eighty-six percent of intoxications happened because of wild mushrooms collected in nature. The most frequent symptoms were nausea (93.8%), and vomiting (87.1%). Increase in liver function tests in 47 patients was observed. Two of these patients died while 10 patients were transferred to further centers for liver transplantation. The remaining patients were discharged from the hospital. Conclusion Wild MP can cause bad clinical outcome. The public should be informed about the probable hazards of wild mushroom ingestion because collection and consumption of wild mushrooms from nature is common. Public health units should take protective precautions against wild MP. Education of health personals regarding MP will lead to successful results in patient management. Introduction Many patients with drug overdose are sedated, but do not have medical reasons to warrant ICU admission. Historically, monitoring behavior and suicide risk was done in the ICU, until the patient was awake enough for psychiatric consultation. Methods A medical psychiatry unit (MPU) was instituted as part of the Department of Clinical Psychiatry. For all patients with drug overdose in the emergency department, a risk assessment was made by the intensivist. Those without ICU indication (such as cardiac or respiratory monitoring) were admitted to the MPU. Alternatively, when awake enough, they were seen by the psychiatrist immediately. We performed an analysis of all patients with drug overdose, admitted to our ICU (before MPU n= 88, after MPU n= 191). We used the Welch t test for comparisons. Results After institution of the MPU, there was a 28% reduction in the number of patients with drug overdose per month, admitted to the ICU. Also, patients admitted to the ICU were sicker and stayed longer (see Table 1). There were no patients admitted to the ICU after initial MPU admission. Table1 (abstract P513). Patient numbers and disease severity before and after introduction of MPU Before MPU Since MPU (18months) (51months) Difference 95% CI +1.8 to +6.2 0.0004 + 9.4 +2.6 to +16.2 0.0069 0.0 to +1.0 0.05 Conclusion Introduction of an MPU was associated with reduced numbers of patients with drug overdose admitted to the ICU. Those admitted to the ICU after the institution of the MPU were sicker, probably indicating more appropriate use of ICU beds. P514 Prospective controlled study to compare the effects of a basic patient safety course on healthcare worker patient safety culture LLing, GJoynt, ALee, WSamy, HFung, CDGomersall The Chinese University of Hong Kong, Shatin, Hong Kong Critical Care 2015, 19(Suppl 1):P514 (doi: 10.1186/cc14594) Introduction It is estimated that about one in 10 patients may be harmed by adverse events during their hospital stay [1]. Transforming organizational culture to improve patient safety culture is considered important. We conducted a prospective, controlled study to assess the impact of a standardized patient safety course on an ICUs patient safety culture, using a validated patient safety culture assessment tool. Methods Staff from two ICUs ICU1 (tertiary referral hospital) and ICU2 (district hospital) in Hong Kong were recruited to compare changes in the measured safety culture before and after a patient safety course. The BASIC Patient Safety course was only administered to staff from ICU1, and safety culture was assessed in both units before and after, using a survey based on the Hospital Survey on Patient Safety Culture [2]. Relative risk (95% CI) of improvement: baseline to follow-up in hospitals in patient safety domains, adjusted for duration of work in the unit (10 years vs. >10 years), was calculated. Responses were coded according to the Survey Users Guide, and positive response percentages for each patient safety domain were compared with the 2012 Agency for Healthcare Research and Quality (AHRQ) ICU sample of 36,120 respondents. Results Preintervention and postintervention period response rates for ICU1 were 88.1% (37/42) and 79.3% (23/29); and for ICU2 63% (20/32) and 63% (15/24). Post intervention, compared with ICU2, ICU1 showed significantly improved perceptions of teamwork within the hospital unit, RR (95% CI for difference between ICUs) 1.55 (1.10 to 2.19, P = 0.01); and overall perception of safety, 1.94 (1.11 to 3.37, P= 0.02); but not increased frequency of reporting mistakes, 0.90 (0.33 to 2.49, P= 0.84). Overall, ICU1 demonstrated a greater improvement in positive responses in five safety culture domains than staff from ICU2. Patient safety culture indices were generally poorer in the two ICUs than the average ICU in the AHRQ database. Conclusion The study provides supportive evidence that a structured, reproducible short course on patient safety is associated with a general improvement in the ICUs patient safety culture, measured with a validated safety culture assessment tool. References 1. de Vries EN, et al. Qual Saf Health Care. 2008;17;216-23. 2. Nieva VF, et al. Qual Saf Health Care. 2003;12 Suppl 2:ii17-23. Introduction The Ionising Radiation (Medical Exposure) Regulations 2001 recommend to ensure that a clinical evaluation of the outcome of each medical exposure is recorded [1]. This audit looked at whether ICU documentation of investigations involving ionising radiation could be improved. Anticipated benefits would be improved communication between the multidisciplinary team and betterinformed decision-making. Methods Patients admitted to the ICU between 21 September 2014 and 2October 2014 were included. If an investigation did not involve ionising radiation or was not requested by intensive care clinicians it was excluded. The indication for imaging was noted, and patient notes were analysed no less than 48hours after the imaging was reported. Results As shown in Figure1, imaging requests were generally poorly documented (61%). In total, 17/26 (65%) chest X-rays (CXRs) were documented. A total of 0/2 CT scans were documented, despite one showing acute changes. In total, 17/20 (85%) CXRs requested following procedures carried out on ITU (such as insertion of central venous catheters) were documented, and the three not documented had no significant findings. The six other CXRs were requested to investigate worsening respiratory function. None were documented. Five had significant findings. Conclusion Investigations following procedures were generally well documented, but investigations seeking pathology were not documented at all, regardless of the findings. This may have influenced the management of the patient and compromised patient safety. As such, the audit was presented at a departmental meeting to emphasise the importance of imaging documentation. A place for investigations was added to the ICU patient list to improve communication between the team, and a second audit is planned to assess the impact of this. Reference 1. The ionising radiation (medical exposure) regulations 2000. London: Stationery Office; 2000. P516 Barriers to the implementation of checklists in the ICU: a survey on the perceptions of 314 Brazilian critical care nurses and physicians JSalluh1, WViana2, FMachado3, ACavalvanti4, FBozza1, MSoares1 1IDOR, Rio de Janeiro, Brazil; 2Hospital Copa DOR, Rio de Janeiro, Brazil; 3UNIFESP, So Paulo, Brazil; 4Hcor, So Paulo, Brazil Critical Care 2015, 19(Suppl 1):P516 (doi: 10.1186/cc14596) Introduction Checklists have been used increasingly in the ICU aiming at mitigating avoidable adverse events, but their content is variable and little is known about barriers to their full implementation. This survey reported practices on the use of checklists and perceptions regarding barriers on its implementation. Methods A web-based survey was conducted among a convenience sample of Brazilian ICU nurses and physicians between August and October 2014. Standard descriptive statistics were used. Results A total of 314 professionals, 104 nurses (33.1%) and 210 physicians (66.9%), responded. The majority (82.4%) had more than 5 years of experience in intensive care. Checklists were applied every day, including weekends, in only 49.8% (n = 227). When we compared the barriers perceived by those working in smaller versus larger ICUs (<10 beds vs. >20beds), the absence of a more comprehensive checklist content (93.6% vs. 81.9%, P= 0.026), the absence of specialized software or app (80.8% vs. 63.8%, P= 0.014), low availability of mobile devices (87.2% vs. 72.4%, P = 0.019), Internet unavailability (83.3% vs. 67.6%, P = 0.017), and the limited number of computers (88.5% vs. 76.2%, P= 0.0366) were the most often barriers to implementation. Checklists were applied with similar frequencies (<3 times a week, three to five times a week, and every day, including on weekends, P >0.05) regardless of the ICU size. When the type of tool used (paper vs. electronic) was considered, the main barrier highlighted was the lack of 100% Internet availability in the ICU (64.8% vs. 100%, P= 0.009). Users of paper form had higher demands for more comprehensive checklist content (84.3% vs. 63.6%, respectively, P= 0.037) and experienced more barriers to team adherence (98.1% vs. 86.4%, respectively, P= 0.034) as compared with those using specialized software. Conclusion Although checklists are recognized as valuable tools for the adherence to best practice in the ICU, it is difficult to ensure the uniformity of their daily use. Resource limitations in smaller ICUs and the absence of comprehensive digital tools, mobile devices and Internet availability preclude full compliance at the bedside. Introduction ICU workflow for physicians, nurses and other healthcare providers is often complicated by distractions, interruptions, difficulties to concentrate, multitasking and the need to frequently change priorities in patient care-related procedures. It is therefore a continuous challenge to communicate and implement plans in an early, efficient and reliable way within the team and to constantly keep track about tasks that are completed, postponed or that are about to be forgotten. To facilitate every caregivers workflow and to early and efficiently communicate, we implemented the After Round Comprehensive Plan Summary (ARCoPS) tool. Methods Most of our patient care-related therapeutic and diagnostic decisions are made during the morning round consisting of intensivists, nursing team, surgeons, respiratory therapists, dieticians, clinical pharmacists and physiotherapists. Immediately thereafter, all plans for the next 24-hour period are again discussed, summarized, confirmed, prioritized and organized by the multidisciplinary team under aspects of optimal patient care and workflow efficiency by entering the plan data into a flat screen visualized template connected to our intranet immediately accessible at every physician and nursing caregiver workstation. Results Twelve months after implementation of the ARCoPS tool we conducted caregiver interviews and identified the following effects: increase in treatment confidence through standardized multidisciplinary decision-making; reduced loss of information through immediate plan summarization by the whole team; reduction of ambiguity and misunderstanding about care plans through early written documentation; higher level of security not to forget procedures or tasks; positive acceptance of the tool to flexibly change priorities of care procedures; positive acceptance of the tool to mark accomplished tasks providing visual feedback about the care plan status; individual caregiver workflow economization through permanent treatment plan availability; and higher job satisfaction throughout the caregiver team. Conclusion ARCoPS tool utilization has become a daily routine in our ICU. It functions as an effective communication and workflow tool and has helped us to reduce patient care-related misunderstandings and delays. It also enhanced the economics of our work sequence, which also highly contributes to a better level of patient safety. Furthermore, it has markedly contributed to an improved level of quality of work for caregivers. P518 Multicenter Thai university-based surgical ICU study (Thai-SICU study): adverse events and outcome in the SICU SKongsayreepong, KChittawatanarat Siriraj Hospital, Mahidol University, Bangkok, Thailand Critical Care 2015, 19(Suppl 1):P518 (doi: 10.1186/cc14598) Introduction The aim of this Thai-SICU was to study the incidence and outcome of adverse events in nine SICU university-based hospitals in Thailand. Methods This multicenter prospective observational study was done in >18years old, admission >6hours surgical patients admitted to the large, postgraduate medical training university-based SICU during April 2011 to January 2012. Patient data were divided into three main phases as admission, discharge data and daily CRFs during the ICU stay. The patients were followed until they were discharged from the ICU or up to 28 days of their ICU admission and up to 28 days following discharge from the ICU if they survived. Results Following a 19.7-month recruitment period, a total of 4,654 patients (17,579 ICU-days) were included in the analysis process. Admitted patients had the median age of 64years. Most of the patients were admitted directly from the OR for postoperative monitoring with median APACHE II score 10, 23% were admitted with priority I who needed aggressive hemodynamic resuscitation and respiratory support. ICU mortality and 28-day mortality were 9.61% and 13.80%. Each day of ICU increment was associated with a 1.38-day increase of hospital stay (95% CI, 1.24 to 1.53; P<0.01). On the surveillance periods, the six most common adverse events were sepsis (19.5%), AKI (16.9%), new cardiac arrhythmias (6.17%), respiratory failure (5.83%), cardiac arrest (4.86%) and delirium (3.5%) respectively. The other events including reintubation within 72hours, intraabdominal hypertension, acute MI, unplanned extubation, upper GI hemorrhage, pneumohemothorax, seizure, drug error and pulmonary aspiration were <3% each. The risk of adverse events on 28-day mortality were significant on cardiac arrest (RR= 9.45; P<0.01), ARDS (RR= 4.58; P<0.01), AKI (RR= 4.18; P<0.01), sepsis (RR= 3.62; P<0.01), iatrogenic pneumohemothorax (RR= 3.23; P<0.01), seizure (RR= 3.12; P<0.01), upper GI hemorrhage (RR= 2.97; P<0.01), cardiac arrhythmia (RR= 2.91; P<0.01), ALI (RR= 2.71; P<0.01), delirium (RR = 2.13; P <0.01), MI (RR = 2.12; P <0.01), unplanned extubation (RR = 2.06; P <0.01), abdominal hypertension (RR = 1.75; P<0.01) and reintubation within 72hours (RR= 1.51; P= 0.02). Conclusion This is the largest systemic surveillance observation in the SICU. The study results are the reference for future research and also provide information for patient and relative advice when confronted with adverse events during SICU admission. Introduction A significant number require a postoperative ICU stay which may be prolonged [1]. Very limited data exist to characterise mortality and ICU length of stay (LOS) in different surgical specialties [2,3]. We aim to describe this relationship in a large cohort of surgical patients. Methods We performed a retrospective observational cohort study of adult surgical admissions to the ICU of a large academic tertiary medical centre. The primary endpoint was 28-day mortality. We used simple descriptive statistics to characterise the population. The Wilcoxon ranksum test or KruskallWallis test was used, as appropriate, for tests of continuous data. Results There were 6,203 surgical admissions during the 8-year study period. For both ICU and in-hospital mortality; the median LOS in days for survivors was 2.2 (IQR: 1.2 to 4.9) and that of nonsurvivors was 3.2 (IQR: 1.5 to 7.9). At 28 days, 1 year, and 2 years, the respective values were 2.2 (1.2 to 4.9) and 3.3 (1.5 to 6.7); 2.1 (1.2 to 4.7) and 3.1 (1.5 to 7.3); and 2.1 (1.2 to 4.6) and 3.0 (1.5 to 7.0), all P<0.0001. The greatest median LOS was found in neurosurgery and cardiothoracic surgery; 3.3days (IQR: 1.7 to 9.5) and 3.1days (IQR: 1.5 to 8.0) respectively. They corresponded to the specialities with the greatest percentage ICU (9.7% and 10.2%) and 2-year mortality (27.9%, and 35%). The greatest mortality and median LOS was found in ventriculostomy cases; 40.8% at 2years and 10.6days (IQR: 4.8 to 18.2). Conclusion There is an association between postoperative ICU LOS and mortality that persists for at least 2years after admission. Neurosurgery and cardiothoracic surgery patients appear to have a worse prognosis and also a more prolonged LOS. Our results may provide a more objective basis for clinical decisions, the use of limited resources, and inform on appropriate expectations of treatment. References 1. Pearse RM, et al. Lancet. 2012:380:1059-65. 2. Timmers TK, et al. Ann Surg. 2011:253:151-7. 3. Williams TA, et al. Br J Anaesth. 2010:104:459-64. P520 Implementation of a horizontal intensive care team can impact efficiency in an emergency observation unit in Brazil SRibeiro, CPetrini, LMarino, RBrandao-Neto Hospital das Clinicas School of Medicine, University of So Paulo, Brazil Critical Care 2015, 19(Suppl 1):P520 (doi: 10.1186/cc14600) Introduction Emergency department observation units are often used to monitor critical patients in a situation of constant emergency department overcrowding and lack of intensive care beds. However, those units are often understaffed and might not have enough personnel and equipment to provide the same quality of care as a conventional ICU. Methods We performed an observational study in a 17-bed, mixed clinical and surgical emergency department observation. Before the year 2012, the staff were composed of first-year internal medicine and surgical residents. There were no senior physicians specifically assigned to this unit, and residents were supervised by the members of the emergency department team, who changed shifts on a daily basis. In February 2012, two senior physicians (one cardiologist and one intensive care doctor) were specifically assigned to supervise the internal medicine residents and provide horizontal care for medical patients during the day, from Monday to Friday. There was no change in assistance for surgical patients. The schedule for nights and weekends remained unchanged. Mortality and length of stay for medical and surgical patients were measured in 2011, 2012 and 2013. Results In the first year after the implementation of the clinic intensive care team, mortality in internal medicine patients decreased from 47% to 34% in 2012 and 33% in 2013. Although other changes happened in this period (the number of beds decreased from 24 to 17, nurses and physical therapists were hired and trained specifically for this unit), we believe the horizontal staff was critical, because mortality between surgical patients remained almost unchanged in the same period of time (23% in 2011, 22% in 2012 and 23% in 2013), in spite of the structural improvements that equally affected those patients. Length of stay decreased from 6.35 days in 2011 to 3.43 in 2012 and 3.15 in 2013 in medical patients and from 3.9days on average in 2011 to 3.2 in 2012 and 2.8 in 2013 in surgical patients. Conclusion Emergency department observation units are an alternative to alleviate emergency room overcrowding when there are no intensive care beds available. However, patients end up staying in those units for days and horizontal care by senior doctors may improve outcomes. References 1. Komindr A, et al. Int J Emerg Med. 2014;5:1-6. 2. Baugh C, et al. Health Care Manag Rev. 2011;36:28-37. Introduction The aim was to know the frequency, criteria and implications of rejection for ICU admission to our ICU unit, a secondlevel hospital (18 beds). Methods An observational retrospective study in a time interval of 6 months (January to June 2013). We retrospectively registered all patients rejected for admission to our unit, analyzing the clinical rejection report used in our hospital. From this report we extracted different variables: demographical (age, sex), provenance (emergency room, hospital), clinical (comorbidity, functional situation, diagnosis, reason of requesting admission), rejection motive (too good, too bad, futility, lack of beds, patient rejection), whether it was definitive or conditional, whether the patient was admitted afterwards, and the state at hospital discharge. We realized a descriptive analysis (frequencies) and multivariant analysis of the factors related to futility rejection. Results There were 165 rejections, which represents 25% of total ICU patients evaluated for admission. A total of 59.4% were male. Mean age was 69 7 years (19 to 98). In total, 53.9% had more than two comorbidities (pluripathological) and 31.5% moderate to severe functional disability. The cause of rejection was in 55.2% of situations that the patient was too good, 37.6% related to qualitative futility, 4.8% was too bad and in 1.2% a mix of lack of space (beds) and patient rejection. In the multivariant analysis the significant variables related to futility rejection were age (by years) with an OR of 1.05 (1.02 to 1.08), severe functional disability, OR of 4.35 (2.09 to 9.06), and the hospital provenance with an OR of 2.82 (1.1 to 7.2). Conclusion Rejection for admission to ICU units is a frequent medical activity in our day-to-day job. The type of patient most rejected is cardiologic, mostly evaluated for thoracic pain probably ischemic but with low risk. In second place we found patients for which we decide rejection based on subjective qualitative futility, related mostly to age, prior functional disability and provenance. P522 Impact of age, physiological status and APACHE score on acceptance of patients to the ICU LTerry, SPassey, DPorter, FClark, RMatsa Royal Stoke University Hospital, Stoke on Trent, UK Critical Care 2015, 19(Suppl 1):P522 (doi: 10.1186/cc14602) Introduction Evidence suggests that age, chronic health status and acute illness severity affect the decision-making of clinicians regarding admission to the ICU (ITU) [1-3]. This prospective service review assesses the impact of age, APACHE II score and WHO functional score towards admission acceptance or refusal to ITU in a tertiary-level facility. Methods Design: a planned prospective review of all referrals over a 14day period. Data collection: review (LT, DP, SP) of case notes of patients referred to ITU with the following variables collected: age, sex, APACHE II scores, WHO functional status score, grade of referrer and source of referral. Data were collected on 37 patients: 22 accepted to ITU and 15 refused admission. Statistics: data were analyzed using GraphPad 6.05. Categorical variables were expressed as mean and standard error of mean. For unpaired variables, statistical significance is determined using unpaired t test. P<0.05 is considered statistically significant. Results The WHO functional status was the most significant variable affecting admission (P<0.001). The APACHE score of patients admitted to ITU was significantly lower than refused patients (P= 0.039). Patient age did not affect admission status (P= 0.15). See Table1. Introduction This Six Sigma project was initiated to evaluate and improve the transfer of care of patients from the OR to the ICU. Medical errors are responsible for billions of dollars in increased healthcare spending. Miscommunication among healthcare providers is a major contributor to these errors, with handoffs a particularly vulnerable period in the care process. At our institution, surgical patients with scheduled admissions to the ICU are first recovered in the postanesthesia care unit (PACU). With this process, multiple, unstructured, and individual handoffs occur in parallel between providers, which may lead to communication errors, differential information sharing, content variability, care delays, and inefficiency. Methods A multidisciplinary QI project was initiated with input from the ICU, anesthesia and surgical services. A series of PDSA cycles were conducted, which began by defining the current process via direct observation and value stream mapping of orthopedic and neurosurgical patients. A new process was then introduced, including direct transfer of the patient to the ICU and a single, structured, bedside report between all care providers. A standardized handoff tool was implemented. We used process times, wait times and information content as process measures and handoff errors as outcome measures. A 10-point satisfaction score was also measured. Results Following implementation of the new transfer process, the average wait time decreased by 58 minutes, process time decreased by 9 minutes, and lead time decreased by 66.5 minutes. The handoff error rate decreased by 1.3 errors/patient and first-time quality rate increased by 67%. Staff satisfaction improved from 48% to 73%. By elimination of the PACU stay, the costs involved in admission to the PACU were deferred. Conclusion A single, multidisciplinary bedside handoff process between the OR and ICU leads to cost and time savings. By elimination of redundant, nonvalue-added processes, less opportunity for medical errors occurred, with substantial improvements in first-time quality. Such a process can be successfully attained while affecting staff satisfaction positively. Introduction There is growing evidence that optimising communication and patient assessment practices including ward rounds and handoffs can improve clinical, safety and operational outcomes, particularly in the critical care setting [1,2]. Here we describe the design and baseline phases of a 5-year project utilising improvement sciences to optimise the quality of interprofessional communication, handoffs and rounding in one of the largest critical care units in the UK. Methods We obtained institutional ethical and research approvals. We used mixed methods including interviews of opinion leaders and a representative cross-section of staff, roundtables, a survey targeting the whole critical care team (n= 546) and a Delphi exercise to generate a baseline consensus for the need to improve and a set of novel quality improvement interventions and tools. We tested two of these in a pilot plandostudyact (PDSA) cycle. Results Baseline consensus for the need and potential to improve was obtained (97.4% and 94.5%). Despite a large degree of heterogeneity of perceptions around current communication and rounding practices, it was possible to develop a set of interventions based on consensus that could be applied in this complex setting. These included a handoff bundle, an operational touch-base, a unit-level safety briefing, a unitlevel safety check, a lean rounding bundle and board rounds. These core interventions were supported by several more detailed resources describing the evidence base around best handoff and rounding practices; and a feedback document that described all outputs and recommendations from the ICARUS project. A pilot PDSA cycle demonstrated a 55.3% and 76.3% improvement in key information transfer using a safety briefing and board round summary. Conclusion Despite wide heterogeneity in baseline beliefs, opinions and perceptions around inter-professional communication, rounding and handoffs, we were able to develop a novel set of feasible quality improvement interventions, targeting these areas, that can be applied in a large complex critical care setting. Furthermore, they can be driven by improvement science methodology and tested for effectiveness using qualitative and quantitative measures. We now plan to use these interventions to deliver quality improvements in communication practices in parallel with the planning and implementation phases of a new critical care facility and electronic clinical information system. References 1. Lane D. Crit Care Med. 2013;41:2015. 2. Starmer AJ. N Engl J Med. 2014;371:1803. Introduction Security policies for the patient are of interest to any health professional. The rates of adverse events in hospitals reach values ranging between 3.7 and 16.6%, being the highest range (40 to 70%) considered preventable or avoidable [1]. The objective of this study is to assess the prevalence and types of adverse effects in intensive care patients according to readmission. Methods During 4years the data from 2,582 patients admitted to the coronary ICU (CICU) were analyzed in the coronary care unit of the city of Presidente Prudente, Brazil. We analyzed the rate of readmissions, length of stay and the mainly detected adverse events. We considered significant P<0.05 two-tailed and confidence intervals at 95% (CI). Results The readmission rate was 15% (n = 392), particularly among males (55% (n = 214)). A 14.3% adverse event rate was observed among the readmitted patients (9.5% among those who were not readmitted). The readmitted patients were older (median (md): 68.0 (95% CI: 65.7 to 67.3) vs. md: 71.0 (95% CI: 67.1 to 71.3); P<0.05) and remained hospitalized for a longer period of time (md: 5.0 (95% CI: 13.2 to 20.7) vs. md: 11.0 (95% CI: 17.0 to 33.2); P<0.05), but not necessarily in the CICU (P= 106).The most prevalent adverse events in readmitted patients were pressure ulcers (n= 16 (4.1%)), drug administration error (n = 13 (3.3%)) and enteral feeding tube (n = 10 (2.6%)). Meanwhile, among the nonreadmitted, phlebitis due to peripheral vein access and pressure ulcers (n= 42 (1.9%)), drug administration error (n= 41 (1.9%)) and enteral feeding tube (n = 31 (1.4%)). There was a tendency (P = 0.71) that readmitted patients were presented with higher prevalence of pressure ulcers (n= 16 (4.1%) vs. n= 42 (1.9%)). Conclusion There is a higher prevalence of adverse events in readmitted patients with similarity in the type of adverse effects despite readmission. Reference 1. Forster AJ, et al. CMAJ. 2004;170:345-9. P526 Out-of-hours discharge from critical care: does it matter? MAhmed, GLumley, SNourse, AHurding, AThomas, MHealy The Royal London Hospital, London, UK Critical Care 2015, 19(Suppl 1):P526 (doi: 10.1186/cc14606) Introduction The aim of this audit was to assess the clinical impact of out-of-hours (OOH) discharge from the adult critical care unit (ACCU) in a tertiary care hospital. Discharging patients from critical care OOH has been associated with both higher mortality and increased rate of readmissions [1,2]. As a result, national guidance stipulates that OOH discharges from critical care should be avoided [3]. Methods A retrospective snapshot analysis of patients was conducted at least 48 hours after discharge from the ACCU in October 2014. Patients discharged OOH (20:00 to 07:59) were compared with those discharged in hours (IH; 08:00 to 19:59). Analysis included: patient demographics, APACHE II score, handover procedure prior to discharge, follow-up by the receiving team, appropriate and timely drug prescribing, recognising and acting upon clinical deterioration and readmission rates. Results A total of 161 patients were discharged from the ACCU in October 2014. Of these, 46% of the patients were discharged OOH. Forty-one (of 74) OOH and 19 (of 87) IH discharges were sampled for further analysis. The baseline demographics and APACHE II score were similar between both groups. The majority of discharges were delayed (>4 hours, 90% IH vs. 93% OOH). More patients had nursing handover completed if discharged IH (88% IH vs. 61% OOH) and doctors summaries were less frequently completed OOH (83% OOH vs. 94.4% IH). A management plan for the ward was outlined in 94% of IH versus 65.% of OOH discharges. Seventy-eight per cent OOH versus 95% IH patients discharged were reviewed by a doctor within 24hours. Twenty-nine per cent OOH versus 67% IH patients discharged were reviewed by a consultant within 24hours. Following discharge a management plan was followed in 94% of IH patients versus 44% OOH, patients had drug charts correctly charted in 100% of IH cases versus 66% OOH and missed/delayed doses were documented in 11.1% of IH cases versus 61% OOH. There was no difference between the groups in incidence of clinical deterioration and recognition and follow-up of clinical deterioration. Two patients were readmitted within 48 hours from the OOH group. Conclusion This audit compares with current evidence suggesting harm from OOH discharge despite most discharges being delayed. Discharging patients is a complex hospital process, but focus needs to be on discharging patients IH. Therefore, areas for improvement include targeting forward flow of patients throughout the hospital, completion of handover documents IH and publication of guidance for receiving teams. References 1. Priestap F, et al. Crit Care Med. 2006;34:2946-51. 2. Hanane T, et al. Crit Care Med. 2008;36:2232-7. 3. Acutely ill patients in hospital. NICE; 2007 Introduction Prolonged hospital stay prior to admission to the ICU was previously shown to be independently associated with poorer outcome [1,2]. This is probably due to slow deterioration of physiological function in hospital and influenced by processes leading to critical care admission [2]. We investigated whether commonly measured severity scoring systems (Acute Physiology and Chronic Health Evaluation (APACHE) II, Intensive Care National Audit and Research Centre (ICNARC) and Sequential Organ Failure Assessment (SOFA) scores) are significantly different in patients admitted with prolonged pre-ICU hospital length of stay, and describe mortality and hospital length of stay. Methods A retrospective analysis of prospectively collected data of all emergency admissions in the ICNARC database of a 44-bed adult critical care unit within a major trauma centre over a 2-year period. Demographic data, APACHE II score, SOFA score, ICNARC model score, mortality, and length of hospital stay prior to and after ICU admission were collected. Five groups of patients were defined as follows: those admitted to ICU within 1week of hospitalization (group 1), within 8 to 14days (group 2), within 15 to 21days (group 3), within 22 to 28days (group 4), and more than 28days (group 5). Chi-squared and ANOVA tests were performed using the SOFA statistics package. Results A total of 2,248 emergency admissions were analysed. The majority of patients were admitted within 1week of hospital admission (n = 1,897). They were younger and had lower APACHE II scores (15 vs. 19; P<0.001). APACHE II scores were the same in all other groups (groups 2 to 5). Patients admitted to the ICU 3weeks following hospital admission had significantly higher hospital mortality (up to 50%; P <0.001) and ICU length of stay (12 15 vs. 8 10 days; P <0.001). ICU mortality remained the same in all groups (20 to 28%). ICNARC and SOFA scores were equal between the groups. The post-ICU lengths of stay were significantly longer in groups 3 to 5. In-hospital CPR prior to admission to ICU was lower in patients from groups 4 and 5, probably signifying appropriate DNAR decisions made on the ward. Conclusion Prolonged pre-ICU hospital admission is associated with higher hospital but not ICU mortality. Commonly measured scores do not reflect this higher mortality in patients admitted after prolonged stay in hospital. Further research into parameters that may reflect changes in physiological reserves may strengthen these scores for such patients. References 1. Higgins TL, et al. Crit Care Med. 2003;31:45-51. 2. Goldhill DR, et al. Intensive Care Med. 2004;30:1908-13. Introduction Hospital costs are a constant concern within health, especially in the ICU. Hospital admissions and average life expectancy have been growing gradually mainly in older and critical patients. This study is aimed to observe the direct costs of patients admitted to an ICU and their relation to the SAPS 3, length of stay in the ICU and final outcome. Methods A retrospective observational study in which the direct costs were studied (materials, medicines, oxygen therapy and hospital fees) for 1,790 ICU patients from November 2013 to November 2014. The readmissions within 48 hours were excluded and also 10% of patients who had the highest and lowest costs. The remaining 1,401 patients were divided by age groups. Results Of the patients studied, 54.6% were male. Average age was 57.8 years (18 to 105 years). The biggest ICU average cost was in the group of patients 81 to 90years old (US$793.00), as well as longest ICU stay (9.25days), highest SAPS 3 (53.96) and higher ICU and in-hospital mortality (14.29% and 19.25% respectively). This study shows that the direct cost of the ICU stay for older patients was higher than for younger patients. The difference was explained by the higher severity measured by SAPS 3 in the older age groups (Figure1), and the required greater length of stay in the ICU (Figure2). As might be expected, the mortality in the group of older patients was also significantly higher. Conclusion This study showed that greater age is associated with higher severity measured by SAPS 3, higher direct costs, and higher mortality both in the ICU and in-hospital environment. Introduction Pregnancy and labour usually progress uneventfully; however, serious complications can occur and develop rapidly, necessitating critical care admission and support. Successive confidential enquires have highlighted deficiencies in this area and suboptimal care leading to increased morbidity and mortality [1]. The National Maternity Hospital is the largest maternity hospital in the Republic of Ireland where a total of 8,954 babies were delivered in 2013. It is a stand-alone institution and onsite facilities include a twobed dedicated anaesthesia lead high-dependency unit. Methods A retrospective observational study was carried out from January 2011 to January 2014 especially looking at the following parameters: admitting diagnosis, demographics, length of stay and the number of admissions requiring transfer for tertiary-level care. Results In total, 29,344 deliveries occurred. A total of 376 HDU admissions were recorded in this period, representing 1.28% of all admissions. The average age of patients admitted to the HDU was 34 years. The predominant reasons for admission were hypertensive disease of pregnancy (49.7%), haemorrhage (antepartum/postpartum) (36.4%), sepsis (4.2%) and other reasons (11.1%) including cardiac rhythm disturbances, neurological complications and pre-existing medical disease. In 2013 the average length of stay was 2days. A total 6.1% of those admitted to HDU required transfer for tertiary-level ICU care in other centres during the study period, this represented 0.07% of all deliveries. Conclusion There is significant demand within our institution for HDU care for our patients, with the number of admissions increasing in 2013. The main admitting diagnoses are hypertensive disease of pregnancy and haemorrhage with an increase in the number of patients being admitted for management of sepsis in 2013. This highlights the increasing awareness, recognition and management of this condition in pregnancy. The increased number of HDU admissions in 2013 could also be explained by the recent introduction of an early warning score for the deteriorating patient in our hospital but this would require further evaluation. The low number of transfers of patients to other tertiary centres underpins the importance of an anaesthesia lead service. Reference 1. Special issue: Saving mothers lives: reviewing maternal deaths to make motherhood safer: 20062008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl S1:1-203. Introduction The objectives of this survey were to establish the prevalence of symptoms of post-traumatic stress in mixed staff groups working in adult and paediatric intensive care settings and to examine the main themes in staff descriptions of the most traumatic event they had experienced at work. Methods A total of 355 health professionals working on three adult and four paediatric units at two centres were asked to rate their current level of post-traumatic stress symptoms on the Trauma Screening Questionnaire (TSQ). Results Paediatric/neonatal intensive care staff were more likely to score above the clinical cutoff point for post-traumatic stress symptoms on the TSQ in relation to an incident at work than adult intensive care staff in this sample (PICU n= 33/193 (17%) vs. AICU n= 13/162 (8%), P <0.001). For the 172 staff who provided a description of the most traumatic event they had experienced, the following themes were most commonly endorsed: patient death (and particularly untimely deaths on adult units); handling distressed families; and concerns about the quality of care and dealing with staff conflict (see Figure1). Conclusion A significant minority of staff reported clinically significant levels of post-traumatic stress related to their work. The facts that posttraumatic stress levels were higher on paediatric units despite their lower rates of mortality and that untimely deaths were frequently mentioned by adult unit staff suggest it may be that untimely deaths are particularly hard to deal with. More research is needed on the prevalence of distress in staff working in these settings. P532 Distribution and mortality factors of cases with traumatic and nontraumatic brain damage treated in ICU SGoksuTomruk, NBakan, GKararen, EAkcay, SKeskin Umraniye Research and Training Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P532 (doi: 10.1186/cc14612) Introduction Cases of traumatic and nontraumatic brain damage have high rates of morbidity and mortality. In this study of cases being treated in the ICU for a diagnosis of brain damage, it was aimed to evaluate the relationship between mortality and the distribution of reason for and resulting type of brain damage and to determine other factors affecting mortality. Methods After local ethics committee approval, a total of 1,004 patients (2012, n= 492; 2013, n= 454; 2014, n= 58) treated in the ICU in a 2-year period were reviewed. This study included for evaluation 135 patients determined with traumatic or nontraumatic brain damage, with a more than 24-hour stay in the ICU. Reasons for brain damage were determined as brain damage associated with head trauma (Group HT), head trauma accompanying general body trauma (Group HT + GBT) and spontaneous haemorrhage (Group SH). The type of brain damage was defined from the radiological diagnosis (CT and/or MRI) as subarachnoid haemorrhage, intracranial haemorrhage (ICH), subdural haematoma (SDH), epidural haematoma (EDH), skull fracture, brain contusion or a combination of these (COM). Operations were evaluated as performed by the brain surgery department. Results The patients comprised 73.3% males and 26.7% females with a mean age of 40.58 24.14years (range, 1 to 87years), mean APACHE II score of 19.07 10.19 (range, 2 to 41), mean GCS of 9.17 4.42 (range, 3 to 15) and 68.1% of whom were discharged and 31.9% were exitus. When the causes of brain damage were evaluated according to the type, the most frequently seen in the HT and HT + GBT groups were COM (37.3%, 42.9%), followed by EDH (13.6%, 28.6%). In the SH group, the most common reason was ICH (43.9%) followed by SDH (24.4%). Directly proportionally, only an increase in APACHE II score increased the mortality risk 1.3-fold (logistic regression analyses, coefficient 0.658) but the duration of intubation and ICH ratio was statistically significantly high and GCS was low in the exitus cases, and rates of EDH were determined as high in discharged cases compared with exitus (P<0.01). No statistical difference was determined in mortality in terms of age, gender, duration in ICU, surgical treatment or not, or reasons for brain damage (P>0.05). Conclusion There is considerable variation in causes of head injury. From this retrospective study it can be suggested that mortality of neurological/neurosurgical patients, regardless of management method, depends on APACHE II, arrival GCS, number of ventilator-days and type of brain damage. Introduction Unexpected trauma is a one of the most major causes of death for children in the world. However, pediatric severe trauma patients are rare and scattered. Although there is a strong association between patients volume of trauma center volume and outcomes in adults, such a report is less in children. In this study, we aimed to clarify the relationship of the amount of registration and outcome in pediatric trauma patients. Methods This retrospective study analyzed data of the Japan Trauma Data Bank from 2004 to 2012. We registered pediatric patients aged younger than 12 years with severe multiple or torso trauma (maximum Abbreviated Injury Scale score 3 or Injury Severity Score 9, and excluded patients with cardiopulmonary arrest on arrival, burn, isolated head or limb injury, lack of data). We divided the facilities into six groups according to every 10 patients registered and compared mortality between each group. Results A total of 1,015 patients from 105 facilities were included in the study. Number of registrations: 0 to 10 patients: 673 patients/68 facilities, 11 to 20: 381/28, 21 to 30: 141/6, 31 to 40: 101/3, 41 to 50: 45/1, 51 to 60: 58/1. Victims of blunt trauma accounted for 98.1%. Median age was 7 (interquartile range: 5 to 10) years, median injury severity score (ISS) was 17 (10 to 26). Multivariate analysis adjusted for age, revised trauma score and ISS revealed that the amount of registration (every 10 patients) was independently associated with survival (odds ratio: 1.55, 95% confidence interval: 1.06 to 2.26, P= 0.023). Conclusion There was a strong association between amount of registration and outcome. P534 Mortality in a French military burn centre: a 12-year retrospective study analysing seasonal variations MBoutonnet1, CDussault2, NDonat1, PLaitselart1, ACirodde1, JSchaal1, CHoffmann1, PJault1, TLeclerc1 1HIA Percy, Clamart, France; 2IRBA, Brtigny sur Orge, France Critical Care 2015, 19(Suppl 1):P534 (doi: 10.1186/cc14614) Introduction Factors associated with mortality in severely burned patients are well known. We aimed to assess the seasonal variations of the mortality of patients admitted to the main French military intensive care burn unit (ICBU) and to determine their relations to seasonal variations of severity or other factors (for example, staffing). Methods We performed a retrospective study analysing the medical records of all patients admitted to the ICBU of Percy Military Hospital (France) between January 2000 and December 2011. Statistical analysis was performed with R version 3.1.2. We first conducted univariate analyses with simple logistic regression, then a simple periodic regression for seasonal variations (with and without harmonics for robustness), and finally a multivariate logistic regression with periodic terms in order to adjust seasonal variations for known severity factors. Results A total of 1,913 patients were admitted for acute burn injury during the study period, with a male to female ratio of 2.34. Mean total body surface area burned (TBSA) was 23.2% (IQR: 10 to 30) and mean full thickness total body surface area burned (FTBSA) was 13.4% (IQR: 0 to 15). Inhalation injury was present in 441 (23.1%) cases, intoxication (CO, CN) was present in 88 (4.6%) cases, and associated traumatisms also in 88 (4.6%) cases. The mortality rate was 10.9%. The following factors were associated with mortality in univariate logistic regression: age, body mass index, past medical history, TBSA, FTBSA, intoxication (CO, CN), inhalation injury, flame burns, self-inflicted burns (all P<0.0001), sex (P<0.001), and admission date (P<0.01). Simple periodic regression showed a biannual seasonal effect on mortality, documented with a 1-year periodic (P<0.01) and a 6-month periodic (P= 0.01) dependency. Multivariate analysis with or without periodic terms identified age, past medical history, TBSA, FTBSA, inhalation, intoxication and admission date as the only factors independently associated with mortality. Conclusion Predictive factors for mortality in our ICBU are in line with the literature. The documented seasonal variations in mortality are fully explained by variations in these severity factors. Complementary analyses are under way to further study a nonlinear age effect. P535 ICU outcomes in patients suffering granulomatosis with polyangitis CHernandez-Cardenas1, GLLugo-Goytia1, MSSierraBeltran2, GDominguezCherit3 1Instituo Nacional de Enfermedades Respiratorias, Mexico DF, Mexico; 2Medica Sur, Mexico DF, Mexico; 3Instituo Nacional de Ciencias Medicas y Nutricin Salvador Zubirn, Mexico DF, Mexico Critical Care 2015, 19(Suppl 1):P535 (doi: 10.1186/cc14615) Introduction This study aims to describe both the clinical course and prognostic factors of patients suffering granulomatosis with polyangitis (Wegener granulomatosis) (GP) who were admitted to the Salvador Zubirn National Medical Sciences and Nutrition ICU. Methods Twenty-two patients suffering GP admitted to the ICU, between January 2002 and December 2012, were included. The Acute Physiology and Chronic Health Evaluation (APACHE) II prognostic score scale was used in order to assess the severity of illness on the first ICU day. The Sequential Organ Failure Assessment (SOFA) score was used to measure organ dysfunction, and the Birmingham vasculitis activity score for Wegener granulomatosis (BVAS/WG) was used to assess vasculitis activity. The outcome measurements taken into account were ICU mortality and ICU length of stay. Results One patient was admitted twice during this period. The sample comprised 11 males and 11 females (50%, respectively). Featuring an average age of 52years, 78% of them were admitted to the ICU because of respiratory failure, 50% were due to diffuse alveoli hemorrhage, 36% due to sepsis, 4% hypovolemic shock and finally 4% because of tuberculosis. According to the BVAS/WG, 20 patients corresponded to severe disease, one to limited diseases and one to persistent disease. The average ICU length of stay was 20.6days and as inpatients 43days. While comparing the SOFA score between alive and deceased patients there was a 0.5-point difference (P= 0.077), 63% of the alive patients were diagnosed while they were in the ICU. Plasmapheresis was found to be a protector factor (P<0.05). Conclusion The BVAS/WG score was significantly different between alive and deceased patients. Plasmapheresis was found to be a survival predictor. This study has shown that both SOFA and APACHE II scores have no prognostic value in these patients. Introduction Knowledge of the impact of liver dysfunction on mortality during septic shock is limited. However, the liver appears to play a key role during septic illness. To better explore this issue, we investigated the data collected during the Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis and Septic Shock (PROWESS-SHOCK) trial in which a cohort of 1,697 septic shock patients were constituted [1]. The study aimed to assess the relationship of liver dysfunction at the onset and during the course of septic shock on short-term and long-term mortality. Methods All of the patients enrolled in the PROWESS-SHOCK were included. Liver dysfunction at baseline was defined by a liver Sequential Organ Function Assessment (SOFA) score >0. The onset of a liver dysfunction post baseline was defined as any post-baseline increase of the hepatic SOFA score from 0. The worsening of liver dysfunction post baseline was defined as any increase of the hepatic SOFA score from the baseline assessment. The post-baseline period studied extended from study drug infusion to day 28. The main outcome was the mortality at day 180, and the secondary outcomes were the mortality at day 28 and at day 90. Cox proportional hazard models were used to estimate the hazard ratio of death. Results Baseline liver function was assessed in 1,565 patients. Of those, 522 (33%) exhibited liver dysfunction at baseline. No relationship was found with mortality according to baseline liver dysfunction status at day 28 (HR, 0.847 (95% CI, 0.647 to 1.109); P= 0.2267), day 90 (HR, 0.883 (95% CI, 0.701 to 1.112); P = 0.2892) and day 180 (HR, 0.885 (95% CI, 0.710 to 1.103); P= 0.2761). A total of 403 (26%) patients developed a new liver dysfunction (257/1,043, 25%) or worsened liver dysfunction (146/522, 28%) in the 28-day post-baseline period. The overall median time to develop or to worsen liver dysfunction was 2 (1 to 4) days. Significant relationships between the new onset or the worsening of liver dysfunction post baseline and mortality at day 28 (HR, 1.67 (95% CI, 1.26 to 2.21); P = 0.0004), day 90 (HR, 1.65 (95% CI, 1.30 to 2.09); P<0.0001) and day 180 (HR, 1.57 (95% CI, 1.26 to 1.97); P<0.0001) were found. Conclusion The new onset or the worsening of liver dysfunction during the course of septic shock impacts strongly on long-term mortality. Septic patients with liver dysfunction need long-term follow-up. Future research should focus on developing specific septic liver therapeutics and new tools for earlier detection of septic liver dysfunction. Reference 1. Ranieri et al. N Engl J Med. 2012;366;2055-64. Introduction In cancer patients, sepsis is the main cause of admission to the ICU and is associated with elevated mortality rates and healthcare costs. In this population, specific factors such as poor functional status and immunosuppression secondary to malignancy and/or antineoplastic treatment contribute to decreased survival. The aim of this study is to identify predictors of mortality in cancer patients admitted to the ICU with septic shock. Methods This is a retrospective study that analyzed predictors of 30day mortality in 269 patients admitted to the ICU of the Institute of Cancer of State of So Paulo, Brazil, from February 2012 to November 2014. Results From 1,250 patients admitted to the ICU, 269 patients had the admission diagnosis of septic shock and were analyzed. The mean age was 62 14years and 152 patients (56.5%) were male. Most patients had solid cancer (93.6%), and 87 patients (34.5%) had gastrointestinal neoplasm. Upon admission, the median SOFA score was 4 (IQR: 2 to 7), median SAPS 3 score was 55 (IQR: 48 to 68) and median lactate level was 1.88mmol/l (IQR: 1.22 to 3.21). After 48hours of ICU admission, acute kidney injury (AKI) was diagnosed according to AKIN classification as follows: 202 patients (75.1%) had grade 0, 49 (18.2%) grade 1, seven (2.6%) grade 2 and 11 (4.1%) had grade 3. The 30-day mortality rate was 24.9%. In the univariate analysis, associated variables with 30-day mortality were age, urea and creatinine levels at admission, SOFA score at admission, SAPS 3 score and 48-hour AKI. In multivariate analysis, the predictive factors for 30-day mortality were SOFA score at admission (OR= 1.12; 95% CI: 1.04 to 1.21, P= 0.002) and 48-hour AKI defined as AKIN grades 1, 2 and 3 (OR= 2.69; 95% CI: 1.45 to 4.97, P= 0.002). Conclusion In cancer patients with septic shock, SOFA score at admission and acute kidney injury at 48 hours of admission were predictors of 30-day mortality. These findings reinforce the needing of early strategies of diagnosis and therapy in this subset of patients. Introduction The admission of malignant hematology patients to the ICU is combined with poor prognosis [1]. A young population on one side and serious prognosis on the other are the main characteristics. Do we help? We are analyzing continuously clinical characteristics, treatment, and outcomes of critically ill patients with hematologic malignancies admitted to the medical ICU to identify predictors of adverse outcome [2]. Methods Demographic characteristics, hematologic diagnosis, reasons for ICU admission, transplant status, the presence of neutropenia, and APACHE II and SOFA scores were analyzed. Predictors of ICU mortality were evaluated using univariate analysis. Results There was a total of 194 patients (103 male), APACHE II score by admission was 27 8, SOFA 9 3. Acute leukemia (L) in 81 patients (41.8%), chronic L in 19 patients (9.8%), lymphoma in 58 patients (29.9%), and multiple myeloma in 28 patients (14.4%) were the etiology. Respiratory insufficiency, hemodynamic instability, AKI and CNS disturbances were responsible for the admission of 169 patients (87.1%) from the hematology ward to the ICU. In total, 127 patients (59.7%) were mechanically ventilated; 93 required invasive mechanical ventilation (MV). Non-invasive ventilation started in 34 patients and was successful in 14 (6.5%). The ICU mortality rate was 104 patients (53.6%), and the mortality of MV patients was 98 (77.2%). Need for vasopressors at admission, MV, neutropenia, and APACHE II and SOFA scores were identified as independent predictors of fatal outcome. Overall mortality of admitted patients was 53.6% (104 patients), and in ventilated patients was 77.2% (98 patients). Conclusion The ICU mortality of critically ill patients with HM is high, particularly in the group on MV. Different factors were independent predictors of mortality, but 46.4% of admitted patients survived because of adequate support possibilities and were transferred back to hematology ward. The ICU admission with organ support is according results important for life saving in this extremely high-risk patient group. References 1. Azoulay E, et al. The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med. 2006;32:3-5. 2. Grgic Medic M, et al. Hematologic malignancies in the medical intensive care unit outcomes and prognostic factors. Hematology. 2014 [Epub ahead of print]. Introduction In recent decades, therapeutic advances resulted in increased survival of patients with hematologic malignancies. These patients are increasingly admitted to the ICU due to infections, treatment toxicity and decompensation of chronic diseases. The aim of this study is to evaluate ICU, hospital and 6-month mortality in patients with hematological malignancies admitted to the ICU and to identify predictors of ICU mortality. Methods We performed a retrospective study of 277 consecutive patients with hematological malignancies admitted to the ICU of the Institute of Cancer of State of So Paulo, Brazil, from January 2010 to December 2013. Patient clinical and laboratory characteristics, evaluation of organ dysfunctions and need for hemodialysis, mechanical ventilation and vasoactive agents in the ICU were collected. The primary outcome was ICU mortality. Data were analyzed with univariate and multivariate logistic regression. Results The median age of the population was 57 years and 144 patients (52%) were male. Upon admission, 15 patients (5.4%) had disease remission and 31 (11.2%) had newly diagnosed disease. The ICU mortality rate was 26%, hospital mortality was 35.7% and 6-month mortality was 55.2%. The median number of organ dysfunction was 3 (IQR 2 to 4) and respiratory failure was the leading dysfunction, being present in 209 patients (75.5%). During the ICU stay, 21 patients needed hemodialysis (8%), 69 (25%) needed mechanical ventilation, 162 (58%) used vasoactive agents and 22 (8%) had a decision for limitation of medical treatment. On univariate analysis, risk factors for hospital mortality were acute myeloid leukemia, hospital stay prior to ICU admission >4days, number of organ dysfunction 2, colonization and infection by a multidrug-resistant (MDR) agent, use of mechanical ventilation, use of vasoactive agents and renal replacement therapy. Multivariate analysis revealed that renal replacement therapy (OR = 6.35 (95% CI: 1.5 to 25.92), P= 0.010), SOFA score (OR= 1.69 (95% CI: 1.38 to 2.06), P<0.001), RDW (OR= 1.27 (95% CI: 1.11 to 1.46), P= 0.001), lactate (OR= 1.04 (95% CI: 1.02 to 1.06), P<0.001), colonization of MDR agent (OR= 10.73 (95% CI: 2.13 to 53.96), P= 0.004) and hospital stay prior to ICU admission >4 days (OR = 4.72 (95% CI: 1.8 to 12.3), P = 0.002) were predictive factors of ICU mortality. Conclusion Patients from our institution have survival rates comparable with data from the literature. Our study suggests that mortality is associated with late ICU admission and colonization of MDR bacteria. Introduction Despite multiple reports demonstrating an improvement in outcomes of critically ill cancer patients admitted to ICUs over the last two decades [1], there is concern that admission policies for patients with cancer are overly restrictive [2]. The purpose of this study was to identify factors associated with mortality in the 180 days following unplanned ICU admission in patients with nonhaematological malignancy. Methods We carried out a retrospective analysis of all patients with solid tumours admitted to the Guys Critical Care Unit (13-bed level 3 ICU) as an emergency between August 2008 and July 2012. Data were collected regarding patient demographics, type of cancer, reason for referral and organ support required during the ICU stay. Results During the 4-year study period there were 356 unplanned admissions of patients with solid cancer (8.3% of all admissions). Three hundred individual patients were admitted and 180-day survival data were available for 293 of these. Mean age at first admission was 65.2 years, 115 (38.3%) were female. The most frequently present malignancies were lung (42.7%), head and neck (17.3%) and renal (6.7%). ICU, hospital and 180-day mortality were 19.1%, 31.0% and 52.2% respectively. Those factors found to be independently associated (in multivariate analysis) with increased risk of 180-day mortality include: metastases (OR= 4.0, 95% CI= 2.1 to 7.6); sepsis on admission (OR= 2.2, 95% CI= 1.2 to 4.1); APACHE II score on admission (OR = 1.06, 95% CI = 1.004 to 1.12); need for inotropes/vasopressors during admission (OR = 2.3, 95% CI = 1.05 to 4.8); and need for renal replacement therapy during admission (OR= 4.65, 1.7 to 12.8). Conclusion In our study, ICU and hospital mortality were lower than the pooled mortalities seen in a recent large systematic review [3] despite our study excluding planned postoperative admissions (who are known to have better outcomes). The 180-day mortality was significantly lower than in a previous study at our own institution [4]. Our study looked at a number of factors that might reasonably be expected to be associated with short-term and long-term outcomes and identified several that were independent predictors of death by 180days. References 1. Mokart D, et al. Intensive Care Med. 2014;40:1570-2. 2. Azoulay E, et al. Ann Intensive Care. 2011;1:5. 3. Puxty K, et al. Intensive Care Med. 2014;40:1409-28. 4. McGrath S, et al. QJM. 2010;103:397-403. P541 Characteristics and outcomes of lung cancer patients requiring ventilatory support: results from a multinational study ACToffart1, JFTimsit1, JSalluh2, GBurghi3, CIrrazabal4, NPattison5, ETobar6, BAlmeida7, EAzoulay8, MSoares9 1Hopital A. Michalon CHU Grenoble, France; 2Post-graduation Program Inst. Nacional de Cancer, Rio de Janeiro, Brazil; 3Hospital Maciel, Montevideo, Uruguay; 4Instituto Alexander Fleming, Buenos Aires, Argentina; 5Royal Brompton Hospital, London, UK; 6Hospital Clinico Universidad de Chile, Santiago, Chile; 7Hospital A.C. Camargo, So Paulo, Brazil; 8Hopital Saint Louis, Paris, France; 9DOr Institute for Research and Education IDOR, Rio de Janeiro, Brazil Critical Care 2015, 19(Suppl 1):P541 (doi: 10.1186/cc14621) Introduction The aim was to evaluate clinical characteristics and outcomes of patients with lung cancer requiring ventilatory support. Methods Secondary analysis of a prospective multicenter study including patients requiring either invasive (IMV) or non-invasive (NIV) mechanical ventilation for >24 hours admitted to 22 ICUs in six countries from Europe and South America during 2011. We used shared frailty models to identify factors associated with 6-month survival. Results Out of 449 patients admitted to the ICUs, 239 (small-cell (SCLC)= 34; non-SCLC= 205) required ventilatory support (NIV= 104; IMV= 135). Out of NIV patients, 31 (30%) were subsequently intubated for IMV. Main reasons for ventilatory support were sepsis (n = 119; among them, 102 patients had pneumonia), airway involvement by tumor (n= 79), ARDS (n= 47) and coma (n= 18). Mean SAPS II score was 54 20 and median SOFA score was 7 (4 to 12) points. Hospital and 6-month mortality rates were 55% and 67%; 94 (39%) patients received treatment limitations in the ICU. Mortality according to ventilatory strategy was 56% for NIV only, 77% for NIV followed by IMV, and 70% for IMV only. In the multilevel model, adjusting for the hospital size, presence of step-down units, type of admission and treatment limitation, performance status (PS) 3 to 4 (HR= 2.25 (95% CI, 1.52 to 3.34)), metastasis (HR= 1.66 (1.18 to 2.33)) and the ventilatory strategy compared with NIV only (HR = 1.73 (1.02 to 2.92), for NIV followed by IMV; HR= 2.25 (1.51 to 3.35), for IMV only) were associated with increased mortality. Conversely, patients with sepsis had higher survival (HR= 0.67 (0.46 to 0.96)). Conclusion In a multinational study, 6-month survival in lung cancer patients requiring ventilatory support is better than perceived a priori. Palliative care should be preferred in patients with poor PS. Acknowledgements Funded by INCA, CNPq and FAPERJ. Introduction Not all patients in need of critical care arrive in clinical distress and some deteriorate after arrival. Identifying these patients early in their clinical course could potentially improve outcome. The present study was performed with the aim of assessing whether nursing and physician staff were able to identify patients in need of critical care using only clinical judgment and to compare this with the National Early Warning Score (NEWS). Methods This was a prospective cohort study of all adult patients with a first-time admission to a medical admission unit at a 450-bed regional teaching hospital over a 3-month period in 2010. All subspecialties of internal medicine are present as well as a level 2 ICU. Upon first contact with the patient after arrival, nursing staff and physicians were asked to report their estimation of the probability of ICU admission (0 to 100%). Survival status was extracted from the Danish Civil Registry. All administrative details (including transfers to other hospitals, wards and ICUs) were extracted from the National Patient Registry, both ensuring complete follow-up. The discriminatory power (ability to identify patients at increased risk) was estimated using area under the receiveroperating characteristics curve. Calibration (accuracy) was assessed using HosmerLemeshow goodness of fit test. Data will be reported as median (range) or proportions (95% confidence interval). Results A total of 2,769 patients were included, median age 65 (18 to 100) years and 52% female. Thirty-day mortality was 4.5% and 2.2% were admitted to ICU. Median time to ICU admission was 1 (0 to 70) day. Nursing staff assessed 65% and physicians 26% of admissions. NEWS could be calculated for 85%. Nursing staff had a discriminatory power of 0.865 (0.786 to 0.944) with little variation with experience. Calibration was acceptable, except for the least experienced nurses (<5 years). Physicians had a discriminatory power of 0.789 (0.641 to 0.937), with little variation with experience. Calibration was very good, regardless of experience. NEWS had a discriminatory power of 0.809 (0.727 to 0.891) and poor calibration. There was no significant difference in discriminatory power between the three assessments. Conclusion Both nursing staff and physicians were as good as NEWS at identifying patients at increased risk of ICU admission after admission to a medical admission unit. However, both nursing staff and physicians had better calibration (accuracy) than NEWS. Introduction In recent years the proportion of older people admitted to the ICU has increased. A variety of clinical and physiological factors are associated with outcome in these patients. The aim of this study is to determine the clinical characteristics associated with survival of ICU mechanically ventilated older patients. Methods We retrospectively studied 74 patients, aged >65 years, admitted to the ICU who underwent mechanical ventilation. Standard demographic, clinical, and physiologic data were recorded. We examined the significant differences in clinical characteristics between survivors and nonsurvivors using the Student t and chi-square tests. Results The mean age of patients studied (43 men and 31 women) was 79 6.4 years. The type of admission was surgical 18%, trauma 26% and medical 57%. The ICU mortality of these patients was 57% and it was not associated with gender and cause of admission to ICU. Patients who survived had lower Charlson Comorbidity Index (P<0.05) and shorter duration of mechanical ventilation (P<0.01). The episodes of ventilation-associated pneumonia, sepsis and renal failure were less frequently in survivors (P<0.05). Also, in addition serum iron and cholesterol levels were significantly lower in nonsurvivors (P<0.01). Conclusion The mortality of ICU older patients is high. VAP, sepsis and renal failure are frequent complications in nonsurvivors. Pre-existing comorbidities considerably affect mortality. References 1. Fuchs L, et al. Intensive Care Med. 2012;38:1654-61. 2. Nielsson MS, et al. Acta Anaesthesiol Scand. 2014;58:19-26. P544 Frailty predicts increased resource use and postoperative care requirements after revision hip surgery APanickar1, NSingatullina1, JStubbs1, CJohnson1, RPorter2, DBryden1 1Sheffield Teaching Hospitals, Sheffield, UK; 2Leicester Hospitals, Leicester, UK Critical Care 2015, 19(Suppl 1):P544 (doi: 10.1186/cc14624) Introduction There is increasing demand for revision hip surgery in older patients with poor frailty. Our previously submitted work demonstrated that frailty predicts the need for medical review [1]. We reviewed patients for a further 16months to see whether frailty impacts on care [2]. This is the largest reported study reviewing frailty and the need for organ supports and outcomes in complex orthopaedic surgery. Methods A retrospective note review of all patients from January 2012 to April 2014 undergoing revision hip surgery. Data collected included frailty, comorbidities, operative blood loss, anaesthetic technique and level of organ supports and patient location at 30days. Figure1 (abstract P544). Frailty versus length of stay. Results A total of 389 patients with a mean age of 68.7 years were identified. Frail patients were significantly more likely to need vasopressors postoperatively (P = 0.012). Each increase in frailty score was associated with 0.16 increase in length of stay on the HDU (P = 0.025). Analysis of patient location at 30 days shows that frail patients stay in hospital longer (P= 0.00). Frail patients also bleed more intraoperatively (P = 0.00 with a coefficient value of 239; that is, for every point increase in frailty, average blood loss increases by 239ml). For each increase by unit of blood transfused, the length of stay increased by 5.3days (P= 0.000). The use of epidural is not associated with increased need for postoperative vasopressors (P = 0.598). See Figure1. Conclusion Frailty is associated with increased intraoperative resource use and postoperative care requirements independent of choice of anaesthetic technique. This type of surgery should be subject to health economic analysis as demand amongst the frailer surgical population increases. References 1. Singatullina et al. Abstract. Crit Care. 2014;18 Suppl 1:P49N. 2. Rockwood K, et al. Can Med J. 2005;173:489-95. P545 Predicting outcomes in critically ill patients in a resource-poor setting: the Rwanda Mortality Probability Model TTwagirumugabe1, ERiviello2, RFowler3, VNovack4, AMueller2, WKiviri1, VBanner-Goodspeed2, DTalmor2 1University of Rwanda, Kigali, Rwanda; 2Beth Israel Deaconess Medical Center, Boston, MA, USA; 3University of Toronto, ON, Canada; 4Ben-Gurion University of the Negev, Beer Sheva, Israel Critical Care 2015, 19(Suppl 1):P545 (doi: 10.1186/cc14625) Introduction ICU mortality prediction models provide robust tools for research and benchmarking in the developed world, but an ICU mortality prediction model has not been validated in a resource-poor setting. We sought to validate the Mortality Probability Admission Model, version III (MPMo-III) in two public ICUs in Rwanda and to develop a simplified Rwanda Mortality Probability Model (R-MPM) for use in developing countries. Methods We prospectively collected data on 339 adult patients admitted to two ICUs in Rwanda between August 2013 and July 2014. We described demographic and presenting characteristics and outcomes. We assessed the discrimination and calibration of the MPMo-III model. Using stepwise selection, we then developed a new logistic model for mortality prediction, the R-MPM. Results Patient median age was 34 (IQR 26 to 49) years; 48.7% were male. Mortality was 50.3%. The variables most predictive of mortality in univariate analyses were: age, sepsis within 24hours of ICU admission, hypotension or shock at ICU admission, Glasgow Coma Scale score at ICU admission, and heart rate (beats per minute) at ICU admission. Using these five variables, the R-MPM predicted mortality with area under the curve of 0.829 and HosmerLemeshow chi-square statistic of 8.881. The MPMo-III predicted mortality with area under the curve of 0.720 and HosmerLemeshow chi-square statistic of 16.391, indicating that the predictive risk scores of the MPMo-III were not well calibrated to the Rwandan data. Conclusion The MPMo-III had modest risk prediction capacity in a population of Rwandan ICU patients. The R-MPM is an alternative severity score with fewer and more accessible variables that provides better predictive power. This model needs to be validated in other ICUs. Introduction Emergency laparotomies have poor outcomes with variable postoperative critical care provision [1-3]. All patients requiring an emergency laparotomy with an estimated risk of death of >10% should go to critical care. Time of surgery should not affect standard of care [3,4]. In advance of the National Emergency Laparotomy Audit (NELA) results [2], our objective was to see whether the level of postoperative care and time of surgery affect outcome. Methods Retrospective data were collected across the Imperial NHS trust for all emergency laparotomies over 3months in 2014: length of stay in days (LOS); mortality; age; ASA; surgery time and postoperative care level, that is ward (L1), high dependency (L2), or ICU (L3). Statistical tests: MannWhitney, Pearson correlation (PCC) and multilinear regression analysis. Results Seventy-one patients underwent surgery. Overall mortality was 13% and 70% of patients went to a L2/3 bed. More ASA 1/2 patients went to L1 and all ASA 4/5 went to L2/3. Median (IQR) for age was 61 (44 to 67) for L1, 65 (48 to 73) for L2/3 (P= 0.11), LOS was 10 (7 to 16) for L1, 19 (12 to 57) for L2/3 (P= 0.002), and mortality (%) was 0 for L1 and 18 for L2/3. For surgery between 08:00 and 17:59, 14 went to L1, 28 to L2/3. Mortality was 5% and LOS 15 (9 to 24). Between 18:00 and 21:59, two went to L1, 10 to L2/3. Mortality was 17% and LOS 22 (8 to 34). Between 22:00 and 07:59, five went to L1, 12 to L2/3. Mortality was 29% and LOS 15 (9 to 36). ASA strongly predicted mortality (P= 0.006, PCC 0.32). There was a negative correlation between postoperative destination and mortality with all deaths happening in those who went to L2/3 (P= 0.038 and PCC 0.25); however, sicker patients may have gone here. There was a strong correlation between mortality and time of surgery, night surgery being a strong predictor of mortality (PCC 0.31, P= 0.008). LOS can be predicted by a combination of ASA, age and care level (P= 0.027); the postoperative care regression coefficient was negative (18.04, SE 10.41) with prolonged LOS in patients admitted to L2/3, which could also be explained by illness severity. Conclusion Trust mortality is similar to that in the Emergency Laparotomy Network audit [1]. Higher ASA patients are appropriately going to L2/3 care. Baseline health status and time of surgery are the strongest predictors of mortality in emergency laparotomy patients. References 1. Saunders D, et al. Br J Anaesth. 2012;109:368-75. 2. NELA project team. Executive summary, first organisational report of the National Emergency Laparotomy Audit. London: RCoA; 2014. 3. 4. emergency-surgery-standards-for-unscheduled-care. Introduction Scoring systems can be used to predict mortality in patients admitted to the ICU. They are produced using variables that are associated with an increased risk of mortality such as patient demographics, physiological measurements and coexisting conditions and can be used to evaluate ICU performance, to stratify patients in clinical trials and to assist in-hospital and healthcare decisions such as resource allocation. The aim of the project was to determine whether a general score derived from routine laboratory parameters could be used to predict mortality rates in patients admitted to the ICU in the UK. Methods P values were calculated using the t test, MannWhitney U test and chi-squared test, depending on distribution of data, in order to determine which variables were significantly different in the survivors and nonsurvivors of critical illness. Significant variables were categorised into subgroups according to medically relevant landmarks and univariately analysed by assessing the correlation with mortality. Forward logistic regression models were used to choose the parameters to include in our score. ROC curves illustrated the sensitivity and specificity of selected variables via their AUC. Results Age, platelets, ALT and APACHE II were selected to be included in the new laboratory-based score. The AUC for the score was 0.714, which was higher than each of the individual laboratory parameters. The AUC was increased further to 0.781 by including all 14 variables (age, lactate, FiO2, urea, creatinine, ALT, APACHE II, platelet, bicarbonate, haemoglobin, pH, ionised Ca, carboxyhaemoglobin and albumin), although this improvement was not considered significant as the confidence intervals of the two scores (4 and 14 variables) overlapped. Conclusion A laboratory-based score was successfully established in ICU patients, revealing an AUC of 0.714 which is comparable with established scores in a similar population. The compilation of the variables to produce a laboratory-based score showed greater prognostic power than individual variables. Model developers require an AUC of >0.7 to be termed useful; however, in order to be used in a clinical setting the AUC must be at least 0.75. Further research including internal and external validation studies must be performed to optimise the model before clinical implementation. P548 Patient preferences for outcomes in critical care trials (OPTICS): preliminary results JMuscedere1, FLamontagne2, GBoyd1, MHerridge3, SFleury1, TSinuff3 1Queens University, Kingston, ON, Canada; 2University of Sherbrooke, QC, Canada; 3University of Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P548 (doi: 10.1186/cc14628) Introduction Although patient-centered outcomes are important to inform therapeutic choices for critically ill patients, patient preferences for outcomes in critical care studies are unknown. It is also unknown whether outcome preferences differ between researchers, decisionmakers and those who have never been critically ill (citizens). The aim of the OPTICS Program is to investigate these preferences. Herein we report the preliminary results for outcomes preferences in citizens. Methods We recruited and surveyed lay public members without a history of critical illness as to their preferences for outcomes in critical care trials. After an in-person educational session, citizens were asked to rank 11 potential critical care trial outcomes in order of personal preference. Each outcome was also rated for importance on a 7-point Likert scale. Participants were then asked to indicate their agreement with potential tradeoffs between potential outcomes. Results The in-person session was attended by 31 citizens whose had a mean age (SD) of 71.6 (5.9) years and 1.5 (1.4) chronic health conditions; 25 (81%) had partially or fully completed post-secondary school education. Of the 11 potential outcomes, the three outcomes ranked of highest importance were: permanent brain dysfunction, quality of life, and requirement for long-term institutional care. The three outcomes ranked of least importance were: duration of hospitalization, death after a prolonged illness, and occurrence of delirium. When rated on a 7-point Likert scale the results were similar. Of the participants, 24/27 (89%) indicated that they would be willing to receive a therapy which was associated with a higher mortality rate but resulted in an improved quality of life in survivors. Conversely, 16/27 (59%) indicated that they would not be willing to receive a therapy which increased the chances of survival but was associated with a reduced quality of life in the survivors. Conclusion The citizens surveyed valued outcomes associated with quality of life and intact neurological function. Mortality and other indices of duration of critical illness were valued less. These preferences need to be confirmed in larger groups with greater diversity. Future research also needs to further understand these outcome preferences in survivors of critical illness, clinicians, decision-makers, and researchers. Understanding the outcome preferences of pertinent stakeholders and whether these preferences are congruent is imperative to inform the design of future critical care trials. P549 Disturbed circadian rhythm in ICU patients as indicated by melatonin levels: a prospective pilot study KKiss1, IFldesi1, LKemny1, VCsernus2, ZMolnr1, JSinger3 1University of Szeged, Hungary; 2University of Pcs, Hungary; 3Hungarian Society for Clinical Biostatistics, Hungary Critical Care 2015, 19(Suppl 1):P549 (doi: 10.1186/cc14629) Introduction The aim of this prospective pilot study was to test how melatonin levels follow the circadian cycle in ICU patients. There is strong evidence that changes of circadian rhythm are reflected in melatonin levels with peak levels at dawn and low levels during daytime [1]. The ICU stay is accompanied by disturbed circadian rhythm [2], which could potentially be the result of artificial lighting conditions. Methods Melatonin levels were determined in eight medical ICU patients on mechanical ventilation, without brain injury or infection. Arterial blood samples were taken on the day of admission at 18:00 (TE0) and 03:00 in the morning (TM0), then at the same time points 48 hours later (TE1, TM1). Blood samples were centrifuged at 3,000 rpm for 8 minutes, and then serum samples were stored at 80C. Measurements were performed using a US-CEA908Ge melatonin ELISA kit. For statistical analysis, a binary (yes/no) variable was created from the pairs for each day, assigning Yes if the TE values were greater than TM (melatonin peak reversion). The proportion of reversals and their 95% confidence intervals were estimated using a GEE model for repeated binary data, assuming a binomial distribution and log link, and accounting for subject as a repetition factor. All calculations were done in SAS 9.4. Results Melatonin levels were not normally distributed and were ranging between 9.2 and 23.7 pg/ml at T0 and 11.3 and 17.9 pg/ ml at T1. The median differences of the morning and evening serum melatonin levels were: TM0 TE0= 2.8 (3.8 (0.2)); TM1 TE1= 1.2 (2.5 (0.4)) presented as median (IQR). The proportion of subjects with peak reversals was 92.9% (80.8 to 100.0%). Conclusion Our preliminary data suggest that circadian rhythm disturbances may occur in critically ill patients within 48 hours after admission, and can be detected by inversion of melatonin peaks. Despite the limitations of this study, it may justify the need for larger observational and randomized trials on the effect of light on melatonin levels and on outcomes in ICU patients. References 1. Pevet P, et al. J Physiol. 2011;105:170-82. 2. Castro R, et al. Annual update in Intensive Care and Emergency Medicine. J.-L. Vincent, editor. Berlin: Springer-Verlag; 2011. p. 766-80. P550 Trait anxiety mediates stress-related psychopathology after cardiac surgery and ICU stay LKok1, MSep1, DVeldhuijzen2, SCornelisse1, ANierich3, JVanderMaaten4, PRosseel5, JHofland6, JDieleman1, CVinkers1, LPeelen1, MJols1, DVanDijk1, MHillegers1 1University Medical Center Utrecht, the Netherlands; 2Leiden University, the Netherlands; 3Isala Clinics, Zwolle, the Netherlands; 4University Medical Center Groningen, the Netherlands; 5Amphia Hospital, Breda, the Netherlands; 6Erasmus Medical Center, Rotterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P550 (doi: 10.1186/cc14630) Introduction ICU survivors are at risk for post-traumatic stress disorder (PTSD) and depression. The development of psychopathology depends partially on stable personality factors such as trait anxiety. Among ICU patients a high level of trait anxiety is relatively common and associated with intrusions, a symptom of PTSD. Independently, childhood trauma and stress exposure throughout life have been associated with depression. In cardiac surgery patients admitted to the ICU postoperatively, the effect of trait anxiety on the relationship between cumulative life stress and stress-related psychopathology remains unknown. Therefore we aimed to assess the mediating or moderating role of trait anxiety in this at-risk patient population. Methods In this multicenter follow-up study of the Dexamethasone for Cardiac Surgery (DECS) trial, validated self-report questionnaires were sent 1.5 to 4 years after cardiac surgery and ICU treatment to assess symptoms of PTSD and depression, in relation to cumulative life stress (that is, childhood trauma, major stressful life events) and trait anxiety as determinants of psychopathology. Data were available for 1,125 out of 1,244 (90.4%) eligible participants. Mediating and moderating analyses were performed with multivariable linear regression to assess the effect of trait anxiety. Subgroup analyses were performed for both sexes. Results Trait anxiety partially mediates the relationship between cumulative life stress and PTSD (-value reduction from 0.325 to 0.068; P = 0.000 to P = 0.003) and fully mediates the association between cumulative life stress and depression (-value reduction from 0.282 to 0.015; P= 0.000 to P= 0.507). Trait anxiety was not a moderating factor between cumulative life stress and psychopathology. Full mediation of trait anxiety was found in female patients (n = 247), whereas only partial mediation was seen in male patients (n = 878) with regard to PTSD symptoms. As for depression, full mediation was present in both female and male patients. Conclusion In cardiac ICU patients, trait anxiety mediates the influence of cumulative life stress on the occurrence of PTSD and depression symptoms. Further prospective research is necessary to establish these factors as reliable measures for the early identification of ICU patients at risk for stress-related psychopathology. Introduction Sleep disruption and deprivation is a continuing problem in the ICU. Strategies to improve sleep are confounded by difficulties in monitoring and measuring sleep in the ICU; traditional polysomnography cannot be utilized. Practical, non-intrusive diagnostic monitoring of sleep is required. The aims were to test two new ambulatory sleep diagnostic devices to monitor sleep in the ICU, compare sleep data generated by the different devices, and characterize sleep in the ICU. Methods The devices were: Watch PAT 200 (Itamar), simple wristwatch style, employing peripheral arterial tone and actigraphy to evaluate sleep time and sleep stage by an automatic algorithm (PAT device); and ALICE PDx (Respironics Philips), miniature polysomnographic device utilizing EEG and EMG recordings, requiring post-study sleep technician scoring (PSG device). Nineteen ICU patients provided informed consent (mean age 37years, two female). Diagnosis of most patients was trauma. Device technical problems terminated one ALICE PDx study and three Watch PAT study; one patient revoked consent. Therefore, 14 patients were recorded successfully in a private room in the ICU, while simultaneously wearing both devices, from 20:00 to 06:00. No patient received sedation. Subjective sleep quality was estimated by the visual analog scale. Results Both devices calculated total sleep time (TST), but the results were significantly different (P<0.05), with mean TST reported as 443.07 and 270.8minutes for PAT and PSG devices. VAS correlated tightly with TST calculated by the PSG device (r = 0.559, P <0.05). Both devices were able to successfully discern different sleep stages, summarized as light sleep, deep sleep, and REM. Measurements of sleep stage were generally in agreement between the two devices; REM sleep time correlated strongly between PAT and PSG devices (P<0.05). Sleep stage distribution was light sleep 62.2% (PAT) and 74.1% (PSG); REM 13.0% (PAT) and 10.7% (PSG); deep sleep 14.5% (PAT) and 7.9% (PSG). Conclusion Both wristwatch-style PAT and miniature PSG devices successfully recorded sleep in ICU patients. Although the simple PAT device overestimated TST, sleep stage times were generally in agreement, especially REM time which correlated strongly. Both devices can be used to effectively monitor and characterize sleep in the ICU environment. P552 Hospital anxiety and depression after ICU survival: results of a post-ICU aftercare program DRamnarain, CSlobbe, WSchapendonk, JVanGorp, IGnirrip, SVoermans, ARutten, GVanderNat, NVanderLely St.Elisabeth Hospital Tilburg, the Netherlands Critical Care 2015, 19(Suppl 1):P552 (doi: 10.1186/cc14632) Introduction Although the ICU survival rate has increased in the last decade, the negative effects on mental health and related quality of life become more clear. In the literature the prevalence of anxiety and depressive symptoms post ICU ranges from 10 to 43% [1]. Early recognition and treatment of anxiety and depressive symptoms is important because depression caries a risk for suicide, limited quality of life, and delayed return to work. We studied hospital anxiety and depression (HAD) symptoms after ICU discharge. Methods Patients who were treated in our ICU from 1 January 2013 until 31 December 2013 for more than 5days were invited to visit our post-ICU aftercare clinic. Six weeks after discharge they received a letter of invitation together with a health-related questionnaire, the Hospital Anxiety and Depression Scale (HADS) questionnaire [2]. Patients were asked to return the questionnaire prior to their visit. All data were analyzed and if the HADS score indicated a clinically significant anxiety or depression, patients were referred to a psychologist for further analyses and treatment. All patient data were analyzed retrospectively. Results Seventy-nine patients, 54 men and 43 women, mean age 57years. Median APACHE II and IV was 18 and 60 respectively. Median ICU and hospitals days were 9 and 20 respectively. Seventy-six percent were mechanically ventilated with a median of 5 days. Median time after ICU discharge to aftercare visit was 165days. Patients were divided into three categories: 1, no HAD (45.4%); 2, possible HAD (9.3%); and 3, clinically significant HAD (45.4%). Women compared with men showed significantly more HAD symptoms (26.8% vs. 18.6%, P<0.05). Patients with subarachnoid hemorrhage, neurotrauma and multitrauma patients showed more HAD symptoms. Pain, fatigue, muscle weakness, impairment of daily activity dyspnea, and hoarseness were significantly associated with clinically significant HAD. No association between age and HAD was found. Diagnosis at ICU admission, length of stay, severity of illness, delirium and use of sedatives were not associated with HAD. Conclusion Prevalence of clinically significant post-ICU HAD was 45.4%. Female sex and post-ICU physical complaints pain, fatigue, muscle weakness, impairment in daily activities, hoarseness and dyspnea were significantly associated with HAD. References 1. Myhren H, et al. Crit Care. 2010;14:R14. 2. Zimond M, et al. Behav Res Ther. 2003;41:1489-96. Introduction Patients who survive ICU treatment may experience psychological distress for some time after discharge from the ICU. In the literature the reported prevalence of post-traumatic stress disorder (PTSD) ranges from 5 to 64% [1]. We studied PTSD symptoms in relation to ICU factors, demographic data and physical complaints reported by patients 4 to 6months after ICU discharge. Methods Patients who were treated in our ICU from 1 January 2013 until 31 December 2013 for more than 5 days were invited to visit our ICU aftercare clinic. Six weeks after discharge a letter of invitation together with a health-related questionnaire, the Hospital Anxiety and Depression Scale questionnaire and Impact of Event Scale (IES-R) questionnaire, was sent to the patient. Patients were asked to return the questionnaires prior to visiting the aftercare clinic. All data were analyzed and if the IES-R score indicated a possible PTSD, patients were referred to a psychologist for further analyses and treatment. All patient data were analyzed retrospectively. The Pearson chi-squared test was used to compare groups and Cramers V analyses was used to examine strength of the association between groups. Results Seventy-nine patients, 54 male and 43 women, with mean age 57years. Median APACHE II and APACHE IV were 18 and 60 respectively. Median ICU days and hospital days were 9 and 20 respectively. Seventysix percent of patients were mechanically ventilated with a median of 5 days. Median time of ICU discharge to aftercare visit was 165 days. Delirium occurred in 22 (22.7%) patients during ICU treatment. The prevalence of PTSD was 43.3% and was most seen in patients after subarachnoid hemorrhage (SAH) (28.6%). Pain, muscle weakness, fatigue, impairment in daily activity, dyspnea, and hoarseness reported during the ICU aftercare clinic visit were significantly associated with PTSD. There was no significant difference in men and women. Sedation, opiates, benzodiazepine, inotropic medication and delirium during ICU treatment were not associated with higher prevalence of PTSD. None of the other demographic data analyzed were significantly associated with PTSD. Conclusion Prevalence of PTSD was 43.3% and most seen in patients after SAH, reflecting the majority of patients treated in our ICU. PTSD was associated significantly with pain, muscle weakness, fatigue, dyspnea, hoarseness and impairment of daily activity after a median 165days post ICU treatment. Reference 1. Griffiths J, et al. Intensive Care Med. 2007;33:1506-18. Introduction Critical illness today is well recognized as being associated with new or worsening physical impairment, diminished mental health and cognitive dysfunction. We studied the scope of somatic complaints in ICU survivors 4 to 6months after ICU treatment. Methods Patients who were treated in our ICU from 1 January 2013 until 31December 2013, for 5 or more days, were invited to visit our ICU aftercare clinic. Six weeks after ICU discharge a letter of invitation together with a health-related questionnaire, the Hospital Anxiety and Depression Scale questionnaire [1] and Impact of Event Scale Revised questionnaire [2], was sent. Patients were asked to return the questionnaires before visiting our clinic. The main purpose of the postICU aftercare was to screen for somatic complaints, mental health and cognitive dysfunction. If necessary, further examination or treatment was advised. All data were retrospectively analyzed. Results Ninety-seven patients visited our aftercare program in 2013. Median time after ICU discharge and visit to our after care clinic was 165 days. Twenty-five patients died after ICU discharge. Fifty-four patients were excluded because of various reasons; that is, language barrier, psychiatric illness, mental handicap, hospital admittance elsewhere, great distance. Seventy patients (81.4%) had somatic complaints influencing daily performance and quality of life. Fatigue (74.4%), muscle weakness (48.8%), dyspnea (34.9%), impairment of daily activity (81.4%), pain (38.4%) and weight loss (33.3%) were the most frequently reported complaints. Pain was most reported in patients with subarachnoid hemorrhage (27.3%), multitrauma (15.2%) and pneumonia (12.1%). Pain was most localized in the head (15.6%), one or both legs (15.6%), back (10.9%), shoulder (9.3%), hip (9.3%) and thorax (6.3%). Muscle weakness, fatigue, dyspnea, impairment of daily activity, pain and hoarseness were associated significantly with PTSD and HAD. There was no significant difference in somatic complaints between men and women. Conclusion Somatic complaints after ICU discharge are frequently reported in our post-ICU aftercare patients, influencing daily performance and quality of life. Patient-centered research and treatment focusing on somatic complaints is of great importance. References 1. Zimond AS, et al. Acta Psychatr Scand. 1983;67:361-70. 2. Creamer M, et al. Behav Res Ther. 2003;41;1489-96. P555 Post-traumatic stress disorder prevalence and subtypes among survivors of critical illness MPatel1, JJackson1, AMorandi2, TGirard1, CHughes1, AKiehl1, JThompson1, RChandrasekhar1, EEly1, PPandharipande1 1Vanderbilt University, Nashville, TN, USA; 2Ancelle Hospital, Cremona, Italy Critical Care 2015, 19(Suppl 1):P555 (doi: 10.1186/cc14635) Introduction Among North American survivors of critical illness, we aim to describe the prevalence of post-traumatic stress disorder (PTSD), and its subtypes of intrusion, avoidance, and hyperarousal. Methods In this prospective, observational, multicenter cohort study from 2009 to 2010, we screened adults (age 18 years) with newonset respiratory failure, cardiogenic shock, or septic shock, who were admitted to medical and surgical ICUs in four facilities. At 3-month and 12-month follow-ups, high probability of PTSD was defined by 17-symptom PTSD Checklist Event Specific Version (PCL-S) score 50. Also, PCL-S responses were mapped onto DSM-IV criteria for PTSD. To augment PTSD identification, those with a moderate probability of post-ICU PTSD (PCL-S score 35) were further confirmed with the Clinician Administered PTSD Scale (CAPS) structured interview. Moderate or greater symptoms for each PTSD subtype of intrusion, avoidance, and hyperarousal were categorized. Results Of the 180 eligible participants at 3 months, PTSD was identified in 10 (6%) using PCL-S scores and 15 (8%) using DSM-IV mapping of the PCL-S. Of the 160 eligible participants at 12 months, PTSD was identified in two (1%) using PCL-S scores and 10 (6%) using DSM-IV mapping of the PCL-S. Of those eligible for CAPS assessments, at 3months only 13 of 24 (54%) interviews were completed resulting in three extra PTSD diagnoses, and at 12months only six of 22 (27%) interviews were completed resulting in two extra PTSD diagnoses. At 3 and 12months, the intrusion subtype was present in 25 (14%) and in 25 (16%), the avoidance subtype was present in 78 (43%) and 60 (38%), and the hyperarousal subtype was present in 82 (46%) and 71 (44%). Conclusion Irrespective of definition using PCL-S or DSM-IV mapping, PTSD was identified in no more than one in 10 survivors of critical illness at either 3 or 12 months post ICU, which is still nearly double the US population past-year PTSD prevalence. In ICU survivors with moderate probability PTSD by PCL-S, the CAPS gold-standard interview is challenging to complete and adds only a small number of diagnoses. However, two in five ICU survivors will develop PTSD subtypes of avoidance or hyperarousal, which both occur twice as frequently as the intrusion subtype. Targeting predominant PTSD subtypes may help optimize treatment strategies for the ICU survivor, such as prolonged exposure and eye movement desensitization and reprocessing for those with the avoidance subtype, and pharmacologic antidepressants targeting the sympathetic nervous system to produce anxiolysis for those with the hyperarousal subtype. P556 Nonpharmacological interventions to reduce short-term or long-term psychological stress in ICU patients: a systematic review DWade1, ZMoon2, SWindgassen2, JWeinman2 1University College Hospital, London, UK; 2Kings College London, UK Critical Care 2015, 19(Suppl 1):P556 (doi: 10.1186/cc14636) Introduction A systematic review was performed of studies of nonpharmacological interventions aiming to reduce short-term or long-term stress in intensive care patients, as little is known about the efficacy of such interventions. Previous work has shown that intensive care patients undergo many stressful experiences, which can affect their long-term psychological well-being. Studies have demonstrated a high prevalence of depression, anxiety or post-traumatic stress disorder after intensive care admissions. Methods A systematic review was carried out according to the Prisma statement. A search was conducted of Medline, Embase and Psychinfo databases. Inclusion criteria included studies of populations of adult patients in mixed or general ICUs. No study designs were excluded, but studies that focused on specific disease states were excluded. Included studies were assessed for risk of bias, using a quality checklist. Results A total of 1,743 papers were retrieved, of which 18 studies were eligible for inclusion in the review. Studies had a combined population of 1,970 patients admitted to 38 ICUs from Europe, Asia and North America. Eleven studies were randomized controlled trials (RCTs). Interventions were classified as four groups music; therapeutic touch; diary and psychotherapeutic interventions. Ten studies found that music interventions were effective in the short term; however, followup results were limited and some studies were low quality. There was moderate quality evidence from three studies for the effectiveness of diary interventions, with medium-term follow-up results. There was mixed-quality evidence for therapeutic touch interventions in the short term from three studies. The two psychotherapeutic interventions studied were of moderate quality, and one showed promising results at 12-month follow-up. Conclusion The evidence for the efficacy of nonpharmacological interventions to reduce short-term or long-term stress in intensive care patients was of low to moderate quality. Studies included mainly shortterm and medium-term follow-up. This highlights the need for largerscale, better-quality RCTs with longer-term outcome measurement. However, the results indicate that nonpharmacological, including psychological, approaches are likely to be beneficial for reducing shortterm or long-term stress in intensive care patients. Introduction Patients recovering from critical illness suffer many physical and psychological problems during their recovery, including muscle weakness, fatigue, signs and symptoms of PTSD, anxiety and depression [1]. At present, specialist intensive care follow-up and rehabilitation is inconsistent and in many geographical areas is nonexistent. As a result, many survivors of critical illness will require using existing community rehabilitation services [2]. The aim of this present service evaluation was to understand the utilisation of community rehabilitation services by critical care survivors. Methods A database of acute referrals to community rehabilitation services was retrospectively analysed from 1May 2014 to 31October 2014. Age, referring specialty and reason for referral for rehabilitation were documented. This database was cross-checked with the critical care database in Glasgow Royal Infirmary to identify which individuals had been admitted to critical care during their admission. Results Over this 6-month period 769 patients were referred from their parent specialty for community rehabilitation in North East Glasgow. Thirty-three of the 769 patients (4.3%) referred had a critical care stay during their admission. Of these, eight patients were referred for rehabilitation by orthopaedics, eight by medicine for the older patients, 11 from acute medicine and the remaining six from other specialties. Six of the 769 patients who had a critical care admission were of working age (<1%). Two individuals were admitted to critical care following trauma whilst four had complex social needs prior to their critical care admission. This included an individual with a high body mass index. None of the individuals of working age were referred as a consequence of their critical care stay. Conclusion This service evaluation demonstrates that very few critical care survivors are referred to community rehabilitation services, Introduction Evidence-based, expert-driven, practical statements improve quality and effectiveness of the diagnostic and therapeutic process of patient care. Although the effectiveness of physiotherapy treatment strategies in ICU patients has been described, statements or guidelines of physiotherapy for ICU patients are not available [1]. Guidelines on safety management and on the diagnostic and therapeutic process may support and guide clinical decision-making leading towards evidence-based tailored care. The aim of this study was to develop an evidence-based statement for the physiotherapy treatment of ICU patients with recommendations for effective and safe diagnostic assessment and intervention strategies. Methods For the development of this evidence statement, we used the EBRO method, as recommended by the Dutch Evidence Based Guideline Development Platform [2]. This method consists of the identification of clinically relevant research questions, followed by a systematic literature search, quality assessment, and summary of the evidence eventually leading to establishing of concept and final recommendations based on feedback from experts. The final recommendations were prepared according to this methodical approach and summarized in figures, flowcharts and appendices. Results Three expert-based relevant clinical questions were formulated within the physiotherapy clinical reasoning process and were classified according to the International Classification of Functioning, Disability and Health. In a systematic literature search, 129 studies were identified and assessed for methodological quality and classified according to the level of evidence. The final Evidence Statement consisted of recommendations for physiotherapy in ICU patients including safety criteria, a core set of instruments to assess impairments and activity restrictions and effective interventions. Conclusion The Evidence Statement for physiotherapeutic diagnostics and intervention in ICU patients will contribute to the quality of clinical practice by supporting the clinical decision-making process. References 1. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41:1543-54. 2. Burgers JS, van Everdingen JJE. Evidence-based richtlijnontwikkeling in Nederland: the EBRO-platform. Ned Tijdschr Geneeskd. 2004;148:2057-9. P559 Early mobilization according to diagnosis in a Brazilian coronary ICU GSZavanelli1, SAPadulla1, MRFranco1, RZPinto1, LLFaccioli1, DNBarbosa1, DTNeves2, CEBosso2 1Universidade Estadual Paulista UNESP, Presidente Prudente, Brazil; 2Instituto do Corao de Presidente Prudente, Brazil Critical Care 2015, 19(Suppl 1):P559 (doi: 10.1186/cc14639) Introduction Early mobilization has been advocated to improve muscle function and, consequently, the patient quality of life after discharge. Nevertheless, few studies have explored it in a coronary ICU (CICU). The aims of the present study were to describe the use of an early mobilization protocol in a CICU and to investigate whether different groups of diagnoses respond similarly to this protocol. Methods This is a retrospective observational study conducted in a medium-sized hospital located in the city of Presidente Prudente, Brazil. The early mobilization protocol consists of five phases: 1 passive exercises for the unconscious patient; 2 active exercises associated with respiratory exercises (patient lying on the bed); 3 phase 2 exercises with the patient sitting on the bed; 4 phase 2 exercises with the patient sitting on a chair or in a standing position; 5 phase 4 exercises plus walking. All hospital records from patients, between September 2013 and August 2014, were included in this study. Data extracted from hospital records were: age, gender, diagnosis (arrhythmia, coronariopathies, congestive heart failure and other pathologies), length of stay, number of discharge and number in each phase of the early mobilization protocol. Pearson chi-square test was used to compare the number of mobilizations (phase 4 and 5) per group of diagnoses. Odds ratios were calculated for those comparisons found to be statistically significant (P<0.05). Results A total of 697 hospitals records were analyzed. Patients had on average (SD) 67.8 (13.1) years and the majority of them were males (57%). Our results revealed that 65% of patients in the CICU received phase 4 and 43% of patients in the CICU received phase 5 of the early mobilization protocol. No differences in the proportion of patients receiving phase 4 or 5 were found among arrhythmia, coronariopathies and congestive heart failure groups. The only difference found was between congestive heart failure group and other cardiovascular pathologies (P <0.001). The congestive heart failure group was mobilized 5.6 times (95% CI: 2.7 to 11.5) and 3.2 times (95% CI: 1.7 to 5.7) more than the other cardiovascular pathologies group in phase 4 and 5, respectively. Conclusion A considerable proportion of patients was mobilized without any serious complications in the CICU. Our findings suggest that patients diagnosed with arrhythmia, coronariopathies and congestive heart failure can be equally mobilized in an ICU. P560 Need for therapeutic interventions as a predictor of mortality in intensive care IEfendijev1, RRaj1, SHoppu2, MBSkrifvars1, MReinikainen3 1HUS, Helsinki, Finland; 2TAYS, Tampere, Finland; 3PKKS, Joensuu, Finland Critical Care 2015, 19(Suppl 1):P560 (doi: 10.1186/cc14640) Introduction Various therapeutic interventions needed in critical care may reflect a high risk of death. We evaluated associations between commonly used interventions and hospital mortality in Finnish ICU patients. Methods We retrieved data on adult patients treated in Finnish ICUs between 2003 and 2013 from the Finnish Intensive Care Consortium database. We used the Therapeutic Intervention Scoring System (TISS-76) for categorizing ICU interventions and the Simplified Acute Physiology Score (SAPS II) for quantifying severity of illness. We excluded readmissions, patients with missing outcome, SAPS II and TISS data. We also excluded very common interventions (arterial line, bolus intravenous medication), very rare ones (prevalence <1%), and interventions only applicable in specific populations (intracranial pressure monitoring, intra-aortic balloon assist). We grouped several TISS categories when applicable. We performed a backward stepwise binary logistic regression analysis with TISS items to assess the impact of each intervention on hospital mortality (expressed as odds ratio (OR) with 95% confidence intervals (CIs)). Age, admission type, and SAPS score (minus age and admission type scores) were adjusted for in the multivariate analysis. Results We identified 161,134 patients eligible for analysis. The multivariate analysis showed that the highest risk for hospital mortality in all patients was associated with cardiac arrest and/or countershock, OR 2.58 (95% CI= 2.43 to 2.73), SAPS II emergency admission, OR 2.52 (95% CI = 2.32 to 2.74), vasoactive drug infusion (>1 drug), OR 1.66 (95% CI= 1.59 to 1.73) and blood transfusion (a combined TISS item), OR 1.53 (95% CI= 1.44 to 1.63). TISS items associated with the lowest risk of mortality in general population were: active anticoagulation, OR 0.51 (95% CI = 0.49 to 0.53), induced hypothermia, OR 0.68 (95% CI= 0.62 to 0.74) and measurement of cardiac output by any method, OR 0.87 (95% CI= 0.83 to 0.91). All aforementioned associations were statistically significant (P <0.001). There was no notable association with mortality for pulmonary artery catheter, platelet transfusion and vasoactive drug infusion (one drug) (P>0.05). Conclusion In this large retrospective multicenter study, the TISS item associated with the highest risk of death was cardiac arrest and/or countershock. Unexpectedly, the independent effect of emergency admission was of comparable magnitude in terms of impact on hospital mortality. Of these, in-ICU cardiac arrest might be amenable to preventive measures and should be studied further. Introduction Increasing cost is an important issue in critical care medicine. We tried to analyze in a level 3 care ICU in Kolkata of a tertiary care hospital whether the different payment options (self-paying vs. insurance/corporate paying) do affect the outcome in the critically ill. Methods Our prospective study included 1,520 patients admitted consecutively to a level 3 care ICU for a period of 20months. Readmitted patients during the same period were excluded. Payment method was documented for all and divided into two groups as self-paying and insurance/corporate paying. Outcome assessment was done using the APACHE IV model for all cases. Demographic data, number of observed deaths, predicted mortality rate (PMR), standardized mortality ratio (SMR), average length of stay (ALOS), predicted length of stay, and number of discharge against medical advice (DAMA) were documented for each group. Statistical analysis was carried out using unpaired Student t test and P<0.05 was considered significant. Results Of 1,520 patients, 995 (65.46%) cases were self-paying while 525 (34.54%) cases were insurance/corporate paying. In the self-paying group, mean age was 59.65years 17.26 SD (median 62), APACHE IV score mean was 62.50 33.61 SD (median 57), average LOS 4.67days 4.29 SD (median 3), PMR was 22.71, 226 observed deaths, 85 cases of DAMA, and SMR was 1.00 (CI = 0.87 to 1.14). In the insurance/ corporate-paying group, mean age was 61.75years 17.19 SD (median 65), APACHE IV score mean was 58.53 32.94 SD (median 54), average LOS was 5.64days 5.61 SD (median 4), PMR was 21.26, 113 observed deaths, six cases of DAMA, and SMR was 1.01 (CI = 0.83 to 1.21). In the two compared groups, predicted mortality and SMR were not statistically significant (P = 0.2808); however, ALOS in the insurance/ corporate paying group was significantly higher than the self-paying group (P = 0.0002), mean age of the insurance/corporate paying group was significantly higher than the self-paying group (P = 0.02), and incidence of DAMA is significantly higher in the self-paying group (8.54%) as compared with insurance/corporate paying group (1.14%). Root-cause analysis showed DAMA cases are mostly financial (>95%). Conclusion Statistically significant differences in ALOS and DAMA in the two groups are probably due to cost of healthcare not affordable to all. Introduction Source of admission to the ICU is of importance. We tried to identify the different sources of ICU admission to a level 3 ICU of a tertiary care hospital in Kolkata and analyze whether the overall patient outcome is affected by the different sources of admission. Methods Our prospective study included 2,056 patients admitted to a level 3 care ICU over a period of 2 years. Numbers of readmissions were not considered. ICU outcome was analyzed using the APACHE IV model and source of admission to the ICU was documented as either from emergency (ER), from the floor or from other hospital. Analysis was carried out between different groups based on admission using unpaired Student t test and P <0.05 was considered significant. Number of ventilations and the mortality rate in each group were also documented. Results Of 2,056 admissions, 1,223 cases (59.48%) were from ER, 809 cases (39.35%) were from floor and 24 cases (1.16%) were from other hospitals. In the ER group, mean APACHE IV was 55.03 31.49 SD (median 50), PMR 16.26, observed deaths 198, ALOS 4.78days 4.83 SD (median 3), SMR 0.995 (CI= 0.86 to 1.14), mean age 60.52years 17.63 SD (median 63), 323 ventilations. In the floor group, mean APACHE IV was 65.17 34.40 SD (median 60), PMR 27.03, observed deaths 234, ALOS 5.23days 5.22 SD (median 3), SMR 1.07 (CI= 0.94 to 1.21), mean age 61.38years 15.72 SD (median 64), 302 ventilations. In the other hospital group, mean APACHE IV was 55.29 29.82 SD (median 50), PMR 18.0, observed deaths 2, ALOS 6days 5.85 SD (median 3), SMR 0.46 (CI: 0.23 to 0.88), mean age 56.08years 17.79 SD (median 56.5), six ventilations. During analysis, the other hospital group was omitted because of inadequate sample size. There was statistically significant differences in APACHE IV (floor >ER, P <0.0001), PMR (floor >ER, P<0.0001), ALOS (floor >ER, P= 0.04) noted between the floor and ER groups. Number of ventilations (37.33% vs. 26.4%), SMR (1.07 vs. 0.995), and mortality rate (28.92% vs. 16.19%) were also significantly higher for patients admitted from the floor. No significant statistical difference was observed in age between two groups (P= 0.26). Conclusion The severity of illness index in patients admitted to the ICU from floors is significantly higher than emergency admissions. Overall outcome for patients transferred to the ICU from the floor is worse based on mortality rate, SMR, and ALOS when compared with the emergency group. Introduction Readmission to the ICU is an important quality indicator of ICU care. We conducted a prospective study in a level 3 care ICU in Kolkata of a tertiary care hospital to analyze whether there are overall outcome differences when comparing the readmission group with the entire group. Methods Our prospective study included 2,140 patients admitted to a level 3 care ICU over a period of 1year. The number of readmissions (n = 85) during the same period was also documented. Readmission was defined as all patients who were transferred back to the ICU prior to hospital death/discharge during the above period. ICU outcome was calculated using the predictive APACHE IV model. Payment methods were documented as either self-paying or corporate/insurance paying. A comparison analysis between the entire group with the readmission group was done using unpaired Student t test and P <0.05 was considered statistically significant. Results In the entire group (n= 2,140), mean APACHE IV was 50.34 31.54 SD (median 42), PMR 15.49, observed deaths 327, ALOS 4.05days 4.55 SD (median 3), SMR 0.99 (CI= 0.88 to 1.1), mean age 60.55years 15.68 SD (median 63), 490 ventilations, 72.71% of patients were self-paying while 27.29% of patients were corporate/insurance paying. In the readmission group (n= 85), mean APACHE IV was 77.16 33.72 SD (median 73), PMR 38.89, observed deaths 42, ALOS 5.23days 4.18 SD (median 4), SMR 1.27 (CI= 0.95 to 1.67), mean age 64.79years 14.40 SD (median 67), 43 ventilations, 75.3% of patients were selfpaying while 24.7% of patients were corporate/insurance paying. During comparison between the two groups there were statistically significant differences, with the readmission group having significantly higher APACHE IV (P<0.0001), PMR (P<0.0001), ALOS (P= 0.002), age (P = 0.005), and SMR (1.27 vs. 0.99) compared with the entire group. Percentage of patients requiring ventilation (50.59% vs. 22.90%) and mortality rate (49.11% vs. 15.28%) were also significantly higher in the readmission group. Readmission was significantly higher in the selfpaying group. Root-cause analysis showed most readmissions were due to deteriorating conditions (desaturation, hypotension, sepsis, arrhythmias); however, it was also associated with cases where transfer policy from the ICU was not followed by stakeholders and financial issues were a cause of early transfer. Conclusion Readmission to the ICU was associated with worse outcome in our study group. Lack of adherence to transfer policy by concerned stakeholders was a concern as well as increasing cost of healthcare. Introduction Out-of-hours (OOH) discharge from critical care is associated with a significantly increased mortality rate in Australasia [1]. In the UK, daytime discharges from critical care are considered a core standard [2]. We sought to assess the impact of OOH discharge from critical care on mortality in a large general ICU, where operational pressures appear to have led to a high rate of OOH discharges. Methods Retrospective data for all patients admitted to our ICU from April 2007 to September 2014 were recorded, using routinely collected data from our databases. Adult patients (>15 years) discharged from their first ICU admission during each hospital stay (episode) were included. Patients that died on the unit and those discharged for palliative care were excluded. Patients transferred to other centres were no longer subject to discharge within our control and were therefore also excluded. Patients discharged directly home from ICU were excluded. We defined OOH discharges as those occurring between 22:00 and 06:59, a standard definition in UK practice. Mortality status at the time of hospital discharge for each episode was used. We also recorded the readmission rate to ICU. The relative risk (RR) for OOH mortality and readmission was calculated. Statistical significance was accepted at P<0.05. Results Of 4,476 index cases, 714 died on the unit and 80 were discharged for palliative care. A total of 490 patients were excluded for transfer to other centres and discharge directly home. Data were missing for three patients, which left 3,189 records for analysis. In total, 2,711 patients were discharged during daytime hours, of which 145 (5.35%) died. A total of 478 patients were discharged at night, 40 died (8.37%). The RR for OOH mortality was 1.56 (95% CI= 1.12 to 2.19, P= 0.0091). Readmission rate was 5.2% by day, 6.1% at night. The RR for readmission was 1.17 (95% CI= 0.79 to 1.72, P= 0.436). Conclusion Our data demonstrate an association between critical care discharge time and mortality, to a statistically significant level. Due to the retrospective observational nature of the study, causation cannot be assumed; however, a number of factors may contribute to the increased risk of harm to patients discharged from the ICU at night. Further work will focus on annual OOH mortality trends, thereby gaining an insight into whether bed occupancy demands impact on the necessity for nighttime discharges. References 1. Gantner D, et al. Int Care Med. 2014;40:1528-35. 2. Faculty of Intensive Care Medicine and Intensive Care Society. Core standards for intensive care units (2013). Introduction Severe critical illness requiring treatment in the ICU may have a serious impact on patients and their families. However, optimal follow-up periods are not defined and data on health-related quality of life (HRQOL) before ICU admission as well as those beyond 2-year follow-up are limited. The aim of our study was to assess the impact of ICU stay up to 5years after ICU discharge. Methods We performed a long-term prospective cohort study in patients admitted >48hours to a medicalsurgical ICU. The Short-Form 36 was used to evaluate HRQOL before admission (by proxy within 48hours after admission of the patient), at ICU discharge and at 1, 2 and 5years following ICU discharge (all by patients). Changes in HRQOL were assessed using linear mixed modeling. Results We included a total of 749 patients (from 2000 to 2007). At 5 years after ICU discharge, 234 patients could be evaluated. After correction for natural decline in HRQOL, the mean scores of four dimensions physical functioning (P<0.001), physical role (P<0.001), general health (P<0.001) and social functioning (P= 0.003) were still significantly lower 5 years after ICU discharge compared with their preadmission levels, although effect sizes were small (<0.5). Conclusion Five years after ICU discharge, survivors still perceived a significantly lower HRQOL than their preadmission HRQOL (by proxies), and that of an age-matched general population. Importantly however, after correction for natural decline, the effect sizes were small suggesting that patients regain their age-specific HRQOL 5years after their ICU stay. P566 Determination of brain death for adult patients with ECMO ICeylan, RIscimen, ECizmeci, NKelebekGirgin, FKahveci Uludag University Faculty of Medicine, Bursa, Turkey Critical Care 2015, 19(Suppl 1):P566 (doi: 10.1186/cc14646) Introduction ECMO support in ARDS is an emerging strategy when conventional treatment modalities fail. ECMO has advantages on oxygenation and circulation but also it has some unfavorable effects. The most serious complication is brain death due to cerebrovascular hemorrhage. An apnea test is the most important component in confirming brain death. For patients supported by ECMO, apnea testing remains challenging. Brain-death diagnosis is often made without an apnea test. Methods We present two cases who receive V-V ECMO support after progression to ARDS. After initiation of ECMO we used sedation to prevent movement and improve adaptation to mechanical ventilation. Also we used anticoagulation with heparin to prevent thromboembolic events and ECMO circuit occlusion. On daily follow-up we noticed that patients had lost their pupil reactions to light. Their sedation was ceased and a computed brain tomography was performed. Both patients had intracerebral hemorrhage. We decided to determine brain death with apnea tests. We increased ECMO blood flow and fiO2 and then decreased sweep gas flow and disconnected the patient from mechanical ventilation respectively. In one patient we did not see any spontaneous breathing efforts after carbon dioxide retention. We concluded that the apnea test was successful and confirmed brain death. On the other hand, we confirmed the brain death of the other patient with cerebral angiography due to the occurrence of hypoxia and hypotension during apnea testing. Results We experienced some challenges while determining brain death in patients under ECMO support for ARDS. It is challenging to conduct the apnea testing during ECMO support. Auxiliary tests are required for patients who cannot tolerate the changes needed to conduct the apnea test. With increasing use of ECMO therapies, clinicians may come face to face with more complicated life-ending decisions. Conclusion Current guidelines do not include brain death criteria using supportive therapies such as ECMO and therefore should be updated. References 1. Goswami S, et al. J Cardiothor Vasc Anesth 2013;27:312-4. 2. Jarrah RJ, et al. Pediatr Crit Care Med. 2014;15:38-43. 3. Marasco SF, et al. Heart Lung Circ 2008;17 Suppl:S417. 4. Farrah JM, et al. Arch Neurol. 2011;68:1543-9. Introduction Psychological safety (PS), for example safety of speaking up, fosters team learning and prevents treatment errors on the ICU [1]. Since speaking up might also prevent excessive and inappropriate (futile) care for patients, we hypothesized that teams with higher PS report less perceived futile care (PFC). We also expected that attending physicians inclusive leadership (IL), which invites nurses and residents participation [2], would decrease PFC and that PS mediates this relationship. Methods The hypotheses were tested in a cross-sectional, multicenter paper-and-pencil survey addressing medical staff on participating ICUs. A total of 22 ICUs and four intermediate care units were included in the sample and 73 attendings, 147 residents and 659 nurses participated in the study (52% participation). Psychometric properties were tested by confirmatory factor analysis (CFA), Cronbachs and intraclass correlations (ICC). A series of hierarchical linear models (HLM) were conducted to test the study hypotheses separately among nurses/residents and attendings. IL and PS were entered as unit-level predictors (mean values per unit). Covariates were demographics, working hours per week, workload and unit size (number of staff ). Mediation effects were tested. Results The CFA showed a good fit indicating factorial validity (CFI: 0.97), reliabilities were from 0.79 to 0.93 and ICCs were significant (~0.20, P<0.001). HLM revealed that unit-level IL of nurses and residents was positively related to PS (b = 0.34, P <0.001). Being a resident and working in a smaller unit also predicted PS. As expected, unit-level PS was negatively related to individual PFC (b= 0.38, P= 0.025). Further predictors of higher PFC were: being a nurse, having more than 5years of job experience and higher workload. PS mediated the relationship between unit-level IL and individual PFC (indirect effect: 0.13, P<0.001). Additional analyses revealed that attendings PFC was negatively related to their perception of residents PS (b= 0.44, P= 0.019). Conclusion A sense of PS in an ICU team might reduce futile care by increasing the safety of speaking-up behavior of nurses and residents. PS can be enhanced by attending physicians who practice inclusive leadership behavior to foster autonomy and participation of residents and nurses. References 1. Manthous CA, et al. Am J Respir Crit Care Med. 2011;184:17-25. 2. Nembhard IM, et al. J Organ Behav. 2006;27:941-66. P568 End-of-life decisions: how do patients die in the ICU? SBarbosa, PCavaleiro, JGuedes, SCastro, CGranja Unidade de Faro Centro Hospitalar do Algarve, Faro, Portugal Critical Care 2015, 19(Suppl 1):P568 (doi: 10.1186/cc14648) Introduction One of the main goals of intensive care medicine is to reduce the mortality of critically ill patients. However, it is essential to recognize end-of-life care as an integral component of critical care. Besides survival, the success of intensive care should also include the quality of lives preserved and the quality of dying. The objective of this study was to evaluate the incidence and type of end-of-life decisions (ELD) in critical patients that died in an ICU. Methods Analysis of all patients included in an ICU running database and who died from 1 November 2013 to 31 October 2014. The following variables were evaluated: age, gender, reason for admission, SAPS II, length of ICU stay and type of ELD. To classify ELD, four concepts were defined: Comfort care, a change from curative therapy to comfort care therapy; Limited therapy, maintenance of curative therapy but without escalating it (for example, no renal substitution); Decision not to resuscitate, not to perform advanced life support if cardiac arrest occurs; and Without previous end-of-life decisions, when there was no prior decision regarding the ELD. Results A total of 507 patients were admitted to the ICU and 132 died (26%). Reasons for admission in those who died were septic shock (47%), post cardiac arrest (13%), cardiogenic shock (8%), and nontraumatic brain bleeding (8%). Fifty-three patients (40%) died after a Comfort care decision, 28 patients (21%) after Decision not to resuscitate and 14 (11%) after a Limited therapy decision. Thirty-seven patients died Without previous end-of-life decisions. However, specifically in this group, when looking for individual records, 32 patients died (86%) in the first 48hours after the admission and four (11%) had evidence of brain death and were organ donors, which leaves one patient (3%) in whom there was no ELD. Conclusion In this study,Comfort carewas the main ELD, which is in line with the concept that ELD are essential to ensure that care provided is consistent with quality of life and death. The apparent large proportion of patients Without previous end-of-life decisions was due to patients who died in the first 48 hours after ICU admission corresponding to conditions refractory to treatment. Additionally, this study also draws our attention to better plan ICU admissions and hospital outreach in order to reduce early ICU mortality. Introduction There is a paucity of data about whether our treatment philosophy is different for our patients as compared with what we would have wanted for ourselves, or while acting as surrogate decisionmakers for our loved ones. Methods An anonymous survey was sent to all the members of Australia and New Zealand Intensive Care Society and the College of Intensive Care Medicine (CICM). The first section comprised a hypothetical case scenario spanning over 6weeks of ICU stay for a patient. At four different stages of the ICU stay, responders were requested to answer multiplechoice questions regarding the philosophy of treatment, based on their perceived prognosis of the patient at that particular time. The following two sections contained the same set of questions with the hypothetical scenario of responders acting as surrogate decision-makers for the patient and that of responders being patients themselves, in the same situation. The responses were compared amongst three sections at each stage using the chi-square test. Results A total of 115 responses were received from the fellows of CICM. The results are presented in Tables 1 and 2. Table1 (abstract P569). Respondents advocating withdrawal for the patient Conclusion Of the ICU physicians who would withdraw care for their patient, the majority would also want the same for themselves. The disparity between decision to continue to treat the patients versus treating self or family increased with increasing length of stay. Reference 1. Korones DN. What would you do if it were your kid? N Engl J Med. 2013;369:1291-3. Introduction A high percentage of patients admitted to ICUs fulfill one or more criteria for palliative care. There are currently few comprehensive studies in critical care settings that have set out to examine the association of palliative care screening criteria with adverse patient outcomes. Methods We performed an observational unicentric study on a 12-bed, medical emergency department intensive care unit (EDICU). A threeitem palliative care screen was developed from consensus reports. A senior critical care physician screened patients upon admission using these questions during a 10-week period. The questions were: does this patient suffer from a life-limiting disease (end-stage lung, liver, heart or kidney disease, severe neurological disability, extreme frailty, locally advanced or metastatic cancer, advanced-stage AIDS). If the answer to the first question is yes, we proceed to the next one: do you believe this patient will survive to hospital discharge? Answers to those questions were recorded, SAPS III was calculated and all patients were followed until death, discharge or transfer to another center. Differences in mortality and SAPS III score between groups were examined using a Students t test. Proportions were compared using chi-square test. P<0.05 was considered statistically significant. Results During the period, 191 patients were admitted to the EDICU, from which 151 had complete data and follow-up. A total of 63 patients (41.7%) suffered from a life-limiting disease and were evaluated as having a high probability of death in 1 year. This group was further divided between 35 patients who in the moment of initial screening were expected to die in this hospital admission and 28 patients who were believed to survive to discharge. Comparison between these two groups showed patients believed to die at this hospital admission had higher SAPS III scores (66.9 vs. 59, P = 0.010) and hospital mortality (48.6% vs. 10.7%, P= 0.001). Conclusion A high percentage of patients admitted to our EDICU have life-limiting disease and might benefit from palliative care. These patients can be identified using simple screening questions at admission and positive answers to those questions can be associated with worse outcomes. References 1. Nelson JE, et al. Crit Care Med. 2013;41:2318-27. 2. Weissman DE, et al. J Palliat Med. 2011;14:17-23. Introduction To analyze the perception of parents regarding their return to the hospital where their children died to participate in a conversation with doctors and to analyze the feelings of parents about their participation in a study evaluating the care provided in the moments leading up to the death of children. Methods A descriptive exploratory qualitative study. The study sites were the pediatric ICUs of the Hospital So Lucas and Hospital de Clinicas de Porto Alegre. Fifteen parents of children who died in the PICUs studied participated in the study. Data collection occurred in 2010 and was conducted through semistructured interviews. Data were analyzed using thematic content analysis. The research was approved by the research ethics committees of both hospitals. Results The ability to return to the hospital and talk to medical assistants was considered by parents as a positive and enlightening opportunity. Parents who participated in the study understood this moment as an opportunity to be heard and demonstrated the intention to contribute with their experiences in order to improve care in the hospitals studied. Conclusion We conclude that there is a need to implement measures to provide palliative care to parents after the death of their children. It is necessary to consider the possibility of providing families with follow-up meetings with the multidisciplinary team after the death of children. References 1. Piva J, Lago P, Othero J, Garcia PC, Fiori R, Fiori H, et al. Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units. J Med Ethics. 2010;36:344-8. 2. Lago PM, Nilson C, Pedro Piva J, Vieira AC, Halal MG, de Carvalho Abib GM, et al. Nurses participation in the end-of-life process in two paediatric intensive care units in Brazil. Int J Palliat Nurs. 2011;17:264, 267-70. 3. Abib El Halal GM, Piva JP, Lago PM, El Halal MG, Cabral FC, Nilson C, et al. Parents perspectives on the deaths of their children in two Brazilian paediatric intensive care units. Int J Palliat Nurs. 2013;19:495-502. Introduction We often need to obtain consent for clinical studies in the ICU. Participant Information Sheets (PIS) can be difficult to understand. A recent French publication [1] supports our hypothesis that PIS have poor readability scores. Methods Protocols submitted for ethics approval between 2008 and 2009 were obtained with permission from the Scotland A Ethics Research Committee. Ethical approval was not required for this observational study. All header, footers, diagrams and tables were removed. Readability scoring was performed using the Flesch Reading Ease and FleschKincaid (FK) grades. Statistical analysis using Excel and MiniTab was then performed. The readability of these documents was compared with everyday documents newspaper articles, politicians speeches [2] and standard contract agreements. Results A total of 104 protocols containing 209 PIS were reviewed. Of these, 99 (47%) were written for patients, 56 (27%) for GPs, 26 (12%) for relatives, 17 (8%) for carers, five (2%) for legal representatives and six (3%) were summary sheets only. Sixty-seven (64%) of these protocols were submitted by academic institutions (for example, university or health boards) and 37 (36%) by pharmaceutical companies. Results are expressed as the median and 25th and 75th percentiles. The word count and number of pages were higher for those PIS submitted by pharmaceutical companies compared with academic institutions: 1,561 (471; 5,167) versus 1,177 (626.5; 1,559.8) with P<0.05 and 4 (2; 10) versus 3 (2; 4) with P<0.05 respectively. The Flesch Reading Ease (63 (56; 69) vs. 60 (52.6; 65.4)) and FK grades (3 (5.4; 7.2) vs. 6.8 (6; 7.6)) were similar for both groups. Further subanalysis demonstrated that PIS designed for GPs had a lower word count, lower Flesch and higher FK grade compared with those for patients the difference in Flesch and FK grade were compared using a MannWhitney test and were statistically significant. Conclusion The FK grade is equivalent to US school grade level. The US government advises all policies produced should have a FK grade of <9. Our study suggests that protocols submitted to the ethics committee are easy to read, comparing favourably with broadsheet journalism and standard contract, for example loan contract. However, the average reading age in the UK is 9years [3], suggesting participants may struggle with the information provided. References 1. Menoni V. The readability of information and consent forms in clinical research in France. PLos One. 2010;5:e10576. 2. 3. Gillies K. Patient information leaflets for UK randomised controls. Trial. 2014;15:62. Introduction Healthcare systems do not make optimal use of evidence, which results in suboptimal patient care. Large amounts of scientific evidence are generated but not implemented into patient care (knowledge to care gap). We sought to identify and prioritize knowledge to care gaps in critical care medicine as opportunities to improve quality and value in care. Methods Using a modified RAND/UCLA Appropriateness Methodology, a committee of 38 providers and decision-makers representing a population-based clinical network of adult (n= 14) and pediatric (n= 2) medicalsurgical ICUs in Alberta, Canada (population 4 million) serially proposed, rated and revised potential knowledge to care gaps as priorities for improvement. The priorities developed by the committee were sent to the networks 1,790 frontline providers to rate their importance. The final list of priorities that were rated as important was disseminated to all network members for feedback. Results Sixty-eight knowledge to care gaps were proposed, rated and revised by the committee over three rounds of review, resulting in 13 priorities for improvement. Then, 1,103 providers (62% response rate) representing nurses, respiratory therapists, allied health professionals and physicians evaluated the priorities and rated nine as necessary. In multivariable logistic regression analyses, provider (profession, experience and teaching status of ICU) and knowledge to care gap characteristics (strength of supporting evidence, potential to benefit the patient, potential to improve patient/family experience, and potential to decrease costs) were associated with priorities rated as necessary. After disseminating the results to all network members, 627 responded (35% response rate) and indicated that the priorities were reasonable choices for quality improvement initiatives (87%), that they were highly supportive of working on initiatives targeting the priorities (61%) and would be willing to act as local champions for the initiatives (n= 92 individuals). Conclusion Our research approach engaged a diverse group of stakeholders to identify nine priorities for improving the quality and value of care provided to critically ill patients. This methodology can be used to engage stakeholders and identify priorities for quality improvement in other healthcare systems and domains. Additional work is required to reconcile provider/decision-maker and patient/ family priorities. Introduction With increasing emphasis on patient and family-centred care, it follows that patients and their family members should be included when priorities for improving care are established. We therefore used a novel methodology that employs former patients and family members as researchers to describe the experiences of critically ill patients and their families with ICUs and to identify opportunities for improvement. Methods Using the patient engagement framework developed by Marlett and Emes, we engaged four former patients and family members trained in qualitative research methods to conduct and analyse semistructured focus groups and interviews with adult patients who had recovered from critical illness and family members of both surviving and deceased patients. Participants were recruited from 13 ICUs in Alberta, Canada. Focus groups and interviews were recorded, transcribed and analysed using phenomenological reduction. Data collection continued until thematic saturation was reached. Results Thirty-two participants including patients (n= 11) and family members (n= 21) participated in five focus groups (n= 23 participants) and eight interviews (n = 9 participants). Participants articulated themes reflecting important components of care organised across three phases of the ICU experience; admission to ICU, daily care in ICU and after ICU discharge. Admission to ICU comprised three themes: patient and family transition into ICU, patient and family disorientation upon admission to ICU and preferred staff actions to help patients/ family adapt to the ICU. The daily care phase of ICU consisted of five themes: honouring patients voices, needing to know, making decisions, culture in ICU and medical care. The experience after ICU discharge comprised two themes: transition from ICU to a hospital ward and long-term effects of critical illness. Participants identified five priorities for improvement: provide families with a guide/navigator; educate providers about the fragility of family trust; improve provider communication skills; inform patients about the long-term effects of critical illness; and develop strategies to facilitate continuity of care between providers. Conclusion Patients and family members are an untapped resource and engaging them as researchers is a viable strategy to identify opportunities for quality improvement that are patient and family centred. Introduction The purpose of this study was to assess the visiting restrictions placed on families visiting adult patients on critical care units within trauma hospitals in England. Whilst it is well recognised that high-quality care for patients is of paramount importance, we should also be aware that supporting patients families offers longterm benefits for patient, family and hospital. In our own unit we are reviewing whether we could adopt a more flexible attitude to visiting times and assessing how to provide a more welcoming environment to relatives. To inform our own review and in order to develop a best practise approach, we surveyed all of the major trauma centres in England. Methods A telephone survey on visiting times was conducted in 53 adult critical care units in trauma centres in England. A list of trauma centres was obtained from the NHS England website. All critical care units (other than obstetric high dependency units and coronary care units, unless part of a cardiothoracic critical care unit) within each hospital were surveyed. Each respondent was asked about the visiting hours, whether children were allowed to visit and how many visitors to a bed space. Results Fifty-three units with between four and 75 beds and covering the whole of England were surveyed: there was a 100% response rate. Visiting hours varied between hospitals and between units within the same hospital. Nine units (17%) had open visiting hours, although most gave advice on times to avoid such as nursing handover. The majority of units (44.83%) operated restricted visiting with a median (range) of 6 (2 to 9) hours. All units allowed a maximum of two visitors to the bedspace. Children were allowed in nine units without restriction, the remaining units advised that it may not be appropriate for children to visit and it was at the discretion of the parents and medical staff. Conclusion The majority of adult critical care units in England, including our own, have restricted visiting policies. Visiting policies are a source of debate amongst staff in intensive care with concerns about open visiting including increased workload and interruptions to normal routine [1]. This is consistent with the views of staff at our own unit who, in appreciative enquiry, have expressed mixed opinions about extending visiting times. Extending visiting times is only part of a wider project to improve the way relatives experience intensive care whilst ensuring both medical and nursing staff feel supported, creating an environment for optimal communication. Reference 1. Berti D, et al. Intensive Care Med. 2007;33:1060-5. Figure1 (abstract P577). Trends in family satisfaction. round (FWR), to enhance and standardise communication and improve satisfaction. Following introduction of the FWR we have audited family satisfaction using the validated FS-ICU questionnaire [1]. Methods This was a prospective study of relatives satisfaction for patients completing their critical care episode. The questionnaire was completed anonymously and data collected. This was a pragmatic study, no changes were made to communication strategies. Results There is a high degree of satisfaction across all domains of the FS-ICU including treatment of family and provision of information (Figure1). One hundred per cent found FWR to be helpful, only 55% had anticipated this. Fifteen per cent changed their perception of critical care. It enabled 15% to raise new concerns. One hundred per cent were able have questions answered satisfactorily. Linked to the FS-ICU, we have seen marked improvements in decision-making and satisfaction. Conclusion We have shown progressive improvement over 3 years across all domains. Marked improvement in information provision and decision-making support from 53% to 96% over 3 years since introducing the FWR correlates with the improved overall satisfaction (Figure1). Interestingly FWR is more helpful than relatives anticipated. The FWR was very well received and our results suggest an unrecognised need is being met. Because this was a pragmatic study, we feel this is a true representation of family satisfaction. It is encouraging that communication, information and decision-making support continue to improve. They have become embedded in the fabric of our critical care practice and lead to marked improvement in satisfaction for families. Reference 1. Wall et al. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. 2007;35:271-9. Introduction For the families of critically ill patients, the death of a loved one in the ICU is often an unexpected and traumatic event, characterised by difficult decisions regarding withholding or withdrawing life-sustaining therapy. Increasingly the importance of bereavement care (BC) in the ICU is being acknowledged, although reports continue to highlight the inadequacies around end-of life care in the critical care environment. In 1998, the Intensive Care Society (ICS) published guidelines mapping out BC in the ICU [1]. We aimed to compare BC in ICUs across England against the recommendations set out by the ICS. Methods All adult ICUs in England were contacted over a 2-week period, using a standardised questionnaire based on the nine domains identified by the ICS. All answers were collected anonymously using SurveyMonkey. An 80% compliance rate was deemed acceptable. Results From the 148 ICUs identified, 113 answered the questionnaire (76%). Forty-three per cent of the responders had access to training in BC and in communication skills, and 54% had a named member of staff responsible for training, writing, auditing and developing the BC policy. When asked about the presence of a written BC policy only 45% responded positively, and even less (19%) had provisions for audit and development of the service. Information to staff about cultural and religious rites around the time of death, and to relatives on what to do after a death was available in 81% and 96% respectively. The general practitioner was informed of the deaths taking place in the ICU in 77% of the cases. In more than 70% of the participating ICUs, efforts were made to ensure privacy of the grieving relatives and to have dedicated follow-up facilities for the bereaved. Even though staff support programmes were recognised as paramount, only 54% of the ICUs had formal ones set up. Conclusion This is the first national audit of BC in the ICU since the initial ICS guideline publication. Even though most ICUs provided relatives with information around the time of death, training, auditing and adequate facilities do not meet the recommended standards. The lack of adherence is definitely multifactorial and requires further research. In the meantime, vigorous implementation of these guidelines is warranted in order to ensure optimal care for the bereaved families. Reference 1. Intensive Care Society (1998). guidelines-and-standards/. 1. Briassouli E , et al. Nutrition . 2014 ; 30 : 1185 - 94 . 2. Fitrolaki DM , et al. BMC Pediatr . 2013 ; 13 : 31 . P48 Prevalence and clinical significance of early endotoxin activity in septic shock patients MBottiroli1 , R Pinciroli1, GMonti2, MMininni1, GCasella2, R Fumagalli2 1Anestesia Rianimazione 3, A.O. Niguarda , Milan, Italy; 2Anestesia Rianimazione 1, A.O. Niguarda , Milan, Italy Critical Care 2015 , 19 (Suppl 1): P48 (doi: 10.1186/cc14128) P53 Association between apoptosis and mortality in severe septic patients LLorente1 , MMartn2, A Gonzlez-Rivero1 , JFerreres3, J Sol-Violn4 , LLabarta5, CDaz6, AJimnez1, J Borreguero-Len1 1Hospital Universitario de Canarias, La Laguna , Tenerife, Spain; 2Hospital Universitario Nuestra Seora Candelaria, Santa Cruz , Tenerife, Spain; 3Hospital Clnico Universitario de Valencia, Spain; 4Hospital Universitario Dr . Negrn, Las Palmas de Gran Canaria, Spain; 5Hospital San Jorge, Huesca, Spain; 6Hospital Insular, Las Palmas de Gran Canaria , Spain Critical Care 2015 , 19 (Suppl 1): P53 (doi: 10.1186/cc14133) P521 Rejection for ICU admission: analysis and results of this modality of limitation of therapeutic effort FAcosta , O Moreno, M Muoz , R Fernandez, MColmenero Hospital Universitario San Cecilio, Granada, Spain Critical Care 2015 , 19 (Suppl 1): P521 (doi: 10.1186/cc14601) Conclusion This study was performed to assess decision-making for admission to the ITU in times of increased demand and limited availability. We want to validate our findings from this short pilot study in a larger prospective study . Multivariate regression analysis will be used to identify significant features that affect clinician decisionmaking in critical care admission . 1. Reignier J , et al. Crit Care Med . 2008 ; 36 : 2076 - 83 . 2. Garrouste-Orgeas M , et al. Crit Care Med . 2005 ; 33 : 750 - 5 . 3. Azoulay E , et al. Crit Care Med . 2001 ; 29 : 2132 - 6 . P527 Pre-ICU length of hospital stay is a predictor of hospital but not ICU mortality KFlavin , D Hall, G Marshall , P Zolfaghari Royal London Hospital, London, UK Critical Care 2015 , 19 (Suppl 1): P527 (doi: 10.1186/cc14607) P540 Factors associated with short-term and long-term mortality in solid cancer patients admitted to the ICU RFisher1 , CDangoisse1, SCrichton2, SSlanova1, LStarsmore1, TManickavasagar1, CWhiteley1, M Ostermann1 1Guy's and St Thomas' NHS Trust , London, UK; 2King's College London, UK Critical Care 2015 , 19 (Suppl 1):P540 (doi: 10.1186/cc14620) particularly those of working age. More work is required to understand optimal rehabilitation pathways in this patient group . 1. Herridge M , et al. N Engl J Med . 2011 ; 364 : 1293 - 304 . 2. Corner EJ , et al. Crit Care . 2014 ; 18 :R55. P572 Parents' return to the hospital after the death of their children: importance of palliative care after death GHalal , PL Lago, JPiva, MHalal Hospital de Clinicas de Porto Alegre , Brazil Critical Care 2015 , 19 (Suppl 1):P572 (doi: 10.1186/cc14652)

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KP Verma, S Jasiowski, K Jones. Revitalising the medical emergency team call, Critical Care, 2015, P409,