Procedural sedation in the emergency department
33rd International Symposium on Intensive Care and Emergency Medicine
P 0 2 4 5 7 9 10 13 14 18 19 22 23 25 27 28 32 33 45 46 47 49 50
Protective role of autophagy in mouse cecal ligation 0 2 4 7 10 14 19 23 25 28 33 46 47 50
puncture-induced sepsis model WTakahashi 0 2 4 5 7 9 10 13 14 18 19 22 23 25 27 28 32 33 45 46 47 49 50
HHatano 0 2 3 4 7 8 10 12 14 17 19 21 23 25 26 28 30 33 44 46 47 48 50
HHirasawa 0 2 4 5 7 9 10 13 14 18 19 22 23 25 27 28 32 33 45 46 47 49 50
SOda 0 2 4 5 7 9 10 13 14 18 19 22 23 25 27 28 32 33 45 46 47 49 50
0 P3 Effect of cdp-choline on microcirculatory alterations during endotoxemia K Schmidt
1 University Hospital , Brest, France Critical Care 2013, 17(Suppl 2):P2 (doi: 10.1186/cc11940)
2 The aim of our study was to observe the effects of TNF
3 Klinikum Stuttgart, Klinik fur Anasthesiologie u. operative Intensivmedizin , Stuttgart, Germany Critical Care 2013, 17(Suppl 2):P3 (doi: 10.1186/cc11941)
4 P2 Reversible depressive effect of TNF
5 Universitatsklinikum Heidelberg , Germany
6 . Results Eight rat hearts Wistar (weight = 325 23 g) were studied. See Table 1
7 P9 Immune paralysis in trauma patients; implications for prehospital intervention M Kox, K Timmermans, M Vaneker, GJ Scheffer, P Pickkers Radboud University Nijmegen Medical Center , Nijmegen, the Netherlands Critical Care 2013, 17(Suppl 2):P9 (doi: 10.1186/cc11947)
8 Haemostasis and Thrombosis Center, Catholic University School of Medicine , Rome , Italy Critical Care 2013, 17(Suppl 2):P13 (doi: 10.1186/cc11951)
9 Catholic University School of Medicine , Rome , Italy
10 P13 Platelet-associated oxidative stress and ADAMTS-13 levels are inversely associated with a poor prognosis in septic shock L Montini
11 Nafplion General Hospital , Nafplio , Greece
12 University of Athens, Medical School , Athens , Greece
13 Radboud University Nijmegen Medical Centre , Nijmegen , the Netherlands
14 P17 Effects of the common 34C>T variant of the AMPD1 gene on immune function , multiorgan dysfunction and mortality in patients with sepsis B Ramakers
15 Alexandra General Hospital , Athens , Greece Critical Care 2013, 17(Suppl 2):P17 (doi: 10.1186/cc11955)
16 'G.Gennimatas' General Hospital , Athens , Greece
17 General Hospital Novo Mesto, Slovenia Critical Care 2013 , 17(Suppl 2):P19 (doi: 10.1186/cc11957)
18 Faculty of Medicine, University of Ljubljana , Slovenia
19 P19 Hypogammaglobulinemia in sepsis is not correlated to high circulating angiopoietin-2 levels U Kovacic
20 University of Louisville School of Medicine , Louisville, KY, USA Critical Care 2013, 17(Suppl 2):P39 (doi: 10.1186/cc11977)
21 University of Basel , Switzerland
22 Kantonsspital Aarau , Switzerland
23 P39 Simple and fast prediction of Legionella sp. in community-acquired pneumonia: validation of a prediction rule S Haubitz
24 University of Szeged , Hungary Critical Care 2013, 17(Suppl 2):P51 (doi: 10.1186/cc11989)
25 P51 Can we predict the postoperative infections? T Mozes
26 Peterfy Hospital , Budapest , Hungary
27 Ministry of Defense Health Centre , Budapest , Hungary
28 P50 Analysis of risk factors for catheter-related bloodstream infection in a parenteral nutrition population I Conrick-Martin
29 Columbia University , New York, NY , USA
30 University of Pittsburgh , PA , USA
31 Peking University People's Hospital , Beijing , China
32 Hospital for Sick Children , Toronto , Canada
33 P489 Variation in acute care burden and supply across diverse urban settings S Murthy
34 D'OR Institute for Research and Education , Rio de Janeiro , Brazil
35 University of Washington , Seattle, WA , USA
36 Intensive Care National Audit & Research Centre , London , UK
37 University of Toronto , Canada
38 Peking Union Medical College Hospital , Beijing , China
39 Oswaldo Cruz Foundation , Rio de Janeiro , Brazil
40 Stanley Medical College Hospital , Chennai , India Critical Care 2013, 17(Suppl 2):P489 (doi: 10.1186/cc12427)
41 Komfo Anokye Teaching Hospital , Kumasi , Ghana
42 Apollo Hospital , Chennai , India
43 University Rehabilitation Institute, Republic of Slovenia , Ljubljana, Slovenia Critical Care 2013, 17(Suppl 2):P530 (doi: 10.1186/cc12468)
44 University of Ljubljana , Slovenia
45 University Medical Centre Ljubljana , Slovenia
46 P530 End-of-life decisions in Slovenian ICUs: a cross-sectional survey S Grosek
47 P542 Recognition of the primary stressors affecting intensive care patients: a systematic review S Birch, S Elliot Leeds Teaching Hospitals, Leeds University Teaching Hospitals Trust , Leeds , UK Critical Care 2013, 17(Suppl 2):P542 (doi: 10.1186/cc12480)
48 Swansea University , Swansea , UK Critical Care 2013, 17(Suppl 2):P541 (doi: 10.1186/cc12479)
49 Morriston Hospital, ABMU Health Board , Swansea , UK
50 P541 Early results of a 6-week exercise programme in post-ICU patients C Battle
Introduction Autophagy is well known as one of the biogenic
responses against various stresses, which possesses the beneficial roles
for survival, but little is known about the dynamics and its significance
during the septic condition. We hypothesized that autophagy is
induced during the septic condition, and contributes to protect from
tissue damage which subsequently leads to organ dysfunction. We
confirm whether the autophagic process is accelerated or sustained in
an acute phase of sepsis and we also determine its physiological role.
Methods Sepsis was induced by cecal ligation and puncture (CLP) in
mice. We examined the kinetics of autophagosome and autolysosome
formation which may explain the status of autophagy by western
blotting, immunohistochemistry, and electron microscopy. To investigate
a precise role of autophagy in CLP-induced sepsis, chloroquine, an
autophagy inhibitor, was administered to the CLP-operated mice, and
blood chemistry, pathology of the liver and survival were evaluated.
Results Autophagy demonstrated by the ratio of LC3-II/LC3-I was
induced over the time course up to 24 hours after CLP. The ratio was
particularly increased in the liver, heart and spleen. Autophagosome
formation became maximal at 6 hours and declined by 24 hours after
CLP. Autolysosome formation as evaluated by both fusion of GFP-LC3
dots with LAMP1 immunohistochemistry and electron microscopy
was also increased after the procedure. Furthermore, inhibition of
autophagy by chloroquine during the CLP procedure resulted in
elevation of serum AST levels, and significantly increased mortality in
Conclusion Autophagy was induced in several organs over the time
course of the CLP sepsis model and then the process was gradually
completed to degradation of the components. Our data suggest
autophagy plays a protective role in organ dysfunction in sepsis.
Introduction Acute myocardial depression in septic shock is common
. Myocardial depression is mediated by circulating depressant
substances, which until now have been incompletely characterized .
Results expressed as percentage of controlSEM. *P <0.05.
Conclusion TNF decreases significantly the heart rate, contractile
force, speeds of contraction and relaxation on isolated perfused
rat heart. TNF probably plays a role in the pathophysiology of
cardiomyopathy during septic shock. The partial reversibility of these
effects could explain why left ventricular hypokinesia in patients with
septic shock is reversible.
1. Vieillard-Baron A, et al.: Actual incidence of global left ventricular
hypokinesia in adult septic shock. Crit Care Med 2008, 36:1701-1706.
2. Hunter JD, et al.: Sepsis and the heart. Br J Anaesth 2010, 104:3-11.
Introduction The cholinergic anti-inflammatory pathway (CAP) is
a physiological mechanism that inhibits cytokine production and
minimizes tissue injury during inflammation. CAP-mediated
antiinflammatory signals in vagal efferent nerve fibers result in the
release of acetylcholine, which interacts with innate immune cells that
express the nicotinic acetylcholine receptor subunit 7 (7nAChR).
Endothelial dysfunction during sepsis is responsible for increased
endothelial permeability, leukocyteendothelial interaction and
functional breakdown of microvascular perfusion.
Endotoxemiainduced endothelial dysfunction can be reduced by cholinergic CAP
activation . The aim of this study was to determine the effects of the
7nAChR-agonist cdp-choline on microcirculatory alterations during
Methods Using fluorescent intravital microscopy, we determined
venular wall shear rate, macromolecular efflux and leukocyte
adhesion in mesenteric postcapillary venules of male Wistar rats.
Endotoxemia was induced over 120 minutes by intravenous infusion
of lipopolysaccharide (LPS). Control groups received an equivalent
volume of saline. Cdp-choline was applied as an i.v. bolus in treatment
groups. Animals received either (i) saline alone, (ii) cdp-choline
10minutes prior to saline administration, (iii)cdp-choline 10minutes
prior to LPS administration, (iv) cdp-choline 30 minutes after LPS
administration or (v)LPS alone.
Results There were no significant differences in venular wall shear
rate between the groups after 120 minutes. There was no significant
difference in the number of adhering leukocytes between the
cdpcholine/LPS groups (iii, iv) and the LPS group after 120 minutes.
Macromolecular efflux significantly increased in all groups over
120 minutes. All groups (i, ii, iii, iv) showed a significantly reduced
macromolecular efflux compared with the LPS group after 120minutes.
Conclusion Cdp-choline has no effect on leukocyteendothelial
interaction and microhemodynamic alterations during endotoxemia.
By activating the CAP, cdp-choline reduces capillary leakage. Thus
cdpcholine might have a prophylactic and therapeutic anti-inflammatory
effect on LPS-induced endothelial permeability. These findings
identify the endothelium as a target of anti-inflammatory cholinergic
mediators and cdp-choline as a potential therapeutic substance in
1. Peter C, et al.: Shock 2010, 33:405-411.
Introduction The purpose of this study was to evaluate the immune
response of patients susceptible to infection by Gram-positive bacteria
after ex vivo provocation with lipoteichoic acid (LTA) and to compare
the reaction with the one of healthy adults.
Methods Blood sample was obtained from 10 healthy volunteers, 10
hemodialysis patients with end-stage chronic renal failure (CRF), 10
patients with type II diabetes mellitus (DM) and 10 ICU patients on the
second day of hospitalization, who suffered nonseptic SIRS and had
an APACHE II score >25. After suitable treatment the samples were
incubated with 1 mg LTA for 8 hours and maintained at 20C until the
measurement of cytokines TNF, IL-6, IL-1, and IL-10, using the ELISA
method. The results are presented as mean valuesSEM. Graph Pad 4.0
was used, applying a t test to test the variation of each cytokine in each
group, and ANOVA to assess the differences between the four groups.
Results Baseline cytokine values in the three groups were increased
compared with the control group, but the difference was significant
only for the ICU group (Table 1, data only for IL-6 and IL-10). The
quotient IL-10/IL-6 of baseline values was between 0.23 and 0.96
among healthy, ESRD and DM persons, and 1.32 among ICU patients.
In all examined groups the levels of cytokines increased significantly
after stimulation with LTA, although ICU patients showed a differential
Table 1 (abstract P4). Levels of cytokines before and after stimulation with LTA
response (a fivefold to ninefold rise compared with other groups who
had an increase of 14-fold to 36-fold).
Conclusion Severely ill patients and secondarily hemodialysis and
diabetic patients are in a proinflammatory state. The response of
all examined groups to provocation by LTA was sufficient, with a
differential expression of severely ill patients, a fact that reflects their
different immunologic status.
Correlation of the oxygen radical activity and antioxidants and
severity in critically ill surgical patients: preliminary report
JLee1, HShim2, JYJang1
1Yonsei University College of Medicine, Seoul, South Korea; 2Wonju Severance
Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
Critical Care 2013, 17(Suppl 2):P5 (doi: 10.1186/cc11943)
Introduction In septic patients, the oxygen radical (OR) showed toxic
effect to induce inflammation and antioxidant activity could affect organ
dysfunction. This study was designed to determine the relationship
between antioxidant level and severity of organ dysfunction.
Methods The medical records of adult patients managed in a surgical
ICU from August 2012 to December 2012 were reviewed prospectively.
Abstracted data included age, body weight (with BMI), APACHE II
scores, SOFA scores, MODS scores, fluid intake, fluid output, nutritional
support, shock, antioxidant levels, OR activities, zinc and selenium
levels, complication and mortality. In addition, length of stay (LOS) in
the ICU and in hospital, and in-hospital mortality were collected. These
data were investigated on the first, the third and the seventh day,
Results A total of 13 patients were enrolled. The in-hospital mortality
rate was 7.7% and mean LOS in the ICU and hospital was 6.5 and 27.6,
respectively. Mean APACHE II score was 20.2. On the first day of ICU, the
mean antioxidant level and OR were 1.5 (0.5)mmol/l and 1.6 (0.5)
mmol/l, respectively. At the same time, SOFA and MODS scores were
7.3 and 5.0, respectively, and zinc and selenium were 32.6 g/dl and
68.4ng/ml. On the third day, mean antioxidant and OR were 1.5 (0.4)
and 1.8 ( 0.7) respectively (SOFA 6.6, MODS 4.9, zinc 50.0, selenium
70.7). On the seventh day, mean antioxidant and OR were 1.4 ( 0.5)
and 1.9 ( 0.7), respectively (SOFA 4.3, MODS 3.1, zinc 62.8, selenium
77.3). In the correlation analysis, MODS scores and antioxidant level
had significant correlations on the first and seventh days of ICU (P =
0.001, P = 0.009).
Conclusion Antioxidant level had a correlation with organ dysfunction
which might be used as a prognostic factor in critically septic patients.
To prove this, large-scale data collection is required.
1. Noveanu M, Mebazaa A, Mueller C: Cardiovascular biomarkers in the ICU. Curr Opin Crit Care 2009, 15:377-383.
2. Piechota M, Banach M, Irzmanski R, Barylski M, Piechota-Urbanska M, Kowalski
J, et al.: Plasma endothelin-1 levels in septic patients. J Intensive Care Med
3. Kotsovolis G, Kallaras K: The role of endothelium and endogenous vasoactive substances in sepsis. Hippokratia 2010, 14:88-93.
Simultaneous analysis of the expression of CD64 and HLA-DR in the
peripheral blood and bronchoalveolar lavage fluid in sepsis
TSkirecki1, MMikaszewska-Sokolewicz2, GHoser1, UZieliska-Borkowska1
1The Centre of Postgraduate Medical Education, Warsaw, Poland; 2 Medical
University of Warsaw, Poland
Critical Care 2013, 17(Suppl 2):P6 (doi: 10.1186/cc11944)
Introduction The core pathophysiological changes in sepsis
involve systemic activation of the immune system followed by the
8.90 0.76, 245.30 26.68
86.60 45.55, 1,310.00 154.80
15.90 1.89, 252.00 35.52
372.40 120.60, 3,659.00 485.20
3.00 1.08, 40.90 7.45
19.20 7.14, 273.10 126.50
15.30 2.08, 350.50 89.42
492.60 66.72, 2,822.00 432.70
anti-inflammatory compensatory response. However, controversies
exist regarding the status of the immune system in local tissue
compartments during sepsis. The aim of this study was to compare
selected markers of activation between the systemic circulation and
local lung environment.
Methods Twenty patients with severe sepsis were included into this
study. Peripheral blood (PB) samples and bronchoalveolar lavage fluid
(BALF) samples were obtained on the day of diagnosis (D1). BALF was
collected from 11 patients. Samples were stained with antibodies:
CD15/CD64 and CD3/CD14/HLA-DR and isotypic control. Cells were
analysed by flow cytometry. Expression of markers of activation was
analysed as the geometric median of fluorescence (GMF). All values
are expressed as median values. Comparisons between groups were
performed using MannWhitney and Wilcoxon tests.
Results The mortality of sepsis reached 70%. Nonsurvivors had
significantly (P = 0.001) elevated expression of CD64 on neutrophils.
Expression of HLA-DR was higher in monocytes from BAL than PB
GMF (1,032 vs. 342; P= 0.02) and this tendency was present in sepsis
originating from both pneumonia and peritonitis. Percentage of
HLADR-positive T cells was lower in PB than in BAL (2.9% vs. 6.5%; P= 0.07),
but the GMF values for HLA-DR were higher in the circulating T cells
(1,904 vs. 1,346; P= 0.004). The expression of CD64 on neutrophils was
not significantly different in PB and BAL, but there was a trend towards
its higher expression in BAL from patients with pneumonia while its
expression was higher in PB of patients with peritonitis.
Conclusion In this study we noticed that during sepsis some significant
differences in the status of activation of immune cells exist between
peripheral blood and lung resident cells. The lung milieu seems to
promote activation of monocytes while neutrophil activation is more
dependent on the site of infection. However, these observations
require further studies in a larger group of patients.
Acknowledgements This study was supported by the Centre of
Postgraduate Medical Education grant no 501-01-02-012 and by the
sources of the Medical University of Warsaw.
Introduction Nicotine exerts anti-inflammatory effects in several cell
types. 7-nicotinic acetylcholine receptor (7-nAChR), which has
high permeability to calcium, is believed to contribute significantly to
nicotinic anti-inflammatory effects. However, the molecular mechanism
is largely unknown. Kupffer cells in the liver play an important role in
inflammatory response to pathogens invading, but whether there is
7-nAChR expression in Kupffer cells or cholinergic anti-inflammatory
pathway involved in this process remains unclear.
Methods (1) Kupffer cells, isolated by collagenase digestion and
differential centrifugation from mice and labeled with FITC-aBGT,
were observed under laser scanning confocal microscope to test the
expression of 7-nAChR. Protein level was also tested by western
blotting, with RAW264.7 as positive control; (2) 100 nM LPS was
given to Kupffer cells, with or without 1mM nicotine. TNF, IL-10 and
HMGB-1 were tested at 4hours, 12hours or 24hours, respectively; (3)
100 BALB/c mice were randomly divided into four group: Group I (only
lethal dose of LPS was given), Group II (nicotine and LPS were given),
Group III (LPS, nicotine and GdCl3 were given), and Group IV (LPS and
nicotine were given and the left cervical vagus nerve was cut off ). The
mortality of mice was observed for 72hours.
Results (1) Expression of 7-nAChR in Kupffer cells was confirmed
by confocal microscope and western blotting; (2) after nicotine was
administered, the level of TNF and HMGB-1 increased and the level
of IL-10 decreased. Given left cervical vagus nerve cut off or aBGT,
the effect of nicotine was weakened; (3) Group I had the highest
mortality rate, while in Group II nicotine did reduce the mortality rate
dramatically. After the left cervical vagus nerve was cut off or aBGT
was given, the effects of nicotine were weakened. Difference for the
mortality rate between Group III and Group IV was not significant.
Conclusion Kupffer cells played a crucial rule in modulating
inflammation and the anti-inflammatory effect of nicotine was partially
weakened after left cervical vagus nerve cut off or aBGT was given. It
was verified that left cervical vagus nerve was essential for the
antiinflammatory effect of nicotine and 7 acetylcholine receptors might
play a critical role.
1. Wang H, et al.: Nicotinic acetylcholine receptor 7 subunit is an essential regulator of inflammation. Nature 2003, 421:384-388.
2. Wang H, et al.: Cholinergic agonists inhibit HMGB1 release and improve survival in experimental sepsis. Nat Med 2004, 10:1216-1221.
Introduction Activation of apoptosis in lymphocytes determines
the development of neutropenia and of sepsis [1,2]. We investigated
prevention of sepsis and correction of lymphocyte apoptosis by
recombinant human granulocyte colony-stimulating factor (hr-GCSF,
Methods With the permission of the ethics committee, a controlled,
randomized, blind clinical trial included 69 term newborns on
mechanical ventilation, without neutropenia and clinical signs of
infection, with a content of lymphocytes in early apoptosis (AnnexinV
FITC+PI) of >9.59%, and in late (AnnexinVFITC+PI+) of 0.56%.
Lymphocytes in apoptosis were detected using antibodies to AnnexinV
and propidium iodide staining method of immunophenotyping (flow
cytometry; Beckman Coulter Epics XL, USA). The survey was conducted
at admission, at 3 to 5 days, and 20 days. The method of random
numbers in Group I included 39 newborns who on admission (with
written parental consent) received an intravenous infusion of hr-GCSF
dose of 10 g/kg, 3 days. Newborns of Group II (n= 30) did not receive
hr-GCSF. Power of the study was 80% ( 0.05).
Results For 3 to 5 days, Group I significantly decreased apoptosis of
lymphocytes in the early from 16.1% to 7.8%, and in late from 1.3%
to 0.1%. The development of sepsis and neutropenia have been
reported. We observed no clinical or laboratory signs of adverse effects
of the drug. Fatal outcomes (n = 4) are not associated with hr-GCSF,
which was confirmed postmortem. Decreased duration of mechanical
ventilation (P<0.05). In Group II, 27 patients at 3 to 5 days developed
neutropenia and increased lymphocytes in apoptosis (P<0.05). Sepsis
was diagnosed in 19 children; eight fatal outcomes.
Conclusion hr-GCSF reduces the incidence of septic complications and
one of the mechanisms of its clinical effectiveness is the reduction of
apoptotic factors affecting the development of neutropenia.
1. Gillan ER, Christensen RD, Suen Y, et al.: A randomized, placebo-controlled
trial of recombinant human granulocyte colony-stimulating factor
administration in newborn infants with presumed sepsis: significant
induction of peripheral and bone marrow neutrophilia. Blood 1994,
2. Pukhtinskaya MG, Estrin VV, Gulova ES: Clinical and diagnostic value of
apoptosis markers in the pathogenesis of neutropenia and bacterial
complications in newborns with respiratory distress syndrome. Cytokines
Inflamm 2011, 10:66-69.
Introduction Multi-trauma is one of the major indications for intensive
care admission. Recovery is frequently complicated by post-injury
immunological complications, caused by a dysfunctional immune
system; for example, sepsis and multiple organ failure. In order to treat
or prevent this immune paralysis, knowledge on the time course of
immune paralysis in vivo and the pathophysiological mechanisms of
immune paralysis is essential. The aim of this study is to determine
factors that could predict and/or induce immunological complications
in these patients to ultimately find a suitable target and timeframe for
Methods Blood was drawn from adult multi-trauma patients (n = 94)
admitted to the emergency room (ER) of the Radboud University
Nijmegen Medical Center. Blood was drawn at the trauma scene by
the helicopter emergency medical services (HEMS), at arrival in the ER
and at days 1, 3, 5, 7, 10 and 14 after trauma. Plasma concentrations of
TNF, IL-6, IL-10, IFN, IL-8 and MCP-1 were determined by Luminex.
Ex vivo 24-hour whole blood stimulations with LPS or pam3cys were
performed and produced TNF, IL-6 and IL-10 was measured using
ELISA to determine the level of immune paralysis. Clinical data for
example, Injury Severity Scores, trauma mechanism, medication and
survival were collected from electronic patient files.
Results The plasma IL-10 concentration at ER was 16.5-fold increased
in comparison with time-point HEMS (P <0.01). Similar but less
pronounced effects were found for IL-8 and MCP-1. A significant
correlation (P = 0.03, R = 0.53) was found between injury severity
scores and IL-10 plasma concentration at time-point ER. Time-courses
of ex vivo produced cytokines suggest that LPS-induced IL-6 and TNF
production is already decreased in the first few hours after trauma
and recovering from day 5. Ex vivo IL-10 production shows an inverse
Conclusion Immune paralysis can be established within hours after
trauma. Production of anti-inflammatory IL-10 in the prehospital phase
could play a crucial role in the pathogenesis. Patients with a higher
injury severity score are more prone to produce excessive IL-10 in this
phase. Immune stimulatory strategies applied by the HEMS or early
after hospital admission could form a potential future approach to
prevent immune paralysis in multitrauma patients in the intensive care
Introduction In the acute phase of sepsis several potential mechanisms
may change the hemoglobin (Hb) concentration. On the one hand,
endothelial activation may lead to increased vascular permeability and
fluid sequestration to the interstitium, leading to hemoconcentration.
On the other hand, degradation of the glycocalyx has been reported .
Shedding of this carbohydrate-rich layer with an estimated thickness of
0.2 to 0.5 m may lead to a substantial increase of the intravascular
space, and thus to decrease of Hb concentration . The aim of this
study is to determine whether there is a decrease in Hb in the acute
phase of sepsis.
Methods In this single-center retrospective analysis we identified
patients with sepsis as the primary reason for non-elective ICU
admission from a standard patient database. Patients who fulfilled the
international criteria of sepsis and organ failure during ICU admission
were included in the sepsis group (S-group). The control group was
formed by patients with other non-elective reasons for ICU admission
(C-group). Exclusion criteria were (recent) bleeding, surgery in the last
6 weeks, chronic renal failure (creat >177 mol/l, or hemodialysis),
untreated chronic anemia, pregnancy, polytrauma, age <18,
Table 1 (abstract P11). Mean RBC fluctuation (daily SOFA score)
hematologic or metastasized malignancies, cardiac arrest, and use of
bone marrow suppressive drugs. Laboratory data were collected from
blood samples, prior to in-hospital i.v. fluid therapy. In order to detect a
difference in Hb concentration of 0.2mmol/l, we anticipated a sample
size of 283 per group, based on a standard deviation (SD) of 1.2, = 0.05
and = 0.8. Data are expressed as meanSD.
Results We included 296 patients in the S-group and 320 in the
C-group. The difference in Hb between the S-group and C-group was
not significant (8.761.18mmol/l vs. 8.931.16mmol/l, P= 0.07). After
correction for a number of confounders, using a multivariate regression
analysis, we observed a significant difference in Hb of 0.23mmol/l in
the S-group in comparison with the C-group (P= 0.01).
Conclusion At first presentation, prior to in-hospital i.v. fluid therapy,
Hb concentration in patients with sepsis is significantly lower in
comparison with controls; however, the difference is very small,
without the existence of anemia.
1. Steppan J, et al.: Sepsis and major abdominal surgery lead to flaking of the endothelial glycocalyx. J Surg Res 2011, 165:136-141. 2. van den Berg BM, et al.: The endothelial glycocalyx protects against myocardial edema. Circ Res 2003, 92:592-594.
Do changes in red blood cell deformability in patients with septic
shock correlate with changes in SOFA scores?
TClark1, SJewell2, MSair1, PPetrov2, PWinlove2
1Derriford Hospital, Plymouth, UK; 2University of Exeter, UK
Critical Care 2013, 17(Suppl 2):P11 (doi: 10.1186/cc11949)
Introduction Traditional whole blood experiments suggest that sepsis
causes abnormal red blood cell (RBC) deformability. To investigate
this at the cellular level, we employed a novel biophysical method to
observe individual RBC membrane mechanics in patients with septic
Methods We collected blood samples from patients with septic
shock until either death or day 5 of admission. Thermal fluctuations
of individual RBCs were recorded allowing a complete analysis of RBC
shape variation over time. Mean elasticity of the cell membrane was
then quantified for each sample collected.
Results We recruited nine patients with septic shock. Table 1 shows
mean RBC thermal fluctuation and SOFA scores.
Conclusion RBC thermal fluctuation analysis allows variations in RBC
elasticity during sepsis to be quantified at a cellular level. We could not
identify any specific trend between sepsis severity and erythrocyte
elasticity. Cells demonstrated both increases and decreases in
fluctuation independent of SOFA score. This is contrary to current evidence
that suggests RBC deformability is reduced during sepsis.
1. Piagnerelli M, et al.: Intensive Care Med 2003, 29:1052-1061.
Do erythrocytes subjected to cardiopulmonary bypass exhibit
changes in their membrane mechanical properties?
TClark1, SJewell2, MSair1, PPetrov2, PWinlove2
1Derriford Hospital, Plymouth, UK; 2University of Exeter, UK
Critical Care 2013, 17(Suppl 2):P12 (doi: 10.1186/cc11950)
Introduction Whole blood experiments suggest that cardiopulmonary
bypass (CPB) causes red blood cell (RBC) trauma and changes in
deformability that may contribute to postoperative microcirculatory
Table 1 (abstract P12). Change in RBC thermal fluctuation relative to baseline: two distinct groups seen
dysfunction. We used a novel fluctuation microscopy technique to
quantify the effects of CPB on RBC elasticity at a cellular level.
Methods We collected blood samples from elective cardiac surgery
patients pre (at induction) and post (immediately, each day until CICU
discharge) CPB. Thermal fluctuations of individual RBCs were recorded
using a high-frame-rate camera allowing a complete analysis of RBC
shape variation over time. Mean elasticity of the cell membrane was
then quantified for each sample collected.
Results Fifteen patients were recruited. Table 1 displays the results.
RBC thermal fluctuation is measured relative to pre-bypass values. An
increase in RBC fluctuation marks a decrease in stiffness. CPB caused
two distinct changes in RBC elasticity; pre-fix A indicates samples
where stiffness increases or shows no change, B those where stiffness
decreases. Data on day 2 were not collected in patients discharged
from the CICU. CPB type or time had no apparent impact on RBC
response to CPB.
Conclusion RBC thermal fluctuation analysis quantifies the impact
of CPB on erythrocyte membrane elasticity. We clearly identified two
separate RBC elasticity responses to CPB. This finding is contrary to
traditional flow measurement techniques that suggest CPB impairs
whole blood flow and reduces RBC deformability.
1. Lindmark et al.: J Thoracic Cardiovasc Surg 2002, 123:381-383.
Introduction Sepsis causes widespread microvascular injury and
thrombosis. Some hemostatic factors mediate the mechanisms
involved in sepsis-related organ ischemia and failure. Oxidative stress
is also increased in sepsis and reactive oxygen species (ROS) favor
secretion of von Willebrand factor (vWF) multimers from endothelium
and inhibit vWF proteolysis by ADAMTS-13. Moreover, the enzyme
indoleamine-2,3-dioxygenase, an important immune regulator, is
activated in sepsis and, through generation of kynurenins, promotes
antioxidative and anti-infective activities. This study evaluated the
relative role of ADAMTS-13, vWF and fibrinogen in the morbidity and
mortality of patients with septic shock (SS). The above hemostatic
factors were measured together with kynurenine and plasma protein
carbonyls, marker of oxidative stress.
Methods One group of 12 patients with SS, defined using standard
criteria, was enrolled in the ICU of the A. Gemelli Hospital (Rome,
Italy). Biochemical, hematologic and hemodynamic parameters were
measured on days 1 to 4, 7, 14 and 21. A group of 12 age-matched and
gender-matched healthy subjects was used as controls.
Results Low ADAMTS-13 activity was observed in SS patients
(268123ng/ml vs. 76080ng/ml in controls). vWF levels (antigen
and activity) were increased ~3-fold compared with controls. Likewise,
plasma protein carbonyls and kynurenine were globally increased in
patients (2.11.5 nmol/mg vs. 0.302 nmol/mg and 14.49.7M
vs. 2.31.3M, respectively). Intra-ICU mortality (3 of 15) was strongly
and inversely correlated with carbonyl levels (P = 0.04) and platelets
Conclusion Hence, we hypothesize that, in the SS setting, platelets
contribute to oxidative stress that counteracts the organ
failureassociated mortality. Thus, low platelet count, irrespective of bleedings,
may favor mortality in SS patients by generating lower ROS amounts.
1. Strauss R, et al.: Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med 2002, 30:1765-1771.
Neutrophil gelatinase-associated lipocalin/lipocalin2, derived from
gut crypt cells, exerts intestinal antimicrobial effect via bacterial
stimulation of Toll-like receptor 4 and 9
KMori, TIgarashi, KInoue, TSuzuki, HMorisaki, JTakeda
Keio University School of Medicine, Tokyo, Japan
Critical Care 2013, 17(Suppl 2):P14 (doi: 10.1186/cc11952)
Introduction Neutrophil gelatinase-associated lipocalin (NGAL)/
lipocalin2, known as a sensitive biomarker of acute kidney injury,
prevents bacterial iron uptake, resulting in the inhibition of its
overgrowth . We previously demonstrated that this protein was
discharged into gut lumen from crypt cells in septic conditions, and
inhibited the growth of Escherichia coli . However, it remains unclear
which pathway is associated with the upregulation of NGAL. We
therefore designed the present study to reveal whether the
patternrecognition receptor of bacteria, the Toll-like receptor (TLR) family,
plays a pivotal role for NGAL secretion from gut crypt cells.
Methods With our institutional approval, the ileum and colon of male
C57BL/6J mice (6 to 7 weeks) were everted and washed by Ca2+ and
Mg2+ free PBS buffer five times. Tissues were incubated with Ca2+ and
Mg2+ free PBS containing 30 mM EDTA for 1 hour to isolate crypt cells
of gut. The cell suspension was filtered through a cell strainer (40m)
twice, and deposited the crypt cells by centrifugation at 700g. The
isolated crypt cells were resuspended in PBS and stained with 0.25%
amido black for labeling paneth cells. The 5105 crypt cells were
resuspended in 50 ml HBSS containing 2.5% fetal bovine serum and
1% penicillinstreptomycin. The crypt cells were incubated at 37C with
or without TLR ligands: lipopolysaccharide (TLR4 ligand, 10g/ml) and
CpG-DNA (TLR9 ligand, 8g/ml). After a 2-hour incubation period, the
crypt cells were deposited and eluted mRNA to measure the expression
of both NGAL and TLR mRNA using real-time PCR.
Results More than 70 to 80% of collected cells were stained by amido
black. LPS significantly upregulated the expression of NGAL and TLR4
mRNA in ileum and colon crypt cells (P<0.05). Although the CpG-DNA did
not upregulate NGAL and TLR9 mRNA in ileum crypt cells, the apparent
expression of NGAL and TLR9 mRNA was found in colon crypt cells (P<0.05).
Conclusion Bacterial stimulation of TLR4 and TLR9 pathways plays a
pivotal role in the expression of NGAL mRNA in gut, suggesting that
NGAL, derived from gut crypt cells, could contribute to the regulation
of the intraluminal microflora in the critically ill.
1. Nature 2004, 432:917.
2. Crit Care Med 2011, 39:46.
Lethal influenza virus A H1N1 infection in two relatives with
autosomal dominant GATA-2 deficiency
JSole-Violan1, ISologuren1, EBetancor2, SZhang3, CPrez1,
EHerrera-Ramos1, MMartnez-Saavedra1, MLpez-Rodrguez1, JPestano2,
JRuiz-Hernndez1, JFerrer1, FRodrguezdeCastro1, JCasanova3,
1Hospital GC Dr Negrn, Las Palmas de GC, Spain; 2Universidad Las Palmas de
GC, Spain; 3The Rockefeller University, New York, NY, USA
Critical Care 2013, 17(Suppl 2):P15 (doi: 10.1186/cc11953)
Introduction Most individuals infected with the 2009 pandemic H1N1
influenza A virus (IAV) (H1N1pdm) experienced uncomplicated flu.
However, in a small subset of patients the infection rapidly progressed
to primary viral pneumonia (PVP) and a minority of them developed
ARDS. Inherited and acquired variability in host immune responses
may influence susceptibility and outcome of IAV infection. However,
the molecular nature of such human factors remains largely elusive.
Methods We report three adult relatives with the autosomal dominant
GATA-2 deficiency. P1 and his son P2 had a history of myelodysplastic
syndrome and a few episodes of mild respiratory infections. They
developed PVP by H1N1pdm which rapidly evolved to ARDS. They died
at the age of 54 and 31, respectively.
Results Patients were heterozygous for a novel R396L mutation in
GATA2. Like other patients with GATA-2 deficiency, the three relatives
had absence of peripheral NK and B cells and monocytopenia. However
a high number of plasma cells, which were found to be pauciclonal,
were observed in peripheral blood from P1 during H1N1pdm infection.
P1 and P2 had normal levels of immunoglobulins and IgG antibodies
against common viruses. Microneutralization test showed that P1
produced normal titers of neutralizing antibodies against H1N1pdm
and against the previous annual H1N1 strain. Our results suggest that
a few clones of long-living memory B cells against IAV expanded in
P1; and that these cells produced cross-reactive antibodies against
H1N1pdm, similar to those recently described. During the flu episode
P1 had a strong increase of IFN-producing T cells and of IFN
production. The Th1-related chemokines CXCL10 and CXCL9, as well as
IFN, MCP-1 and IL-8, were strongly elevated in serum from P1 and P2
in the course of H1N1pdm infection.
Conclusion GATA-2 deficiency is the first described Mendelian
inborn error of immunity underlying severe IAV infection. Primary
immunodeficiencies predisposing to severe IAV infections may debut,
even in adults without a history of previous severe infections. The
massive IFN-mediated cytokine storm may explain the fatal course of
H1N1pdm infection in our patients.
Bacterial translocation primes proinflammatory responses and is
connected to early death in an experimental model of lethal injury
NBaxevanos, TTsaganos, APistiki, DDroggiti, ASpyridaki,
University of Athens, Medical School, Athens, Greece
Critical Care 2013, 17(Suppl 2):P16 (doi: 10.1186/cc11954)
Introduction Some cases of multiple trauma are rapidly deteriorating;
the mechanism was investigated.
Methods Forty-one rabbits were assigned into two groups;
shamoperated and subject to crush of the right femur. Survival was
recorded; peripheral blood was sampled for LPS measurement by the
kinetic QCL-1000 LAL assay; quantitative tissue growth was assessed
after death. Some rabbits were sacrificed at 48 hours; blood was
sampled from the portal vein for LPS measurement; splenocytes were
isolated and incubated for 24hours in the presence of 10 ng/gl LPS of
Escherichia coli O55:B5 and of 5g/ml phytohemagglutin (PHA); TNF
was measured in supernatants by a bioassay on L929 fibroblasts.
Results Fifty percent of rabbits died early; that is, within the first
48 hours. Mean SE log10 bacteria in the liver and lung of animals
that died early was 2.270.62 and 3.160.78cfu/g; respective values
of rabbits that started dying late (that is, after 72 hours) were below
the limit of detection. Mean circulating LPS at 24hours was 2.09EU/
ml and 1.99 EU/ml respectively (P= NS). Mean LPS of the portal vein
of the sham and of the injury groups were 1.25 and 5.62 EU/ml (P =
0.047). Concentrations of TNF in splenocyte supernatants are shown
Conclusion Early death after injury is not related to peripheral
endotoxemia and sepsis; bacterial translocation priming for enhanced
proinflammatory responses is a likely explanation.
Introduction Adenosine exerts anti-inflammatory and tissue protective
effects during systemic inflammation. While the anti-inflammatory
properties may induce immunoparalysis and impede bacterial
clearance, the tissue protective effects might limit organ damage.
The effects of a common loss-of-function variant of the adenosine
monophosphate deaminase 1 gene (AMPD1), which is associated with
increased adenosine formation, in patients with sepsis are unknown.
Methods In a prospective cohort, genetic-association study, the
effects of the presence of the AMPD1 gene on immune function,
multiorgan dysfunction and mortality in septic patients was studied.
Pneumosepsis patients (n = 402) and controls without infection (n =
101) were enrolled.
Results In pneumosepsis patients and controls, a similar prevalence
of the 34C>T (rs17602729) mutation in the AMPD1 gene was found.
Univariate logistic regression analysis showed a tendency of increased
mortality in patients with the CT genotype, compared with patients
with the CC genotype (OR 1.53; 95% CI 0.95 to 2.5). Moreover, carriers of
the CT genotype tended to suffer more from multiorgan dysfunction,
OR 1.4 (0.84 to 2.3) and 3.0 (0.66 to 13.8), for CT and TT, respectively
(P= 0.07). In septic carriers of the CT genotype, the ex vivo production
of TNF by LPS-stimulated monocytes was attenuated (P = 0.005),
Figure 1 (abstract P17). KaplanMeier curve for the 402 sepsis patients.
indicative for more pronounced immunoparalysis in these patients.
Conclusion The presence the 34C>T variant of the AMPD1gene is not
related to infection susceptibility; however, it is associated with more
pronounced immunoparalysis in patients with sepsis, and shows
a tendency towards increased mortality. Mechanistically, the
antiinflammatory effects of adenosine may account for this and apparently
overrule its tissue protective effects.
Exploring the translational disconnect between the murine and
human inflammatory response: in vitro analysis of the dose
response relationship of LPS and NFB activation in murine and
human immune cells
EPMcCarron, IWelters, DWilliams, DAntoine, AKipar
University of Liverpool, UK
Critical Care 2013, 17(Suppl 2):P18 (doi: 10.1186/cc11956)
Introduction Inflammation, as seen in sepsis and systemic inflammatory
response, is dependent on the activation of the NFB pathway through
Toll-like receptors (TLRs) . Recreating an inflammatory response
using lipopolysaccharide (LPS) can provide results that are different to
clinical sepsis . By examining NFB activation in murine and human
cells, a species comparison can be made to investigate differences at
the cell level that may contribute to the translational disconnect seen
Methods THP1 human monocytes (passages 9 to 11) and RAW 264.7
murine macrophages (passages 15 to 20) were cultured in RPMI-1640
and DMEM respectively and then challenged with LPS. After settling
for 24 hours, cells were dosed with six or seven doses of LPS. After
1hour, nuclear extraction and proteins were separated by acrylamide
gel electrophoresis. Membranes where then immunoblotted for actin
and p65, followed by densitometric analysis in order to quantify the
amount of p65 that had translocated from the cytoplasm to the nucleus
(by subtraction from consistent nuclear actin).
Results Murine cells required higher doses of LPS compared with
human cells in order to detect p65 (human, 1 pg/ml to 100 ng/ml;
murine, 30 pg/ml to 1,000 ng/ml). THP1 cells showed a greater fold
increase in the p65:actin ratio compared with RAW 264.7 cells. Human
cells responded to lower concentrations of LPS. Murine cells appeared
to show a molecular resistance to lower doses, but their response was
very sensitive at higher doses. A doseresponse relationship of LPS
dosing and NFB activation was observed in both cell lines.
Conclusion Immunoblotting for p65 is a reliable and reproducible
method to determine NFB activation in cultured cells. Macrophages
are more responsive to LPS than monocytes  so differences between
cell lines would have been expected to be the reverse of what was
observed. The species difference in response to LPS may contribute
to the apparent disconnect between human and murine responses to
LPS and may partially explain the difficulties of translating therapeutic
interventions into clinical human sepsis.
1. Bonizzi G, Karin M: Trends Immunol 2004, 25:280-288.
2. Remick DG, Ward PA: Shock 2005, 24(Suppl 1):7-11.
3. Takashiba S, et al.: Infect Immun 1999, 67(11):5573-5578.
Introduction Hypogammaglobulinemia has been frequently found
in adult patients with severe sepsis and septic shock. Furthermore, it
seems that at least a low serum level of IgM is correlated with higher
mortality in sepsis. The mechanisms of hypogammaglobulinemia in
septic shock have not yet been explained. It has been hypothesized
that outflow of immunoglobulins into the extravascular space due to
increased capillary permeability could reduce immunoglobulin serum
concentrations. Angiopoietin-2, which directly disrupts the endothelial
barrier, is markedly elevated in sepsis and other inflammatory states
and its serum level has been correlated with microvascular leakage,
end-organ dysfunction and death in sepsis.
Methods In the prospective, noninterventional study, we assessed the
correlation between the capillary leakage marker angiopoetin-2 and
serum levels of IgG and IgM in 41 patients with community-acquired
severe sepsis or septic shock on admission. Blood samples were
obtained during the first 12 hours after admission to hospital.
Results Mean age of patients (17 females) was 70 years. Median
APACHE II and SOFA scores at admission were 24 and 11, respectively.
The mortality rate was 45%. Thirty-four percent of all patients had level
of IgG <650mg/dl. The median concentration of angiopoietin-2 in the
hypo-IgG group was 11,958pg/ml, which was not statistically different
(MannWhitney; P >0.05) than in the rest of patients with normal levels
of IgG (15,688 pg/ml). The concentration of IgM <40 mg/dl was found in
only four patients (10%) and all died. Pearsons correlation test showed
that the correlation between the concentrations of angiopoietin-2
and IgG (correlation coefficient 0.191) or IgM (correlation coefficient
0.0408), respectively, were not statistically significant (P<0.05).
Conclusion At present the hypothesis that increased microvascular
leakage is responsible for hypogammaglobulinemia in septic patients
could not be accepted. Studies on larger number of patients are
needed. In addition, it is necessary to further explore other possible
mechanisms, such as increased catabolism and consumption of
antibodies or inadequate synthesis of immunoglobulins, which could
also be responsible for hypogammaglobulinemia in sepsis.
1. Taccone FS, et al.: Gamma-globulin levels in patients with communityacquired septic shock. Shock 2009, 32:379-385.
2. Werdan K, et al.: Score-based immunoglobulin G therapy of patients with sepsis: the SBITS study. Crit Care Med 2007, 35:2693-2701.
TREM-1 levels are elevated in patients with liver cirrhosis
SDGurney1, CRGraham2, PKelleher2, NSoni1, MFoxton1, SSingh1
1Chelsea and Westminster Hospital, London, UK; 2Imperial College, London, UK
Critical Care 2013, 17(Suppl 2):P20 (doi: 10.1186/cc11958)
Introduction Sepsis and spontaneous bacterial peritonitis (SBP) are
common sequelae in patients with cirrhosis. Cirrhotics admitted
Figure 1 (abstract P20). TREM-1 expression in healthy controls compared with cirrhotic patients.
to the ICU have an in-hospital mortality of up to 50% . Microbial
translocation (MT) is the pathogenic mechanism implicated in SBP. The
triggering receptor expressed by myelocytes-1 (TREM-1) modulates
the immune response with resultant production of proinflammatory
cytokines and has been used as a biomarker in the diagnosis of bacterial
infection. We wish to evaluate the role of TREM-1 as a biomarker in
Methods Blood samples were obtained from 18 healthy controls (HC)
and 29 cirrhotic patients (CA) as defined by clinicoradiological criteria.
Disease severity was graded according to ChildPugh class (median
10, range 5 to 13) and modified end-stage liver disease (MELD) score
(median 14, range 6 to 21). Simultaneous ascitic fluid samples were
taken from 10 patients in the CA group. Soluble TREM-1 and CD14 levels
(a surrogate marker of MT) were measured by ELISA. Flow cytometry
was used to quantify the expression of TREM-1 on monocytes and
neutrophils in blood and ascitic fluid.
Results TREM-1 expression is significantly higher in the CA group
compared with HC across all monocyte subsets but not neutrophils,
even in the absence of sepsis (see Figure 1). There is no correlation
between cell surface TREM-1 expression and severity of cirrhosis by
ChildPugh or MELD score. sTREM and sCD14 levels were elevated in
the CA group compared with HC (P= 0.0010 and 0.0016 respectively).
In addition, plasma sTREM-1 levels correlated with disease severity
according to MELD score (R= 0.71, CI= 0.22 to 0.92 P= 0.012) and serum
bilirubin (R= 0.78,CI= 0.36 to 0.94, P= 0.004). There was no correlation
with either form of TREM-1 with sCD14 levels. There was no difference
in cell surface or soluble TREM-1 expression between blood and ascitic
fluid monocytes in culture-negative, non-neutrophilic ascites.
Conclusion Blood monocyte and soluble TREM-1 are elevated in
cirrhotic patients even in the absence of sepsis. Soluble TREM-1 levels
correlate with disease severity in cirrhosis. Further studies are ongoing
to ascertain the utility of TREM-1 as a biomarker in cirrhosis.
1. Olson JC, et al.: Intensive care of the patient with cirrhosis. Hepatology 2011, 54:1864-1872.
Introduction The bloodbrain barrier (BBB) is highly restrictive of
the transport of substances between blood and the central nervous
system. Lipopolysaccharide (LPS) from Gram-negative bacteria was
reported to affect the permeability of the BBB. BBB disruption using a
LPS is used as a model of septic encephalopathy in mice. The present
study was designed to investigate the effects of different doses and
serotypes of LPS on BBB integrity in SpragueDawley rats.
Methods Male SpragueDawley rats weighing 200 to 250 g were
used in the study. Rats were given two different types of LPS
(026:B6L5543 and 026:B6-L2762) in different doses (3, 5, and 10 mg/kg; i.v.).
Rectal temperature and arterial blood pressure measurements were
recorded for sepsis severity. The changes in the BBB permeability were
measured using the Evans blue (EB) and sodium fluorescein (NaFl) dye
extravasation techniques 24hours after LPS administration.
Results Both LPS serotypes showed comparable arterial blood pressure
and rectal temperature recordings and the severity of the disease
increased with the increasing doses (5 mg/kg and 10 mg/kg) of LPS
and the mortality rates were found to be 29% and 63% respectively.
The extravasated contents of EB and NaFl tracers did not significantly
increase in brain parenchyma following the administration of different
doses of LPS with different serotypes.
Conclusion Our results showed no disruption to BBB by two different
serotypes of LPS even administered in increasing doses. These result
indicate that the BBB integrity of SpragueDawley rats are resistant to
the effects of two different serotypes of LPS.
Bioenergetic imbalance and oxidative stress in the pathophysiology
of septic encephalopathy
JDAvila1, RRodrigues2, HCastro-Faria-Neto1, MOliveira3, FBozza4
1Oswaldo Cruz Foundation FIOCRUZ, Rio de Janeiro, Brazil; 2Federal
University of Rio de Janeiro (UFRJ) and DOr Institute for Research and
Education (IDOR), Rio de Janeiro, Brazil; 3UFRJ, Rio de Janeiro, Brazil; 4Oswaldo
Cruz Foundation FIOCRUZ and IDOR, Rio de Janeiro, Brazil
Critical Care 2013, 17(Suppl 2):P22 (doi: 10.1186/cc11960)
Introduction Septic encephalopathy is a frequent complication in
severe sepsis but its pathogenesis and mechanisms are not fully
understood. Oxygen supply and utilization are critical for organ
function, especially for the brain, a tissue extremely dependent on
oxygen and glucose. Disturbances in oxygen utilization are common
in sepsis and a number of mitochondrial dysfunctions have been
described in different tissues in septic animals as well as in septic
patients. Our group described mitochondrial dysfunctions in the brain
during experimental sepsis.
Methods Experimental sepsis was induced by endotoxemia (LPS 10 mg/
kg i.p.) in SpragueDawley rats and by polymicrobial fecal peritonitis in
Swiss mice. Brain glucose uptake was observed in vivo in endotoxemic
rats using positron emission tomography with [18F]fluorodeoxyglucose
and autoradiography with 2-deoxy-14C-glucose.
Results Mice with polymicrobial sepsis present hypoglycemia,
hyperlactatemia and long-term cognitive impairment. We observed
a rapid increase in the uptake of fluorescent glucose analog
2-deoxy2-((7-nitro-2,1,3-benzoxadiazol-4-yl)amino)-D-glucose in brain slices
from septic mice in vitro. A similar increase in brain glucose uptake
was observed in vivo in endotoxemic rats. Remarkably, the increase
in glucose uptake started 2 hours after LPS injection, earlier than
other organs. The brains of mice with experimental sepsis presented
neuroinflammation, mitochondrial dysfunctions and oxidative stress,
but mitochondria isolated from septic brains generated less ROS in
vitro in the first 24hours. This led us to investigate the role of NADPH
oxidase, an enzyme induced during innate immune response, as a
potential source of reactive oxygen species in experimental sepsis.
Inhibiting NADPH oxidase with apocynin acutely after sepsis prevented
cognitive impairment in mice.
Conclusion Our data indicate that a bioenergetic imbalance and
oxidative stress is associated with the pathophysiology of septic
encephalopathy. We are observing a new metabolic phenotype in
the brain during sepsis, characterized by a rapid increase in glucose
uptake and mitochondrial dysfunctions that may be secondary to
inflammation and hypoxia.
Introduction Pathophysiology of brain dysfunction associated
with sepsis is still poorly understood. Potential mechanisms involve
oxidative stress, neuroinflammation and bloodbrain barrier
alterations. Our purpose was to study the metabolic alterations and markers
of mitochondrial dysfunction in a clinically relevant model of septic
Methods Twelve anesthetized (midazolam/fentanyl/pancuronium),
invasively monitored, and mechanically ventilated pigs were allocated
to a sham procedure (n= 5) or sepsis (n= 7), in which peritonitis was
induced by intra-abdominal injection of autologous feces. Animals
were studied until spontaneous death or for a maximum of 24 hours.
In addition to global hemodynamic and laboratory assessment,
intracranial pressure and cerebral microdialysis were assessed at
baseline, 6, 12, 18 and 24 hours after sepsis induction. After death,
brains were removed and brain homogenates were studied to assess
markers of mitochondrial dysfunction.
Figure 1 (abstract P23).
Results All septic animals developed a hyperdynamic state associated
with lower arterial pressure, fever and organ dysfunction in comparison
with control animals. In the septic animals, we observed increased
brain dialysate glutamin levels at 12, 18 and 24 hours after sepsis
induction, as compared with control animals. Moreover, after analyzing
homogenates from the frontal cortex, we found higher concentrations
of glutamin and glutamate in septic as compared with control
animals (85.67 14.98 vs. 28.77 7.0; P = 0.01 and 132.1 19.72 vs.
53.3316.83; P= 0.02, respectively). See Figure1.
Conclusion We found higher concentrations of glutamate and
glutamin in brain tissues of septic animals as compared with control.
Furthermore, glutamin concentrations increased over time in the
extracellular space as measured by cerebral microdialysis. These
findings suggest an increased excitatory state that is potentially
associated with high energy expenditure. However, associations with
neuronal injury need further study.
Cholinergic modulation of hippocampal activity during septic
AZivkovic1, CPBengtson2, OSedlaczek1, RVonHaken1, HBading2, SHofer1
1Universittsklinikum Heidelberg, Germany; 2Universitt Heidelberg, Germany
Critical Care 2013, 17(Suppl 2):P24 (doi: 10.1186/cc11962)
Introduction Septic encephalopathy is a sepsis-related brain
dysfunction with a deterioration of cortical functions. The experimental
studies in the rat brain revealed a deranged neurotransmitter profile
during septic encephalopathy. Glutamatergic synapses, essential in
learning and memory, undergo use-dependent changes in synaptic
strength, referred to as plasticity. Permanent strengthening of synapses
after a brief stimulus, termed long-term potentiation (LTP), was
discovered in the hippocampus, and here it has been most thoroughly
studied. Cholinergic neurotransmission plays an important role in
regulating the cognitive functions of the brain. It acts as a
signal-tonoise ratio modulator of sensory and cognitive inputs. The irregularities
in brain functions give rise to the symptoms of delirium, including
disorganized thinking and disturbances of attention and consciousness,
which in turn might affect learning and memory. Possible mechanisms
for cholinergic deficiency include impairment of synaptic functions
of acetylcholine. Imbalances in the cholinergic system during sepsis
might therefore play an extensive role in the septic delirium.
Methods By using MRI imaging we identified functional changes in the
hippocampal region of patients with severe sepsis. This finding was
further supported by the experimental recordings in the rat brains of
lipopolysaccharide (LPS)-treated rats using the electrophysiological
patch clamp technique.
Results Critically ill ICU patients diagnosed with septic delirium using
the CAM-ICU method underwent diagnostic MRI scans. The serial MRI
analysis revealed increased signal intensity in the hippocampal region
in diffusion-weighted MRI (DWI). We used endotoxemia model to induce
sepsis in the rats. Electrophysiological analysis of the hippocampal
neurons in LPS-treated rats showed impaired LTP in the excitatory
synapses, as compared with controls. Application of physostigmine, a
bloodbrain barrier permeable cholinesterase inhibitor, resulted in a
partial recovery of LTP in the hippocampal synapses of LPS-treated rats.
Conclusion The patients with septic delirium show functional changes
in the hippocampus. Furthermore, we show that endotoxemia affects
synaptic plasticity in the rat hippocampus, suggesting the involvement
of this brain region in the pathophysiology of septic delirium. Moreover,
the effect of the cholinergic neurotransmission onto the induction
and maintenance of synaptic plasticity in the rat hippocampus during
endotoxemia suggests that cholinergic neurotransmission might play a
critical role in septic encephalopathy.
Introduction The neutrophillymphocyte count ratio (NLCR) is an
easy to analyse biomarker reacting very early in the course of acute
inflammation. It has previously been reported to correspond to
bacteremia and recently to disease severity in community-acquired
pneumonia . We have looked at 205 consecutive patients with
Escherichia coli infections (ECI) and found the same to be true for
ECIs. This may be of great clinical importance since E. coli is the most
frequently isolated pathogen in patients with infections requiring in
Methods This study is part of a 9-month consecutive study of
community-acquired severe sepsis and septic shock in adults at
Skaraborg Hospital in the western region of Sweden. The hospital
serves a population of 256,000 inhabitants and has approximately
60,000 annual visits to the ED. All patients admitted to the hospital
receiving intravenous antibiotic treatment within the first 48 hours
of admission were evaluated for severe sepsis and septic shock. Upon
admission, two sets of blood cultures and other relevant cultures were
obtained from each patient as well as sampling for NLCR and venous
plasma lactate. The patient records were evaluated by one infectious
diseases specialist. Approximately 2,300 patients were diagnosed
as having a bacterial infection. From those, an informed consent to
participate in the study could be obtained from approximately 1,600
Results Of the 1,600 patients who gave consent to participate in the
study, 205 had an ECI. Sixty-four had a positive blood culture for E. coli.
Fifty of the patients met one or more criteria for severe sepsis or septic
shock. The NLCR was significantly higher (P<0.001) within the severe
sepsis group (median= 21.1 with quartiles 11.1 to 42.4) compared with
the group with no severe sepsis (median = 11.6 with quartiles 7.6 to
Conclusion The NLCR can be used as a biomarker of disease severity
even in ECIs. The biomarker reacts rapidly, is cheap and needs no extra
sampling. The higher the value, the higher the probability for severe
sepsis. A high value can even precede the development of severe
sepsis or septic shock. However, a low value never excludes neither
bacteremia nor severe sepsis. The method cannot be used in patients
with disturbances in neutrophil or lymphocyte levels due to other
causes than sepsis.
1. de Jager C, et al.: The neutrophillymphocyte count ratio in patients with
community acquired pneumonia. PLoS ONE 2012, 7:e46561.
Introduction Chronic inflammation has recently been recognized as
an important factor in the pathophysiology of obesity and associated
morbidities . In this clinical study we aimed at identifying possible
effects of obesity on inflammatory markers in severe sepsis.
Methods With institutional ethical committee approval, 243
consecutive patients treated for severe sepsis or septic shock in the
ICUs of two university hospitals over a period of 5 months were studied.
Six patients were excluded due to cachexia, syndromal disorders or
missing clinical data. Diagnosis of sepsis was made according to SCCM
criteria. Serum levels of C-reactive protein (CRP, mg/l) and procalcitonin
(PCT,ng/ml) on day 1 of sepsis were compared among five body mass
index (BMI) strata according to WHO definitions. Two groups (BMI <30,
normal weight, and BMI 30, obesity) were formed for further analysis,
and PCT was logarithmically transformed (LogPCT), resulting in normal
distribution. Statistical analysis was performed using a t test.
Results Patients with BMI 30 had higher values of PCT and CRP
(Table 1). The difference in LogPCT was of borderline significance (P=
0.052). However, patients with positive blood cultures had significantly
higher LogPCT values (P= 0.017) (Figure 1). Difference in CRP was not
significant (P= 0.09). The trends over all five BMI strata (Table 1) were
Conclusion Obesity with BMI 30 seems to be associated with an
increase in inflammatory markers in patients with severe sepsis,
particularly in bacteraemia. The role of adipose tissue in severe sepsis
should therefore be studied in more detail.
1. Wellen K, et al.: Inflammation, stress, and diabetes. J Clin Invest 2005, 115:1111-1119.
Table 1 (abstract P26). PCT and CRP as median (IQR)
Figure 1 (abstract P27). Cytokine mRNA levels in trauma (time 0) and control groups.
Figure 1 (abstract P26).
Introduction Identifying a group of patients at high risk of developing
infectious complications is the first step in the introduction of effective
pre-emptive therapies in specific patient groups. Quantifying cytokine
gene expression also furthers our understanding of trauma-induced
immunosuppression. Our group has already demonstrated that a
predictive immunological signature derived from mRNA expression in
elective thoracic surgical patients accurately predicts pneumonia risk .
Methods In total, 121 ventilated polytrauma patients were recruited.
mRNA was extracted from PaxGene tubes collected within 2 hours
of the initial insult, at 24 and 72 hours. T-helper cell subtype specific
cytokines and transcription factors mRNA was quantified using qPCR.
Ten healthy controls served as a comparator.
Results The Median Injury Severity Score (ISS) was 29. Time 0 bloods
demonstrated a reduction in TNF, IL-12, IL-23, RORT* and T bet, and
an increase in IL-10* and IL-4 mRNA levels in comparison with the control
group (*P<0.0001, P<0.001 to 0.0001, P<0.01 to 0.001, P<0.05 to 0.01).
There was a positive correlation between ISS and IL-10 whilst both IL-23
and RORT were negatively correlated at time 0. TNF, IL-10* and IL-27
increased and IFN, IL-12*, IL-17A, RORT* and T bet* mRNA levels
decreased over the initial 24 hours. Subsequent bacteraemia (18/121
patients) was associated with a lower TNF/IL-10 ratio at baseline.
Similarly, higher IL-10 and lower T bet mRNA at 24 hours also predicted
later bacteraemic episodes. Development of pneumonia followed a
similar pattern. A multivariate logistical regression model proved highly
accurate in predicting infectious complications from mRNA analysis of
early blood samples. See Figure1.
Conclusion Cytokine gene expression patterns indicate an immediate
and sustained impairment in Th1, Th17 and innate immunity with
concurrent upregulation of the Th2 response following major trauma.
The magnitude of this response predicts subsequent infectious
1. White M, et al.: Chest 2011, 139:626-632.
Introduction The evaluation of sepsis severity is complicated by the highly
variable and nonspecific nature of clinical signs and symptoms. We studied
routinely used biomarkers together with clinical parameters to compare
their prognostic value for severe sepsis and evaluate their usefulness.
Methods A cohort study of 150 patients >18years with severe sepsis
according to the Surviving Sepsis Campaign, in an ICU of a university
hospital. Demographic, clinical parameters and coagulation, infection
and inflammation parameters during the first 24 hours from severe
sepsis or septic shock onset were studied. Descriptive and comparative
statistical analysis was performed using SPSS version 15.0 (SPSS Inc.,
Chicago, IL, USA).
Results We analyzed 150 consecutive episodes of severe sepsis (16%)
or septic shock (84%) in the ICU. The median age of the patients was
64 (interquartile range, 48.7 to 71) years; the main sources of infection
were intra-abdomen (45%) and respiratory (38%); 70.7% had medical
diseases. The 28-day mortality was 22.7%. The profile of death patients
were men (64.7%, n=22), with significantly higher average age (63 vs.
57 years; P= 0.049), as well as clinical severity scores, APACHE II (29.8 vs.
24.1; P<0.001) and SOFA (12.1 vs. 8.9; P<0.001) and major dysfunction
organ number (4.6 vs. 3.6; P<0.001). Bilirubin was the best predictor of
28-day mortality with the largest AUC (0.71), followed by hemoglobin
(0.69) and C3 (0.67). The multivariate logistic regression was adjusted
for three risk parameters, hemoglobin (OR: 0.68; 95% CI: 0.51 to 0.94),
bilirubin (OR:1.63; 95% CI: 1.08 to 2.45) and white blood cells (OR:1.04;
95% CI: 1.01 to 1.08) and with these parameters a ROC analysis was
performed, giving an AUC of 0.77 (0.69 to 0.84).
Conclusion The assessment of routine biomarkers (bilirubin, white
blood cells and hemoglobin) may be a helpful tool in the
decisionmaking process at the bedside, for the evaluation of early ICU admission
of recoverable patients, as indicators of inflammatory response, organ
dysfunction or catabolism level, and their significant predictive value
1. Glickman SW, Cairns CB, Otero RM, et al.: Disease progression in
hemodynamically stable patients presenting to the emergency
department with sepsis. Acad Emerg Med 2010, 17:383-390.
Introduction We analyze procalcitonin (PCT) as a prognostic marker, in
order to assess the clinical impact of a daily PCT measure.
Methods From November 2010 to November 2011 we collected clinical
data, drug administration, scores and PCT values of 420 consecutive
patients during hospitalization. Statistical analysis was made using
SPSS software. We calculated ICU mortality, 1-month mortality and
1-year mortality. Median percentage daily variation was calculated as:
(PCT day after PCT of the date value) / PCT of the date value100.
PCTvariation in the last 48hours of hospitalization was calculated as:
(PCT at discharge PCT at 48 hours before discharge)/ PCT 48hours
before discharge100. We compared peak values in dead patients
versus alive patients. A logistic regression was performed in order to
assess mortality odds ratio.
Results Of the 420 patients, 63 (15%) died in the ICU, 12 (2.86%) died
1 month after ICU discharge and 16 (3.80%) died 1 year after ICU
discharge. PCT values were higher during the last day of hospitalization
in dead patients versus alive patients. PCT percentage variation during
the last 48 hours of hospitalization had a slower trend in patients who
died than in those who survived; these differences are even more
marked in patients who had a septic event. A slower descending trend
of daily PCT values was found in patients who died than in those who
survived. PCT peak levels during the ICU stay were higher in dead
patients with respect to alive ones. At logistic regression analysis PCT
decrease in the last 48 hours <30% (OR 3.71), PCT peak higher than
10ng/ml (OR 2.38), and PCT last day/PCT peak ratio >50% (OR 2.064)
were ICU mortality risk factors. PCT values were a higher predictive ICU
mortality risk factor than SOFA and APACHE II scores. Other prognostic
factors were age and lactate values. Only age was a risk factor in
1-month and 1-year mortality.
Conclusion PCT is a good prognostic marker and is strongly correlated
to the clinical status and gravity of the patients, so PCT seems to be a
useful marker in an intensive care scenario.
1. Jensen JU, Heslet L, Jensen TH, et al.: Procalcitonin increase in early identification of critically ill patients at high risk of mortality. Crit Care Med 2006, 34:2596-2602.
2. Fritz HG, Brandes H, Bredle DL, et al.: Post-operative hypoalbuminaemia and
procalcitonin elevation for prediction of outcome in cardiopulmonary
bypass surgery. Acta Anaesthesiol Scand 2003, 47:1276-1283.
Introduction Although absolute values for C-reactive protein (CRP) and
procalcitonin (PCT) are well known to predict sepsis in the critically ill, it
remains unclear if and how changes in CRP and PCT predict evolution
of infectious disease and how they compare in this respect.
Methods In 72 critically ill patients with new-onset fever, CRP and
PCT were measured on day 0, 1, 2 and 7 after inclusion, and their
clinical course was documented over 1 week with follow-up to day 28.
Infection was microbiologically defined, as was bloodstream infection;
septic shock was defined as infection plus shock.
Results From peak at day 0 to 2 to day 7, CRP decreases most when
(bloodstream) infection and septic shock (day 0 to 2) resolve and
increases most when complications such as a new (bloodstream)
infection or septic shock (day 3 to 7) supervene (area under the receiver
operating characteristic curve 0.70 or higher, P = 0.04 or lower). PCT
decreases most when septic shock resolves (AUC 0.72, P= 0.007) and
increases most when a new bloodstream infection or septic shock
supervenes (AUC 0.82 or higher, P<0.001). The day 7 value of PCT rather
than of CRP was predictive for 28-day outcome (AUC 0.70, P= 0.005).
Conclusion The data, obtained during ICU-acquired fever and infections,
suggest that CRP and PCT changes predict the course of infectious
disease and its complications. CRP may be favoured over PCT courses
in decisions on appropriateness and duration of antibiotic treatment,
whereas PCT rather than CRP courses may help predicting complications
such as bloodstream infection, septic shock and mortality.
Introduction Differentiation of acute heart failure from infection in
patients with respiratory symptoms and a history of congestive heart
failure (CHF) is challenging due to overlap of clinical symptoms and
X-ray findings. The BACH study found higher mortality rates if patients
presenting with dyspnea were treated with antibiotics and their
procalcitonin (PCT) levels were low indicating absence of bacterial
infection. Yet the BACH study was observational and causal inference
cannot be drawn. Herein, we analyzed the effects of PCT-guided
antibiotic stewardship in CHF patients from a previous trial (ProHOSP).
Methods This is a secondary analysis of a previous randomized trial
of adult ED patients with respiratory symptoms and a history of CHF.
Patients were randomized to administration of antibiotics based on a
PCT algorithm (PCT group) or standard guidelines without knowledge
of PCT levels (control group). The primary endpoint of this analysis is
the risk of adverse outcome defined as death or ICU admission within
30 days after ED admission.
Results A total of 233 patients met the inclusion criteria, with 116 in
the PCT-guided group and 117 in the control group. In the subgroup
of patients with low initial PCT levels <0.25ng/l (n= 110), PCT-guided
patients had a significant reduction in antibiotic exposure (mean 3.7
vs. 6.5 days, difference 2.8 (95% CI 4.4, 1.2), P<0.001). Furthermore,
PCT-guided patients had a significant lower risk for death and ICU
admission (4% vs. 20%, odds ratio 6.0 (1.3, 28.2), P= 0.02). See Figure1.
Conclusion In CHF patients with suspicion of respiratory infection,
use of a PCT protocol resulted in a significant decrease of antibiotic
exposure and significantly improved outcomes in patients with low PCT
levels indicating absence of bacterial infection. Whether inadequate
antibiotic therapy in these CHF patients requiring diuretic treatment
explains this difference in clinical outcomes needs verification.
Introduction Pulmonary complications after cardiac surgery like ARDS
are frequent and linked to high mortality . Pro-adrenomedullin
(pro-ADM) has a possible role in the development of ARDS  and a
positive correlation between levels of pro-ADM and inflammation
was found . In this study we investigated whether intraoperative
and postoperative pro-ADM transpulmonary gradient could predict
Methods In this prospective cohort study, 39 patients undergoing
cardiac surgery using CPB were included. Blood was collected before
surgery (T0), after induction of anesthesia (T1), after termination of CPB
(T2), at ICU arrival (T3) and 3 hours (T4), 6 hours (T5) and 18 hours (T6)
after arrival. Pro-ADM was measured with a sandwich immunoassay.
Primary endpoints were length of ICU and hospital stay (ICU-LOS,
Results An increase of arterial and venous pro-ADM plasma
concentrations was observed after surgery. Immediately after termination of
CPB the venous concentration was significantly lower than arterial
proADM concentration, but at T6 the venous concentration was significantly
higher, indicating a switch from a negative to positive transpulmonary
gradient (Figure1). The pro-ADM venousarterial difference at T5 was a
significant predictor of ICU-LOS (P= 0.032) and the difference at T3 was a
significant predictor of hospital-LOS (P= 0.001).
Conclusion We found that the transpulmonary gradient of pro-ADM
was a predictor for ICU-LOS and hospital-LOS at T3 and T5, respectively.
Pro-ADM might be a promising marker for prediction on outcome of
patients undergoing cardiac surgery on CPB. The transpulmonary shift
of pro-ADM might be caused by an inflammatory response.
1. Apostolakis E, et al.: J Card Surg 2010, 25:47-55.
2. Kamei M, et al.: Acta Anaesthesiol Scand 2004, 48:980-985.
3. Ueda S, et al.: Am J Respir Crit Care Med 1999, 160:132-136.
Pro-adrenomedullin as prognostic biomarker in the sepsis
MDeLaTorre-Prados, AGarcia-DelaTorre, AEnguix, MMayor,
NZamboschi, CTrujillano-Fernndez, AGarcia-Alcantara
Hospital Virgen de la Victoria, Mlaga, Spain
Critical Care 2013, 17(Suppl 2):P33 (doi: 10.1186/cc11971)
Introduction Measurement of biomarkers is a potential approach to
early assessment and prediction of mortality in septic patients. The
purpose of this study was to ascertain the prognostic value of
proadrenomedullin (pADM), measured in all patients admitted to the ICU
of our hospital with a diagnosis of severe sepsis or septic shock during
Methods A cohort study of 117 patients >18 years with severe sepsis
according to the Surviving Sepsis Campaign, in an ICU of a university
hospital. Demographic, clinical parameters and pADM, C-reactive
protein and procalcitonin were studied during 1year. Descriptive and
comparative statistical analysis was performed using the statistical
software packages Statistica Stat Soft Inc 7.1 and MedCalc 22.214.171.124.
Results We analyzed 117 consecutive episodes of severe sepsis (15%)
or septic shock (85%) in the ICU. The median age of the patients was
64 (interquartile range, 53 to 72) years; the main sources of infection
were respiratory tract (46%) and intra-abdomen (21%). The 28-day
mortality was 32.5%. The profile of death patients had a significantly
higher average age (64.7 vs. 57.6 years; P = 0.024), as well as clinical
severity scores, APACHE II (26.6 vs. 23; P= 0.006) and SOFA (11.6 vs. 89.2;
P<0.001). KaplanMeier survival analysis was significant. P= 0.0017 for
patients with pADM <1.2 nmol/l. Cox regression analysis also showed
statistical significance (P= 0.0033) and a likelihood ratio= 1.18 per each
1nmol/l increase in pADM.
Conclusion The protein pADM is an important prognostic biomarker
of survival when measured on admission of septic patients to the ICU.
1. Pezzilli R, Barassi A, Pigna A, et al.: Time course of proadrenomedullin in the
early phase of septic shock. A comparative study with other
proinflammatory proteins. Panminerva Med 2012, 54:211-217.
2. Wang RL, Kang FX: Prediction about severity and outcome of sepsis by proatrial natriuretic peptide and pro-adrenomedullin. Chin J Traumatol 2010, 13:152-157.
Introduction IL-6, a proinflammatory cytokine, is synthesized from
fibroblasts, T lymphocytes, endothelial cells and monocytes. It serves as an
important mediator during the acute phase response to inflammation in
sepsis. We hypothesized that the plasma IL-6 is correlated with mortality
and severity scores in critically ill patients with sepsis.
Methods We conducted a prospective study of plasma IL-6 level at the
initial phase of sepsis and the risk of mortality. A total of 203 patients
with sepsis, who were admitted to the medical ICU at Phramongkutklao
Hospital, Bangkok during January to December 2011, were analyzed.
Serum IL-6, C-reactive protein (CRP), and lactate were measured within
the first 24 hours of ICU admission. Severity scores (APACHE II, SAP II,
and SOFA scores) were measured. The primary outcome variable was
28-day all-cause mortality.
Results We found that the overall 28-day mortality was 46% (93 out of 203
patients). There was a significantly positive correlation between mortality
rate and plasma IL-6 (survivors vs. nonsurvivors; 74 (4.4 to 1,718) vs. 206
(19 to 5,000)pg/ml, P<0.05), lactate (survivors vs. nonsurvivors; 1.65 (0.7
to 11.61) vs. 2.47 (0.94 to 19.13)mmol/l, P<0.05), but not CRP levels (P=
0.24). Compared with the patients with plasma IL-6 <100 pg/ml, septic
patients with IL-6 levels 100 were associated with an increased 28-day
mortality with the odd ratio of 2.99 (95% CI 1.42 to 6.29, P<0.05). We
also found that plasma IL-6 levels were well correlated with APACHE II
(P<0.05), SAPS II (P<0.05), and SOFA (P<0.05) scores.
Conclusion The initial phase plasma IL-6 levels were correlated with
severity and mortality in critically ill patients with sepsis.
1. Pathan N, et al.: Crit Care Med 2005, 33:1839-1844.
2. Harbarth S, et al.: Am J Respir Crit Care Med 2001, 164:396-402.
Compared values of presepsin (sCD14-ST) and procalcitonin as early
markers of outcome in severe sepsis and septic shock: a preliminary
report from the Albumin Italian Outcome Sepsis (ALBIOS) study
PCaironi1, SMasson2, ESpanuth3, RThomae4, RFumagalli5, APesenti5,
MRomero6, GTognoni6, RLatini2, LGattinoni1
1Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Universit
degli Studi di Milano, Milan, Italy; 2Istituto di Ricerche Farmacologiche Mario
Negri, Milan, Italy; 3Diagnostic Engineering & Research GmbH, Heildelberg,
Germany; 4Mitsubishi Chemical Europe GmbH, Munich, Germany; 5Ospedale
San Gerardo, Monza, Italy; 6Consorzio Mario Negri Sud, Santa Maria Imbaro,
Critical Care 2013, 17(Suppl 2):P35 (doi: 10.1186/cc11973)
Introduction Sepsis results from complex interactions between
infecting microorganisms and host responses, often leading to
multiple organ failures and death. Over the years, its treatment has
been standardized in early goal-oriented therapies, which may benefit
from circulating biomarkers for early risk stratification. We aimed to
evaluate the prognostic value of presepsin (sCD14-ST), a novel marker
of bacterial infection.
Methods We performed a nested casecontrol study from the
randomized controlled Albumin Italian Outcome Sepsis (ALBIOS)
trial, enrolling patients with severe sepsis or septic shock from 100
ICUs in Italy. Fifty survivors and 50 nonsurvivors at ICU discharge
were selected, matched for age, sex, center and time of enrollment
after inclusion criteria were present. EDTA-plasma samples were
collected at days 1, 2 and 7 after enrolment for presepsin
(immunechemiluminescence assay PATHFAST Presepsin, URL 320 pg/ml, CV 5%;
Mitsubishi Chemicals) and procalcitonin assay (PCT, Elecsys BRAHMS
Cobas PCT, URL 0.046ng/ml, CV 8.8%; Roche Diagnostics).
Results Clinical characteristics were similar between the two groups,
except for a worse SOFA score at day 1 in decedents. Presepsin at
day1 was significantly higher in decedents (2,268 (1,145 to 4,305) pg/
ml, median (Q1 to Q3)) than in survivors (1,184 (855 to 2,158) pg/ml,
P = 0.001), while PCT did not differ (18.5 (3.3 to 45.7) vs. 10.8 (2.6 to
46.4)ng/ml, P= 0.31). Presepsin decreased over time in survivors, but
remained elevated in decedents (974 (674 to 1,927) vs. 2,551 (1,438
to 5,624) pg/ml at day 7, P = 0.02 for timesurvival interaction); PCT
decreased similarly in the two groups (P = 0.19). Patients with early
elevated presepsin had worse SOFA score, higher number of MOFs,
hemodynamic instability (lower mean arterial pressure at baseline
and after 6 hours), and mortality rate at 90 days (75% vs. 42%,
logrank P<0.001). The association between presepsin and outcome was
more marked in patients with late enrollment (6 to 24 hours), and in
septic shock. Early presepsin had better prognostic accuracy than PCT
(AUROC 0.69 vs. 0.56, P= 0.07), and improved discrimination over SOFA
score, especially in septic shock.
Conclusion Early presepsin measurements may provide important
prognostic information in patients with severe sepsis or septic shock,
and may be of crucial importance for early risk stratification.
Introduction The level of presepsin is useful for differentiating sepsis
from noninfectious systemic inflammatory response syndrome. It has
been reported that the presepsin levels in patients with chronic renal
failure are abnormally high. However, there are no studies investigating
the usefulness of presepsin for diagnosis of sepsis in patients with acute
kidney injury (AKI). Our purpose of this study is to clarify the diagnostic
accuracy of presepsin in patients with AKI and the relationship between
presepsin level and AKI severity.
Methods This study was conducted as a single-center retrospective
study. Blood samples were collected from patients admitted to the
emergency room at Fukuoka University Hospital between June 2010
and October 2012. We enrolled 254 patients with suspected sepsis and
other disease patients. We classified the patients into an AKI group
according to the RIFLE criteria (Risk n= 52, Injury n= 39, Failure n= 41,
Loss of kidney function and End-stage kidney disease n= 7) and a
nonAKI group (n= 115). The AKI patient group was further classified into a
sepsis group and a nonsepsis group in each AKI stage and we analyzed
the diagnostic accuracy of presepsin in patients with sepsis.
Results For the non-AKI patients, the median of presepsin in patients
with nonsepsis (n= 78) and the sepsis group (n= 37) were 406pg/ml
(range: 86 to 4,374) and 1,065pg/ml (range 86 to 9,960), respectively
(P<0.0001). For the Risk patients, the median of presepsin in patients
with nonsepsis (n= 25) and the sepsis group (n= 27) were 299pg/ml
(range: 71.2 to 3,361) and 831pg/ml (range: 233 to 16,759), respectively
(P<0.01). For the Injury patients, the median of presepsin in patients
with nonsepsis (n= 12) and the sepsis group (n= 27) were 463pg/ml
(range: 122 to 1,197) and 1,451pg/ml (range: 237 to 4,200), respectively
(P<0.001). For the Failure patients, the median of presepsin in patients
with nonsepsis (n= 14) and the sepsis group (n= 27) were 1,607pg/ml
(range: 454 to 8,516) and 1,523pg/ml (range: 293 to 16,764), respectively
(P= 0.175). The diagnostic accuracy of presepsin in patients with sepsis
was determined by ROC analysis, the area under the curve was 0.789
for the non-AKI patient group, 0.735 for the Risk patient group, 0.855 for
the Injury patient group and 0.593 for the Failure patient group.
Conclusion In Failure and more progressed AKI patients, the diagnostic
accuracy of the presepsin level was lower than the other groups.
1. Endo S, et al.: J Infect Chemother 2012, 18:891-897.
2. Bellomo R, et al.: Crit Care 2004, 8:R204-R212. doi:10.1186/cc2872
Introduction As a method for the diagnosis of sepsis, we previously
reported an ELISA method for measuring the serum levels of presepsin.
That method, however, took approximately 2 hours to yield results.
Methods To resolve this problem, we later developed a simplified
assay kit making use of immunochromatography (Point of Care test;
POC test), and are currently evaluating the usefulness of this kit for
diagnosis of sepsis and evaluation of its severity. In 21 septic patients
with sepsis, we analyzed the serum levels of presepsin in relation to
APACHE II and SOFA scores.
Results APACHE II and SOFA scores at baseline were 28.7 7.5 and
10.8 3.9, respectively, in these patients. These were significant
correlations between the serum presepsin levels and the APACHE II
score, and also between the serum presepsin levels and the SOFA score.
Conclusion Furthermore, there was also a significant correlation
between the results of the POC test and the serum presepsin levels.
These results indicate that measurement of the serum presepsin might
be useful for evaluating the severity of sepsis.
Relationship between serum nitrite/nitrate levels in the early phase
of septic acute lung injury and prognosis
MSato, YSuzuki, TMasuda, GTakahashi, MKojika, YInoue, SEndo
Iwate Medical University, Morioka, Japan
Critical Care 2013, 17(Suppl 2):P38 (doi: 10.1186/cc11976)
Introduction Serum nitrite/nitrate (NOx) levels in the early phase of
septic acute lung injury (ALI)/acute respiratory distress syndrome
(ARDS) have recently been reported to possibly play a key role in
pathogenesis of ALI/ARDS.
Methods NOx levels in the early phase of septic ALI/ARDS were
measured by autoanalyzer (TCI-NOX 1000; Tokyo Kasei Kogyo Co., Ltd,
Tokyo, Japan). Cytokine was measured by ELISA (Medogenix, Fleurus,
Results Both NOx and TNF levels were significantly higher in the ARDS
group than in the ALI group. A negative correlation was found between
the PaO2/FIO2 (P/F) ratio and serum NOx levels. In addition, a positive
correlation was found between the TNF and serum NOx levels. The
30-day, 60-day and 90-day mortality rates were 8.7%, 15.2% and 19.6%,
respectively, in the patients with ALI/ARDS. There were no differences
in the P/F ratio, serum NOx levels or TNF levels in the early phase
of ALI/ARDS between the 30-day survival and death groups. On the
other hand, the P/F ratio, serum NOx levels and TNF levels in the early
phase of ALI/ARDS were significantly higher in the 60-day and 90-day
death groups than in the corresponding survival groups. There were
no significant differences in the 90-day mortality rates between the ALI
and ARDS groups.
Conclusion Our findings suggested that NOx may be involved in the
pathogenesis of ALI/ARDS.
Introduction Ruling out Legionella sp. in patients presenting with
community-acquired pneumonia (CAP) is important due to differences
in treatment regimens. Yet antigen tests as well as blood cultures have
low sensitivity and an important time delay, making empirical broad
spectrum coverage necessary particularly in severe cases. Fiumefreddo
and colleagues recently proposed a clinical score based on six clinical
and laboratory variables (fever, cough, sodium, lactate-dehydrogenase,
C-reactive protein, platelet count) which allowed assessing the
likelihood of Legionella . Yet these variables need validation in
an independent patient cohort before implementation into clinical
Methods We analyzed data from a large multinational database of
patients with CAP (CAPO)  between 2001 and 2012. We performed
logistic regression analysis and the area under the receiver operating
characteristics (AUC) curve to study the association of these variables
with the diagnosis of Legionella.
Results Data for 8,278 CAP patients were analysed; the infectious
organism was known in 2,321 cases (28%), including a total of 101
patients with urinary antigen-confirmed Legionnaires disease and
983 patients with confirmed pneumococcal disease. All variables were
predictors for Legionella with odds ratios ranging from 1.002 to 5.767.
Combining the variables in a joint logistic regression model showed a
high predictive accuracy with an AUC of 0.86.
Conclusion This analysis validates the Legionella score in an
independent sample and shows high diagnostic accuracy. Interventional
trials with adapted antibiotic regimes for non-inferiority in a real live
population are warranted.
1. Fiumefreddo R, Zaborsky R, Haeuptle J, et al.: Clinical predictors for
Legionella in patients presenting with community-acquired pneumonia
to the emergency department. BMC Pulm Med 2009, 9:4.
2. Ramirez JA: Fostering international multicenter collaborative research: the CAPO Project. Int J Tuberc Lung Dis 2007, 11:1062-1065.
Introduction It has been shown that polymorphic variants at some
host genes can modify risk of community-acquired pneumonia (CAP),
including those critical for the host response to CAP innate immune
system, the lungs defense against inhaled microorganisms, and
inhibition of fibrinolysis and the reninangiotensin system. The aim of
the study was to analyze polymorphisms in genes potentially relevant
to CAP pathogenesis mechanisms to reveal novel and confirm reported
genetic risk factors in the general Russian population.
Methods Patients with CAP (n = 334), volunteers without a previous
history of CAP, control group A (n = 141) and a second control
group B (n = 314) were included in the study. Using allele-specific
tetraprimer PCR, all subjects were genotyped for 13 polymorphic
variants in the genes of xenobiotic detoxification CYP1A1 (rs2606345,
rs4646903, rs1048943), GSTM1 (Ins/Del), GSTT1 (Ins/Del), ABCB1
(rs1045642); immune and inflammation response IL-6 (rs1800795),
TNF (rs1800629), MBL2 (rs7096206), CCR5 (rs333), NOS3 (rs1799983),
angiotensin-converting enzyme (ACE; rs4340), and occlusive vascular
disease/hyperhomocysteinemia MTHFR (rs1801133).
Results Seven genes CYP1A1 rs2606345T/T, GSTM1 Ins/*, ABCB1
C/C, IL-6 C/C-G/G, NOS3 T/T-G/G, CCR5 Ins/Ins, and ACE Del/Del were
associated with CAP. The highest effect was detected for the CYP1A1
rs2606345: in comparison with the control A, P = 3.9105, OR =
2.40, 95% CI: 1.59 to 3.64; and in comparison with the control B, P =
1.4105, OR= 2.0, 95% CI: 1.46 to 2.74. For the two genes CYP1A1 and
GSTM1, associations remained significant after correction for multiple
comparisons. Multiple analysis by the number of all risk genotypes
showed a highly significant association with CAP (P = 2.4107, OR =
3.03, 95% CI 1.98 to 4.64) with the threshold for three risk genotypes.
Using the ROC analysis, the AUC value for multi-locus model was
estimated as 68.38, which is rather high for genetic markers.
Conclusion We have provided the first experimental evidence for the
associations of genes coding detoxification enzymes with the risk of
CAP. Our results also demonstrate that predisposition to CAP is strongly
attributed to the effects of a number of genes with low penetrance
and therefore imply that inter-locus interactions may be regarded as
an important component of polygenic and multifactorial factors of
susceptibility to CAP.
Outcome of severe community-acquired pneumonia: the impact of
JMPereira1, JAPaiva1, FFroes2, JPBaptista3, JGonalves-Pereira4
1Centro Hospitalar S. Joo, Porto, Portugal; 2Hospital Santa Maria-CHLN,
Lisboa, Portugal; 3Hospitais da Universidade de Coimbra CHUC, Coimbra,
Portugal; 4Hospital So Francisco Xavier, Lisboa, Portugal
Critical Care 2013, 17(Suppl 2):P41 (doi: 10.1186/cc11979)
Introduction Several comorbidities have been independently
associated with both predisposition to community-acquired pneumonia
and a worse outcome. The goal of this study was to evaluate the impact
of comorbidities on the outcome of patients with severe
communityacquired pneumonia (SCAP).
Methods A prospective, multicentre, observational cohort study of
all patients with SCAP consecutively admitted to 14 Portuguese ICUs
during a 12-month period. Several comorbidities were evaluated:
congestive heart failure, cancer, chronic renal failure, chronic
respiratory failure, chronic hepatic disease, alcoholism, diabetes mellitus,
neurologic disease, immunosuppression, HIV infection. To evaluate the
impact of comorbidities associated with hospital mortality in univariate
analysis, a logistic regression analysis adjusted to other variables
(clinical relevant or statistically significant in univariate analysis) was
Results A total of 536 (14%) of the 3,766 enrolled patients had SCAP.
They were mostly male (66%) with median age 59 (29 to 82) years,
median SAPS II 44 (21 to 80) and total SOFA score 8 (3 to 16).
Thirtyseven per cent of the cases were microbiologically documented (St.
pneumoniae 24%; Enterobacteriaceae 20%; influenza A (H1N1)
virus 18%) and 45% had septic shock. Antibiotic combination was
used in 76% of the patients and 61% received a macrolide. Median
hospital length of stay was 19 (3 to 70) days and hospital mortality
was 35%. Comorbidities were present in 70% of the patients. The most
frequent were: diabetes mellitus (21%), chronic respiratory failure
(18%) and alcoholism (15%). Median Charlsons comorbidity index
(CCI) was 4 (0 to 13). In univariate analysis, the presence of at least one
comorbidity (odds ratio (OR) 2.29; 95% CI 1.49 to 3.52), namely cancer
(OR 3.80; 95% CI 2.14 to 6.74; P<0.001), chronic renal failure (OR 3.23;
95% CI 1.53 to 6.82; P= 0.001), immunosuppression (OR 2.12; 95% CI
1.15 to 3.92; P= 0.014) and neurologic disease (OR 1.87; 95% CI 1.10 to
3.17; P= 0.02), increased the chances of dying in the hospital. Median
CCI was also significantly higher in nonsurvivors (5 vs. 3; P<0.001; OR
per point 1.10 (95% CI: 1.05 to 1.15)). The only independent risk factor
for hospital mortality was the presence of at least one comorbidity (OR
2.09; 95% CI 1.13 to 3.85).
Conclusion In SCAP, the presence of at least one comorbidity doubles
the chances of dying in the hospital and is an independent risk factor
for hospital mortality.
Introduction Infective endocarditis (IE) is a high-mortality disease,
especially in the early surgery subgroup. The aim of this study was try
to identify prognostic factors of IE that will require surgery during the
same admission of their diagnosis, including evaluation of surgical
Methods A retrospective study (5 years) of all patients admitted to
a tertiary hospital in northern Spain with diagnosis of IE (modified
Duke criteria) who required early surgery. Demographic, clinical and
microbiology data were collected. Chi-square and Student t tests.
Significance: P<0.05. SPSS17.
Results We had 73 patients, 79.5% men, age 65 years. Eighty-two
percent had positive blood cultures. Forty-one percent of cases
required previous ICU admission. Surgery was urgent in 35%. Fifty-six
per cent of patients had postoperative shock and 58% suffered
postsurgery ARF. Hospital mortality was 31.5%. Regarding prognostic scales:
the mean EuroSCORE was 11.383.93 points. No patient was placed in
the low-risk group. Ninety-four per cent of cases were at high risk. The
Parsonnet mean score was 27.711.6. The mean Beth Israel Medical
Center was 37.610 points. The mean Ontario scale was 7.092.7. The
mean Surgical risk scale of Roques was 6.69. And the mean by Pons
Scale was 24.02. Dead patients are older, with previous heart disease,
require urgent surgery and have previous ICU stay; usually they have
MOF and they had received less than 7days of antibiotic treatment. The
etiology did not worsen the prognosis.
Conclusion In early surgery IE, it appears to be associated with mortality:
age >70years, previous heart disease, emergency surgery, antibiotics
within 7 days before surgery, preoperative MOF, and high scores on
scales of Pons and Ontario. The causal agent and echocardiography
have no relation with worse prognosis. The general syndrome debut
and the Streptococcus spp. etiology seem to have lower mortality. IE
has pathologies with high .preoperative severity scores but these are
not sufficient to guide therapeutic decisions.
Introduction Urosepsis associated with urinary tract calculi is a critical
disease. Patients with this condition occasionally require drainage,
mostly ureteric stent placement and these patients need longer
hospitalization. However, indications for timely ureteric stenting for
urosepsis associated with urinary tract calculi have not been clearly
determined. The objective of the study was to evaluate whether earlier
stent placement might lead to shorter length of stay (LOS) in hospitals.
Methods For patients who required ureteric stent procedures for
urosepsis associated with urinary tract calculi in our hospital from
July 2008 to July 2012, we compared the LOS in our hospital between
patients with earlier stenting and those without it. A linear regression
model was used for multivariable-adjusted comparison.
Results In a total of 30 patients (mean age, 72; 13 males), the mean
days from emergency room admission to ureteric stenting was 3.5days
(range, 1 to 14 days) and the overall mean LOS was 36 days (range,
8 to 102 days). The early-stenting group (mean LOS, 21 days) had
significantly shorter LOS than the delayed-stenting group (mean LOS,
50days) with adjusted coefficient of 26days (95% CI, 46, 6).
Conclusion In patients with urosepsis associated with urinary tract calculi,
earlier stenting within 2 days of admission may reduce the hospital LOS.
1. Yamamoto Y, et al.: BMC Urol 2012, 12:4.
2. Yoshimura K, et al.: J Urol 2005, 173:458-462.
Introduction Analysis of mortality-related factors in urinary sepsis
Methods A retrospective descriptive study of urologic sepsis patients
in the ICU from 2008 to 2010. Clinical, epidemiological and outcome
variables were analysed. Quantitative variables are expressed as
either mean and standard deviation or as median and interquartile
range for asymmetric variables. Qualitative variables are expressed as
percentages and absolute values. MannWhitneys U test and Fishers
exact test were applied ( error was 5% in both cases), as well as binary
logistic regression for multivariate analysis.
Results There was a total number of 44 patients (aged 59.3917.71;
63.8% females). APACHE II score upon admission was 18 6. Out of
these patients, 27.3% showed no underlying disorder and 18.2% (no=
8) showed chronic renal failure; 25% were immunodepressed patients;
31% underwent urinary instrumentation in the previous 15 days, yet
only three of them had undergone permanent urine catheterization.
Observed mortality was 25%, while sepsis-related mortality was 22.7%.
The patients who died were, on average, older that those who survived
(67.9 7 10.2 vs. 56.818.7; P= 0.02). Besides, the former also reported
greater delay in turning to the hospital after symptom onset (13.46.6
vs. 6.2 4.7 days; P = 0.0001). Immunodepressed patients presented
higher mortality rate: OR 8.7 (95% CI 1.7 to 42.3), as well as those who
underwent inappropriate initial antibiotic treatment: OR 10.8 (95%
CI 2.1 to 54.7). No relation was observed between germ typology or
resistance to -lactam antibiotics and mortality. After adjustment of
mortality due to APACHE II score upon admission, delay in the onset
of appropriate antibiotic treatment was an independent predictor of
mortality in our patients: OR 1.2, 95% CI (1.02 to 1.42).
Conclusion Urinary sepsis mortality is associated with late-onset and/
or inappropriate antibiotic use, as well as with immunodepression and
1. Clech C, Schwebel C, Franais A: Does catheter-associated urinary tract infection increase mortality in critically ill patients. Infect Control Hosp Epidemiol 2007, 28:1367-1373.
2. Marx G, Reinhart K: Urosepsis: from the intensive care viewpoint. Int J Antimicrob Agents 2008, 31S:S79-S84.
Nosocomial pneumonia in the postoperative period after heart
RGmezLpez1, PFernndezUgidos1, PVidalCortes1, MBouzaVieiro2,
JMiiz2, SFojonPolanco2, MPaniaguaMartin2, RMarzoaRivas2,
1Complexo Hospitalario Universitario de Ourense, Spain; 2Complexo
Hospitalaro Universitario de A Corua, Spain
Critical Care 2013, 17(Suppl 2):P45 (doi: 10.1186/cc11983)
Introduction Infections are a major complication during the
postoperative period after heart transplantation (HT). In our hospital,
nosocomial pneumonia is the most frequent infection in this period.
The objective of this study is to determine the epidemiological and
microbiological characteristics of this disease in our centre.
Methods A descriptive retrospective study of all medical records of HT
performed in a single institution from 1991 to 2009 followed until June
2010. Clinical and microbiological variables were considered. Centre
for Diseases Control (CDC) criteria were used to define nosocomial
infections. Invasive aspergillosis was considered if there were criteria
for probable aspergillosis according to IDSA criteria.
Results In 594 HTs there were 97 infectious episodes in 75 patients
(12.6%). Eighty-five patients (14.3%) died during hospitalization.
Infection is the second cause of mortality during the postoperative
period (17.9% of dead patients). The most common locations of
infections were pneumonia (n = 31, 31.9% of infection episodes),
bloodstream (n= 24, 24.7%), urinary tract (n= 14, 14.4%), surgical site
(n= 13, 13.4%) and intraabdominal infections (n= 13, 13.4%). Patients
with pneumonia were treated according to knowledge in a specific
moment, thus different antibiotics were used. The duration of antibiotic
therapy was 2015.5 days. In nine episodes of pneumonia according
to the CDC no germ was isolated in the cultures. Six of the episodes
were polymicrobial infections. The most frequent microbes isolated
were E. coli (n = 7, 22.5% of pneumonia cases), A. fumigatus (n = 7,
22.5%), S. aureus (n= 3, 9.68%), P. aeruginosa (n= 3, 9.68%), P. mirabilis,
K. pneumoniae, E. cloacae, E. faecalis, C. glabrata, and S. marcescens (one
case each, 3.22%). Pneumonia was suspected but not confirmed in 75
patients. Despite this, antibiotic treatment was maintained for a media
of 17.35 7.01 days: 56 wide-spectrum treatments and 18 targeted
therapy after knowing the antibiogram. The length of ICU stay was
38.470.8 (3 to 264) days, of hospital stay was 66.280.5 (3 to 304)
days and of mechanical ventilation was 27.350.2 (3 to 264) days. The
mortality of patients with pneumonia was 32.3%.
Conclusion Nosocomial pneumonia is the most frequent infection
in our series. Despite when infection was not confirmed, antibiotic
therapy was maintained in suspect cases. We found a high incidence of
aspergillosis. Limitations because of wide duration of this study should
Introduction Despite many therapeutic interventions,
ventilatoracquired pneumonias (VAP) are frequent in the ICU and are associated
with major morbidity and mortality. Sepsis causes a time-dependent
modification of the inflammatory response. This reprogramming
could promote the occurrence of a secondary infection and worsen
the prognosis. In animals, peritonitis is associated with an alteration
of pulmonary immunity and an increasing mortality from secondary
Methods To investigate, in humans, the potential involvement of
previous intra-abdominal infection (IIA) in preventing or promoting
VAP, we realized a prospective observational study using data from a
multicenter database (OUTCOMEREA), including all patients admitted
Figure 1 (abstract P46). Cumulative incidence of VAP.
Figure 2 (abstract P46). Cumulative occurrence of death.
to the ICU for severe sepsis or septic shock who required mechanical
ventilation for at least 72 hours.
Results In total, 2,623 patients were included, of which 290 had an
IIA. A total of 862 patients (33%) developed a VAP, 56 (19%) in the IIA
group and 806 (34%) in the non-IIA group (P<0.01). VAP, after sepsis,
occurred less frequently and later in patients with IIA. The occurrence of
IIA, in comparison with another sepsis, is a protective factor against VAP
(HR= 0.643 (0.478 to 0.863), P= 0.003). There is, however, no significant
difference between the groups in terms of ICU mortality (28% vs. 32%,
P= 0.16). See Figures 1 and 2.
Conclusion In this study, the presence of an abdominal sepsis, in a
context of severe sepsis or septic shock, was associated with a lower
incidence of later VAP. These results have to be confirmed in other
studies, especially prospective. They open interesting new research
Introduction Ventilator-associated pneumonia (VAP) is a serious illness
with substantial morbidity and mortality and increases the cost of
hospital care. Even when bundles of care to prevent VAP have been
implemented, the incidence of VAP was not dramatically improved.
This study aims to determine the incidence and risk factors of VAP in
the SICU of Siriraj Hospital.
Methods During a 1-year period, 228 patients admitted to the SICU
were enrolled. All patients required ventilatory support longer than
48 hours. Data were collected by reviewing patient medical records
including demographic data, onset of VAP, type of organisms,
medication used, number of central venous catheters (CVC) used and
blood transfusion. VAP outcomes were also reported.
Results VAP occurred in 21 patients (9.21%) or 8.21 per 1,000
ventilatordays. The onset of VAP was late in the majority of patients. The most
common organism was A. baumannii (66%), followed by P. aeuruginosa
(19%). Compared with non-VAP groups, patients in the VAP group had
higher APACHE II score (18 vs. 13, P<0.001), blood transfusion (95% vs.
75%, P= 0.04), numbers of CVC used (3 vs. 1, P<0.001), muscle relaxant
used (43% vs. 3%, P<0.001) and steroid used (33% vs. 4%, P<0.001).
The VAP group also had a significantly higher number of intubation,
reintubation and self-extubation. Multiple logistic regression showed
that numbers of CVC, intubation and surgery, the use of muscle
relaxant and steroid were independent risk factors for developing VAP.
Ventilator days and ICU length of stay were longer in the VAP group
(25 vs. 6 and 25 vs. 7 days, respectively). Lastly, the hospital mortality
rate was significantly higher in the VAP group (33% vs. 12%, P= 0.008).
Conclusion The incidence of VAP was 9.2% in the SICU of Siriraj Hospital,
which was comparable with previous reports. Bundles of care to
prevent VAP should include weaning from a ventilator. Muscle relaxant
and steroid should be administered according to strong indication.
Meticulous care of the airway should be implemented as protocol in
order to prevent complications that can result in the development of
1. Werarak P, Kiratisin P, Thamlikitkul V: Hospital acquired pneumonia and
ventilator associated pneumonia in adults at Siriraj hospital, etiology,
clinical outcomes and impact of antimicrobial resistance. J Med Assoc Thai
2010, 93(Suppl 1):126-138.
Introduction This is a 1-year prospective study to determine the
incidence, source and etiology of hospital-acquired bloodstream
infection (HABSI) in the Indian context. The resistance pattern was also
Methods A single-centre prospective study in a 35-bed ICU. HABSI
was defined according to current CDC guidelines. HCAP,
catheterassociated UTI (CAUTI) and skin-related infections causing BSI was also
defined according to recent guidelines and analysed.
Results Out of 332 positive samples, 90 samples (n= 45) were HABSI.
The microbiological analysis showed 60% were Gram-negative, 6%
were candida and 27% were Gram-positive. The commonest isolate
was klebsiella and MRSA was commonest in Gram-positive. The source
of HABSI showed CRBSI was the commonest cause at 69%, which
correlates with international data. Ventilator-associated pneumonia
and CAUTI caused 9.5% BSI respectively. The resistance pattern among
Gram-negative bacteria showed multidrug-resistant (MDR) and
extreme drug-resistant (XDR) isolates were highest. See Tables1 and 2.
Table 1 (abstract P48). Source
Table 2 (abstract P48). Resistance pattern
Conclusion The incidence of HABSI is 27%. Of this, CRBSI cause 70%
and Gram-negative bacteria were commonest with high resistance.
This is in contrast to western data where Gram-positive infections are
common. Our study highlights need for stringent guidelines for CRBSI
1. Richard et al.: Crit Care Med 1999, 27:887-892.
2. Valles et al. : J Infect 2008, 56:27-34.
Introduction Preventing catheter-related bloodstream infections
(CR-BSI) can reduce the duration of hospital stay, healthcare costs, and
mortality rates. Identifying the risk factors and correction of modifiable
factors should be one of the main objectives of infection control
measures. The aim of this study is to determine the risk factors of CR-BSI
in a cohort of surgical ICU patients admitted to Baskent University
Methods Following Institutional Review Board approval, data for 876
patients admitted to the surgical ICU between January 2009 and July
2012 were reviewed retrospectively. After completing the review, 25
patients diagnosed with CR-BSI were compared with 66 appropriate
matches who did not have CR-BSI. Demographical features, underlying
diseases, APACHE II (Acute Physiology and Chronic Health Evaluation)
and SOFA (Sequential Organ Failure Assessment) scores, length of stay,
organ dysfunctions, laboratory values, use of vasopressors, mechanical
ventilation, nutrition, antibiotics, transfusions, and features related to
central venous catheterization were recorded. Patients who did not
have a central venous catheter and were discharged within 2 days of
ICU stay were excluded.
Results Out of 91 patients included in the final analysis, 25 (27%)
patients had CR-BSI. When compared with patients who did not have
CR-BSI, those who did were older (P = 0.029), required more blood
product transfusions during the first 3 days of ICU (P = 0.016), had a
longer duration of catheter stay (P= 0.019), and were more frequently
catheterized via the internal jugular vein (IJV) (P = 0.022). A logistic
regression model revealed that advanced age (OR: 1.037; 95% CI: 1.001
to 1.073; P= 0.042) was an independent risk factor for CR-BSI.
Fourteenday and 28-day mortality rates for CR-BSI were 12% (P= 0.749) and 28%
(P= 0.406), respectively.
Conclusion Although age, blood product transfusion, duration of
catheter stay, and use of IJV were different between patients who did
and did not have CRBSI, advanced age was the only independent risk
factor for CR-BSI. Early suspicion of CR-BSI by the other well-known risk
factors has a substantial effect on the treatment of CR-BSI.
1. OGrady NP: Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011, 52:e162-e193.
2. Bouza E: Catheter-related infections: diagnosis and intravascular treatment. Clin Microbiol Infect 2002, 8:265-274.
Introduction Catheter-related bloodstream infection (CRBSI) is a
complication of central venous catheters (CVCs) with an attributable
morbidity, mortality and cost . We examined patient risk factors for
CRBSI in an adult parenteral nutrition (PN) population.
Methods The study was carried out in a 525-bed tertiary-referral
teaching hospital over a 14-year study period (1997 to 2010). All
inpatients referred for PN via CVCs were included. Prospectively collected
data were recorded in a specific PN record. The CRBSI audit group met
quarterly to review all sepsis episodes, assigning a diagnostic category
(CRBSI or non-CRBSI). Patient risk factors for development of CRBSI
were examined using a logistic regression model to take account of
the dichotomous nature of the outcome. Odds ratios from a model
incorporating demographic and clinical data were tested for statistical
Results The study population was 1,961 patients in whom 3,213 CVCs
were utilised over 19,511 CVC days. There were 256 CRBSI episodes in
216 patients. Median (IQR) patient age was 62 (23), and 58% were male.
The incidence of CRBSI decreased significantly (P <0.001) during the
study period from 16% of patients in the period 1997 to 2003 to 7%
in 2004 to 2010. The corresponding rate of CRBSI infection (per 1,000
CVC days) decreased from 18 to 10. There was a significant decrease
(P <0.001) in numbers of CVCs inserted per patient (from 1.87 to
1.49). Each extra CVC PN day was associated with an increased risk of
developing CRBSI of 3.4% (OR 1.034, P<0.05). The number of PN CVCs
was associated with developing CRBSI (OR 1.218, P <0.10). Patient
factors significantly associated with CRBSI included perioperative PN
use (compared with medical patients) (OR 2.414, P<0.01), and male sex
(OR 1.952, P<0.01).
Conclusion This prospective study demonstrated that perioperative
PN use was associated with increased risk of CRBSI. The association
between CRBSI and CVC PN days is consistent with the theory
suggesting benefit to limiting CVC duration and changing from PN to
enteral nutrition as soon as appropriate.
1. Blot SI, et al.: Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infection. Clin Infect Dis 2005; 41:1591-1598.
Introduction Many patients develop infections following operations.
Decreased immune competence has been demonstrated in
acute neurological conditions. A strong cytokine-mediated
antiinflammatory response was observed in stroke patients at infection,
although infection due to the decreased proinflammatory mediators
can be expected as well. To investigate this question the following
experiment was performed.
Methods Twenty-two urinary bladder cancer patients with radical
cystectomy and lymphadenectomy were studied. Blood samples were
taken on day 0 (before) and days 1, 3, 6, 9 and 14 after operation as
well as on days 30, 60, 90 and 270 during follow-up. TNF, soluble TNF
receptor I and IL-6 levels in sera were determined by HS ELISA and/or
ELISA. Plasma ACTH and cortisol values were measured by RIA kits.
Results From 22 patients, eight deep wound and urine infections
were found in 14 days and six urine and wound infections in 30 days
after surgery, all survived. All patients were bacterially contaminated,
as wound samples taken at the end of operation demonstrated. On
day 0 the circulating TNF values were lower in infected patients.
TNF started to increase from day 3 to day 9, never reaching values of
the uneventful healing group. Soluble TNF receptor I, IL-6, ACTH, and
cortisol concentrations did not demonstrate any difference on day 0
but from day 1 started to increase transiently, reaching higher levels in
Conclusion A low proinflammatory response is a key facilitating factor
for the development of infection. Measuring serum TNF levels before
and after operations can thus predict the outcome.
Results for introduction of a new hand hygiene program in the ICU
PVos, AHarts-Laurijsen, RSnoeren, RRamnarain, JAVanOers
St Elisabeth Hospital, Tilburg, the Netherlands
Critical Care 2013, 17(Suppl 2):P52 (doi: 10.1186/cc11990)
Introduction Although hand hygiene is known as a core element
in prevention of healthcare-associated infections, compliance to
its program is not high. With a new campaign we tried to enlarge
awareness on hand hygiene.
Methods We performed an experimental, before and after, study design
on our 30-bed, mixed medicalsurgical ICU. We conducted a baseline
evaluation during 3days in May 2012 including direct observation of
hand hygiene compliance by control nurses and hand cultures of 50
healthcare workers (HCW). Based on the WHO Guidelines on Hand
Hygiene in Health Care , cleaning of hands with alcohol-based hand
rubs (Sterillium) was prescribed before touching a patient and before
aseptic procedures, after body fluid exposure risk and after touching
a patient and touching his/her surroundings. Promotion of the hand
hygiene program consisted of lectures and web-based self-learning,
posters located near points of care and verbal reminders by control
nurses. New observations of hand hygiene by control nurses during
3days and hand cultures of 50 healthcare providers were performed
in September 2012. Consumption of alcohol-based hand rub (product
volume use per patient-days) was used as a surrogate marker of hand
hygiene over time. The difference in hand hygiene compliance during
the two periods was examined using a chi-squared test. Differences
in hand cultures were examined using a Students t test. Time trends
in the consumption of alcohol-based hand rub were examined using
linear correlation. P<0.05 was considered statistically significant. The
study was approved by the institutional Ethics Review Board.
Results During the survey, in May 158 opportunities to observe hand
hygiene were presented and 286 in September. Overall compliance
improved from 34.2% (54/158) to 51% (146/286), 2= 11.7 (P<0.001). In
May, 50 HCW had a mean of 63.2039.37 colony-forming units (CFU)
on their hands compared with 43.0 40.19 CFU on the hands of 50
HCW in September (P = 0.024). We also observed an initial increased
use of alcohol-based hand rubs from 21 ml per patient-day in May to
a maximum 72 ml per patient-day in June, but a decline to 44 ml per
patient-day in September, Pearson correlation coefficient = 0.31 (P =
Conclusion Implementation of a new hand hygiene program at our ICU
resulted in improved hand hygiene compliance and less CFU on the
hands of HCW. There was no significant increased use of alcohol-based
hand rubs over time. The results indicate that constant awareness is
vital for success.
1. Pittet D, et al.: Infect Control Hosp Epidemiol 2009, 30:611-622.
Introduction ICU-acquired infection is directly related to hospital
mortality. Hand hygiene is an effective, low-cost intervention that
can prevent the spread of bacterial pathogens, including
multidrugresistant organisms. Historical compliance with hand hygiene
guidelines by physicians, nurses and other care providers is poor.
Methods Present expectations by the Infection Control Committee are
to pump in, pump out of every room, using 63% isopropyl alcohol. We
performed 17,622 observations of hand hygiene in the surgical ICU
from March through October 2012, and intervened to change behavior
by providing monthly feedback to specific provider groups and
services. We made use of the Unit Coordinator to measure compliance
of all individuals in the ICU.
Results Overall compliance by physicians was 82.1%, for nonphysicians
was 84.8%. Feedback to physicians, individually and by service,
dramatically increased hand hygiene compliance, defined as both
on entry and exit from the patient room, over the study period. See
Conclusion Physician behavior is responsive to monthly feedback
that is specific to the individual or surgical service. Use of the Unit
Coordinator was very effective at gathering a very large sample size in
a short period of time.
Compliance with the implementation of an ICU cluster-randomized
trial assessing the benefits and potential harms of universal glove
DKett1, DJMorgan2, LPineles2, MJZervos3, LSMunoz-Price1, ADHarris2,
1University of Miami/Jackson Memorial Hospital, Miami, FL, USA; 2University
of Maryland/VA Maryland Healthcare System, Baltimore, MD, USA; 3Henry
Ford Health System, Detroit, MI, USA
Critical Care 2013, 17(Suppl 2):P54 (doi: 10.1186/cc11992)
Introduction The Benefits of Universal Glove and Gowning (BUGG)
study is a cluster-randomized trial to evaluate the use of wearing gloves
and gowns for all patient contact in the ICU. The primary outcome is
VRE and MRSA acquisitions; secondary outcomes include frequency of
healthcare worker visits, infection rates, hand hygiene compliance and
Methods We enrolled 20 ICUs in 15 states. ICUs collected nasal and
perianal swabs on all patients at admission and discharge/transfer.
After a 3-month baseline period, 10 units were randomized to the
intervention arm and required to wear gloves and gowns for all patient
contact. An intervention toolkit was created based on site feedback
and compliance reports. Swab collection compliance was fed back
and discussed during site conference calls on a weekly basis. Site
coordinators monitored compliance with gloves and gowns, hand
hygiene and frequency of HCW visits and reviewed patient charts for
Results During the 12-month study period, 100,210 swabs were
collected. After the baseline period, we were able to achieve and
maintain swab compliance rates between 85 and 97%. Monthly
discharge compliance increased by 21% by the beginning of the
intervention period (Figure1). Observers found 86% compliance with
universal glove and gowning over 1,242 30-minute observation periods
(Figure1). Ninety charts at each site were reviewed for adverse events.
Conclusion Over a diverse group of US hospitals, we achieved high
compliance with surveillance cultures and implementing universal
gloving and gowning was achieved quickly with high compliance.
Figure 1 (abstract P53).
Figure 1 (abstract P54). Swab collection and gown/glove compliance.
Introduction Sepsis accounts for a very high mortality. The Surviving
Sepsis Campaign recommends a first 6 hours resuscitative bundle to
improve patient outcome. Despite this, the bundle is poorly performed
because of several organizational and cultural barriers. In recognition
of this, we guess that an Educational and Organizational Intervention
out of the ICUs could impact on septic patient outcome. In order to
test our hypothesis we carried out, in 12 hospitals, a pre-intervention
survey of the human and organizational resources (HOR) available
in the management of septic patients. The aim is to seek any barrier
potentially affecting correct Guidelines implementation.
Methods Thirty-nine medical wards (MW) and 12 emergency
departments (ED) were enrolled. Every unit was asked to fill in a pre-agreed
HOR Checklist focused on the main requirements suggested by the
Results Analysing the human resources available, we see that the
bedto-doctor ratio significantly (P<0.01) increases from the day to the night
shift: from 6 to 43 beds per doctor on the MW (median). Otherwise,
the ED staff remains roughly the same: from 3.5 to 2.5 doctors on duty
(median). The analysis of the organizational tools (Table 1) points out
Diagnostic and therapeutic protocol for septic patient management
Use of early warning score for diagnosis and management
Microbiology laboratory: open 7 days a week
Lactate dosage: 24 hours a day availability
Central venous catheter insertion (CVC) available 24 hours a day
Hospital empirical antibiotic therapy guidelines
Infectious diseases team advice in any case of severe sepsis septic shock 25
Infective source eradication protocols
Intervention radiology available 24 hours a day
Operating room available 24 hours a day
Specific infection management protocol (that is, CVC infection)
Imaging reporting service available 7 days a week
a low percentage of hospitals having: a Diagnostic and Therapeutic
Protocol for sepsis management (8.3%), some Hospital Empirical
Antibiotic Therapy Guidelines (0%) and an Infective Source Eradication
Protocol (8.3%). Moreover, just 25% of hospitals involve an infectious
diseases expert in every case of severe sepsis or septic shock.
Conclusion We guess that the poor availability of HOR showed by the
hospitals could have a role in the Guidelines implementation and in
the patients outcome. Only a comparison between these results and
data collected from a Clinical Checklist, focused on sepsis bundle
compliance, and from a patients outcome summary could confirm our
hypothesis. This is the aim for our next part of the study.
1. Dellinger RP, et al.: Intensive Care Med 2008, 34:17-60.
Introduction The incidence of patients carrying ESBL-positive
bacteria in our ICU (12 in 780 admissions in 2011) was not considered
problematic. However, routine cultures had identified ESBL-negative
patients who had become colonized with ESBL strains during their
ICU stay. Self-disinfecting siphons, preventing bacterial growth by
antibacterial coating and intermittent heating, and biofilm formation
by electromechanical vibration, were placed in all sinks in the ICU. The
aim of the present study was to evaluate the effect of this intervention.
Methods An intervention study in a 12-bed ICU. The intervention
involved placement of 19 self-disinfecting siphons (Biorec). All patients
with an expected ICU stay of 2 days or more between January 2011
and December 2012 were studied. Samples of throat, sputum and
rectum were taken at admission and twice weekly, and cultured for
ESBLs. Between June 2011 and October 2011, sinks in patient rooms
were cultured regularly for ESBLs. After the intervention in April
2012, multiple repeat cultures were taken. Whenever the species and
antibiogram of bacteria cultured from patients and sinks matched, they
were typed by AFLP.
Results Before intervention Multiple ESBL-forming strains were found in
sinks of all patient rooms. Eighteen patients who were ESBL-negative
on ICU admission became colonized with 11 different ESBL strains,
that were present in sinks of their admission rooms (Figure 1). Four
contaminations were proven by AFLP-tying. One patient died of
ESBLpositive E. cloacae pneumonia. After intervention All sinks were negative
for ESBL strains. No further patients became ESBL colonized during the
Conclusion Wastewater sinks were the likely source of ESBL
colonization for 18 ICU patients. After placing self-disinfecting siphons
Figure 1 (abstract P56). Design and results of the intervention.
Introduction Assessing whether a critically ill patient should be
admitted to an ICU remains difficult and mortality amongst ICU
patients is high. To render intensive care with no prospect of success
is an immense emotional burden for both patient and relatives, and
a great socioeconomic burden for society as well. Therefore, validated
strategies that can help identify patients who will benefit from
intensive care are in demand. This study seeks to investigate whether
preadmission quality of life can act as a predictor of mortality amongst
patients admitted to the ICU.
Methods All patients (>18 years) admitted to the ICU for more than
24 hours are included. In order to assess preadmission quality of life,
the patient or close relatives complete the Short-Form 36 (SF-36)
within 72 hours after ICU admission. Mortality is evaluated from ICU
admission until 30 days hereafter. Logistic regression and receiver
operating characteristic analyses are employed to assess predictive
value for mortality using five models: SF-36 Physical Component
Summary (PCS) and APACHE II (model A), SF-36 PCS (model B), SF-36
General Health (GH) and APACHE II (model C), SF-36 GH (model D),
and APACHE II (model E). Classification tables are composed in order
to assess sensitivity, specificity, positive and negative predictive values
and likelihood ratios.
Results Preliminary results, based upon data from 175 included patients,
reveal an ICU mortality of 12.6% and 30-day mortality of 22.9%. No
patients were lost to follow-up. When the Physical Component of SF-36
(PCS) was used as an estimate of preadmission quality of life, the area
under the curve for model B (AUC=0.80) was comparable with model E
(AUC=0.81), and better than model A (AUC=0.85). The General Health
item of SF-36 (GH), used as an estimate of preadmission quality of life,
gave an AUC=0.76 (model D). All models were controlled for sex and
Conclusion Preliminary results indicate that the SF-36 GH and the
SF-36 PCS are as good as APACHE II to predict mortality 30days after
ICU admission. However, in order to conclude whether preadmission
quality of life can contribute to triage, by successfully identifying
patients suitable for intensive care, final analyses, due in 2013, are
awaited. These results will clarify whether future randomized controlled
trials, in which preadmission quality of life acts as a supplement to
triage, are justifiable.
Predicting physical function and mental health in trauma intensive
care patients 2years after hospitalisation
LAitken1, BMacfarlane1, WChaboyer2, MSchuetz1, CJoyce1, AGBarnett3
1Princess Alexandra Hospital, Brisbane, Australia; 2Griffith University,
GoldCoast, Australia; 3Queensland University of Technology, Brisbane,
Critical Care 2013, 17(Suppl 2):P482 (doi: 10.1186/cc12420)
Introduction Long-term compromise after traumatic injury is
significant; however, few modifiable factors that influence outcome
have been identified. The aim of this study was to identify acute and
early post-acute predictors of long-term recovery amenable to change
Methods Adults (>17 years) admitted to the ICU, Princess Alexandra
Hospital, Australia following injury were prospectively followed.
Data were collected on demographics, pre-injury health, injury
characteristics and acute care factors. Psychosocial measures
(selfefficacy (SE), illness perception (IP), post-traumatic stress disorder
(PTSD) symptoms and psychological distress) and health status (SF-36)
were collected via questionnaire 1, 6, 12, and 24 months post injury.
Outcomes of interest were the Physical Function (PF) and Mental Health
(MH) subscales of the SF-36. Regression models were used to estimate
predictors of physical function and mental health over a 2-year period.
A subject-specific intercept in a mixed model was used to account for
repeated data from participants over time.
Results Participants (n = 123) were young (median 37, IQR 22 to
55 years), predominantly male (83%) and spent on average 3 days
in the ICU and 3 weeks in hospital. Response rates were over 55% at
each follow-up, with responders similar to nonresponders except for
being generally older. PF and MH scores improved over time, although
the averages remained below the Australian norms at 24 months.
Introduction Swiss Diagnosis Related Groups (SwissDRG) have been
effective since 1 January 2012. The influence of this new system on
patients discharge characteristics from a large ICU is not known. With
the introduction of the DRG we expect patients to be discharged after
a shorter length of stay on the ICU and with higher severity of illness.
Methods The ICU of the City Hospital Triemli in Zurich has an
interdisciplinary organization with surgical and internal medical patients,
with a maximum occupancy of 18 beds and a center function for the
surrounding hospitals. In this ongoing prospective observational
study, we collect and analyze the anonymized data of all patients
discharged from our ICU prior to and after the introduction of the
SwissDRG. The primary endpoint was the length of stay on the ICU
in hours. The secondary endpoints were the severity of illness of the
patients at the time of discharge, detected by the scoring system SAPS
II as well as measured by the number of readmissions to the ICU. Initially
all patients were analyzed and in a second step only patients within
percentiles 6 to 94 were considered. We also analyzed the subgroups of
patients referred internally, patients sent back to referring hospital and
patients regionalized to a homebase hospital. The statistics have been
done with SPSS and P<0.05 was considered significant.
Results We present the results of an 18-month period, 9months prior
to and 9months after the introduction of the SwissDRG. Data of 1,491
and 1,492 patients were analyzed, respectively. When all patients were
included, we found prior to and after the introduction of the DRGs a
comparable length of stay on the ICU (meanSD of 52.12.2hours vs.
50.822.2hours), no difference in the severity of illness at discharge
detected by the SAPS II (mean SD of 27.9 0.3 vs. 28.4 0.3) and
the number of readmissions (91 vs. 92). There was also no significant
difference when only percentiles 6 to 94 were included or when the
three subgroups were analyzed.
Conclusion Up to now, the introduction of the SwissDRG has no
influence on patients discharge characteristics from a large ICU. Data
assessment will continue and further data analysis has to be performed.
Introduction The new Swiss financing system by means of Diagnosis
Related Groups (DRG), effective 1 January 2012, forms the basis of a
performance-based system to reimburse general hospital services.
There are only few data on the influence of DRG on ICU patients [1,2].
We expect that the introduction of the DRG in Switzerland will change
the number of admissions from external hospitals to a large ICU with
a centre function and will influence the severity of disease of the
Methods The ICU of the Triemli City Hospital in Zurich has an
interdisciplinary organisation with surgical and internal medical patients,
with a maximum occupancy of 18 beds and a centre function for
the surrounding hospitals of the region. In this prospective ongoing
observational study, we collect and analyse the anonymised data of all
patients admitted to our ICU from an external hospital during 12months
prior to (1 January to 31 December 2011) and after (1 January to 31
December 2012) the introduction of the DRG in Switzerland. Exclusion
criteria are admissions by the emergency department, self-assignments
into the hospital and internal relocations. The primary endpoint is the
number of admissions from an external hospital to our ICU. Secondary
endpoints are the severity of the disease of the admitted patients,
detected by the scoring systems SAPS II and APACHE II as well as the
length of stay in external hospitals before admission. The statistical
analysis is descriptive.
Results We present the preliminary data for 10months (in each case
January to October) before and after the introduction of the DRG.
We observed an increase of 9.2% (391 vs. 427 patients) of admissions
to our ICU after the introduction of the DRG. The severity of disease
determined by the SAPS II score is unchanged (mean 26.7 vs. 26.0
points, P=0.466). The severity of disease determined by the APACHE
II score is significantly lower (15.4 vs. 14 points, P = 0.017). We also
noted that after the introduction of the DRG the patients were earlier
transferred from an external hospital to our ICU (mean time until
transfer 29.9 vs. 18.7hours), but this value was not significant (P=0.55).
Conclusion Up to now the introduction of the DRG in Switzerland
has had a complex influence on the number and the kind of patients
admitted from an external hospital to an ICU with centre function. Data
assessment and analysis will continue.
1. Ahmad M, et al.: Chest 1988, 93:176-179.
2. Thomas F, et al.: Chest 1987, 91:418-423.
Introduction The ICU consumes almost 20% of total hospital resources,
despite accounting for less than 10% of hospital beds. Medical
cost can be divided into a fixed part, consisting of personnel and
accommodation expenses, and a variable part, determined by the
needs of each patient (medications, consumables, examinations). In
order to rationalize medical cost, estimation of expenses must be real
and individualized. The aim of this study was to assess the variable cost
of critically ill patients in a new, seven-bed, adult, general ICU, using
bottom-up costing methodology.
Methods All 138 patients who were treated during 2011, and stayed for
at least 24hours, were included in the study. Data were retrospectively
collected from patient records and included demographics, cause
of admission, APACHE II score at admission, length of stay (LOS) and
outcome. Cost was recorded for everyday and for every patient, based
on a hospital-specific cost catalogue and on national agreements. Data
are presented as meanSEM. Analysis of data was carried out using
Graph Pad Prism 5.0., applying Students t test.
Results The age of participants (84 men and 54 women, 71 medical and
67 surgical) was 68.751.18, APACHE II score was 18.640.61, LOS was
18.462.54, and mortality was 19%. The majority of the patients (61%)
were mechanically ventilated. The totaldays of ICU stay were 2,548 and
the total variable cost was 1,460,465 (573.18 per patient and perday).
Cost per patient was subdivided as follows: medication (including drugs,
fluids, blood products, nutrition): 56.49%, examinations (including
laboratory, microbiological assays and diagnostic procedures):
22.23%, consumables: 21.26%. As for medication cost, the largest part
was comprised of antibiotics (45.69%), followed by blood products
(17.61%) and cardiovascular drugs (12.39%). Costs for medical patients
were significantly higher than those for surgical patients (P<0.0001).
Conclusion The total average cost per patient and perday was found
to be 573.18. Medication expenditure was responsible for the highest
Introduction Leicester Royal Infirmary is a (funded) 15-bed ICU, annual
admission 1,102 patients peryear (ICNARC data 2011 to 2012). It houses
a broad range of specialty, has over 1,000 beds and an emergency
department (ED) responsible for 297 admissions over the 2011 to 2012
period. Unit guidelines state that a doctor should be immediately
available to the unit at all times, ideally physically present on the unit.
This audit looked in detail at each occasion a junior doctor left the unit,
the timings, reason, and outcome of each episode.
Methods Between 17 October 2011 and 14 November 2011, and
between 2 July 2012 and 30 July 2012, junior doctors on the ICU
completed a data-capture form after each occasion that they left the
unit for a clinical need. Data collected were matched to the objectives.
The 2011 audit results were communicated at the University Hospitals
of Leicester Trust ICU Audit Meeting. A system was introduced so
thatdaytime referrals were directed to the ICU consultant. The impact
of this intervention was assessed by the 2012 re-audit.
Results There were 105 occasions when a junior doctor left the unit
in 2011, totalling 118hours and 38 minutes (5days), a continuation of
the upward trend from the previous 2years. In 2012 this reduced to 47
occasions totalling 40 hours and 55 minutes. Most attended referrals
were during thedaytime, 54% in 2011 and 68% in 2012. The majority
of referrals originated from the ED/medicine, combined numbers
58% in 2011 and 38% in 2012. In 2011 only 30% of ED referrals had
been discussed with a consultant of the referring team and only 32%
of medical referrals. Just two of the 14 inappropriate ED referrals were
discussed with the referring consultant, and none of the six inappropriate
medical referrals were discussed with a medical consultant. In 2012 just
33% of ED/medical referrals had prior discussion with a consultant from
the referring team. At the point of leaving, the ICU was left without a
doctor on 22 occasions in 2011 and six occasions in the 2012 audit. Most
occasions occurred at either night shift/weekend (86% in 2011/100%
in 2012). Referral resulted in a patient being admitted to the ICU on 20
occasions in 2011 and 12 in 2012.
Conclusion The latest audit follows introduction of a referral system
directly to the ICU consultant and may account for the reduction in
numbers of referrals attended by junior doctors. ED/medicine persist
as the main source of referral to the ICU. Discussion with the referring
team consultant may reduce inappropriate referrals. ICU staffing
should not be reduced.
Impact of the time elapsed between ICU request and actual
admission on mortality and length of stay
GMFilho1, TASilva1, ARSantana1, FBSoares1, LJAlmeida1, LGGodoy1,
TARodrigues1, MOMaia2, JANeto2, APAmorim3, EBMoura2, FFAmorim1
1Escola Superior de Cincias da Sade, Braslia, Brazil; 2Unidade de Terapia
Intensiva Adulto do Hospital Santa Luzia, Brasilia, Brazil; 3Liga Academica de
Medicina Intensiva do Distrito Federal (LIGAMI), Brasilia, Brazil
Critical Care 2013, 17(Suppl 2):P487 (doi: 10.1186/cc12425)
Introduction Measures to ensure an appropriate early treatment for
critically ill patients result in significant decreases in mortality [1,2]. This
study aims to evaluate the impact of the time elapsed from request
until admission to the ICU on mortality and ICU length of stay (LOS).
Methods A retrospective cohort study performed on patients in the
ICU of Hospital Regional de Samambaia over a period of 4years, from
January 2008 to December 2011. The patients were allocated into two
groups: patients who waited longer than 6hours, long waiting period
(LWP, n=300); and patients whose waiting time was equal to or less
than that period, short waiting period (SWP, n=113).
Results In total, 413 patients were included, 300 of which belonged to
the LWP group (65.4%). For the entire cohort, the mean APACHE II score
was 197, the mean age was 5222years, and 211 patients were male
(51.1%). The LWP group did not show difference in the APACHE II score
(197 vs. 188, P=0.13), but was older (5520 vs. 4923, P=0.01).
LWP also had a higher incidence of primary bloodstream infection (23.8%
vs. 10.4%, P=0.01) and catheter-associated urinary tract infection (10.2%
vs. 1.9%, P=0.01). LWP patients had higher mortality (37.8% vs. 25.9%,
P=0.02) and longer ICU LOS (2147 vs. 1418days, P=0.01). Relative
risk for death in the LWP was 1.74 (95% CI: 1.11 to 2.72).
Conclusion Despite showing no significant differences on APACHE II
scores from the SWP group, patients from the LWP group presented
greater incidence of primary bloodstream infection,
catheterassociated urinary tract infection, higher mortality outcomes and
longer ICU LOS.
1. Amorim FF, et al.: J Clin Med Res 2012, 4:410-414.
2. Rivers E, et al.: N Engl J Med 2001, 345:1368-1377.
Medical problems: review from the major nuclear incidents
YHaraguchi1, YTomoyasu2, HNishi3, MHoshino4, MSakai5, EHoshino6
1Disaster Medicine Compendium Team, Japan, Tokyo, Japan; 2Shirahigebashi
Hospital, Tokyo, Japan; 3Tokyo Disaster Medical Center, Tokyo, Japan; 4Shisei
Hospital, Saitama, Japan; 5Tokyo Womens Medical College, Tokyo, Japan;
6Chiba Nursing Association, Chiba, Japan
Critical Care 2013, 17(Suppl 2):P488 (doi: 10.1186/cc12426)
Introduction Intensivists are expected to have many roles during
and after a major disaster/catastrophe; that is, triage, intensive care,
education for people, and so forth. The roles of intensivists against
special disaster or nuclear disaster are studied based on actual
Methods Several disasters are studied. The Fukushima Daiichi Nuclear
plant explosion after the Higashinihon earthquake 2011 was medically
reviewed based on the total 30-day stay on-site in addition to severaldays
around the site. The Chernobyl incident 1986 was inspected 15 years
after the incident. Other nuclear disasters are included.
Results Many serious problems were revealed in the medical teams,
which are as follows: inappropriate basic preparedness against large
special disasters, including nuclear disaster; lack of appropriate
education and training for medical teams against nuclear disaster
that is, most members of Japan DMAT or the disaster medical assistance
team are still laypersons; incorrect standard/rules of Japan DMAT, which
were excessively focused upon cure of the usual type of injury and
planned short period or nearly 48hours, which should be abandoned;
and insufficient consideration to the weak/vulnerable people or CWAP,
children, (pregnant) women, aged people, and the poor people/sicker
patients. Many of them died because of an insufficient emergency
transportation system from their contaminated houses or hospital.
Conclusion In order to cope with the special disasters, such as NBC
or nuclear, biological and chemical disaster, it is insufficient to take
makeshift measures or use cheap tricks. Working out the systematization
of disaster medicine, based upon the academic viewpoints and
philosophy/reliability, is essential to protect the people and the nation.
Introduction The World Bank has warned that the rapid growth of the
worlds urban population can only be accommodated safely if cities
adequately develop key infrastructure, such as the provision of acute
care resources. Yet, even basic descriptive information on urban acute
care supply and demand is extremely limited. We therefore conducted
a pilot assessment across seven diverse urban settings across the world.
Methods We selected a convenience sample of seven large cities with
varying geographical and socioeconomic characteristics: Boston, Paris,
Bogota, Recife, Liaocheng, Chennai, and Kumasi. To estimate acute care
supply, we developed an instrument to collect data on acute and critical
care infrastructure. We collected data from municipal authorities and
local research collaborators. We expressed the burden of acute disease
as the number of deaths due to acute illnesses, estimated from the
2008 Global Burden of Disease Study. Results were expressed as acute
care supply and acute deaths per 100,000 population and acute care
supply per 100 acute deaths.
Results The supply of hospital beds varied from 72.4/100,000
population in Kumasi to 245.8/100,000 in Boston. ICU beds with
capacity for invasive mechanical ventilation and intensive nursing
services ranged from 0.4/100,000 in Kumasi to 19/100,000 population
in Boston. The number of ambulances varied 70-fold between cities.
The gap between cities widened when demand was estimated based
on disease burden, with a 70-fold difference between cities in ICU
beds/acute deaths. In general, most of the data were unavailable from
Conclusion The provision of acute care services, a key aspect of urban
infrastructure, varied substantially across the seven diverse urban
settings we studied. Furthermore, the local municipal authorities
generally appeared to have little knowledge of their acute care
infrastructure, with implications for future planning and development.
Introduction Medical and surgical patients use the ICU differently.
Resources may not always be allocated by severity of illness, but by
custom or habit, particularly if different groups administer bed control
and triage. Specialty-specific differences may exist even when a single
team controls triage. Variability in resource utilization has important
implications for cost-containment and triage.
Methods Patients admitted to a single, closed medical/surgical
ICU with full-time intensivists and unified triage control in a large,
university-affiliated hospital were evaluated during 2011 to 2012.
Patients who died in the ICU were excluded. Theday of discharge (D/C)
and severity using APACHE IV and its related Acute Physiology Score
(APS) component were calculated daily for the first 7days. Trend was
assessed acrossdays by Cuzicks test.
Results A total of 719 surgical and 925 medical patients met inclusion
criteria. In total, 20.2% of surgical and 21.3% of medical patients had an
ICU LOS <1; P=0.58. Admission severity was correlated with length of
stay, P=0.014 for both medical and surgical patients. Medical patients
are sicker on admission and D/C from the ICU than surgical patients
Conclusion ICU utilization differed by patient type even with unified
triage control within a single unit. Surgical patients were less severely
ill on admission to and D/C from the ICU. A significant percentage of
medical and surgical patients are D/C within 1day and may be more
efficiently served in a less resource-intensive environment. The reasons
for the differences in ICU utilization for surgical versus medical patients
require clarification and may have implications for both resource
utilization and cost.
Educational effectiveness of introductory training for the Rapid
Response System in Japan
TKodama1, MNakagawa2, EKawamoto3, SFujiwara4, HImai3, SFujitani5,
1The University of Texas Southwestern Medical Center at Dallas, TX, USA;
2Social Insurance Kinan Hospital, Tanabe-City, Japan; 3Mie University Hospital,
Tsu-City, Japan; 4NHO Ureshino Medical Center, Ureshino-City, Japan;
5Tokyobay UrayasuIchikawa Medical Center, Urayasu-City, Japan; 6Osaka City
General Hospital, Osaka-City, Japan
Critical Care 2013, 17(Suppl 2):P491 (doi: 10.1186/cc12429)
Introduction Interest in safety and clinical outcomes of inpatients
has been growing in Japan, because the 100,000 Lives Campaign was
introduced under the Japanese Patient Safety Act in 2008. In this act,
an introduction of the Rapid Response System (RRS) was one of the
mainstreams to inpatients care. However, many Japanese healthcare
providers cannot understand how to achieve the introduction of
the RRS, because there are few who have knowledge of the system.
Therefore, we developed a new introductory training course for
the RRS. The educational effectiveness was analyzed through the
surveillance questionnaires after the course.
Methods The educational program includes a lecture series
concerning the outline and management methods, introduction of facilities
that have already deployed, small group discussions, and teaching
methods-of-training for the medical emergency team using a simulator.
Evaluation was made in the five-point scale by 82 participants (58
physicians, 16 nurses and eight other professions) throughout seven
courses. The questionnaires are: A. understanding of RRS, B. knowledge
acquisition about patient safety, C. expectation for decreasing the
cardiopulmonary arrest by RRS, and D. expectation for decreasing the
psychological burden by RRS.
Results Seventy-three participants (89.0%) answered the
questionnaires. The numbers of participants who scored more than four points
were as follows: A. was 71 (97.2%), B. was 70 (95.9%), C. was 64 (87.7%),
and D. was 68 (93.2%), respectively. The majority of participants
obtained the correct knowledge, and had a solid understanding for
the RRS. It was evident that providing abundant material and didactic
lectures traced from the introduction to management, and collecting
and resolving the questions, promoted comprehension. However,
there is a limitation of whether or not the participants introduce the
RRS into their own institutions. It is essential to improve the course and
continue to support the activities of the participants.
Conclusion Our training course may promote the introduction and
dissemination of the RRS in Japan.
1. Leape LL, et al.: JAMA 2005, 293:2384-2390.
2. Jones D, et al.: N Engl J Med 2011, 365:139-146.
Introduction The management of emergency medical admissions has
been a subject of recent clinical incidents. There was a high percentage
of patients that were referred to the ICU by staff in training, and 21%
of referrals were made by junior doctors. Consultant physicians had no
knowledge of the case in 57% of referrals.
Methods A prospective study of 21 cases of referrals and admissions to
the ICU was conducted at the Glasgow Victoria Infirmary Hospital from
8 to 21 September 2012. A questionnaire was produced relating to the
referrals, admissions, seniority involvement, cause of referral, and time
of patient review by the ICU consultant after ICU admission. They were
distributed to specialist registrars and the ICU consultants. All data
were electronically recorded into an Excel database. Questionnaires
that were not completely filled were further investigated using patient
clinical notes and contact with medical staff. Information that may
identify a patient or clinician was removed from the questionnaire for
Results Twenty-one complete questionnaires were collected.
Fiftyseven percent (12/21) of cases involved admission to the ICU. Nine
percent of the cases involved contacting either a specialist registrar
or ICU consultant intensivist for assistance in practical procedures. Of
the patients admitted to the ICU, 33% (4/12) were from medical wards,
33% were admitted from A&E. Consultants were the most common
professionals who referred patients to critical care (48%; 10/21).
Fourteen percent of cases (3/21) involved the referral of patients into
ICU by a junior doctor, but only one of the referrals was accepted by
the ICU intensivist. Consultants referred or were aware of the referral
in 71% (15/21) of cases. Of admissions, 58% (7/12) were accepted by
the ICU consultant and the remaining by the specialist registrars. All
accepted were acknowledged by the ICU consultant. After admission
all of the patients were reviewed by the ICU consultant and the time of
review after admission was on average 1hour 23 minutes (25 minutes
to 3hours 45 minutes).
Conclusion There is still an issue with junior doctors referring patients
to the ICU without the acknowledgement of consultant physicians,
resulting in unnecessary admissions and decreased time that ICU
trainees spend in the ICU. There are more appropriate ICU admissions
when there is involvement with seniority. Contact with ICU staff to
perform practical procedures outside the ICU and not about admissions
should be explored further.
1. Gillbe C, Gunning K: Standards for Consultant Staffing of Intensive Care Units. ICS & IBTICM Standards. Intensive Care Society; 2006.
Introduction Teaching of medical ethical issues including
confidentiality and consent have long been a small part of the medical
curriculum. These issues are more complex in an ICU where patients
may lack capacity. Documents such as Good Medical Practice 1995,
Confidentiality 2009 and the Mental Capacity Act 2005 give guidance
to medical professionals in these matters in the UK.
Methods A questionnaire was distributed amongst staff in four ICUs in
South London. Results were analysed according to level of experience
and background (medical/nursing or allied health professional (AHP)).
Results Of 225 questionnaires distributed, the response rate was
66% (31% doctors, 56% nurses and 13% AHP). Staff with either less
than 1 year experience or greater than 10 years experience had the
greatest exposure to the Mental Capacity Act and Data Protection
Act, suggesting a gap in knowledge in staff with intermediate
experience. Knowledge of the Caldicott principles were unaffected
by experience, with many experienced respondents having No Idea.
The majority of respondents (unaffected by experience) felt that
when giving information to relatives face to face, relatives should be
kept fully informed. When giving information over the telephone,
most doctors felt the response should be tailored to the knowledge
of the person being spoken to whilst nurses were split between
tailoring the response, giving full information, setting up a password
system and not giving any information at all. Most respondents felt
date of birth and hospital number constituted Patient Identifiable
Information. However, experienced staff did not appreciate the
importance of unusual diagnosis and clinical photographs as also
being able to identify patients. Similarly, the majority knew that the
patient themselves identified the Next of Kin but 7% (unaffected
by experience) felt this was decided by the family and felt the family
could decide on resuscitation status. When consent is required for an
elective procedure in a patient who lacks capacity, doctors tended
to have a better understanding of the need to delay the procedure
where possible than nurses, the majority of which felt this could be
decided by the next of kin or two consultant doctors. Most doctors
felt that Acting in the Patients Best Interests would mean doing what
would give the patient the best outcome rather than doing what the
patient would have wanted (unaffected by experience). The majority
of staff, on answering this questionnaire, felt that they lacked sufficient
knowledge on the subject and most felt annual reminders would be
Conclusion The ICU is an environment where issues of consent,
confidentiality and disclosure of information occur daily. Staff feel they
lack knowledge in these areas that is unaffected by their experience.
We need to ensure that all staff have the necessary knowledge to deal
with these situations.
Survey of alcohol-related admissions to critical care and the
resource and financial implications
MSlattery, PTemblett, MHeatley, NSingatullina, BJones
ABMU University Trust, Swansea, UK
Critical Care 2013, 17(Suppl 2):P494 (doi: 10.1186/cc12432)
Introduction Alcohol-related hospital and ICU admissions are known
to have a huge impact on healthcare resources in the UK. Excessive
use of alcohol is independently associated with sepsis, septic shock
and hospital mortality among ICU patients. This study assesses the
relationship between alcohol abuse and intensive care resource
utilisation in a mixed medical, surgical and neurosurgical ICU.
Methods A prospective survey of emergency alcohol-related
admissions over a 1-year period was undertaken at a tertiary university
adult general and neurosurgical ICU. All patients were screened for
acute and chronic alcohol abuse on admission. Acute alcohol abuse was
defined as being intoxicated with alcohol at the time of admission and
chronic alcohol abuse was defined as chronic alcohol use exceeding
recommended UK national guidelines on consumption. The amount
of alcohol consumption was obtained, diagnosis on admission, ICU
and hospital mortality, length of stay, and total cost were recorded. All
patients were screened for alcohol-related comorbidities. Comparative
retrospective data were obtained for the same time period for
nonalcohol-related emergency ICU admissions. Data were analyzed
Results In total, 7.7% of patients were admitted with a history
of acute/chronic alcohol excess. Sixty-seven per cent of
alcoholrelated admissions were due to acute alcohol excess. Neurosurgical
patients admitted due to alcohol excess had higher ITU mortality
than nonalcohol-related neurosurgical patients: 32.1% versus 14.39%
(P = 0.02), respectively. Ninety-three per cent of alcohol-related
neurosurgical admissions were caused by acute alcohol intoxication.
The intensive care cost was significantly higher for alcohol-related
(12,396 per patient) compared with nonalcohol-related neurosurgical
admissions (7,284 per patient). Of the medical patients admitted,
60% of these admissions were due to acute alcohol excess. The cost
of intensive care treatment was lower for alcohol-related medical
Conclusion This is one of the largest studies of alcohol-related
admissions to critical care. Our survey confirms that alcohol-related
admissions to the ICU are commonplace; however, our frequency
is significantly less than previously reported. Our study reveals
interspecialty variations in demographic data, APACHE II scores,
mortality and cost of admission. Neurosurgical alcohol-related
admissions bear higher mortality and result in greater resource
utilisation relative to nonalcohol-related neurosurgical admissions.
Alcohol continues to burden both our patients and critical care.
Introduction The prevalence of sleep disordered breathing (SDB)
is presumably high among individuals with cardiac diseases ,
nonetheless SDB remains predominantly undiagnosed. However,
unrecognized SDB might have relevant impact on the postoperative
course of patients undergoing cardiac surgery .
Methods Polygraphic recordings of 181 patients, without previous
diagnosis of SDB, undergoing standard cardiac surgical procedures
with extracorporeal circulation were obtained during a preoperative
night. The apneahypopnea index (AHI the number of apneas,
hypopneas per hour recorded) was determined and compared with
clinical characteristics and postoperative course.
Results The prevalence of SDB was considerably high among all
examined patients. Median AHI was 20.8 (interquartile range, 10.6 to
36.4). Preoperative AHI was >30 in 32% of all examined individuals.
During the first three postoperative days, preoperative AHI >30 was
associated with a prolonged weaning time, a reduced oxygenation
index (arterial pO2/FiO2), an impaired kidney function, an augmented
inflammatory response and an overall increased length of stay in the
ICU. The observed association of high preoperative AHI values with
postoperative clinical characteristics remained statistically significant
throughout the first three postoperativedays.
Conclusion Undiagnosed SDB is highly prevalent among cardiac
surgical patients. Clinical trajectories of individuals with severe SDB
are described by a prolonged recovery of pulmonary function, delayed
weaning and a pronounced inflammatory response after surgery.
Screening for SDB might identify patients that are susceptible for a
complicated postoperative course.
1. Schiza et al.: J Clin Sleep Med 2012, 8:21-26.
2. Kaw et al.: Br J Anaesth 2012, 109:897-906.
Introduction A literature review was performed to assess whether
massage benefits patients postoperatively following coronary bypass
grafts (CABG) and or valve replacement/repair. A case study on a patient
who had suffered a hypoxic brain post cardiac arrest was conducted.
Methods A review on MEDLINE and Cochrane using search terms
massage, cardiac and ICU identified nine research papers on the
benefits of massage postoperatively for the aforementioned patient
group. Other papers were listed but unrelated to cardiac surgery. None
of the nine papers identified for this review were ICU specific in the title
but the ICU was mentioned in the main text body. For the purpose of
this review the selected papers are researching the effects of massage
on physiological parameters, anxiety, pain, calm and perceived stress
indicators in the CABG and/or valve repair/replacement. Out of these
nine papers, one is British (2002). Five are American (2006 to 2012),
two are Brazilian (2010) and one is an Indian paper (2010). All papers
are randomised control trials (RCTs). Papers written prior to 1999 were
excluded from this literature review.
Results Research from 1999 states there are methodological errors
in prior papers and very few large-scale studies prior to this date,
destabilising the validity and reliability of research from the papers
written before 1999. The later research suggests that any change in
the measured physiological parameters of blood pressure, heart rate
and respiratory rate are insignificant (P>0.05). Pain, anxiety, rest and
a calm score perform better with P >4.71 overall. Another American
study showed that the length of stay is reduced if a patient receives
healing touch postoperatively. However, in one RCT pain and anxiety
increases and in some case SpO2 decreases. A case study was chosen
by the author and the results support the benefits of massage with the
cardiac patient group.
Conclusion There appears to be some benefits but larger-scale studies
are required within this and other ICUs in Britain. The author will be
inquiring at her workplace whether further studies can be performed
and whether she can initiate the research. She will identify further case
studies and trial massage on select patients. The author recommends
training for nurses interested in massage therapy so a bigger caseload
can be identified.
Introduction In our hospital there are a general intensive care unit
(GICU) and a neurointensive care unit (NICU). Despite the preference
for the NICU, in both there are admissions for ischemic stroke. There
are different staff for each ICU, with the same physicians leadership.
We have decided to evaluate the performance of both ICUs, analysing
whether there are differences in results as some authors publish best
results in specialized ICUs.
Methods Using prospectively collected data, we undertook a
retrospective evaluation of all patients admitted to the GICU and NICU
of our hospital with the diagnosis of ischemic stroke, from December
2010 to November 2012. In both ICUs there are intensivists, but in the
NICU the intensivists have special expertise in neuroscience. Data were
collected from Epimedmonitor.
Results A total of 3,854 admissions were registered in the period in
both ICUs, with 257 (6.7%) being by ischemic stroke 49 in GICU and
208 in NICU. Mean age of patients: 73years in GICU and 70.1years in
NICU. Admissions from emergency unit: 44 (89.8%) GICU, 181 (87%)
NICU. Mean SAPS 3 score: 50.7 (29 to 71) GICU, 50.6 (29 to 98) NICU.
Patients admitted with infection: 6 (12.2%) GICU, 10 (4.81%) NICU. Mean
Charlson comorbidity index points: 1.61 (median 1.0) GICU, 1.1 (median
1.0) NICU. Mean length of ICU stay: 4.8days (median 3) GICU, 4.3days
(median 3) NICU. Mean length of hospital stay: 12.2 days (median
8) GICU, 14.5 days (median 8) NICU. Predicted hospital mortality (mean SD): 20.07% 13.48 GICU, 20.4% 13.83 NICU. Hospital mortality rate: 12.5% GICU, 5.39% NICU. Observed-to-expected (O/E) mortality ratios: 0.62 GICU, 0.26 NICU.
Conclusion Despite the similar proportions numbers for patients in
both ICUs, the mortality rate and the O/E mortality ratio for ischemic
stroke were higher in patients of the GICU when compared with the
1. Varelas PN, et al.: Neurocrit Care 2008, 9:293-299.
2. Berchad EM, et al.: Neurocrit Care 2008, 9:287-292.
Introduction VAP has continued to be a major cause of morbidity
and mortality in critically ill patients in Thailand for decades. Previous
research found that the implementation of VAP care bundles and the
educational program can reduce VAP incidence in the ICU . In this
research we aimed to observe the reduction of VAP incidence after the
implementation of VAP care bundles to ICU medical personnel.
Methods Inclusion criteria: all adult surgical patients (>18 years old)
who are on ventilatory support in the surgical ICU at Siriraj Hospital.
There are two groups, divided into pre-educational group (group I) and
post-educational group (group II) (n = 220/group). We also observed
the adherence rate to VAP care bundles according to the educational
program. The pretest and post-test to determine the efficacy of the
educational program were done. The VAP care bundles consisted of
weaning according to weaning protocol, sedation vacation,
headof-bed elevation, measurement of cuff pressures four times/day, 2%
chlorhexidine use for mouth care and emptying of ventilator circuit
Results There were 45.38 and 25.25 episodes of VAP per 1,000
ventilatordays in group I and group II, respectively (P=0.020). The incidence of
VAP was 21.82% in group I and 9.09% in group II (P=0.000). There was
significant reduction in the length of ventilatory support per person
(group I=2, group II=1 (median), P=0.013, 95% CI=0.319 to 0.936)
and mortality rate (group I=15.5%, group II=8.2%, P=0.017). There
was no significant difference in LOI, LOH and ATB cost. The pretest
scores were 15.53 and 17.53 on average from 40 medical personnel in
group I and group II, respectively (P=0.000). The head-of-bed elevation
adherence rate was improved after the educational program (group
I = 50.1%, group II = 70.36%, P = 0.017). But the adherence to other
bundles was not improved. See Tables 1 and 2.
Table1 (abstract P498). Impact of the educational program on outcomes
Table 2 (abstract P498). Adherence rate to VAP care bundles
Conclusion The educational program and the implementation of VAP
care bundles can reduce the incidence of VAP, length of ventilatory
support and mortality rate in the ICU.
1. Apisarnthanarak A, Pinitchai U, Thongphubeth K, Yeukyen C, Warren DK, Zack
JE, et al.: Effectiveness of an educational program to reduce
ventilatorassociated pneumonia in a tertiary care center in Thailand: a 4-year study.
Clin Infect Dis 2007, 45:704-711.
Development of a severe influenza critical care curriculum and
training materials for resource-limited settings
JVDiaz1, PLister2, JROrtiz3, NKAdhikari4, NAdhikari5
1World Health Organization, San Francisco, CA, USA; 2Great Ormond
Street Hospital, London, UK; 3University of Washington, Seattle, WA, USA;
4Sunnybrook Health Sciences Centre and University of Toronto, Canada;
5Health Sciences Centre and University of Toronto, Canada
Critical Care 2013, 17(Suppl 2):P499 (doi: 10.1186/cc12437)
Introduction The 2009 H1N1 pandemic caused surges of severely ill
patients with viral pneumonia requiring ventilation and particularly
affected high-dependency medical services such as ICUs in settings
that lack sufficient personnel and resources to provide optimal care.
Ministries of Health of several countries asked the World Health
Organization (WHO) for clinical management guidance.
Methods We developed (2009 to 2011) and piloted (2011 to 2012)
curriculum and training materials targeted at clinicians without formal
critical care training who care for adult and paediatric patients with
severe acute respiratory infections in ICUs in resource-limited settings.
Results With contributions from 37 global experts, we developed a
3-day course including 14 learning units in early recognition,
pathophysiology, oxygen therapy, influenza diagnostics, infection control,
resuscitation of septic shock, antimicrobial therapy, monitoring,
lungprotective ventilation for acute respiratory distress syndrome, sedation,
weaning, preventive care, quality improvement, and ethics. Teaching
techniques are appropriate for adult learners and include short
slideshow-based lectures, interactive small-group role-play sessions
and a toolkit with practical resources such as checklists. With funding
from the WHO and local Ministries of Health, the training course was
piloted among 67 clinician participants in the Caribbean and Indonesia
(29 and 38, respectively) and taught by external critical care specialists.
Participants daily evaluations rated all units as at least very good.
Test scores to assess participant critical care knowledge improved
significantly from before the training to immediately after (Caribbean,
58 to 80%; Indonesia, 56 to 75%; P<0.001 for both).
Conclusion It was feasible to develop and deliver an advanced critical
care curriculum and related training materials in a short, interactive
workshop for noncritical care trained clinicians in resource-limited
settings. However, the small-scale programme was labour and time
intensive. Widespread dissemination of these materials requires
identification of target countries, engagement of Ministries of Health,
and secure funding. Longer-term evaluation is necessary to determine
whether such programmes improve processes of care and clinical
outcomes for critically ill patients.
Introduction Following our study of severe sepsis care across three
centres , we aimed to introduce a rapid feedback mechanism into
our rolling audit programme. Whilst previous audits raised awareness
of severe sepsis, only whole organisation performance was reported
and no feedback was given to individual clinicians. It is recognised that
such feedback loops can improve clinical practice .
Methods Patients admitted to critical care (58 beds, four units) with
a primary admission diagnosis of infection were screened for severe
sepsis. Pre-ICU care was then audited against the Surviving Sepsis
Guidelines . Time zero is defined as when criteria for severe sepsis
were first met. An individualised traffic-light report was then generated
and emailed to the patients consultant and other stakeholders
involved in care (Figure1). We aimed to report cases within 7days of
critical care admission. A cumulative report is generated monthly to
track organisation-wide performance.
Figure1 (abstract P500). Example report.
Figure 2 (abstract P500). Compliance with pre-ICU resuscitation bundle.
Introduction When we talk about safety culture, we speak of being
aware that things can go wrong. We must be able to recognize mistakes
and learn from them, sharing that information fairly and impartially
to try to prevent its recurrence. Organizations such as the Agency for
Healthcare Research and Quality (AHRQ) have developed tools to help
organizations measure their safety culture and there is little information
about our country.
Methods A descriptive survey study. We sent the Spanish version of the
questionnaire on patient safety culture (AHRQ) to the nursing staff of a
polyvalent ICU of 42 beds in a tertiary hospital.
Results The questionnaire was sent to 179 nurses, receiving correctly
answered 88 surveys (response rate of 49.16%). On a scale of 0 to
10, 6.97 points was obtained to estimate the safety climate for staff
respondents. The item best scored was teamwork in the unit (65.9%).
Detected as a fortress, communication between nurses at shift
changes (76.1% positive responses). The worst rating was obtained in
the section on human resources, followed by management support in
the field of patient safety.
Conclusion The perception of safety culture in an ICU by nursing staff is
far from optimal levels. The team work dimension was identified as the
most valued by workers, with the transmission of information on shift
changes the most valued item.
Introduction The requirements for the intensivist in handling medical
technology are constantly growing. It appears necessary to acquire
technological competences particularly within the fields of medical
technology and physics. In the masters degree program MasterOnline
Physico-Technical Medicine, such technical authority is conveyed.
To cope with the intensive vocational situation of the physician,
this study course follows the blended-learning concept; that is, it is
conceived as an online study course with small portions of intermittent
presence phases. Within the first year, technical basic skills such as
measurement technique, informatics, and advanced physics are
covered. Subsequently, two of various advanced courses in different
fields of medical technology (technology in intensive care medicine,
technology in surgery, technical cardiology, radiology, and other) are
Methods In a survey, we evaluated the study course. Therefore, a
questionnaire was distributed among all students including the topics
course contents, learning materials, time management, supervision,
and overall impression. The students were asked to score their
agreement to the statements content is well structured, content
extent is appropriate and content is relevant for medical purposes on
a scale ranging from 1 (fully disagree) to 5 (fully agree).
Results The students participated actively in this study course with
highest motivation and large commitment. The students workload
was in the targeted range of about 10hours/week. Content structure
was scored with 4.3 0.1, content extent with 4.1 0.2 and medical
relevance with 4.30.2.
Conclusion The blended-learning concept fulfills the requirements
for occupation-accompanying continued medical education, since it
offers the possibility to study self-employed accessing text documents,
lecture recordings, and electronic lectures and to convert in
concentrated presence phases this knowledge into practical exercises.
Introduction The first-hour protocol determines the patient-specific
resources for the start of an ICU stay . Staff resources are decided
through triage. Task charts direct the start of intensive care. Our primary
goal is to improve patient care.
Methods A triage method (red, yellow, green) is used to manage ICU
resources according to the severity of illness. For example, one doctor
and one nurse would admit a stable (green) patient coming from the
operating room for postoperative ICU care. A patient in septic shock
with multiple organ disorder (red), on the other hand, would be
admitted by a team of two doctors and three nurses. Each staff member
has a task chart in a checking-list format. Also, an admission chart is used
to improve data collection. The use of the protocol started as a pilot
study in early 2012. Simulation education for staff members started in
August 2012 and has included video recordings and debriefing of each
simulated ICU admission. Primary goal-directed therapy goals have
been mean arterial pressure (MAP >65 mmHg), SpO2 >94%, timing
of the laboratory tests, start of antibiotics, and blood glucose level
6 to 8 mmol/l. Quality indicators have been followed from the data
provided by The Finnish Intensive Care Consortium. Questionnaires for
the staff members have been used to evaluate opinions about the
Results According to the questionnaire replies, 80% (n=64/80) of our
nurses estimate that the first-hour protocol has improved the starting
process of our patientsintensive care. Twenty percent (n=16/80) of the
nurses considered that the protocol has no effect, and none thought
it to be adverse for patient care. Corresponding numbers for our ICU
doctors were 87% (beneficial n=13/15), 13% (no effect n=2/15) and
0% (adverse). Furthermore, 82.5% (n=66/80) of the nurses replied that
education of new nurse staff members has improved because of the
first-hour protocol. A total of 17.5% (n=14/80) thought there has been
no effect, and none considered the protocol harmful for education.
For ICU doctors the protocol did not bring either clear educational
advantages or disadvantages. The variable life-adjusted display curves
(The Finnish Intensive Care Consortium) have shown improvement in
our patient care after the implementation of the first-hour protocol.
However, we cannot determine whether it is a significant factor in our
intensive care results.
Conclusion The first-hour protocol has helped us in resource
management, start of the patients intensive care and education of
1. Brown R, et al.: Aust Crit Care 2012, 25:178-187.
Introduction Demand for critical care services is increasing yet a
comprehensive understanding of how critical care nurses the largest
group of ICU direct care providers impact outcomes remains unclear.
The purpose of this study was to determine how critical care nurse
education (hospital proportion of bachelors prepared ICU nurses) and
ICU work environment influenced 30-day mortality of mechanically
ventilated older adults.
Methods A multi-state cross-sectional nurse survey was linked to
hospital administrative data and Medicare claims (2006 to 2008). The
final sample included 55,159 mechanically ventilated older adults in 303
hospitals. Logistic regression modeling was employed to jointly assess
the relationship of critical care nurse education, work environment and
staffing on 30-day mortality while adjusting for hospital and patient
characteristics and accounting for clustering.
Results A 10% increase in the proportion of ICU nurses with a bachelors
degree or higher was associated with 2% lower odds of death while
controlling for patient and hospital characteristics. Patients cared for
in better work environments experienced 11% lower odds of
riskadjusted death than those cared for in poorer ICU work environments.
Conclusion Patients cared for in hospitals with a greater proportion of
bachelors prepared ICU nurses and in better ICU work environments
experienced significantly lower odds of death. As the demand for
critical care services increases, attention to the education level of ICU
nurses and ICU work environment may be warranted to optimize
currently available resources and potentially yield better outcomes.
Activity and case-mix changes in a medical ICU after the
geographical transfer of a third-level university hospital
JCCebrin, FMMonsalve, JBBonastre
Hospital Universitario y Politecnico La Fe, Valencia, Spain
Critical Care 2013, 17(Suppl 2):P505 (doi: 10.1186/cc12443)
Introduction Information about big hospital geographical transfer is
scarce in the medical literature. On 20 February 2011 our hospital (in fact,
a big university complex) was transferred from their previous location
in the north-center of our city towards a new southern peripheral,
geographical location. This transfer has been done without any changes
in assisted population or nursing/medical staff. The only change was a
slight increase in bed number (21 to 24). Our aim is to analyze changes
in activity indexes (length of stay, occupancy rate, and so forth) and case
mix (origin, previous quality of life and NYHA score, main diagnostic
groups, severity scores, in-ICU and in-hospital mortality).
Methods To compare our number of admissions, related activity and
case-mix indicators 1 year before and after the geographical change
was done. We analyzed our whole number of patients admitted to the
ICU. We used the chi-square test for categorical variables and one-way
analysis of variance for quantitative data. Minitab and Statbas statistical
programs were used. We plotted activity data using the Barber
Johnson 1 diagram.
Results A total of 2,774 cases (63% males; mean age 61 years) were
admitted to our ICU during the period (1 year before and after the
transfer). No differences between both groups were founded in
demographic data, Knaus score and NYHA status. Regarding their
origin, we found more patients admitted from other hospital centers
(20 vs. 29%; P<0.001). APACHE II score increased from 17.24 to 19.08%
(P<0.001) and a slight increase change in SAPS 3 score was also found
(52.29 to 53.75; P <0.01). Our in-ICU mortality remains lower (15.5
to 15.6%) whereas observed mortality decreased (22.37 to 19.88%;
P <0.001). An increase in our neurologic patients has been the most
consistent change regarding diagnostic groups. The activity indexes
show a slightly decrease in occupancy rate (79.2 vs. 76.8).
Conclusion According to the previous data our ICU seems to perform
better in the new location with a decrease in the standardized mortality
rate. On the other hand, we are admitting more patients transferred
from other hospitals. A better occupancy rate was found.
1. Yates J: Hospital Beds: A Problem for Diagnostic and Management. Heinemann Medical Books; 1982.
Are general wards sufficiently staffed to care for level 1 patients?
GRajendran, CTjen, SHutchinson, SFletcher
Norfolk & Norwich University Hospital, Norwich, UK
Critical Care 2013, 17(Suppl 2):P506 (doi: 10.1186/cc12444)
Introduction There are several definitions of level 1 (L1) care, all refer
to a group at risk of clinical deterioration on the ward [1-3]. There is
evidence that ward patients who become acutely unwell often receive
suboptimal care . A regional study commissioned by Norfolk, Suffolk
& Cambridgeshire Critical Care Network (NSCCCN) found that a majority
of ward patients may be of L1 dependency and death rates appear to be
correlated with L1 status. We aim to examine the relationship between
the ward distribution of illness acuity, staffing and patient outcome.
Methods Data were collected as part of NSCCCNs observational
prevalence study in 2010. Ward surveys included acuity of illness,
staffing levels and skill mix. Secondary data were obtained from the
Patient Administration System. Emergency, oncology, paediatric and
maternity units were excluded.
Results Complete datasets were obtained from 1,402 patients in 22
wards in our university hospital over two seasons. This constitutes
98.3% of inpatients from those wards. The mean ward occupancy rate
was 94% (10th to 90th percentile: 85% to 100%). At least one L1 acuity
criterion was scored by 898 (64%) patients, with 25% from geriatrics
followed by orthopaedics (17%) and general surgery (10%). Each ward
had an average of eight qualified nursing staff (range: 4 to 12) equating
to an average staff:patient ratio (SPr) of 0.253. There was no correlation
between ward occupancy and nursing staff (Pearson correlation, corr:
0.55), nor between prevalence of L1 criteria and staffing (corr: 0.34). The
admission rate to intensive care was noted to be higher if the patients
were nursed in a ward with lower than average SPr compared with
higher SPr (2.7% vs. 1.2%, P = 0.058 Fishers exact), but this was not
statistically significant. Senior nursing (Band 6) staff were part of the
skill mix on only nine of 44 ward surveys.
Conclusion Better outcome with improved SPr may be unsurprising,
although if proven conclusively would significantly inform workforce
planning. Lack of correlation between staffing levels and occupancy or
acuity is also interesting given that we know L1 criteria are associated
with worse outcome.
1. Levels of Critical Care for Adult Patients. Intensive Care Society; 2002.
2. Acutely Ill Patients in Hospital. NICE Guideline 50. NICE; 2007.
Introduction Prolonged shifts, workload, stress, and different
conflicts are associated with burnout, loss of psychological wellbeing,
and probably with an inadequate sleep quality (ISQ). This relevant
disturbance leads to deterioration of the work performance, may impair
quality of care provided to patients and increases the incidence of
serious adverse events. The objective was to determine the prevalence
of ISQ and sleepiness among Uruguayan ICU workers, and to evaluate
risk factors associated with ISQ.
Methods A survey was conducted in six Uruguayan ICUs. The sleep
quality was evaluated on the basis of the Pittsburgh score (PS), and the
sleepiness was identified by the Epworth scale. ISQ was defined as PS
greater than 5 points and sleepiness by an Epworth scale higher than
6points. ICUs, patients, and clinicians characteristics were assessed for
their association with the prevalence of ISQ. All variables with P<0.2
in univariate analysis were included in a model of ordinal regression.
P<0.05 was considered statistically significant.
Results The survey was completed by 129 ICU workers. The global
prevalence of ISQ in ICU was 67.4%. ISQ was observed in 45% of
physicians and 82% of nurses and nurses assistant (P <0.001). Sleep
medication was used by 13.3% of the ICU team. Univariate analysis
showed that ISQ was significantly associated with sex (73% vs.
43%, P = 0.03 in women and men, respectively), marital status (84%
vs. 61%, P = 0.01 in single and couple workers, respectively), more
than 60 hours working in the last week (76% vs. 61%, P = 0.07) and
less than 6 sleeping hours (95% vs. 54%, P <0.0001). Multivariable
analysis demonstrated that a sleep duration less than 6 hours was
independently associated with ISQ (OR=24.5; 95% CI=5.2 to 115.8;
P<0.0001). Furthermore, pathologic sleepiness was present in 59.3%
of ICU workers. Sleepiness was independently associated with use of
sleep medication (OR=5.9; 95% CI=1.2 to 28.5; P=0.025).
Conclusion The prevalence of ISQ and sleepiness is very high among
ICU workers. Those disturbances are independently associated with a
sleep duration less than 6hours, and sleep medication use, respectively.
These results highlights that strategies to decrease ISQ and sleepiness
in ICU clinicians are urgently needed to improve work performance,
improve quality of care provided and prevent adverse events.
Work-related stress amongst doctors in intensive care, anaesthetics,
accident and emergency and general medicine
JITuthill, MSAhmed, GMathew, ACBolton, AAMolokhia
University Hospital Lewisham, London, UK
Critical Care 2013, 17(Suppl 2):P508 (doi: 10.1186/cc12446)
Introduction Work-related stress is a potential problem among
doctors and is associated with anxiety, depression, reduced job
satisfaction,days off work, errors and near misses . To compare stress
levels between different groups of doctors and identify causes of stress,
we conducted a survey at University Hospital Lewisham using the UK
Health and Safety Executives Management Standards (HSEMS). HSEMS
is a validated tool developed to identify work conditions that warrant
interventions to reduce stress levels across organisations .
Methods We conducted an anonymous survey of doctors working
in anaesthetics, intensive care, general medicine and accident and
emergency (A&E) departments over 6 weeks using the HSEMS
questionnaire. We also surveyed awareness of the Trusts stress
management services and whether staff had a designated supervisor
or mentor. Results were analysed using the HSEMS Analysis Tool, which
rates stressors with a score from 1 to 5 (5 represents the lowest amount
of stress). We compared the Trusts results against HSEMS national
Results Seventy-two doctors completed the survey. Lowest stress
levels were found in doctors working in intensive care (n=12, mean
3.63, SD 0.39). This was followed by medicine (n = 26, mean 3.55,
SD 0.47), anaesthetics (n = 27, mean 3.40, SD 0.44), and A&E (n = 7,
mean 3.11, SD 0.65), which had the highest stress levels. There was
no significant difference in stress levels between different grades of
doctors. When compared with HSEMS targets, staff relationships and
peer support exceeded national standards. However, management
of organisational change and demands at work need improvement.
The majority of doctors (82%) had no idea what stress management
services were provided by the Trust. Seventy-nine per cent of doctors
had an allocated supervisor or mentor, 91% of those felt able to
approach their supervisor.
Conclusion These survey results provide reassurance that stress levels
in intensive care compare well, despite critically unwell patients and
higher mortality rates. We identified areas that need improvement
within the Trust and will present these results to all relevant
departments. With the support of hospital management we will initiate
HSEMS-validated measures to reduce stress.
1. Kerr et al.: HSE management standards and stress-related work outcomes. Occup Med (Lond) 2009, 59:574-579.
2. Health and Safety Executive Management Standards [http://www.hse.gov.
Introduction South-east London (SEL) presents unique challenges to
healthcare providers due to its diverse demographic. The high levels of
poverty, immigration and psychiatric illness impact delivery of obstetric
care. These were identified as risk factors for poor outcome in the latest
CMACE report . The Intensive Care National Audit and Research
Centre (ICNARC) produced data on obstetric critical care admissions in
2007 . We reviewed the obstetric critical care admissions in three SEL
hospitals and compared this with the national average determined in
the ICNARC and CMACE data.
Methods All critical care admissions in three high-risk obstetric units
in SEL (1 August 2009 to 31 July 2011) were screened for patients who
were currently or recently pregnant. We compared local results with
national data by ICNARC and CMACE.
Results There were 68 obstetric critical care admissions in the SEL
hospitals within the audited time frame. The mean age was 30.05 in
ICNARC data compared with 33.93 in SEL. Average APACHE II scores
were lower in SEL compared with the ICNARC data, but length of
stay was greater in SEL (2.72days) compared with ICNARC (1.5days).
Haemorrhage was the most common reason for admission in SEL,
whilst sepsis was the leading cause of death according to the latest
CMACE report (Figure1).
Conclusion Data from national audits may guide protocol, but services
must be tailored to local circumstances. SEL has unique population
characteristics and obstetric critical care admissions differ significantly
from national statistics; in particular, haemorrhage is over-represented
in our region. Critical care services were generally required for a short
period of time; during this period, routine postpartum care may be
omitted as treatment priorities differ. Dedicated critical care services on
the labour ward may be a way to combine postnatal care with transient
high-dependency requirements. This may enhance patient experience
and prove cost-effective.
1. Centre for Maternal and Child Enquiries: Saving mothers lives: reviewing
maternal deaths to make motherhood safer: 200608. The Eighth Report
on Confidential Enquiries into Maternal Deaths in the United Kingdom.
BJOG 2011, 118(Suppl 1):1-203.
2. Female Admissions (Aged 1650 Years) to Adult, General Critical Care
Units in England, Wales and Northern Ireland, Reported as Currently
Pregnant or Recently Pregnant [http://www.oaa-anaes.ac.uk/assets/_
Influence of adverse drug events on the mortality and the length of
hospital stay in ICUs in Japan: the JADE Study
YOhta1, MSakuma1, DBates2, TMorimoto1
1Kinki University, Osaka, Japan; 2Harvard University, Boston, MA, USA
Critical Care 2013, 17(Suppl 2):P510 (doi: 10.1186/cc12448)
Introduction Adverse drug events (ADEs) are associated with a
substantial increase in morbidity and mortality in any setting. Because
patients in ICUs were critically ill with complex diseases and varied
organ dysfunction, the incidence of ADEs on such patients is much
more crucial than the counterparts. We thus assessed the nature of
ADEs and their influence in ICUs.
Methods We conducted a prospective cohort study at ICUs at three
large tertiary-care hospitals in Japan. Trained research nurses reviewed
all medical charts, incident reports and reconciliations from the
pharmacy to identify suspected ADEs as well as the background of
patients. ADEs are any injuries that result from the use of a drug. After
suspected ADEs are collected by research nurses, physician reviewers
independently evaluated them and classified them as ADEs or rule
violations. We used the validated methodology .
Results We included 459 patients with 3,231 patient-days. The median
age was 70years and the median length of stay was 3days. In total, 70
patients (15%) had at least one ADE during their stay in the ICU. The
median ICU stay in patients who had ADEs was 14days while 2days
in patients who had no ADEs (P <0.0001). The median length of the
ADE onsetdays since admission was 3days. Regarding the mortality,
73 patients (16%) were dead during their ICU stay: 12 deaths (17%) in
patients who had ADEs and three of 12 deaths were caused by an ADE,
and 61 deaths (16%) in counterparts (P=0.8). There were no significant
differences of patients characteristics between patients with ADEs and
without ADEs (Table1).
Conclusion ADEs were associated with longer stay and caused a part of
death in ICU (4%) although they did not increase the mortality. Because
the characteristics of patients were not associated with ADEs, early
detection and intervention for ADEs could be important to improve the
morbidity and reduce the death caused by ADEs in ICUs.
1. Morimoto T, et al.: Qual Saf Health Care 2004, 13:306-314.
Table1 (abstract P510). Patient characteristics
Heart failure, NYHA = 4
Clinical laboratory measurements, median (25%, 75%)
Blood urea nitrogen (mg/dl)
Aspartate aminotransferase (IU/l)
Number of medications on admission,
median (25%, 75%)
21 (15, 39) 19 (14, 31)
0.8 (0.5, 1.5) 0.9 (0.7, 1.7)
27 (20, 47) 30 (22, 48)
20 (13, 42) 20 (12, 33)
6.7 (5.9, 7.4) 6.6 (5.9, 7.3)
GCS, Glasgow Common Scale; NYHA, New York Heart Association.
Introduction In Hungary, despite the high level of social support, the
number of organ recoveries from deceased donors has not changed
significantly. The donation activity shows a positive relationship with
the level of education of staff in ICUs as well as with their attitude
towards transplantation. The aim of this cross-sectional study is to
estimate the attitude and knowledge of intensive care specialists and
nurses as regard donation and transplantation.
Methods The self-completed questionnaire that consisted of 20 items
was completed at the Congress of Hungarian Society of Anesthesiology
and Intensive Therapy in 2011. Besides the epidemiological data, the
intensive care specialists (n = 179) and nurses (n = 103) were asked
about donation activity, participation in an organ donation course,
selfreported knowledge of joining Eurotransplant, donor management,
legislation, and transplantation. The data were analyzed by SPSS 17.0.
Results A total of 53.6% of physicians and 16.7% of nurses attended
an earlier organ donation course (P<0.01). The average age of those
who participated in training was significantly higher among doctors
(P <0.01). Fifty-nine percent of doctors and 65.1% of nurses did not
even want to participate in such training. Donation activity was
higher among staff who joined training (P <0.01). Independently
from accepting the presumed consent legislation (91.1%), 66% of
physicians agreed with the hospital practice that requests the adult
donors relatives to consent to organ recovery. This standpoint did
not depend on donation activity, participation in an organ donation
course, opinion about legislation and the nature of staff. A total
95.4% of participants consented to their organ retrieval after death.
The staff who participated in an organ donation course had more
knowledge regarding the law and ethics of donation (P<0.01), donor
management (P <0.01), living and deceased donor transplantation
(P<0.01) and joining Eurotransplant (P<0.01). Older professionals had
more information about all fields (P<0.01). Nurses had less knowledge
concerning donor management (P<0.01), law and ethics (P<0.01) and
deceased donor transplantation (P<0.01) than doctors.
Conclusion Education about organ donation needs to be part of
specialist training of intensive care staff, and refresher courses every
fifthyear as well. The course should include knowledge regarding brain
death, donor management and communication with family. This is the
first step to improve the number of transplantations.
1. Roels L, et al.: Transplant Int 2010, 23:842-850.
Introduction In the UK, three people die eachday awaiting
transplantation, due to the unavailability of donor organs. Traditionally, donor
identification has been restricted to the ICU. However, following the UK
Organ Donation Taskforce report in 2008 , a number of emergency
departments (EDs) have been working with specialist nurses for organ
donation (SN:OD) to identify potential donors and approach their
families for consent in the ED. We present our initial experience after
the introduction of a SN:OD to an Irish teaching hospitals ED.
Methods We conducted a retrospective review of deaths in our
ED during a 28-month period. For those who died in the ED, case
notes were reviewed to identify those suitable for organ donation.
Referral and donation rates were compared in two cohorts, pre and
post introduction of a SN:OD. Fishers exact test was used to assess
differences between groups.
Results Ninety-one deaths occurred in the study period. Following
introduction of the SN:OD, referrals increased from zero to eight. Of
the eight referred, three received consent and were transferred to the
ICU, two of whom became successful donors. The number of missed
potential donors fell from six to one (P=0.009).
Conclusion Introduction of a SN:OD and a clinical pathway has led to
the identification of previously missed potential organ donors in the
ED. Several patients have subsequently been admitted to critical care
solely to facilitate organ donation.
1. UK Organ Donation Taskforce: Organs for Transplants: A Report from the Organ Donation Taskforce. Department of Health; 2008.
Sepsis in HIV patients admitted to the ICU
PVidal-Corts1, PLameiro-Flores1, MMourelo-Faria2, AAller-Fernndez2,
RGmez-Lpez1, PFernndez-Ugidos1, MAlves-Prez1, ERodrguez-Garca1
1CHU Ourense, Spain; 2CHU A Corua, Spain
Critical Care 2013, 17(Suppl 2):P513 (doi: 10.1186/cc12451)
Introduction Our objective was to analyze septic HIV patients admitted
to intensive care.
Methods A retrospective study of HIV patients admitted to our ICU
between January 2005 and December 2009. We identify patients
admitted to the ICU with sepsis and analyze demographic factors,
etiology, organ failure and outcome, and we compare immune status,
frequency of organ failure and outcome between these patients and
those admitted for other reasons. We use Students t test to compare
quantitative variables, and the chi-square test for qualitative data.
Results A total of 104 HIV patients were admitted to our ICU during
the study period, 62 with sepsis (71% men, mean age: 40.59 8.12).
Of sepsis patients, 56.5% were admitted from the ER and 38.7% from
a medical ward; 66.1% had history of intravenous drugs use, other
comorbidities: COPD (9.7%), cirrhosis (8.1%), solid or hematologic
malignancy (12.9%); 8.1% patients were unaware of their condition
(2.4% in non-infected patients, P=0.223) and 40.3% were under HAART
(64.3% in patients admitted without infection, P = 0.016). Mean CD4
count at admission: 219.62 353.93 cells/mm3 (vs. 370.22 362.56,
P=0.048). Mean viral load: 4.573.25 log (vs. 2.2571.96, P=0.001).
Of sepsis patients, 62.1% were on their CD4 nadir (vs. 34.5% in
nonseptic patients, P=0.009). Mean albumin levels were 2.30.53 g/
dl (vs. 2.920.94, P<0.001). APACHE II at admission was 21.987.97
(vs. 18.158.47, P=0.046). At admission, 52.8% were on severe sepsis
and 44.3% on septic shock. The lung was the most frequent source of
infection (65.6%) followed by CNS (16.4%), UTI (4.9%) and IE (4.9%). The
most common pathogen isolated on these patients was S.pneumoniae
(28.8%), followed by P.jirovecii (13.6%), toxoplasma (8.5%), E.coli (5.1%)
and H.influenzae (5.1%). In total, 62.9% needed vasopressors (vs. 28.6%
in non-infected patients, P = 0.001), 79% mechanical ventilation (vs.
42.85%, P <0.001) and 19.4% renal replacement (9.5% in no septic
patients, P=0.173). Mean ICU and hospital LOS was 10.4310.52 and
34.7629.64days in septic patients versus 6.048.45 (P=0.026) and
20.5427.93days (P=0.016). ICU mortality: 33.9% (19% in nonseptic
patients, P=0.098), hospital mortality: 41.9% (vs. 23.8%, P=0.057).
Conclusion Sepsis is a common reason for admission to the ICU in
HIV patients and is accompanied by high mortality. Pneumonia is the
most frequent source of infection. Septic patients are less frequently
under HAART and have a worse inmune status (lower CD4 count
and higher viral load). Despite a higher APACHE II, and a higher need
for hemodynamic and respiratory support, there is no statistically
significant difference in ICU and hospital mortality between septic and
Introduction Although recent reports show an improvement in
outcomes for pediatric hematology patients requiring intensive care [1,2],
respiratory failure remains one of the major risks of pediatric mortality.
This study was conducted to assess our hypothesis that mortality
associated with respiratory failure is higher than that for other organ
failures in pediatric hematology patients admitted to our ICU.
Methods A retrospective study analyzed children with hematological
disorders admitted to our ICU between April 2005 and June 2012. All
of the included children required emergency admission and invasive
mechanical ventilation. Those who did not need intubation, or required
intubation only for therapeutic intervention and died within 24hours
of ICU admission were excluded. The survival group was defined as
patients who were discharged from the ICU, and the nonsurvival
group was defined as those who died in the ICU or within 7days after
discharge from the ICU. The PELOD score and PIM-II were applied as
morbidity scoring systems
Results Twenty-seven patients, including 18 males and nine females,
with a median age of 6.1years (range, 0.2 to 16.6years) were analyzed.
Sixteen patients had leukemia, five had hemophagocytic syndrome,
six had solid tumors. The average predicted mortality rate was 31.3%
in PIM-II. The survival group included 15 patients (56%) and the
nonsurvival group included 12 patients (44%). When the survival group
was compared with the nonsurvival group, there were no significant
differences in the systolic blood pressure (101.3 13.9 mmHg vs.
92.8 25.4 mmHg; P = 0.15), the proportion of patients requiring
continuous renal replacement therapy (33.3% vs. 50.0%; P=0.30), and
PELOD score (15.510.4 vs. 21.815.4; P=0.22). In the nonsurvival
group, the PIM-II was higher than that in the survival group (27.910.4
vs. 35.79.0; P=0.06); the PaO2/FiO2 (272.5136.7 vs. 153.3123.3;
P=0.03) and oxygenation index (6.78.1 vs. 14.19.5; P=0.04) were
significantly worse in the nonsurvival group than in the survival group.
Conclusion The data show that respiratory failure is more strongly
associated with mortality than other organ failures in pediatric
hematology patients requiring intensive care. These results also suggest
that mechanical ventilation intervention in patients with respiratory
failure must occur earlier to improve the outcomes for these patients.
Introduction Critically ill patients with haematological malignancies
(HM) have high hospital mortality . Severity of illness scores may
underestimate mortality in such patients .
Methods Data collection was conducted at three hospitals from 2008
to 2011. Patients with any active HM condition were matched with
two control patients at two hospitals and with one control at Christie
Hospital. Control patients had the same APACHE II (within 2 points) and
admission diagnosis, but no HM. Readmissions and planned surgical
cases were excluded.
Results A total of 163 patients with HM were compared with 237
control patients. Seventy-four admissions with HM were identified at
two hospitals, and each was matched with two control patients.
Eightynine admissions with HM from Christie Hospital were identified. These
were matched with 89 controls. Patients with HM spent significantly
longer in hospital before ICU admission (Table 1). Unit and hospital
mortality rates were not statistically different between patients with
HM and without HM (Table 2).
Table1 (abstract P515). Patient characteristics
Table 2 (abstract P515). Unit and hospital mortality
Conclusion Unit mortality of critically ill patients with HM was similar
to those without HM. Hospital mortality in patients with HM was higher
than those without HM, although not statistically significant. Severity
of illness at presentation to critical care is the main determinant of
outcome in patients with HM.
1. Hampshire PA, et al.: Crit Care 2009, 13:R137.
2. Massion PB, et al.: Crit Care Med 2002, 30:2260-2270.
Introduction ICU admission policies regarding patients with
haematological malignancy still vary despite data showing an acceptable
prognosis. Our aim was to review ICU and 6-month outcomes in this
group when requiring emergency admission to the ICU in a tertiary
Methods A retrospective review of medical notes between 2004 and
Results A total of 249 patients were admitted, of whom 54 had more
than one admission. There were 310 episodes in total. Leukaemia n=85;
lymphoma n=90; myeloma n=36. We compared the characteristics of
those who survived ICU admission with those who failed to survive to
discharge from ICU. The two populations were similar (age 51 vs. 57;
males 59% vs. 57%). Those who survived had a lower APACHE II score
on admission (19 vs. 23; P<0.001), lower mean organ failure scores (1
vs. 2; P<0.05), lower requirements of inotropes (26% vs. 50%; P=0.001),
ventilation (31% vs. 64%; P = 0.001) and filtration (11% vs. 26%;
P=0.004). There was no difference in the prevalence of sepsis at the
time of admission (64% vs. 70%). Both groups included patients with
prior bone marrow transplant (38% vs. 40%). Of note, ICU and 6-month
survival were 27% and 50%, respectively. These values are lower than
those reported in the literature to date.
Conclusion ICU and 6-month mortalities were 27% and 50%, respectively.
Patients with haematological malignancy stand to benefit from intensive
care, and should be offered admission based on clinical need.
1. Cuthberson et al.: The outcome of haematological malignancy in Scottish
intensive care units. J Intensive Care Soc 2008, 9:135-140.
2. Evison JM, et al.: Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors. Swiss Med Wkly 2001, 131:681-688.
3. Beed et al.: Intensive care management of patients with haematological
malignancy. Conti Edu An Crit Care Pain 2010, 10:167-171.
4. Kleber et al.: Comorbidity as a prognostic variable in multiple myeloma:
comparative evaluation of common comorbidity scores and use of a novel
MMcomorbidity score. Blood Cancer J 2011, 1:e35.
5. McGrath S, et al.: ICU and 6-month outcome of oncology patients in the intensive care unit. QJM 2010, 103:397-403.
Introduction In theyear 2009, the organizational structure of the ICU
in the Kanazawa University Hospital changed from an open to a
semiclosed format ICU. The objective of this study was to evaluate the effect
of this organizational change on outcome in high-risk surgical patients.
Methods The medical records of all consecutive high-risk surgical
patients admitted to the ICU from 2006 to 2009 (open format, n=1,598)
and from 2009 to 2012 (semi-closed format, n=1,521) were reviewed.
Parameters studied were mortality and ICU length of stay.
Results Mortality of ICU patients was 9.9% in the open format group
and 6.6% in the closed format group (P<0.05). The average length of
hospital stay was 4.9days in the open format group and 4.8days in the
closed format group.
Conclusion Our results suggest that a semi-closed format is a more
favorable setting than an open format to improve mortality in the ICU
and to warrant safe outcome in this patient group.
Introduction Many evidence-based interventions are not delivered to
patients . This may not be due to a clinicians intentional decisions.
The aim of this project was to compare the use of starch before and
after removing it as an option from an e-prescribing template.
Figure1 (abstract P518). Starch administration between November
2008 and November 2012.
Methods Our e-prescribing software enables users to prescribe
intravenous fluids from a series of menus. One of these is a template
that has several fluids available to use as a bolus when instructed by
a clinician. We removed starch as an option from the template in April
2009. Starch could still be prescribed elsewhere on the prescribing
system. Data on the use of starch from November 2008 to November
2012 were analysed as the mean volume of starch infused per patient
per month. The mean of each set of parameters was then compared
using a Students t test.
Results The mean volume of starch per patient administered before
and after electronic prescription options were altered was 480 ml and
21 ml, respectively (P=0.004). See Figure1.
Conclusion Despite clinicians intending to reduce the use of starch it
was still regularly administered on our ICU. The removal of a default
prescribing option dramatically reduced the volume of starch used
whilst not restricting the ability to make a conscious choice to prescribe
it. Adjusting default options has potential to influence clinical decisions
and ensure more reliable, evidence-based care.
1. Schultz MJ, et al.: J Crit Care 2005, 20:199-204.
Introduction Early detection of sepsis is important for a sufficient
treatment to reduce mortality. We hypothesized that using modified
systemic inflammatory response syndrome criteria over 1hour using an
electronic software program facilitates the clinical diagnosis of sepsis.
Methods After IRB approval and informed consent we enrolled in this
prospective, observational, single-center study 1,119 consecutive
patients (age 68.6 16.4, female/male 476/649) admitted over a
6-month period to a surgical ICU. A total 149 of them met modified
systemic inflammatory response criteria. Patients were monitored by
an electronic software program using live data from the laboratory and
bedside monitors to detect modified systemic inflammatory response
syndrome criteria persisting over 1hour. The physicians were blinded
to the software program alerts that notified in real time when modified
systemic inflammatory response syndrome criteria were detected and
persisted over 1hour, but did not provide treatment recommendations.
Results There was a total of 149 modified systemic inflammatory
response syndrome criteria alerts. Seventy-four were confirmed as
true sepsis cases by physicians. The overall incidence of sepsis was 7%.
Patients were categorized into length of stay <24hours, 24 to 96hours
and >96hours. The overall sensitivity of our system for detecting sepsis
was 68% and the specificity was 91%. The positive predictive value is
34% and the negative predictive value is 98%.
Conclusion Real-time alerts using an automated, electronic monitoring
of modified systemic inflammatory response syndrome criteria
facilitate the clinical diagnosis of sepsis.
Admission to the ICU overnight: is it really a bad thing?
MAdams, PDean, KMacDowall, PStenhouse, AMackay
Victoria Infirmary, Glasgow, UK
Critical Care 2013, 17(Suppl 2):P520 (doi: 10.1186/cc12458)
Introduction Admission to hospital overnight has been shown
to increase mortality and decrease hospital length of stay . The
objective of this study was to determine whether this relationship is
valid in patients admitted to our ICU, and whether length of stay was
Methods A retrospective data collection identified 5,827 patients
admitted to a five-bed ICU from April 1994 to November 2012. Data
regarding patient age, sex, APACHE II score and ICU admission date
and time were collected along with the length of stay in the unit and
hospital. Definitions ofday and night were set to local ICU standards of
9:00 am to 8:00 pm. Patients were then separated into two groups and
analysed using Analyse-It software for Excel.
Results Crude ICU and hospital mortality rates in patients admitted
during theday and overnight were examined. There was no significant
difference in unit mortality (day 22.3% vs. night 22.7%, OR=1.02, 95%
CI=0.91 to 1.16, P=0.718) or hospital mortality (day 30.7% vs. night
29.1%, OR=0.93, 95% CI=0.83 to 1.04, P=0.203). The mean unit length
of stay showed no difference in patients admitted during daytime
compared with those admitted overnight (4.27 days vs. 4.09 days,
P=0.162). The mean hospital length of stay was decreased in patients
admitted duringdaytime compared with patients admitted overnight
(19.3 days vs. 21.7 days, P = 0.004). The average age of patients was
less in those admitted out ofhours (night 56.5years vs.day 59.2years,
P=<.0001). There was no significant difference in APACHE II scores of
patients between the groups (day 19 vs. night 19, P=0.580).
Conclusion There is no significant difference between the mortality of
patients admitted overnight and patients admitted during theday to
our unit. The hospital length of stay is increased in patients who are
admitted overnight to intensive care; however, ICU length of stay is
not affected. Adjustment for other confounders such as current bed
occupancy and staffing ratios during the entire patient stay may help
to understand the differences seen in the hospital length of stay.
1. Kuijsten HA, et al.: Intensive Care Med 2010, 36:1765-1771.
Introduction Interdisciplinary rounds (IDRs) in the ICU are increasingly
recommended to support quality improvement and to reduce
conflicts, but uncertainty exists about assessing the quality of IDRs.
We developed, tested, and applied a scoring instrument to assess the
quality of IDRs in ICUs.
Methods A literature search was performed to identify criteria for
instruments about assessing team processes in the ICU. Then, 10
videotaped patient presentations led by different intensivists were
analyzed by Delphi rounds. Appropriate and inappropriate behaviors
were highlighted. The IDR-Assessment Scale was developed and
statistically tested. The inter-rater reliability was evaluated by
rating nine randomly selected videotaped patient presentations by
three raters. Finally, the scale was applied to 98 videotaped patient
presentations during 22 IDRs in three ICUs for adults in two hospitals
Results The IDR-Assessment Scale had 19 quality indicators,
subdivided into two domains: Patient Plan of Care, and Process. The
domain Patient Plan of Care reflects the technical performance from
the initial identification of a goal to the evaluative phase. The domain
Process reflects the team processes that are important to ensure that
the appropriate plan of care is agreed, understood, and executed as
planned by all care providers. Indicators were essential or supportive.
The inter-rater reliability of nine videotaped patient presentations
among three raters was satisfactory ( = 0.85). The overall item
score correlations between three raters were excellent (r = 0.80 to
0.94). Internal consistency in 98 videotaped patient presentations
was acceptable ( = 0.78). Application to 22 IDRs led by 14 different
intensivists in three ICUs in two hospitals demonstrated that indicators
could be unambiguously rated. The staff and management of all three
ICUs that were rated had considered their IDRs to be adequately
performed, and they were surprised by these study results.
Conclusion This study showed that the quality of IDRs can be reliably
assessed for patient plan of care and process. The IDR-Assessment
Scale had satisfactory inter-rater reliability, excellent overall item score
correlations, and acceptable internal consistency. Our instrument
may provide feedback for ICU professionals and managers to develop
adjustments in quality of care. Testing the IDR-Assessment Scale in
other ICUs may be required to establish general applicability.
1. Reader TW, et al.: Developing a team performance framework for the intensive care unit. Crit Care Med 2009, 37:1787-1793.
Introduction The development of patient-centered care by
interdisciplinary teams in the ICU has focused attention on leadership
behavior. The purpose of this intervention study was to measure
the effect of leadership training on the quality of performed
interdisciplinary rounds (IDRs) in the ICU.
Methods In this nonrandomized intervention study, participants
included nine intensive care medicine fellow trainees (intervention
group) and 10 experienced intensivists (control group). Participants
in the intervention and control groups previously were untrained in
leading IDRs in the ICUs. After each participant led an IDR that was
videotaped, the fellow trainees participated in a 1-day leadership
training, which was consistent with principles of adult learning and
behavioral modeling. After training, each fellow trainee led another
IDR that was videotaped. Quality of the performed IDRs was measured
by review of videotapes of the 19 IDRs lead by 19 intensivists, including
198 patient discussions subdivided into four ICUs, and assessment with
the IDR-Assessment Scale.
Results Comparison of the intervention versus control groups shows
that the intervention group has more yes scores on the IDR-Assessment
Scale than the control group. This difference was significant in 12 of the,
in total, 19 quality indicators.
Conclusion Quality of leadership will be reliably trained and measured
in the context of IDRs in ICUs. Training in a simulation environment, with
real-life IDR scenarios including conflicting situations, and
workplacebased feedback in the preparation and feedback phases, appears to be
effective to train leadership behaviour.
1. Ten Have ECM, et al.: Assessing the quality of interdisciplinary rounds in the intensive care unit. J Crit Care 2013, in press.
2. Miller A, et al.: Uni- and interdisciplinary effects on round and handover
content in intensive care units. Hum Factors 2009, 51:339-353.
3. Pronovost PJ, et al.: Perspective: physician leadership in quality. Acad Med 2009, 84:1651-1656.
Introduction Harefield Hospital is a 150-bed cardiothoracic tertiary
referral centre with transplantation, artificial heart, ECMO and primary
angioplasty services. Our 35-bed critical care department consists of
18 intensive therapy unit, seven recovery and 10 high-dependency
beds. Intentional rounds or proactive patient rounds were recognised
by the Royal College of Physicians and the Royal College of Nursing 
as structured, evidence-based processes for nurses to carry out regular
checks with individual patients at set intervals. The senior nursing team
decided to adapt this initiative to the intensive care setting in order
to address clinical challenges and provide guidance for shift leaders to
focus on key elements of care.
Methods Our intentional rounds, performed once per shift (twice daily),
include two components. First, pressure area care this component
involves the shift leader checking whether key elements of pressure
sore prevention have been performed. These include completion
of the Waterlow risk assessment tool , noting the frequency of
repositioning, use of lateral positioning and pressure-relieving pads.
Second, renal replacement therapy rates this element was identified
as an area for focus after we established that our haemofiltration fluid
use perhour of therapy was twice that of a near identical clinical setting.
This pattern continued even after adopting similar therapy guidelines.
The shift leader was guided to check whether therapy rates had been
adjusted in line with latest biochemical results.
Results The incidence of pressure ulcers in the 4 months since the
initiative began has averaged 2.25 permonth compared with 7.8 per
month prior to commencement of intentional rounding. Added to the
rounding tool at the end of September 2012, RRT rates in the preceding
4months averaged 31.5 ml/kg/hour over 24hours, an 11.9% reduction
from the previous average of 35.75 ml/kg/hour. If the pattern of RRT
was to continue, this could equate to a cost saving of UK40,000 per
Conclusion The use of a modified targeted intentional rounding tool
by the nursing shift leader can help ensure that best practice guidelines
are adhered to. This strategy can improve patient outcomes and
provide potentially significant fiscal benefits.
1. RCP, RCN: Ward Rounds in Medicine. Principles for Best Practice. London: Royal College of Physicians, Royal College of Nursing; 2012.
2. Waterlow J: The importance of accurate risk assessment and appropriate intervention in tissue viability. Br J Nurs 2009, 18:1090.
Prospective observational study of handover in a medical ICU
AMukhopadhyay1, BLeong1, ALua2, RAroos2, JWong2, NKoh2, NGoh2,
KSee1, JPhua1, YKowitlawakul3
1National University Health System, Singapore; 2National University of
Singapore, Singapore; 3Alice Lee School of Nursing, National University of
Critical Care 2013, 17(Suppl 2):P524 (doi: 10.1186/cc12462)
Introduction Handovers are often associated with poor
communication. ICU patients with multiple complex problems are ideal to study
naturally occurring handovers. However, few studies have been
conducted in the ICU.
Methods We conducted questionnaires of physicians and nurses
involved and observed handovers in real time of medical ICU patients
Results We interviewed 580 of 672 physicians and nurses involved
(86.3%) and observed 90 real-time handovers (45 patients, 26.8%) of
168 patients. Mean duration of handover was 391.3 ( 263.6) seconds,
78.5% were face to face and 1.26 ( 1.75) distractions per handover
were noted, person-to-person calling being the commonest mode
of distraction (46.7%). Nurses received training during induction
in significantly higher numbers, covered allied specialties more
and reviewed the patients early (all P <0.05). Perception of the
relative importance of different components of the handover varied
significantly between donors, recipients, physicians and nurses. Both
physicians and nurses seldom (39.7%) reviewed the available electronic
past medical records of the patient before handover, which in addition
to training in handover and overall confidence level in the management
following handover are significantly associated with better satisfaction
in univariate analysis; only the confidence level in patient management
remained significant after multivariate analysis. However, agreement
between donor and recipient on overall satisfaction was poor
(P>0.05). Nursing handovers were significantly longer than physicians
(572.08 214.68 vs. 168.6 97.27 seconds, P <0.001) but are also
associated with higher distractions particularly during evening shifts.
Conclusion A higher percentage of nurses received handover training;
nursing handovers are longer and more inclusive of other components
of patient management; perceived importance of components of
handover varies among healthcare professionals; distractions are
common during handovers and associated with longer duration,
by nurses and in the evening shifts; and higher confidence level in
patients management following the handover is associated with
1. Ye K, et al.: Handover in the emergency department: deficiencies and
adverse effects. Emerg Med Australas 2007, 19:433-441
2. Apker J, et al.: Communicating in the gray zone: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med 2007, 14:884-894.
Impact of knowledge transfer through the implementation of a
telemedicine program in a community hospital in Brazil
CAAbreuFilho1, MSteinman1, AAndrade2, RCal1, NAkamine1, JTeixeira2,
ESilva1, AKanamura1, MCenderoglo1, CLottenberg1
1Hospital Israelita Albert Einstein, So Paulo, Brazil; 2Hospital Municipal Dr.
Moyss Deutsch, So Paulo, Brazil
Critical Care 2013, 17(Suppl 2):P525 (doi: 10.1186/cc12463)
Introduction Emergency survival rates vary significantly according
to the quality of care, which depends on human and technological
resources. Emergency and critical care medicine physicians must make
fast decisions; the presence of experienced consultants improves
survival. In developing countries, there is a shortage of skilled
doctors. The aim is to describe the first Brazilian initiative of
realtime teleconferencing telemedicine (TM) providing 24/7 emergency
department (ED) and ICU coverage.
Methods Since May 2012 a TM program has been implemented at
two hospitals in So Paulo, Brazil Hospital Municipal Dr. Moyss
Deutsch (HMMD), a public, secondary hospital, and Hospital Israelita
Albert Einstein (HIAE), a tertiary private philanthropic entity due to
a partnership with the Brazilian Health Ministry. TM Central Command
was located at HIAE with Endpoint 97 MXP Cisco Solution and a
mobile Intern MXP ISDN/IP Cisco for the remote hospital (HMMD) via
dedicated GB/sec connection. Imaging examinations were evaluated
using PACS technology. Every recruited patient was assessed by the
Central Command through TM with an experienced consultant.
Results Over a 6-month period, 131 teleconsultations (114 patients)
were done. Mean age was 50.1 years, 57.1% was male and mean
APACHE II score was 24.3. A total of 64.8% originated from the ICU and
35.2% from the ED. Main consultation diagnoses were sepsis (31.3%);
stroke (29.8%); survival from cardiac arrest (6.1%); trauma (6.1%); and
acute myocardial infarction (5.3%). TM improved diagnosis in 14.5%
and influenced the clinical management in 85.5% of the consultations.
Invasive procedures were indicated in 61.1%. Life-saving procedures
were TM related in seven patients (6.1%): stroke thrombolysis (n=6)
and limb amputation (n=1). Seven patients (6.1%) were transferred and
submitted to surgical procedures (heart surgery (n=2), neurosurgery
(n=4) and liver transplantation (n=1)). The majority of the patients
remained at HMMD and were discharged.
Conclusion ATM program is feasible to be implemented in a community
hospital. The major benefit is expertise medical transfer from the
tertiary hospital to the community setting, improving diagnosis and
management of critical care patients, and avoiding routine transfer to
a major urban center.
Introduction Our objective is to present our experience from Shriners
Hospital and Massachusetts General Hospital in Boston, MA, USA in
using telemedicine to provide acute burn and critical care consultation
on pediatric and adult burn patients in Lviv, Ukraine, as well as in triage
and transport of critically ill patients from Lviv to a tertiary-care facility
in the USA for further management.
Methods Using a new telemedicine learning center established at City
Hospital #8 in Lviv, Ukraine, consultations regarding acutely injured
burn victims occurred between physicians in Ukraine and physicians at
Shriners Hospital and Massachusetts General Hospital in Boston. After
the initial presentation, each patient was reviewed on a daily basis by
physicians in Boston. Skype, an Internet-based communication tool,
was used in communication with the Burn Center in Lviv. Radiographic
images were scanned and digitalized using an electronic scanner,
and JPEG image compression was used to facilitate the transmission
of radiographic images and patient charts. Informed consent and
HIPPA guidelines were followed in transmitting any patient-related
Results Since 2011 we have provided consultation on 14 patients in
Lviv, Ukraine, ranging in age from 15months to 63years. Each patient
had an average of six consultations. We present two of these cases as
examples of the capabilities of our telemedicine program. The first
case involved a 15-month-old female with 40% TBSA from scald injury,
where telemedicine was instrumental in the primary assessment as
well as to arrange a direct assessment from a nearby burn surgeon. The
second case resulted from a house fire with multiple casualties, where
physicians in Boston were able to utilize telemedicine to guide the
initial resuscitation and airway management of three critically burned
children, as well as to arrange for transport of one of the victims, an
11-year-old male with 87% TBSA, from Ukraine to the USA for acute
management. Multiple difficulties were overcome in implementing the
system between the two countries including: time zone differences,
language barrier, and different approaches to patient care.
Conclusion We have established a telemedicine program linking
physicians in Boston, MA, USA with City Hospital #8 in Lviv, Ukraine
to improve care in pediatric and adult burn patients. Our program has
provided consultation on 14 patients since 2011, and it highlights the
capabilities of telemedicine for acute consultation as well as triage and
transport of critically ill patients to tertiary-care facilities.
Introduction During the last few years the frequency of
end-oflife decisions (EOLD) significantly increased in ICUs. The method of
nurse involvement in making EOLD is different worldwide [1,2]. The
purpose of this study was to analyze opinions of nurses about therapy
restriction. We have examined with a multicenter study the opinions of
the medical stuff about end-of-life care in Hungarian ICUs.
Methods We performed a questionnaire evaluation among physicians
and nurses of ICUs about influencing factors of therapy restriction, the
method of the decision-making process, and the frequency of different
EOLD. The questionnaire, containing 21 questions, was delivered
electronically to Hungarian ICUs, and then we analyzed the responses
anonymously. The retrieved 302 answers (191 physicians, 102 nurses)
were analysed using a nonparametric Students test.
Results A total 71% of the nurse responders work in university clinics,
2% in regional centrum, 24% in municipal hospital, 3% in other ICUs.
The nurses found both human (2.72/5 vs. 1.98/5) and material (2.81/5
vs. 2.12/5) resources more restrictive factors during patient admission
than physicians (P = 0.025, P = 0.0024). Nurses working in municipal
hospital were more strongly influenced by lack of material and human
resources (3.34/5, 3.3/5) than nurses working in university clinics (2.2/5,
2.43/5), P = 0.01, P = 0.025. Younger nurses (working between 6 and
10 years) were more interested in the patients or surrogates wishes
than older nurses (working more than 10 years). Religion did not
influence patient admission and forego therapy; however, religious
nurses compared with atheists and nonpracticing believers preferred
to prolong therapy against the patients will (P=0.04). Nurses felt that
physicians slightly involved them in the end-of-life decision-making
process (2.1/5 vs. 2.4/5 P=0.0001).
Conclusion We found that the workplace, level of medical attendance,
godliness, work experience, and position in medical staff strongly
influenced making EOLD. While limitation of the therapy should
be team work, nurses felt their opinions were hardly taken into
consideration, although nurses seemed to be more realistic in the
1. Prendergast et al.: A national survey of end-of-life care for critically ill
patients. Am J Respir Crit Care Med 1998, 158:1165-1167.
2. Banbenishty et al.: Nurse involvement in end-of-life decision making: the ETHICUS Study. Intensive Care Med 2006, 32:129-132.
Introduction More than one in five people admitted to an ICU will die
there. Research has highlighted concerns about support for patients
and families and decision-making in this context [1,2]. Here, we describe
the development and evaluation of a tool to improve palliative care in a
32-bed general ICU in a central London teaching hospital.
Methods Medical Research Council guidance for complex interventions
Phase 0 to I comprised literature review, theoretical modelling,
observation and qualitative interviews and focus groups with staff and
families exploring concerns and views of interventions identified in
the literature review. Phase II comprised intervention development,
implementation and evaluation of tool feasibility and effects using staff
survey, observation, audit of records and relative survey.
Results Phase I: 47 staff and 24 family members were interviewed.
The short time between decisions for treatment withdrawal and
death, plus concerns for support management, communication and
decision-making, highlighted a need to ensure excellent psychosocial
assessment for all. Phase II: as part of integrated care guidelines, we
developed the Kings Psychosocial Assessment and Care tool (K-PACE).
K-PACE is used for all patients entering the ICU, completed within
24 hours of admission. It contains psychosocial assessment of the
family and patient needs, and identifies key individuals for contact.
Educational training was supported by K-PACE and was implemented
in two waves. Post-implementation survey of 95 ICU staff found that
most (80%) were aware of K-PACE. Eighty-two per cent of nurses but
only 17% of doctors had completed the tool. In total, 158/213 (74%)
family members responded to the survey (additionally three patients
responded). There were high levels of satisfaction for symptom control
and psychosocial care but concerns continued regarding explanation
of treatment and care.
Conclusion K-PACE is a feasible tool to improve the palliative care of
patients and their families in the ICU. Further refinement is needed and
planned, with consideration of roll-out into the wider medical centre.
1. Azoulay E, et al.: Half the families of ICU patients experience inadequate
communication with physicians. Crit Care Med 2000, 28:3044-3049.
2. Asch DA, et al.: Conflicts between physicians practices and patients wishes. Am J Respir Crit Care Med 1995, 151:288-292.
End-of life thoughts in the ICU: results of a survey
AYaguchi, MNamiki, NSaito, RNagai, MTakeda, THarada, RMoroi
Tokyo Womens Medical University, Tokyo, Japan
Critical Care 2013, 17(Suppl 2):P529 (doi: 10.1186/cc12467)
be concerned involving the familys will. Especially, stopping or
withdrawing therapy is a quite difficult operation in Japan because of
legal issues. Our hypothesis is that some difference exists in thoughts
between physicians and nurses for terminal patients in the ICU. The aim
of this study is to know their real thoughts.
Methods A questionnaire survey was performed on physicians and
nurses in our medico-surgical ICU. The questionnaire consists of
11 questions with five optional answers related to the thoughts of
participants about treatment of hopeless or brain death patients.
Concretely, the questions were; whether to withhold therapy or not,
whether to accept to withdraw therapy or not and with familys will,
whether to accept to immediately stop therapy and with familys will,
whether to positively or not donate organs from a brain death patient,
necessity of ICU care for brain death patients, and feeling guilty and
stress for stopping or withdrawing therapy. The optional answer has
five gradations from Yes to No for all questions. The participants were
asked to answer the questionnaire by expressing themselves without
regarding legal issues or the consensus. It was guaranteed to be
anonymous for them in the data analysis. The answers were compared
between physicians and nurses. The MannWhitney U test was used
for statistical analysis. P<0.05 was considered statistically significant.
Results There were in total 52 participants (response rate 98.1%) with
20 physicians and 32 nurses. Withdrawing therapy was significantly
accepted in nurses than in physicians (83% vs. 55%, P=0.039), when the
family well understood. Withholding therapy should not be operated
for brain death patients for physicians (65%), while it seemed a difficult
judgement for nurses (23%, P=0.021). ICU care for brain death patients
is less necessary for physicians than nurses (80% vs. 53%, P = 0.016).
There were no significant differences in other questions between
physician and nurses such as feeling guilty or stress for stopping or
Conclusion Some of end-of-life thoughts in the ICU showed differences
between physicians and nurses.
Introduction The purpose of our study was to assess the attitudes of
Slovenian intensivists towards end-of-life (EOL) decision-making and to
analyze the decision-making process in their clinical practice.
Methods A cross-sectional survey among Slovenian intensivists and
intensive care medicine residents from 35 different ICUs was performed
using a questionnaire containing 43 questions about views on EOL
decision-making. Fishers exact test and the FisherFreemanHalton
test were applied to cross-tabulated data; significance level was set at P
0.001 due to the large number of tested hypotheses.
Results The response rate was 72.1% (267 questionnaires were
returned out of 370 distributed), which represented roughly the same
percentage of all Slovenian intensivists. Termination of futile treatment
was assessed as ethically acceptable (P <0.001). The statement that
there is no ethical distinction between withholding and withdrawing
of treatment could not be confirmed (the answers there is a difference
and undecided were less frequent, but not statistically significant;
P=0.216). A do-not-resuscitate order (DNR) was used more often than
other withholding treatment limitations (P <0.001). A DNR was used
most frequently in internal medicine ICUs (P <0.001; compared with
paediatric and surgical ICUs). Withdrawal of inotropes or antibiotics
was used more often than withdrawal of mechanical ventilation or
extubation (66.7% vs. 12.0%; P <0.001). Withdrawal of mechanical
ventilation or extubation was more often used in the paediatric ICUs
(21.7%) as compared with the internal medicine ICUs (19.6%) and the
surgical ICUs (3%) (P <0.001). Over two-thirds (70.6%) of intensivists
were against termination of hydration, which would be more often
used in the internal medicine ICUs (P <0.001). Thirty-one percent of
intensivists used written DNR orders.
Conclusion Termination of futile treatment was found to be ethically
acceptable for Slovenian intensivists, although they were not convinced
that withholding and withdrawing of treatment were ethically equal. A
DNR would be used most often. Withdrawal of inotropes or antibiotics
would be used more often than withdrawal of mechanical ventilation
or extubation. Termination of artificial hydration would be rarely used
Attitudes of intensivists in the UK to withdrawal of futile therapy
MMariyaselvam, MIrvine, JCarter, MBlunt, PYoung
Queen Elizabeth Hospital, Kings Lynn, UK
Critical Care 2013, 17(Suppl 2):P531 (doi: 10.1186/cc12469)
Introduction We aimed to determine the current practice and
attitudes of consultants in intensive care medicine when withdrawing
futile life-sustaining therapy. Published guidelines suggest variation
in withdrawal of futile life-sustaining therapy and are therefore not
prescriptive . Although there is an awareness of differing practices,
the extent of these variations is not established.
Methods We surveyed a convenience sample of delegates at the
Intensive Care Society (UK) State of the Art Meeting (2012) on attitudes
and practice regarding withdrawal practice. Anonymised data were
collected using surveymonkey.com.
Results Of 457 consultant attendees from the UK, 149 completed the
survey (33%). For 58% of consultants there was no formal institutional
protocol for withdrawal of futile therapy. When deciding to withdraw
therapy, 57% of consultants routinely seek and document a second
opinion. Regarding donation after cardiac death (DCD), 93% of
consultants were happy to delay withdrawal to facilitate successful
donation, 85% have already done so in their practice and 14%
routinely withdraw therapy in theatres rather than on the ICU. Even
if it would impact on the care of other patients, 48% would delay
withdrawal of therapy to facilitate DCD. For patients accepted for
DCD, 36% think that some intensivists withdraw more aggressively
(in essence, hasten death) in the hope of improving the likelihood of a
successful organ donation and 29% have felt pressurised to withdraw
therapy more quickly than their usual practice. Furthermore, 45%
experienced pressure to refer a patient for DCD when it they felt it
was not appropriate.
Conclusion This survey confirms variation in the practice and attitudes
to withdrawal of futile therapy amongst UK consultant intensivists.
Formal protocols were frequently unavailable to guide withdrawal
and second opinions were often not sought. Nearly one-half of the
intensivists delay withdrawal to facilitate donation, even if this may
impact on the care of other patients. Many intensivists have felt
pressure to refer for donation when they feel this is inappropriate
and there is a perception that some intensivists may withdraw care
more aggressively in those who are accepted for DCD to improve the
likelihood of a successful donation. This survey may help inform debate
in this ethically challenging area.
1. Organ Donation after Circulatory Death
Introduction The aim of the study is evaluate the perceptions of
parents of children who died in two Brazilian pediatric ICUs.
Methods An exploratory-descriptive study with a qualitative approach
in the PICU of Hospital So Lucas and Hospital de Clinicas de Porto
Alegre involving 15 parents of children who died. Data collection was
performed through three steps: (a) the researchers contacted the
parents through a telephone call to invite them to attend the hospitals;
(b) at the hospital, the doctors who assisted the children clarified doubts
about the therapy offered; and (c) an interview was carried out by two
researchers not involved in the care. Data analysis was performed using
the technique of thematic content analysis.
Results and conclusion The research shows that the difficulty of
communication is a factor that impacts negatively on the grieving process.
Moreover, it stresses the importance for parents to rediscuss the
moment of their childs death with health professionals.
1. Meyer E, Ritholz M, Burns J, Truog R: Improving the quality of end-of-life
care in the pediatric intensive care unit: parents priorities and
recommendations. Pediatrics 2006, 3:469-457.
2. Meyer E: On speaking less and listening more during end-of-life conferences. Crit Care 2004, 32:1609-1611.
3. Piva, JP, Lago P, Othero J, Garcia PC: Evaluating end of life in ten Brazilian
pediatric and adults intensive care units. J Med Ethics 2010, 36:344-348.
4. Meert, K et al.: Parents perspectives on physician-parent communication near the time of a childs death in the pediatric intensive care unit. Pediatr Crit Care 2008, 9:2-7.
Introduction Despite our efforts in making patients healthy and going
home, critical illness has a mortality, in Danish ICUs, of 10 to 12%.
Approximately 90% of deaths in ICUs happen after life-sustaining
therapy has been withheld or withdrawn. Although trying to provide
patients and family with what we suppose is a good death, most
patients would prefer dying at home, and sometimes patients and
family ask for the possibility of doing that. The last 2years we transferred
seven patients from our unit to end-of-life care in their own home.
Methods After making the decision of withholding or withdrawing
intensive care therapy, the care of the patient changes from an active,
medical, technological treatment to relief and care. In that period we
determine whether the patients condition is stable enough to go
home. We try to find out if it is a wish for the patient to go home, and
if the family has resources to take care of the patient at home. If that is
the case, we start planning care at home, arrange for transportation,
and contact the primary care physician and nurse. Due to the patients
condition on theday of transferring, we plan following the patient by
either a nurse or a doctor.
Results Seven terminally ill patients wishing to go home for dying were
transferred home. Diagnoses varied: end-stage lung disease, cancer,
surgical complications. Ages ranged from 68 to 84 years. All patients
survived transport home, and time at home varied from a fewhours to
4days. Later contacts with patients families indicated that both patient
and family were grateful, and that they did not experience the patient
having pain or dyspnea at home.
Conclusion Sending critically ill patients home to die is not common.
Anyhow, our experiences doing that are only positive. Terminally ill
patients, awake to make a decision of their own, and in a condition
making it possible, should have the choice to go home to die, with our
help in logistics, planning and transportation.
1. Lusardi P, et al.: The going home initiative: getting critical care patients home with hospice. Crit Care Nurse 2011, 31:46-57.
Introduction This study assessed the effect of a hospital-based aerobic
exercise programme on physical fitness and health-related quality of
life (HRQoL) for survivors of ICU admission. Including the qualitative
arm of the study, we examined the patient experience after critical
illness, their views of the exercise programme and the effects on their
Methods A randomised controlled trial was undertaken in adult
survivors of ICU admission. They were allocated to receive an
8-week in-hospital supervised aerobic programme consisting of two
cycle ergometry and one unsupervised session per week (exercise
group) or no exercise (control group). Primary outcomes were the
anaerobic threshold (in ml O2/kg mass/minute), physical function
and mental health scores (SF-36 questionnaire), measured at weeks
9 and 26. Participants were then allocated to focus groups where the
interpretation of experiences was compared with outcomes from the
Results Fifty-nine patients were recruited to the study. The anaerobic
threshold increased at week 9 in the exercise group by a clinically and
statistically significant amount of 2 ml O2/kg mass/minute (90% CI, 1
to 3 ml/kg/minute). There was further improvement in fitness levels in
both groups by week 26 (although no significant difference between
groups). No significant difference in HRQOL measures between
groups was demonstrated; however, the exercise group did show an
improvement in their mental health scores. The focus groups centred
on feelings of isolation, abandonment, vulnerability, dependency and
reduced physical activity post hospital discharge. Many reported a
lack of social inclusion as they did not have the energy or confidence
to venture outside. However, those in the exercise group felt that
the rehabilitation programme was motivating, built up confidence,
improved fitness, helped social interaction and gave them a sense of
Conclusion The 8-week exercise intervention resulted in statistically
significant improvements in fitness at 9 weeks while focus group
participants highlighted the positive effects of the exercise intervention
leading to enhanced energy levels, motivation and achievement.
Psychological benefits of the exercise programme are apparent from
the focus group, emphasising the important link between physical and
Introduction Survivors of critical illness often have a prolonged stay
on the ICU. These patients may suffer from ICU-acquired weakness. It
has been shown that reduction in muscle mass and muscle strength
occurs early after admission to the ICU. However, in the very early stage
on the ICU, patients are often sedated and not able to participate in
any active mobilizations. Therefore the use of neuromuscular electrical
stimulation (NMES) is becoming a treatment of interest in the ICU. The
aim was to study the feasibility and safety of NMES in a surgical and
medical ICU of a large, tertiary referral university hospital.
Methods Fifty patients with an expected prolonged stay on the ICU
of 5 more days (judged on day 3) with no trauma or neurological
disease were included. They then received daily a NMES session (DUO
500; Gymna, Belgium) for 25 minutes on the quadriceps bilaterally
during their entire stay on the ICU. The main outcome was the ability
to produce a contraction of the quadriceps through NMES. The muscle
contraction was quantified on a 5-point scale: 1 (no contraction
palpable and visible) up to 5 (contraction very well palpable and visible).
Patients were classified as responders when an adequate muscle bulk
was obtained in 75% of the sessions. The potential factors associated
with the feasibility were: gender, age, body mass index (BMI), diagnosis
of sepsis, Barthel index prior to admission to the hospital, APACHE II
score, Glasgow Coma Scale (GCS), five questions for adequacy, stimulus
intensity and leg edema. A multiple regression analysis was performed
to identify the factors determining whether or not a contraction could
be expected in a patient. Safety of NMES was assessed through heart
rate, blood pressure, oxygen saturation and respiratory rate.
Results In 48% of the patients we were able to achieve adequate muscle
contractions in more than 75% of the sessions. GCS (P=0.047), edema
(P=0.001) and sepsis (P=0.010) were significantly different between
responders and nonresponders. Responders had a lower mean GCS
(73 vs. 93), lower amount of edema and were less likely to have
had sepsis. In a multiple regression analysis, sepsis, edema, BMI and age
explained 51% of the variance. As for safety, none of the parameters
Conclusion In patients with a better neurological condition, sepsis and/
or leg edema it was more difficult to obtain an adequate quadriceps
contraction with NMES. NMES is safe to apply on the ICU.
Follow-up and counseling service in trauma patients: needs and
goals a preliminary study
DLGrieco, MBiancone, SLCutuli, GPintaudi, MTSantantonio,
ESTanzarella, FToni, AGDeBelvis, MGBocci, CSandroni, MAntonelli
Catholic University School of Medicine, Rome, Italy
Critical Care 2013, 17(Suppl 2):P536 (doi: 10.1186/cc12474)
Introduction Trauma is the most common cause of morbidity in young
people. It has a high social impact both because of the high cost of
the acute treatments and because of the physical and psychological
consequences that it may cause. A prospective, observational,
singlecenter study on quality of life 12 to 24months after trauma was carried
out. The aim of the study is to evaluate life quality after trauma and to
identify the most important needs of the patients, in order to improve
the level of care after an ICU stay and to implement a faster and more
effective reintegration into the active and productive society.
Methods All patients admitted to the 18-bed ICU of our university
hospital between 5 May 2010 and 28 February 2011 because of a
trauma who stayed in the ICU for at least 48hours were eligible for the
study. Patients were contacted and invited to attend a multidisciplinary
interview. Data concerning family, working and economic status, main
disabilities and medical needs were collected. The SF12 questionnaire
was administered to define physical component summary (PCS) and
mental component summary (MCS) scores. SPSS 20.0 was used to
perform statistical analysis.
Results Sixty-two patients matched inclusion criteria and were
contacted. Thirty-three patients (90.9% males; age 38.7 14.3 years;
mean SAPS II 33.75 11.79) were interviewed. Mean ICU stay was
25.7 15.3 days. Fifteen patients (45.5%) had undergone temporary
tracheostomy. Twenty-six patients were employed at the moment
of trauma: of these, 11 (42.3%) stated to be jobless and one was
pensioned at follow-up. In the whole cohort, the unemployment
rate increased from 12.1 to 45.6%. Mean PCS was 43.596.43, mean
MCS was 41.04 7.69. At follow-up, the 14 employed patients had a
lower MCS versus the 19 jobless patients (37.947.14 vs. 43.337.44;
P=0.04), while no differences concerning PCS were found. The three
patients that were living on their own when the trauma occurred
showed, at follow-up, a lower mean MCS score towards the rest of the
cohort (32.20.47 vs. 41.937.51; P<0.001).
Conclusion Trauma is associated with an increase of the unemployment
rate in young people. Patients that are employed at follow-up seemed
to have a worse mental health status towards the unemployed ones.
Conversely, the employed patients did not show any trend to a
lower physical health status. Thus a counseling service that provides
psychological care would be useful to implement more effective work
reintegration for trauma patients.
Introduction Post-traumatic stress disorder (PTSD) is a well-recognised
complication in patients discharged from the ICU. ICU clinics have
been recommended to treat physical and psychosocial problems post
discharge, with guidelines issued by the Department of Health UK .
Recent evidence has advocated the use of patient diaries to reduce the
incidence of new-onset PTSD . Family support groups may also play
a pivotal role . We performed a national survey via the Intensive Care
Society (ICS) to determine the provision of follow-up clinics, patient
diary services and family support groups.
Methods An online structured questionnaire was sent via the ICS to all
ICU linkmen at 124 hospitals in the UK. Responses were received from
77 ICUs, a 62% response rate.
Results Out of 77 ICUs, 37 (48%) run a follow-up clinic. The majority
of clinics (51%) only invite patients who have been admitted for more
than 3 to 4 days. Only 10 clinics (30%) receive funding from the ICU
budget or PCT, with the majority (67%) receiving no funding at all. Only
44% (34) of ICUs use patient diaries, mostly as a nonfunded service
(68%). Additionally, 91% of ICUs do not run family support groups; from
the minority that do, these are mostly held quarterly and are largely not
Conclusion This survey demonstrates that the provision of ICU clinics
in the UK is not well established, with only 48% currently providing
a regular service. Currently 67% of clinics are not funded and further
resources should be employed so this service becomes an integral
part of the ICU pathway. Despite recent evidence demonstrating that
diaries reduce new-onset PTSD, only 44% of ICUs in our study provide
this service. Ninety-one per cent of ICUs do not provide family support
groups; similarly, it appears that financial constraints are the limiting
1. DH and Modernisation Agency: The National Outreach Report. London: NHS Modernisation Agency; 2003.
2. Jones C, et al.: Crit Care Med 2010, 14:168.
3. Orcutt TA:. Nurs Crit Care 2010, 5:33-37.
Introduction The aim was to analyse the outcomes and patient
satisfaction of a recently implemented ICU follow-up clinic. These
clinics are National Institute for Clinical Excellence recommended .
Methods A retrospective analysis of prospective collected data
from January to December 2012. The clinic is run monthly by an ICU
consultant and a critical care outreach sister. Criteria to be invited to the
clinic are mechanical ventilation 3days. Patients filled an anonymous
satisfaction survey after the clinic.
Results Our attendance rate is 50% (26 patients), which is similar to
other series reported in the literature. Those patients who attended the
clinic required a longer length of mechanical ventilation (5.3days vs.
7.1) and a longer length of stay in the ICU (7.6 vs. 13) and in hospital
(14 vs. 28). We identified a wide range of physical and nonphysical
morbidities on these patients (Figure 1). We referred them to the
appropriate specialities. Patients were very satisfied with this new
service (Figure 2).
Figure1 (abstract P538). Physical and nonphysical morbidity.
Figure 2 (abstract P538). Patient satisfaction survey.
Conclusion Our follow-up clinic has enabled us to identify a wide range
of complications related to ICU admission and coordinate their future
management. This clinic improved patient satisfaction.
1. Rehabilitation after Critical Illness [www.nice.org.uk/CG83]
Introduction This study aims to quantify the acute exercise response to
early passive and active activities in order to inform exercise prescription
when designing rehabilitation programmes for the critically ill. Critical
care survival is often associated with a poor functional outcome ,
with recent investigations presenting the case for early rehabilitation
in order to optimise functional recovery . There, remains, however,
a scarcity of research investigating the immediate response to exercise
and subsequent exercise prescription, in the acute phase following
Methods This study is a prospective randomised controlled trial with
a repeated-measures crossover design. Eligible participants, requiring
mechanical ventilation for 4 or more days, completed two exercise
activities routinely used in early critical care rehabilitation, a passive
chair transfer (PCT) and active sitting on the edge of the bed (SOEOB).
The oxygen consumption and cardiovascular parameters were
measured to quantify and compare the exercise response between the
Results Data are presented as the median (interquartile range). Data for
five patients have been collected, aged 68years (23), with an ITU stay of
Oxygen consumption (ml/minute)
Carbon dioxide production (ml/minute)
Mean arterial pressure (mmHg)
PCT (n=5) SOEOB (n=5)
15days (10.5) and duration of mechanical ventilation 8days (12), at the
point of intervention. Exercise response results are reported (Table1).
Conclusion Intensive care patients with prolonged mechanical
ventilation demonstrate a higher rate of oxygen consumption when
actively sitting on the edge of the bed, compared with a passive chair
transfer. This may have important consequences for early mobilisation
of the critically ill.
1. Unroe et al.: Ann Intern Med 2010, 153:167-175.
2. Thomas: Phys Ther Rev 2011, 16:46-57.
Randomized, controlled pilot study of early rehabilitation strategies
in acute respiratory failure
DFiles, PMorris, SShrestha, SDhar, MYoung, JHauser, EChmelo,
CThompson, LDixon, KMurphy, BNicklas, MBerry
Wake Forest University School of Medicine, Winston Salem, NC, USA
Critical Care 2013, 17(Suppl 2):P540 (doi: 10.1186/cc12478)
Introduction Optimal patient evaluations of ICU rehabilitation therapy
Methods One hundred ICU patients with acute respiratory failure
were randomized to receive early rehabilitation (ER) or usual-care (UC).
Cohort 1 (n=50) received ER as one physical therapy (PT) session/day
versus UC; Cohort 2 (n=50) received ER as 2 PT/day with the second
session resistance training, versus UC. UC was without ER. Blood was
drawn for cytokines throughday 7. Cohort 2 underwent strength and
physical functional assessments using the Short Physical Performance
Battery (SPPB), a valid and reliable measure of physical function
consisting of walking speed, balance, and repeated chair stands. It is
a well-studied composite measure in older persons, but has not been
used in ICU survivors. Small changes of 0.5 to 0.6 points in the SPPB
have been shown to be clinically meaningful.
Results Baseline parameters were similar between groups. Median
days from enrollment to first PT were 4 (IQR 1 to 7.25). Deaths occurred
in eight UC subjects and four in ER (P=0.22). For both arms, ventilator
days, ICUdays and hospitaldays were not statistically different. ER had
ventilator-freedays of 22, 95% CI=19.9 to 24.6, where UC had 22.3days,
19.9 to 24.6, P=0.99. ICU-freedays for ER was 21, 95% CI=19.1 to 23.6,
and that for UC was 21.0, 18.8 to 23.2, P=0.84. Similarly, hospitaldays
for ER was 16.7, 95% CI=11.8 to 21.4, and for UC was 18.2, 13.8 to 22.7,
P=0.45. TNF, IL-6 and IL-8 throughday 7 were not different between
groups. Despite similar baseline acuity and inflammatory profiles,
Cohort 2 ER group strength scores were numerically but not statistically
higher. Grip strength, as a percentage of predicted for ER was 66 versus
39 for UC, P=0.06. Dynamometry for ER was 211 versus 181 lbs for UC,
P=0.124. Although the difference in SPPB values for ER versus UC (5
vs. 3, P = 0.172) was not statistically different, it was greater than the
minimal clinically significant difference. There were no differences in
Conclusion In this pilot study, early ICU rehabilitation was safe, and was
associated with numerically although not statistically shorter hospital
stay, greater strength and improved functional scores. Particularly, the
SPPB demonstrated discriminatory ability in groups of ICU survivors
with low physical function. Future early ICU rehabilitation studies
should consider ICU survivor assessments using the SPPB due to its
ease, reproducibility and discriminatory ability following ICU and
Acknowledgement Supported by NIH grants 1R011186-01 and P30
Introduction The aim of this study was to investigate the effect of
a 6-week exercise programme on outcomes in post-ICU patients.
With improvements in intensive care medicine, increasing numbers
of patients are surviving catastrophic illness . Severe weakness
is common in patients with prolonged critical illness and results in
considerable morbidity, mortality and healthcare costs . The NICE83
guidelines Rehabilitation in Critical Care recommend follow-up for
post-ICU patients and that further research is needed in this field .
Methods Patients who have been discharged home from hospital
following an ICU stay of 48hours or more were recruited to the study.
Patients were only excluded if they were not considered safe for
exercise. Baseline measurements were completed prior to stratified
(age, gender, APACHE II score) random allocation to either the exercise
or control group. Outcome measures included cardiopulmonary
fitness (6-minute walk test), balance (Berg Balance Scale), grip strength
(JAMAR grip dynamometer) and hospital anxiety and depression (HAD
score). The exercise group completed a 6-week supervised exercise
programme, twice a week for up to 1 hour. In the seventh week, all
patients repeated the baseline measurements. An unpaired Students
t test was used to compare any differences between the control and
Results At baseline measurements, there were no statistical differences
in age, gender, length of stays or APACHE II scores between the two
groups. Results indicate that the exercise group (n=10) had significantly
greater improvements in cardiopulmonary fitness (P <0.001) and
balance (P <0.05) compared with the control group (n = 10). Greater
improvements were also evident in anxiety, depression and grip
strength in the exercise group, although not statistically significant.
Conclusion This pilot study highlights that a 6-week supervised
exercise programme can significantly improve cardiopulmonary fitness
and balance in post-ICU patients. Further recruitment to the study and
6-month/1-year follow-up is needed.
1. Baker C, et al.: Physical rehabilitation following critical illness. J Intensive Care Soc 2008, 9:166-169.
2. Jones C, et al.: Long term outcome from critical illness. Anaesth Intensive Care Med 2006, 7:155-156.
3. CG83 Critical Illness Rehabilitation: Guideline 2009 [www.nice.org.uk/CG83]
or alleviate this stress . To action this it is important to identify the
main stressors from the patients perspective. A systematic review
was performed to provide a list of what patients consider stressors
in intensive care. These were then ranked in order to provide an
identification tool that can be used to shape appropriate care.
Methods A systematic review was performed using MEDLINE, CINAHL,
Psych INFO and Academic Search Complete. Grey literature was
included and searches were not restricted to type of intensive care or
country. Criteria were used to filter those articles that identified the
patients views of their stressor, not the patient experience. Eligible
articles were critiqued using the Critical Appraisal Skills Programme for
qualitative studies  and brought together using a narrative synthesis.
All of the reviewed studies used a questionnaire as a means to identify
what elements on the intensive care patients found stressful. A list
of the top-10 stressors could then be expressed for each study and
compared. From this information, a set of guidelines for best practice
Results A total 1,424 articles were systematically assessed for suitability
and applicability. Of these, 14 articles remained eligible for review. The
stressors were ranked by their frequency in the individual studies
top10 lists. In rank order: 1, Tubes. 2, Pain. 3, Sleep Difficulties. 4, Thirst.
5, Lack of Patient Understanding. Overall, stressors were found to be
similar throughout all of the studies.
Conclusion The review identified a list of the most pertinent common
stressors. Awareness of these and ranking in priority may enable plans
of care to be instigated to effectively alleviate patient stress.
1. Jones C, et al.: Clin Intensive Care 1998, 9:199-205.
2. Scragg P, et al.: Anaesthesia 2001, 56:9-14.
3. Perrins J, et al.: Intensive Crit Care Nurs 1998, 14:108-116.
4. Ballard KS: Issues Ment Health Nurs 1981, 3:89-108.
5. Public Health Resource Unit: Critical Appraisal Skills Programme. 10 Questions to Help You Make Sense of Qualitative Research. [http://www.medev.ac.uk/ static/uploads/workshop_resources/166/166_Qualitative_Appraisal_Tool.pdf ]
Quality of care in the ICU from the perspective of relatives
MVanMol1, EBakker2, ARensen3, IMenheere3, LVerharen3
1Erasmus MC, Rotterdam, the Netherlands; 2OU, Heerlen, the Netherlands;
3HAN, Nijmegen, the Netherlands
Critical Care 2013, 17(Suppl 2):P543 (doi: 10.1186/cc12481)
Introduction This study describes the development and validation
of the Consumer Quality Index Relatives in ICUs (CQI R-ICU), which
aims to measure the satisfaction of relatives and to identify aspect
of care that need improvement in the ICU in a reliable and valid way.
According to the quality standards of the Dutch Society of Intensive
Care, every ICU needs to record the satisfaction of relatives . At this
moment there is insufficient insight into the quality of care offered to
relatives on the ICU because an evidence-based Dutch measurement
instrument is missing.
Methods The CQI R-ICU has been developed based on a scientific and
standardised method . A mixed design method is used, consisting of
qualitative and quantitative survey studies. Factor analyses are carried
out to determine the underlying structure of the newly developed
questionnaire. Multiple regression analysis is used to explore the
relationship between demographic variables and the perceived quality
Results In six hospitals the CQI R-ICU is sent to relatives after receiving
informed consent (n=441), 55.1% of the respondents are the patients
partner. Respondents seem to be most satisfied with the presence
of a professional at first entrance to the ICU. The highest need for
improvement scores relate to information about meals, parking
and other disciplines (for example, social worker, spiritual worker or
psychologist). Factor analysis shows that quality of care is determined
by four clusters of items: Support, Communication, General Information
and Organisation. The reliability of the CQI R-ICU is sufficiently high,
only Communication and Support are significant predictors of total
quality judgement of relatives (adj. R2 = 0.74). In addition, there is a
significant difference in mean total quality judgement between the six
hospitals as well as between the four wards within Erasmus MC. None
of the demographic variables such as sex, age, education, race and
length of stay had an effect on perceived quality of care.
Conclusion The CQI R-ICU turned out to be a valid, reliable, sensitive
and feasible instrument. Large-scale implementation is recommended.
Acknowledgements Thanks to researchers of Ziekenhuis Gelderse
Vallei, Kennemer Gasthuis, Catharinaziekenhuis, Ziekenhuis
Rivierenland and Scheperziekenhuis.
1. Vos et al.: Quality measurement at intensive care units: which indicators should we use? J Crit Care 2007, 22:267-274.
2. Sixma et al.: Handboek CQI Ontwikkeling: richtlijnen en voorschriften voor de ontwikkeling van een CQI meetinstrument. Utrecht: Nivel; 2008.
Introduction Following recommendations made by the Scottish
Intensive Care Society , we have introduced an annual Family
Satisfaction Survey in the intensive care unit (FS-ICU), in anticipation
that this will become an integral part of how we measure, improve
and strive to advance patient care in the future. We aim to recognise
factors impacting patient care and highlight areas for improvement.
Improving understanding of patients needs is currently a UK national
goal for CQUIN 2011/2012. An estimated 6.9 billion per year can be
saved by reaching these goals  and a positive patient experience
results in improved long-term outcomes and shorter hospital stays .
Methods We performed a study to assess Family Satisfaction over a
10week period in a 16-bed critical care unit (CCU). A modified version of
an FS-ICU published in US and Canadian studies  was distributed to
up to two family members per patient. Five-point Likert scale responses
were linearly transformed to give percentage scores. Higher values
represented a greater degree of satisfaction.
Results We received and analysed 32 completed surveys.
Seventyeight per cent of relatives reported that the treatment of the patient
was excellent, including symptom control such as pain, breathlessness
and agitation (72%, 69%, 100%, respectively). Ninety-one per cent
felt the care and frequency of communication provided by nurses
was excellent or very good, compared with 81% by doctors. Only 9%
of family members were offered spiritual support during their CCU
experience. Forty-seven per cent felt they would have liked more
involvement in the decision-making process.
Conclusion The vast majority of relatives rated their overall experience
on CCU as excellent or very good. The study highlighted two main areas
for improvement: provision of spiritual support as well as family and
patient involvement in the decision-making process. We will arrange
multi-disciplinary teaching sessions focusing on the positive impact,
and therefore importance of patient satisfaction. A poster providing
information about available spiritual support will be displayed around
our CCU. Further studies are required to evaluate these measures.
Introduction We are conducting a cluster randomized trial with two
parallel arms to evaluate strategies to improve family satisfaction with
the care that themselves and their critically ill relatives receive in the
ICUs of nonacademic Brazilian public hospitals. Here we report the
results of the baseline phase of this trial.
Methods In this baseline phase, we interviewed the family member
most closely involved with the care of critically ill patients who stayed
in the ICU for at least 72hours. We applied a form with 24 questions
divided into four domains: overall ICU experience, communication,
decision-making, and questions related to end-of-life care for patients
who died in the ICU. Each question scored from 0 (very poor) to 100
(excellent). The form was adapted from the Family Satisfaction with
Care in the ICU (FS-ICU 24). As many questions assessed the quality
of intensivist care or communication, the interview was applied by a
psychologist or a nurse.
Results Families of 564 patients were interviewed. A total 45/564
(8.3%) died in the ICU. Most respondents were satisfied with overall ICU
experience (meanSD score 85.511.9). However, family satisfaction
with communication (67.8 18.0) and decision-making (69.5 21.1)
resulted in somewhat lower scores. Most families of patients who
died in the ICU (38/45 (82.6%)) considered that their relatives life
was neither extended nor shortened unnecessarily. Also, most of the
families believed that their relative did not suffer or suffered little in the
ICU (37/46 (80.4%)) and felt supported by the healthcare team (40/46
Conclusion Most families were satisfied with the care themselves and
their critically ill relatives received in the ICU. Also, most relatives of
patients who died in the ICU felt that end-of-life care was adequate.
Although we believe there is much room for improvement in
communication, decision-making and support critically ill patients and
their families, as their baseline satisfaction with patient care is quite
high, it may be hard to demonstrate substantial improvement after
1. Quality Indicators for Critical Care in Scotland [http://www.sicsag. scot.nhs. uk/SICSQIG-report-2012-120209 .pdf ]
2. Using the Commissioning for Quality and Innovation (CQUIN) Payment Framework - Guidance on National Goals for 2011 /12 [http://www.dh.gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/ digitalasset/dh_123009.pdf ]
3. 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 - 279 .