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
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,
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
1. Dellinger R, et al. Crit Care Med. 2013;41:580-637. 2. http://bit.ly/1nzV3Kp. 3. http://bit.ly/12Y3KHq. 4. http://bit.ly/10PYi8G.
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
. Prior studies demonstrate the benefit of early recognition and
treatment of sepsis in reducing mortality . The Sepsis Six  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.
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
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,
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
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.
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.
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
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
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
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).
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
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
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.
Pre-exposure to mechanical ventilation and endotoxin influence
bacterial growth and immune response during experimental
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
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
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) . 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
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
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.
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) . The surviving sepsis
campaign was initiated in 2002. The first, second and third publications
were published in 2004, 2008 and 2012 respectively .
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 . 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.
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
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
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 . 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
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.
1. Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS. International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-6.
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,
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
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
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.
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  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  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.
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
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
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
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 . 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
1. Kremmyda LS, et al. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155:195-218.
Lower platelet mitochondrial function in severe septic patients than
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
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,
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
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
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.
Phenotypic factors associated with outcome in 977 intensive care
patients with faecal peritonitis: analysis of trends in the GenOSept
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 . We aimed at establishing
whether dynamic assessment of trends in selected variables
may be associated with outcomes, and therefore inform medical
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.
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 . 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
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.
1. de Stoppelaar SF, van t Veer C, van der Poll T. The role of platelets in sepsis.
Thromb Haemost. 2014;11:666-77.
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
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
Acknowledgement This research was performed within the framework
of CTMM, the Center for Translational Molecular Medicine (http://www.
ctmm.nl), project MARS (grant 04I-201).
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.
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
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.
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
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 . 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 . 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.
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.
Reduced responsiveness of blood leukocytes to lipopolysaccharide
does not predict nosocomial infections in critically ill patients
LAVanVught, MAWiewel, AJHoogendijk, BPScicluna, HBelkasim, JHorn,
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
Figure1 (abstract P38). Similarly reduced responsiveness of whole blood leukocytes to lipopolysaccharide.
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 
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 .
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.
Early heat shock protein 72 and 90 intracellular and extracellular
responses in patients with severe sepsis or systemic inflammatory
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.
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
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
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 . In vitro, repeated LPS stimulation induces a tolerant
or M2 macrophage phenotype, characterized by decreased cytokine
production , 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
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 . 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
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
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.
1. Cajander S, et al. Crit Care. 2013;17:R223.
HLA-DR monocyte antigen expression as predictors of outcome in
patients with community-acquired infections presenting with fever
DLogothetis, EGiourou, IStarakis, ALekkou, GTheodorou, MLeotsinidis,
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
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
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 (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
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
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.
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 . 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
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 . 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.
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
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
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 . This clinical study will address
the question of whether S1P blood concentrations are associated with
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.
1. Maceyka M, et al. Sphingosine-1-phosphate signaling and its role in disease. Trends Cell Biol. 2012;22:50-60.
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
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,
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
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
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.
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 . 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
. 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.
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 . 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
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
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.
1. The ionising radiation (medical exposure) regulations 2000. London: Stationery Office; 2000.
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
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
Multicenter Thai university-based surgical ICU study (Thai-SICU
study): adverse events and outcome in the SICU
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
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 . 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
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
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.
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.
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
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
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.
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
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.
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 . 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
1. Forster AJ, et al. CMAJ. 2004;170:345-9.
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 .
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
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 . 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
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
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
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 . 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
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
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.
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
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.
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.
ICU outcomes in patients suffering granulomatosis with polyangitis
CHernandez-Cardenas1, GLLugo-Goytia1, MSSierraBeltran2,
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 . 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
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.
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
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 . 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 .
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
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 , there is concern that admission policies for patients
with cancer are overly restrictive . The purpose of this study was to
identify factors associated with mortality in the 180 days following
unplanned ICU admission in patients with nonhaematological
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 
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 .
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
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.
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
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.
1. Fuchs L, et al. Intensive Care Med. 2012;38:1654-61.
2. Nielsson MS, et al. Acta Anaesthesiol Scand. 2014;58:19-26.
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 . We
reviewed patients for a further 16months to see whether frailty impacts
on care . This is the largest reported study reviewing frailty and
the need for organ supports and outcomes in complex orthopaedic
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
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
1. Singatullina et al. Abstract. Crit Care. 2014;18 Suppl 1:P49N.
2. Rockwood K, et al. Can Med J. 2005;173:489-95.
Predicting outcomes in critically ill patients in a resource-poor
setting: the Rwanda Mortality Probability Model
TTwagirumugabe1, ERiviello2, RFowler3, VNovack4, AMueller2, WKiviri1,
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 , 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
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 . 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.
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. www.ncepod.org.uk/2011poc.htm. 4. www.rcseng.ac.uk/publications/docs/
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
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.
Patient preferences for outcomes in critical care trials (OPTICS):
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
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.
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 . The ICU stay is accompanied by disturbed circadian rhythm
, 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.
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.
Trait anxiety mediates stress-related psychopathology after cardiac
surgery and ICU stay
LKok1, MSep1, DVeldhuijzen2, SCornelisse1, ANierich3, JVanderMaaten4,
PRosseel5, JHofland6, JDieleman1, CVinkers1, LPeelen1, MJols1,
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
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.
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% . 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 . 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.
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% . 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
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.
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  and Impact of Event Scale
Revised questionnaire , 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.
1. Zimond AS, et al. Acta Psychatr Scand. 1983;67:361-70.
2. Creamer M, et al. Behav Res Ther. 2003;41;1489-96.
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.
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 . 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 . 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
. 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 . 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.
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.
Early mobilization according to diagnosis in a Brazilian coronary ICU
GSZavanelli1, SAPadulla1, MRFranco1, RZPinto1, LLFaccioli1, DNBarbosa1,
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.
Need for therapeutic interventions as a predictor of mortality in
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
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
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
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
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
. In the UK, daytime discharges from critical care are considered a
core standard . 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.
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). http://www.ficm.ac.uk/standards.
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.
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
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
Conclusion Current guidelines do not include brain death criteria using
supportive therapies such as ECMO and therefore should be updated.
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
. 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 , would decrease PFC and that PS mediates this
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
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.
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.
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.
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
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  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  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
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 , suggesting participants
may struggle with the information provided.
1. Menoni V. The readability of information and consent forms in clinical
research in France. PLos One. 2010;5:e10576.
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/
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
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
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
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
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 . 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.
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 .
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
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.
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 . 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.
1. Intensive Care Society (1998). http://www.ics.ac.uk/ics-homepage/ 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 .
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