Determination of the best volume of perfluorocarbone to ensure partial liquid ventilation in the pig with ARDS
Critical Care The Official Journal of the Critical Care Forum Editor: Jean-Louis Vincent
Chairman: J-L Vincent Manager: Carl Vanhaesendonck 0 1 2 4 5 6 7 8 9
0 19th International Symposium on Intensive Care and Emergency Medicine Brussels, Congress Center , 16-19 March 1999
1 NW Knudsen, MW Sebastian, RA Perez-Tamayo, WL Johanson and SN Vaslef Duke University Medical Center , Durham, NC , USA
2 C Gorman, T Rogers, J Price, A Waboso, L Flackett and N Stallard Intensive Care Service, University Hospital of Wales , Cardiff, CF4 4XW , UK
3 Norwegian Air Ambulance , Stavanger , Norway
4 K Kokkinis, T Vrettos, K Lefkaditi, P Manolopoulou and K Zbouki Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras , Greece
5 K Yasumoto and I Kagami Department of Anesthesiology, Showa University Hospital , 1-5-8 Hatanodai Shinagawa-ku, Tokyo , Japan
6 MY Yassin Libanese University School of Medicine, Department of Internal Medicine, Pulmonary and Critical Care Division, Hammoud Hospital , Sidon- Lebanon
7 RD Branson, RS Campbell, M Ottaway and JA Johannigman University of Cincinnati, Department of Surgery
8 JG Hardman Department of Anaesthesia and Intensive Care, University of Nottingham , UK
9 D Kindgen-Milles, A Gabriel, R Buhl, H Böhner and E Müller Department of Clinical Anaesthesia, Heinrich-Heine-University , 40001 Düsseldorf, FRG
s of Posters A d'Hollander (Brussels, Belgium) Scientific advisors
With the collaboration of:
Poster abstracts 1
A prospective study of the incidence of iatrogenic ocular damage in critically ill patients
Crit Care 1999, 3 (suppl 1):P1
Introduction: Critically ill patients requiring intensive care are at
risk of iatrogenic ocular damage. Studies have reported an
incidence of eye problems of up to 40% in critically ill ventilated
patients. We conducted this study to assess the incidence of ocular
complications in our intensive care unit where all patients are
cared for according to an eye care standard.
Methods: All ventilated patients over a 2 month period were
included. Ophthalmic assessment was performed on admission
and repeated every other day during the period of ventilation. At
each assessment the average Ramsey sedation score over the
previous 24 h, the presence of tracheal secretions and the presence of
ventilation associated pneumonia was noted. Eye care performed
Results: Sixty patients were included. One patient developed
corneal exposure keratopathy. No patient developed
conjunctivitis or corneal ulceration. Further advice on appropriate measures
of eye care was given in five cases (8%). Nine patients (15%) had
large amounts of respiratory secretions with positive
Conclusion: This study confirms that the use of an eye care
standard is associated with a low incidence of ocular surface
complications. The incidence of ocular complications in this group of
patients is far lower than previously described.
Intensive care unit procedures: cost savings and patient safety
Crit Care 1999, 3 (suppl 1):P2
Introduction: Intensive Care Unit (ICU) management of critically
ill patients often includes the requirement for tracheostomy and
feeding access, most often a pecutaneous endoscopic gastrostomy
(PEG). Although advances in ICU airway management include
percutaneous tracheostomy, semi-open tracheostomy and
conventional tracheostomy, the majority of critically ill surgical and
injured patients still receive open tracheostomy in the Operating
Room at Duke University Medical Center (DUMC). Although
percutaneous tracheostomy is performed routinely in many
medical ICU settings, in high risk surgical and trauma patients
who often have unstable cervical spine injury and tissue edema,
direct visualization of the cervical structures and trachea is
imperative during tracheostomy. We have undertaken open
tracheostomy and PEG in the ICU in selected patients as part of a
collaborative, mulitidisciplinary ICU patient management strategy
at DUMC. This initiative has been undertaken to address the risk
of patient transport, the inappropriate use of OR time, and the
cost to the patient as part of an effort to standardize and improve
Methods: After informed consent, utilizing DUMC conscious
sedation protocol, full ICU monitoring, and sterile OR technique,
13 tracheostomies and 8 PEG placements were performed in 13
patients in the ICU since July, 1998. There were no
complications. Operating Room costs include basic room fee and charge
per minute for general surgery and anesthesia and the anesthesia
professional fee. Surgical professional fee, tracheostomy tube cost,
and gastroscope maintenance are identical and not included in the
analysis. ICU costs include gowns, gloves, drapes and
tracheostomy tray. For purposes of analysis, OR tracheostomy and
OR PEG times were defined as 120 min and 60 min respectively;
although analysis of fiscal year 1997–1998 yield widely divergent
average OR times for these procedures.
Results: A table of cost comparison for individual procedure, total
to date and associated cost savings are shown below.
PEG (n = 8)
Conclusion: Tracheostomy and PEG placement in the ICU in
selected patients are safe, avoid patient travel, improve OR
utilization and show a significant reduction in cost.
Fiberoptic bronchoscopy of the intubated patient with life-threatening hemoptysis
H-J Düpree, J-C Lewejohann, J Gleiß, E Muhl and H-P Bruch
Medical University of Luebeck, Dept. of Surgery, Ratzeburger Allee 160, 23538 Luebeck, Germany. E-mail:
Crit Care 1999, 3 (suppl 1):P3
Introduction: Bleeding into the tracheobronchial tree is a
potentially fatal occurrence for intubated patients. The subsequent
acute respiratory failure requires an effective therapy. Fiberoptic
bronchoscopy represents an easy available technique for the
diagnosis and treatment of this type of hemoptysis.
Methods: We show the bronchoscopic management of
endobronchial bleeding in intubated patients at our ICU. During the
period 7/97–12/97 seven consecutive patients with acute
endobronchial bleeding were treated with fiberoptic bronchoscopy. All
patients received an endobronchial instillation of epinephrine and
physiological saline solution (1:10 000–100 000).
Critical Care 1999, Vol 3 suppl 1
Goiter, large retrosternal, sternotomy
Stenosis of the left internal carotid artery
Ruptured abd. aortic aneurysm
Aspergilloma left lung, acute myeloic leucemia
Lung contusion, polytrauma
Acute abdominal pain, urosepsis, nephrectomy
SaO2 [%] before treatment
Results: Control of bleeding was achieved with 1 to 20 (m ± SEM:
5.86 ± 0.93) bronchoscopic interventions. Hemostasis was
accomplished in a period of 0.5 h and 10 days. Cardiocirculatory
instability was observed in five patients. One patient died because of
persistent bleeding caused by severe aspergillosis. Six patients
survived without further interventions.
Conclusion: Endobronchial instillation of epinephrine and
physiological saline solution represents an effective method in case of
lifethreatening hemoptysis in intubated and mechanical
The compliance characteristics of the Portex Soft-Seal cuff improves seal against leakage of fluid in a pig
PJ Young and MC Blunt
ICU, Queen Elizabeth Hospital, Kings Lynn, PE30 4ET, UK
Crit Care 1999, 3 (suppl 1):P4
A high volume low pressure (HVLP) cuff does not protect the
lower airway from contamination by material leaking along
longitudinal folds within the cuff wall . This is a major factor in the
pathogenesis of ventilator associated pneumonia . The
combination of shape and high compliance of the Portex Soft-Seal cuff
might eliminate the folds in the cuff walls circumferentially for a
portion of the cuff and prevent leakage. We have tested the
SoftSeal cuff in a pig trachea model to establish whether protection
against leakage is better than that afforded by standard HVLP
Method: The Portex Soft-Seal, Mallinckrodt Hi-Lo, Sheridan
Preformed and Portex Profile size 8 mm internal diameter HVLP
cuffed tracheal tubes were assessed for leakage of dye placed in
the subglottic space to the trachea in a benchtop ventilation
model and in six isolated pig tracheas. All cuffs were inflated at
30 cmH O pressure.
Results: There was no leakage in the ventilation model or in the
pig tracheas with the Portex Soft-Seal group, but rapid leakage
occurred in all the pig tracheas for the standard HVLP cuffs.
Conclusion: This benchtop study suggests that the improved
HVLP cuff compliance characteristics and shape of the Portex
Soft-Seal cuff might be beneficial in the prevention of leakage of
fluid to the lungs known to occur with HVLP cuffs.
Colibri coloriometric technology rapidly detects oesophagal intubations
Crit Care 1999, 3 (suppl 1):P5
Introduction: Rapid verification of correct placement is extremely
important [1,2]. We have tested a new coloriometric CO2
detection indicator meant for this purpose .
Methods: An entdotracheal tube was placed both in the trachea
and the oesophagus in otherwise healthy patients undergoing
elective surgery under general anaesthesia. We compared the four
first ventilations of the endotracheal and oesophageal tube using
capnography and a Capno Bri indicator with four different colour
Poster abstracts 3
gradings. (Blue ~ 0.5%, dark green ~ 1.0%, light green ~ 3.0% and
yellow ~ 4.0%)
especially suitable in emergency situations where capnography is
Results: In all patients (n = 9), the indicator confirmed correct
placement of the tube in the trachea at the first ventilation (yellow
color). The indicator also verified incorrect oesophageal
placement at the first ventilation in all patients (blue color).
These results were confirmed by the capnography.
Conclusion: The Colibri technology is a reliable technique for
confirmation of correct endotracheal tube placement. It may be
1. Sum Ping ST: Accuracy of the FEFCO2 detector in the
assessment of endotracheal tube placement. Anaest
Analg 1992, 74:415-419.
2. Sayah AJ: End-tidal CO2 measurement in the detection of
esophagus intubation during cardiac arrest. Ann Emerg
Med 1990, 19:8.
3. Singer M: Colibri: a new means of CO2 detection. ESA
Congress in Barcelona 1998.
Lung volume and oxygenation changes with a closed suction system (CSS) in patients undergoing volume
controlled ventilation (VCV)
M Cereda, E Colombo, F Villa, G Greco, L De Marchi and A Pesenti
Istituto di Anestesia e Rianimazione, Ospedale S. Gerardo, via Donizetti 106, Monza (MI) 20052, Italy
Crit Care 1999, 3 (suppl 1):P6
We wished to measure changes in lung volume (DLV), airway
pressures, and oxygenation during tracheal suctioning performed
with a CSS and with an open suction system (OSS). We enrolled 7
adult patients, sedated and paralyzed, VCV ventilated by a
SERVO 900C ventilator (Siemens, Sweden) with PEEP
³5 cmH O and FiO2 ³ 0.4. Keeping all remaining ventilatory
tings unchanged, we set trigger sensitivity at –2 cmH2O,
inspiratory time at 25%, inspiratory pause at 10%. We performed four
suctioning manouvers at 20 min intervals using alternatively a CSS
and an OSS. With both systems, we used 12 F size catheters. We
performed no pre-oxygenation manouvers. Suction was applied
for 20 s at a pressure of 100 cmH2O. We continuously recorded
signals of respiratory inductance pletismography (RIP, Respitrace
Plus, NIMS, FL), arterial oxygen saturation (O2Sat) by pulse
oxymetry, and airway pressures. We obtained DLV as the change in
the RIP signal measured during VCV and during suction. We
measured Respiratory Rate (RR), peak inspiratory pressure (PIP),
positive end-expiratory pressure (PEEP), and mean airway
pressure (MAP) during VCV and during suction with the CSS.
Results: variables are reported as mean ± DS.
*P < 0.01 vs CSS, †P < 0.05 vs VCV, ‡P < 0.01 vs VCV
Comment: the use of the OSS resulted in discontinuation of
ventilatory support with a loss in lung volume and in O2Sat. The CSS
effectively preserved lung volume and oxygenation by
maintaining airway pressures during the suction manouvre. The increase in
RR observed with the CSS was due to activation of the trigger
Balloon laryngoscopy reduces head extension and blade leverage in patients with potential cervical spine
SD Mentzelopoulos, MV Tsitsika, MP Balanika, MJ Joufi and EA Karamichali
Department of Anaesthesia, Evangelismos General Hospital, 45 Ypsilantou Street, GR-10676, Athens, Greece
Crit Care 1999, 3 (suppl 1):P7
Background: In trauma patients, rigid cervical collar placement
reduces head extension (HE) during laryngoscopy . In patients
with difficult airway, upper teeth or gums may be traumatized by
excessive laryngoscope blade levering motion (LBLM) needed for
laryngeal visualization . The current study aims to compare,
under stimulated spine precautions, HE and LBLM upon
maximum glottic exposure (MGE) achieved with #4 conventional
Macintosh blade (CMB) and #4 modified Macintosh blade
(MMB) carrying two 10 Foley catheters (Fig. 1).
Methods: Anaesthesia was induced in 17 male, ASA I, Mallampati
I, elective surgery patients. Spine precautions included rigid board
placement under the shoulders and occiput and a rigid collar
placement round the neck. Laryngoscopy was performed twice,
changing between MMB and CMB. Before each laryngoscopy, the
patients head was placed in the neutral position. MMB
laryngoscopy technique consisted of MMB tip insertion into vallecula,
right catheter balloon inflation with 2 ml air and MMB elevation
until MGE achievement. The angles of laryngoscope handle axis
(Fig. 2 AH) and of maxillary molars occlusal surface axis (OS)
relative to horizontal (angles â1 and â2 in Fig. 2) were recorded upon
MGE. Angles â1 and â2 were measured with an automatic angle
finder (Fig. 1). The difference of 90°–â2 was defined as HE angle
and the difference â1–â2 was defined as LBLM angle (angle â3 in
Fig. 2), He and LBLM angles were compared with paired t test;
P < 0.05 was considered statistically significant.
Results: MMB laryngoscopy resulted in significantly less HE and
LBLM than CMB laryngoscopy (P < 0.001). Results and
summarized statistics are presented in the Table. Values are shown as
Critical Care 1999, Vol 3 suppl 1
means ± SD, Cormack-Lehane grade of laryngoscopic view was
£II during all laryngoscopies.
Laboratory study of new technique using a one-pass dilator for percutaneous dilatational tracheostomy
P Ciaglia and W Marx
St Elizabeth Medical Center, 2215 Genesee Street, Utica NY 13501, Masonic Medical Research Laboratory, Utica, SUNY HSC, Syracuse, NY, USA
Crit Care 1999, 3 (suppl 1):P8
Background and objectives: Percutaneous dilatational
tracheostomy requires the use of several dilators of increasing size. It
would be a marked advantage to use only one dilator to achieve
the desired 36 F. This report presents preliminary animal studies
using freshly sacrificed dogs, adult pig tracheas fresh from the
slaughterhouse and live piglets.
Methods: The usual technique for percutaneous dilatational
tracheostomy was first followed to insert a guidewire into the
trachea. A well-lubricated, one-pass, long, tapered dilator was
threaded over the guidewire into the trachea. With twisting, it was
inserted to the 36 F level. The one-pass dilator was removed
leaving the guidewire in place and the chosen tracheostomy tube
was passed over the guidewire into the trachea using the usual
technique of percutaneous dilatational tracheostomy.
Results: A total of 50 dog cadavers and 25 slaughterhouse sheep
tracheas were successfully tracheotomized using the one-pass
dilator employing 7 and 8 mm I.D. tubes. Six live piglets were
finally used successfully. No perforations or false passengers
Concusions: A one-pass technique was used successfully on fresh
dog cadavers and should be evaluated on human beings.
Percutaneous dilatational tracheostomy with a lightwand device
Crit Care 1999, 3 (suppl 1):P9
Percutaneous dilatational tracheostomy (PDT) is a new technique
which shares the same indications as surgical tracheostomy. We
describe our experience with the PDT in combination with
Patient population: Elective PDT was performed in 55 critically
ill patients, mean age 54.5 ± 16 (22–72), intubation time 6.5 ± 3.2
Technique: The procedure was undertaken on the bedside using
the Griggs-Portex PDT set as has been already described .
Before cannulation of the trachea the trachlight device (trachlight,
Poster abstracts 5
Leardal Medical) was inserted into the endotracheal tube with the
tip at the end of the tube. By pulling back the endotracheal tube
with the trach-light we examined the anatomy of the trachea and
the location of the first and second tracheal rings. Besides the
proper position of the end of the tube above the first tracheal ring
was achieved. Afterwards we continued with the PDT technique.
At the end the exact tracheotomy site and the correct placement
of the tracheostomy tube was evaluated by endoscopy.
Results: The procedure lasted from 7 to 21 min (m.v. 9.5 min).
The maneuver with the trachlight device lasted between 40–80 s
Perioperative complications are listed below:
1) Hemorrhage minor: 2 patients
Hemorrhage major: 0 patients
2) Premature extubation of the translaryngeal tube: 0 patients 3) 4) 5)
Puncture of the endotracheal tube/cuff: 0 patients
Paramedian puncture of the trachea: 0 patients
Hypoxemia: 0 patients
Conclusion: PDT is a simple bedside procedure with a low
complication rate. The combination with the trachlight device gives
the opportunity for better identification of the anatomy of the
trachea as well as the correct placement of the endotracheal tube
above the first endotracheal ring. These contribute to better
conditions for safe and accurate tracheal puncture and cannulation.
Percutaneous dilatational tracheostomy (PDT): a report on 103 consecutive cases of the translaryngeal
tracheostomy (TLT) technique
A Karnik and JW Freeman
Featherstone Department of Intensive Care, Queen Elizabeth University Hospital, Birmingham B15 2TH, UK
Crit Care 1999, 3 (suppl 1):P10
Introduction: We describe our experience with the TLT
technique, which is a purely dilatational PDT with low inherent risks.
The technique has the additional benefit of maintained
ventilation and airway protection.
Technique: The TLT consists of a reinforced tracheostomy tube,
with an integral dilator, which is pulled out between tracheal rings
following retrograde insertion through the larynx . A cuffed oral
5mm-tracheal tube inserted past the proposed stoma site maintains
ventilation and airway protection. We prospectively collected data
in 103 consecutive patients, 56 males and 47 females, undergoing
this technique. The authors (JWF & AK) performed
tracheostomies on all patients (16 to 88 years old). Pre-existent
coagulopathy was not corrected. Indications for tracheostomy were
mainly for term ventilation (39) and weaning difficulties (44).
Results: 102 tracheostomies were performed successfully. One was
converted to a Ciaglia technique after accidental decannulation.
Mean duration of operative procedure was 13.9 min. The INR
ranged from 0.8–2.6, (mean 1.3), platelets ranged from 23–667
× 109 (mean 184 × 109). There were six transient episodes of
hypoxia (SpO2<90%), three cases of hypotension, two related to
the anaesthetic technique and one following traumatic intubation.
There were four episodes of accidental decannulation and one
case of minor subcutaneous emphysema. There was one case of
moderate blood loss (100–250 ml). There was one episode of loss
of airway, in a patient who was difficult to intubate (Gr. III). We
had two cases of wound infection associated with pre-existent
systemic bacteremia. Total duration of the tracheostomy ranged from
1–65 days. Total closure of the stoma took a mean of 4 days (range
2–9 days). The resultant scar was minimal.
Conclusion: This pure dilatational and bronchoscopically
visualised method is easy to perform with training. It is worthy of
consideration in patients with coagulation abnormalities. We feel it
offers better control over the airway than other available
techniques although there is a definite risk of decannulation while
withdrawing the cannula over the obturator. The overall morbidity
of this technique is low.
Independent lung ventilation using a double-lumen endobronchial tube by nasotracheal intubation
Crit Care 1999, 3 (suppl 1):P11
Independent lung ventilation (ILV) is effective for the patient
who is suffering from unilateral lung disease. When we ventilate
the patients with ILV, they should be intubated with a
doublelumen endobronchial tube. While ILV is continued for some time
a number of difficulties related to the management of the
doublelumen endobronchial tube (DLT) arise. Movements of the patient
and routine turning of the patient threaten the DLT position and
can lead to loss of lung isolation or lobe occlusion. Nasal
intubation is better suited for long-term intubation than oral intubation
because it is safer for equipment attachment. We have ventilated
six patients (Table) with ILV using the DT by nasotracheal
Post upper lobectomy 155.5
Aspiration pneumonia 145
Aspiration pneumonia 153
Critical Care 1999, Vol 3 suppl 1
intubation for 25 to 120 h. We intubated Portex #5.5 DT for all
cases. There was no case in which DLT was required to correct its
position during ILV. Although we examined the condition inside
the nose, there was no severe damage by the DLT. We concluded
that nasotracheal DLT intubation was done safely and could be
used for ILV up to 7 days.
The effect of dexamethasone on the incidence of post extubation stridor in pediatric patients
AK Kalloghlian, BM Pittappilly and NT Matthews
The Pediatric Intensive Care Unit, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354 Riyadh, Saudi Arabia
Crit Care 1999, 3 (suppl 1):P12
Post extubation stridor is due to reactive subglottic laryngeal
edema at the cricoid ring. Dexamethasone has been used to
reduce the incidence of stridor in such patients. The evidence in
the literature however is not conclusive. We conducted a
prospective, randomized, double blind study of dexamethasone versus
placebo to assess the efficacy of dexamethasone in reducing the
incidence of post extubation stridor in children. Fifty-one patients
without any known preexisting upper airway problems were
studied. There were 27 patients in the treatment group and 24 in
the placebo group. Both groups had similar weight, age and length
of intubation. Dexamethasone was given at a dose of 0.6 mg/kg at
12 h and 1 h prior to extubation for a total of 2 doses. The control
group received placebo at corresponding times.
There was no statistical difference in the incidence of post
extubation stridor in the two groups. Ten of 24 children in the placebo
group (41.7%) and 8 of 27 (30%) in the dexamethasone group
developed stridor (P = 0.39). There were 3 patients in placebo
group and 1 in dexamethasone group that needed reintubation,
but again the difference was not statistically significant (P = 0.33).
This study, although with relatively small sample size, suggests
that routine use of dexamethasone to prevent post extubation
stridor, in children without any known upper airway abnormality,
is not warranted.
Evaluating the effect of steroids on the incidence of reintubation rates in children with
J Rajah, J Riera-Fanego, J Keeton, A Ramjee, R Bhana and H Hon
Intensive Care Unit, Chris-Hani Baragwanath Hospital, University of Witwatersrand, P O Bertsham, 2013, South Africa
Crit Care 1999, 3 (suppl 1):P13
Introduction: Postextubation stridor is a serious problem in
children with an incidence of up to 33% in electively intubated
children. Our aim was to determine whether steroids decreased
reintubation rates and to identify other risk factors for
Methods: Retrospective analysis (1994–1996) of the 82 children
(72 received steroids). Steroids were categorized according to the
type used and the time of administration. Recognized risk factors
for postextubation stridor including age (<1 and >1 year) and
duration of intubation (<120 and >120 h) were analyzed.
Results: There was no significant difference in either the
preintubation grade or stridor (P = 0.67) in both outcome groups
(reintubated 22/23 grade 3 and not-reintubated 50/59 grade 3) or in the
postextubation grade of stridor between both groups (P = 0.1).
Neither type of steroid (P = 0.32), nor time administered (P = 0.79),
nor age (P = 0.22) nor duration of intubation (P = 0.35) was found
to significantly influence reintubation rates.
Conclusion: The prophylactic use of corticosteroids in routine
elective extubations for laryngotracheobronchitis cannot be
Advantages of a new humidification technique
Intubation (2 days)
ICU stay (days)
ommended, based on current findings. Overall, 28% of all patients
needed to be reintubated. However, reintubation seems to be
correlated best with atelectasis rather than the degree of
G Via, M Olivei*, A Palo, S Neri, G Ragni, M Bertolini, N Fusilli, F Capra-Marzani, G Rodi, G Iotti and A Braschi
Anestesia e Rianimazione Io, *Lab. Tecn. Biomediche IRCCS S. Matteo P. le Golgi 2 27100-Pavia, Italy
Crit Care 1999, 3 (suppl 1):P14
Recently, an active HME (AHME) (Humid-Heat, Gibeck) has
been developed. The AHME combines a HME with a unit which
adds humidity and heat to the patient-side of the HME. The
supply of humidity and heat is automatically regulated, in order to
achieve 100% humidity of inspired gases at 37°C. The operation
of AHME requires only the user-set input of the patient minute
Poster abstracts 7
ventilation. We evaluated the potential advantages of the AHME
over a conventional active humidifier.
Methods: The study included seven mechanically ventilated
patients. In each patient, the AHME was used for 24 h and then
substituted with a conventional active humidifier (F&P) (MR730,
Fisher & Paykel) with a heated wire in the inspiratory limb, for
the next 24 h. AHME was preset to keep the temperature of
inspired gases at 37°C. The F&P was set to 37°C in the
humidifier-chamber, and to 37°C at the Y piece. The AHME and the
F&P were compared in terms of: humidity and temperature
output, water consumption and condensate in the water traps.
The humidity output was evaluated on the basis of the
condensate in the flex tube, which was scored from 0 (absent) to 3
Results: Minute ventilation did not differ during application of
AHME and of F&P. Both devices kept the set temperatures, and
provided adequate humidification, as assessed by the condensate
in the flex tube. However, when the F&P was used, there was
formation of condensate in the ventilator tubings, and the water traps
needed to be emptied on average eight times (range: 6–9) per day.
Minute ventilation (l/min)
Insp. gases temperature (°C)
Condensation in the flex tube (score) 2 ± 0
No. of water traps emptying
Quantity of H2O in the water traps
H2O consumption (ml)
means ± SD; Student t test.
No condensation of water was found in the ventilator tubings with
AHME. Compared with F&P, the AHME remarkably reduced the
Conclusion: Compared to a conventional active humidifier, the
AHME provides equivalent humidification, with the advantages
of both reducing the time-expenditure for handling, and of
eliminating the risk caused by water condensation in the ventilator
Heat and moisture exchanger PALLBB22-15F can prevent ventilator-associated pneumonia (VAP) in short
term mechanically ventilated ICU patients
Crit Care 1999, 3 (suppl 1):P15
Introduction: VAP is a serious infection with a mortality rate
exceeding 50%. It also leads to an increase in the duration of the
treatment and adds to hospital costs. Bacteria, in intubated
patients, may be directly inoculated into the endotracheal tube
from the hands of medical personnel or from contaminated
respiratory therapy equipment (i.e. humidifiers). We tried a heat and
moisture exchanger to substitute the conventional ventilator
humidifiers to prevent VAP in the ICU setting.
Methods: Subjects were intubated and attached to the
conventional respiratory assistance cascades in the first year of the study
(July 1992–June 1993). Retrospectively, cases of VAP were
calculated prospectively, during the following year (July 1993–June
1994), subjects were intubated and attached to respiratory
assistance cascades; but PALL filter, a heat and moisture exchanger,
was in-line and the machine humidifiers were bypassed. The
cases of VAP were calculated.
Study population: Intubated ICU patients with normal CXR on
admission to the unit.
Results: VAP rates decreased in the group of HMEF dramatically
in comparison to the conventional humidification method (see
Total patients in group
VAP rate, incubated 1 day
VAP rate, intubated 2–4 days
VAP rate, intubated > 5 days
Conclusion: We concluded that heat and moisture exchanger
filters can prevent VAP in short term mechanically ventilated ICU
patients, and can halve its rate in long term durations.
A clinical evaluation of a new humidifier in long-term mechanical ventilation
M Olivei*, G Via, A Palo, S Neri, G Maggio, T Mediani, C Galbusera, M Belliato, E Haeusler, G Iotti and A Braschi
Anest. e. Rianimazione Io *Lab. Tecn. Biomediche IRCCS S. Matteo P. le Golgi 2 27100-Pavia, Italy
Crit Care 1999, 3 (suppl 1):P16
The adequacy of humidification of heat and moisture exchangers
(HMEs) during long-term mechanical ventilation is still
controversial. Recently, an active HME (AHME) (Humid-Heat, Gibeck)
has been developed. This AHME combines a HME with a unit
which adds water and heat between the patient and the HME.
The AHME automatically regulates the water and heat supply.
The only user-set input for AHME is the minute ventilation (V’e)
of the patient. We evaluated the AHME efficiency for
humidification during long-term mechanical ventilation.
Methods: The AHME was used for 5 days on seven patients
which were mechanically ventilated in different modes. On each
Critical Care 1999, Vol 3 suppl 1
day we measured the number of tracheal aspirations, the
secretions characteristics, the condensate in the flex tube and in the
water traps, the airway temperature, the number of changes of the
V’e setting on AHME. A chest X-ray and a bronchoscopy were
performed on days 1, 3 and 5. We scored the secretions
characteristics and the condensate in the flex tube from 0 (insufficient) to 3
(excessive), the atelectasis at chest X-ray from 0 (absent) to 2
(evident), and the bronchial occlusions at bronchoscopy from 1
(absent) to 4 (complete).
Results and conclusion: AHME provided adequate humidification
over the 5 days, as indicated by the secretions characteristics and
Viscosity of secretions (score)
Condensation in the flex tube (score)
Bronchial obstruction (score)
RX atelectasis (score)
Insp. gases temperature (°C)
Nr. of changes of V’e set on AHME
means ± SD. ANOVA.
by the absence of new atelectasis and of secretions accumulation
in the bronchi. The temperature of inspired air was adequate. The
value of V’e set on the AHME was changed on average twice
(range: 0–8 times) per day, to maintain this setting close to the V’e
of the patient. No water condensate was found in the water traps.
The AHME is adequate for humidification in long-term
mechanical ventilation, and eliminates the problem of condensation in the
ventilator tubings. The humidification efficiency of AHME is not
influenced by the mechanical ventilation mode, provided that the
V’e setting of AHME is kept close to the V’e of the patient.
Comparison of conventional heated humidification to a new active heat and moisture exchanger in the ICU
Crit Care 1999, 3 (suppl 1):P17
Background: Heated humidification (HH) is commonly used with
or without a heated wire circuit (HWC) to humidify inspired gases
during mechanical ventilation (MV). We compared HH and HH
with a HWC to a new active heat and moisture exchanger
(AHME). The AHME (Humid Heat, Gibeck, Sweden) consists of
a typical HME and a heat and water source delivered between the
patient and the HME. The volume of water delivered and heat
output are based on a set minute ventilation. A pre-set airway
temperature of 37°C is used.
Methods: Thirty patients requiring MV for >72 h were studied.
Pts received humidification via a HH, HH + HWC (Fisher &
Paykel), and AHME in random sequence for 24 h each. All
devices were set to deliver 37°C at the proximal airway. During
each period of ventilation, the following were measured; airway
temperature, min and max body temperature, number of
suctioning attempts, volume of secretions, consistency of secretions,
number and volume of saline instilled, water usage, condensate,
ventilator settings, minute volume, number of circuit
disconnections. Water usage was measured by weighing the water bag
before and after 24 h use. Consistency of secretions were judged
as thin, moderate, or thick as previously described (Suzukawa:
Respir Care 1989, 34:976). Condensate was measured by emptying
fluid into a graduated container and sputum volume measured by
collecting secretions in a Luken’s trap. Airway temperature was
measured at the ET tube using a rapid response thermistor.
Resistance of the AHME was measured before and after use.
Results: There were no differences in any of the variables related
to humidification efficiency (secretion volume and consistency,
number of suctioning attempts, or volume of saline used). Water
usage and volume of condensate were significantly different
between devices, but delivered airway temperatures were not.
Statistical analysis was done with ANOVA. *P < 0.05, see Table.
Water Usage (ml) Condensate (ml) Airway Temp. (°C)
Minute volume was similar between groups (11.6 ± 3.3 vs
11.9 ± 3.4 vs 11.8 ± 2.7 l/min) as was bias flow during flow
triggering (5.8 ± 2.5 vs 5.4 ± 2.6 vs 5.9 ± 2.3). AHME resistance before and
after use was unchanged (1.66 ± 0.11 vs 2.28 ± 0.82 cm H2O/l/s).
Conclusion: In this early study, the AHME provided equivalent
humidification as HH and HH + HWC with a lower water usage.
This occurs because the HME portion of the AHME returns
~32 mgH2O/l, which only requires the active portion to add
~12 mgH2O/l to reach 44 mgH2O/l. Additionally, by placing the
AHME between the patient and ventilator circuit, continuous
flow from flow triggering systems is not humidified. No other
differences were noted. Disadvantages of the AHME include
Poster abstracts 9
deadspace (~70 ml), weight on the ET tube and the heat source
near the patient. Measured external temperature of the AHME
did not exceed 38°C. Further long term studies are required to
define the role of the AHME.
A new device for 100% humidification of inspired air
A Larsson and L Svanborg
Department of Anesthesia and Intensive Care Medicine, University Hospital Lund, Sweden and Louis Gibeck AB, Upplands Väsby, Sweden
Crit Care 1999, 3 (suppl 1):P18
Introduction. Passive heat/moisture ex-changers (HME) which are
based on a hygroscopic condensor principle usually provide
adequate humidity (up to 32 mgH2O/l air) of the inspired gas during
ventilator treatment [1,2]. However, in about 5–10% of the
patients with e.g. thick secretions [1,2] active humidifiers that can
provide 100% humidity are needed. These devices cause free
water condensation in the tubings  with risks of contamination
and of compromising the ventilator function. To avoid this a new
humidifier has been developed. It consists of a supply unit with a
microprocessor and a water pump, and a humidification device,
which is placed between the Y-piece and the endotracheal tube.
The humidification device is based on a hygroscopic HME, which
absorbs the expired heat and moisture and releases it to the
inspired gas. External heat and water are then added to the
patient side of the HME, so the inspired gas reaches 100%
humidity at 37°C (44 mgH2O/l air). The external water is delivered via a
pump onto a porous membrane and then evaporated in the
inspired air by an electrical heater. The microprocessor controls
the water pump and the heater by an algorithm using the minute
ventilation (which is fed into the microprocessor) and the airway
temperature measured by a sensor mounted in the flex tube on
the patient side of the humidification device.
The aim of this study was to test the performance of this
humidifier at different ventilator settings in a lung model.
Methods: The lung model is based on the ISO 9360 International
Standard with the exception of that the water-bath temperature is
regulated to have a constant temperature of 35.5 ± 0.5°C. The
model was ventilated with a Siemens 900 B ventilator set a minute
ventilation from 5 to 25 l/min, I:E 1:2, and a rate of 12, 15 or
20/min during 90 min. The moisture content (MC) in the inspired
air was calculated from the water delivered (WD) and the loss of
water from the lung model (WL): MC = WL– WT + (WD–WH),
where WT is the water in the tubing between the device and the
lung model and WH the water trapped in the HME. WL, WT,
WD, and WH were found by weighing before and after the
experiment. During the experiment no condensation was found in the
flex tube between the device and the lung model.
20 2 3 4 5 6 7 8 Mi9nute Ventilation (l/1m2in) 13 14 15 16 17 18 19 20
Conclusion: In a lung model, ventilated with 5–25 l/min, the new
humidifier gave an absolute humidity of 39–45 g/l, with the lower
level at the highest ventilation. Thus, the device had the intended
Modelling the effect of ambient oxygen fraction on hypoxaemia during apnoea
Crit Care 1999, 3 (suppl 1):P19
Hypoxaemia during apnoeic oxygenation complicates tests for
brainstem death and exposes the patient’s organs to the risk of
anoxic damage. This study investigates the effect on hypoxaemia
of varying the ambient oxygen fraction during apnoea.
Methods and results: The Nottingham Physiology Simulator is a
validated simulation of advanced, iterative physiological models
. The model was set up as a 70 kg adult with normal
physiological values other than: pulmonary venous admixture 20%, alveolar
deadspace fraction 20% of tidal volume and functional residual
capacity 2 l. The patient’s lungs were ventilated with 100%
Critical Care 1999, Vol 3 suppl 1
oxygen for 2 min and the patient was then apnoeic with an open
airway exposed to 21, 50, 80 or 100% oxygen. Arterial oxygen and
carbon dioxide tensions (PaO2, PaCO2) were recorded
continuously until arterial oxygen saturation fell to 50%. The changes in
PaO2 and PaCO2 are shown in the figure on the previous page.
Obstructive sleep apnea in acute respiratory failure
Discussion: Provision of very high ambient oxygen fractions
greatly extends the safe duration of apnoea. As oxygen fraction is
increased, increasingly large effects are achieved.
S Pivetti, F Navone, B Tartaglino, R Urbino and V Gai
Medicina d’Urgenza e P.S. Medicina, E.D., Az.Osp. ‘S. Giovanni Battista’ di Torino’, Torino, Italy
Crit Care 1999, 3 (suppl 1):P20
Study objectives: Emergency medicine deals with the diagnosis
and the prevention of potentially life-threatening events, as well
as prevention, diagnosis and treatment of acute illnesses; one of
this event is sleep apnea syndrome (SAS). The relationship
between obstructive sleep apnea (OSA) and acute respiratory
failure (ARF) is not well established.
The aim of the study was to evaluate the prevalence of OSA in
hypercapnic ARF patients and its correlations with the severity
and length of nocturnal arterial oxygen desaturation, diurnal
arterial carbon dioxide (PaCO2) and oxygen (PaO2) tensions, diurnal
oxygen saturation, sudden death and BMI.
Methods: 46 patients with chronic obstructive pulmonary disorder
(COPD) (31 men and 15 women; M=68 years; range 36 to 83) with
hypercapnic ARF underwent a full night of polysomnography.
The polysomnography consisted of continuous polygraphic
recording (by Compumedic Sleep PTYLTD Abbotsford) from
surface leads for electroencephalography, electrooculography,
electromyography and ECG, and from noninvasive sensor for
nasal airflow, tracheal sounds, body position, thoracic and
abdominal respiratory efforts, and oxymyoglobin level. The number and
duration of nocturnal sleep apneas and hypopneas and the
consequential oxygen desaturation were evaluated; sleep apnea was
defined as more than five episodes of apnea or hypopnea per hour
of sleep (apnea/hypopnea index = AHI >5). Furthermore BMI,
basal diurnal PaCO2, PaO2 and arterial oxygen saturation were also
Results: Overnight polysomnography was successfully performed
in 39 of the 46 studied patients; 4 patients were intolerant to the
study and 3 patients were awake all the sleep time. OSA was
found in 13 of the 39 ARF patients (33.3%) and the mean AHI
was 19.3 events per hour. We found statistically significant
correlations between OSA and BMI (P < 0.01; M=38), PaO2 (P < 0.001;
M=65), diurnal oxygen saturation (P < 0.001; M=86) and nocturnal
oxygen desaturation (P < 0.001; M=80).
Conclusion: The overnight polysomnography detects the possible
existence of OSA in hypercapnic ARF. We also found a statistical
significance positive correlation between OSA and hypoxemia.
Polysomnography may be indicated to exclude sleep-induced
desaturation contributing to the actual ARF, but it may also
improve therapeutic and prevention strategy.
Nasal continuous positive airway pressure: do mask pressures reliably reflect intratracheal pressures?
Crit Care 1999, 3 (suppl 1):P21
Introduction: Nasal continuous positive airway pressure (nCPAP)
increases intrathoracic pressure. This way, it may increase
functional residual capacity, improve pulmonary oxygen transfer, and
reduce the need for endotracheal intubation in acute respiratory or
cardiac failure. However, little is known about the loss of
externally applied pressure on its way from mask via pharynx into the
trachea. We studied the correlation between mask and
intratracheal pressures in 8 surgical ICU-patients.
Patients and methods: In 8 postoperative patients after
extubation, pressures were measured in nasal mask and trachea (via a
catheter, o.d. 0.9 mm) during nCPAP treatment with either 5 or
10 mbar positive pressure (high-flow gas source, 65 l/min,
maskpressure adjusted with a PEEP-valve). From the area under the
pressure–time curves, absolute pressures, but also the percentage
of mask pressure transmitted into the trachea were calculated.
Study performed with approval of the committee of medical
ethics and informed consent; mean ± SD; t-test, P < 0.05.
Poster abstracts 11
Conclusion: NCPAP is an effective noninvasive means to increase
airway pressure in postoperative patients after extubation.
However, only with mask pressures of 9–10 mbar, but not with
5 mbar, intratracheal pressures will be maintained reliably and
continuously positive during the whole respiratory cycle.
Effects of mask–ventilator interface elements in a home noninvasive portable ventilator. Study in cold
A Esquinas, G González, M Del Baño, P Jara, M Rodríguez, F García and A Carrillo
Intensive Care Unit, Hospital Morales Meseguer, Murcia. Spain
Crit Care 1999, 3 (suppl 1):P22
Noninvasive mechanical ventilation (NIMV) in hypercapnic
COLD excacerbations with a home portable ventilator with a
single ventilatory tube has some technical considerations.
Objective: We analyze influence of elements used in the
maskventilator interface in hypercapnic COLD with a NMV: To
compare differents 1). Design of filters (A, B, C, D), 2)
Nonrebreathing expiratory valve: a) Swisper and b) Plateau exhalation
valve 3) Rramp inspiratory time: (0.05, 0.1, 0.5 seg) affect a
predetermined level inspiratory positive pressure (IPAP) (15 cmH2O),
2) Hypercapnia (PCO2) control and 3) Subjective responses:
a) Dysnea Brog index (low: 2 to 10 high) and psychological dependence at different stages of therapy (low 2 to high 10).
Subjects: Twelve hypercapnic COLD stable patients.
Material: BiPAP ST-D (Resp, Inc). Facial mask.
Results: See Table.
Conclusion: Subjective (dysnea Brog index), objective respiratory
response (hypercapnia) and level of IPAP pressure applied during
IPAP drops pressure from
base line/type of filter
IPAP: 15 cmH2O
PCO2/pH – type of
Dysnea Borg index/ramp
Dysnea Borg index
NMV were influenced by a specific design of element intercalates
at mask–tube–ventilator line. A specific design of these elements
as we showed with a home portable single tube ventilator could
affect NMV efficacy in hypercapnic COLD exacerbations.
Evaluation by volunteers of respirator characteristics in modes used in non-invasive ventilation
R Rokyta, P Hora, M Nalos, J Ruzicka, M Matejovic, I Novak and V Sramek
ICU, Medical Department I, Charles Uni Hospital Plzen, Alej Svobody 80, CZ-30466 Plzen, Czech Republic
Crit Care 1999, 3 (suppl 1):P23
Introduction: We studied the medical personnel’s power of
distinction between various types of respirators in CPAP and
CPAP+pressure support (PS) modes.
Materials and methods: Five blindfolded volunteers (2 ICU
doctors and 3 nurses) performed random evaluation (5 point scale,
1 = best) of following respirators: Elema Siemens 300 (ES300),
Adult Star 2000 (AS 2000) and Bird 8400 STi. All volunteers were
comfortably seated and instructed to breathe freely with the
Results: Individual scores and mean values ± SD are listed in
Tables 1 and 2.
When CPAP and CPAP+PS were tested together significant
differences were found within the group (P < 0.05). Generally, CPAP
was better tolerated than CPAP+PS. ES 300 and AS 2000 yielded
better results than Bird respirator.
Conclusion: ICU personnel may easily differentiate between
characteristics of ICU respirators. Respirator with best characteristics
may then be used for NIV and possibly also for difficult weaning.
Acknowledgement: Supported by IGA grant No. 3999-3
Noninvasive positive pressure ventilation (NPPV) in critically ill patients: preliminary experience
R Urbino, C Antro, S Pivetti, B Tartaglino, MG Gregoretti, C Bonetto and V Gai
U.O.A Medicina d’Urgenza e P.S. Medicina, Azienda Ospedaliera San Giovanni Battista di Torino, Corso Bramante 88, 10126 Torino, Italy
Crit Care 1999, 3 (suppl 1):P24
Study objective: To validate the efficacy of NPPV in patients with
hypercapnic or hypoxemic acute respiratory failure (ARF)
admitted to a Medical Intensive Care Unit.
Materials and methods: Thirty-two patients (23M, 9F, mean age
66, range 25–91) received NPPV if they met the following criteria:
severe dyspnea at rest, respiratory muscle fatigue, normal
mentation, normal upper airways, stable hemodynamic status and, as for
hypercapnic ARF, pH <7.35, PaCO2 >45 mmHg, respiratory rate
(RR) >25 bpm and, as for hypoxemic ARF, PaO2/FiO2 <200, RR
>30 bpm. Eighteen patients (12M, 6F, mean age 68,4, range
50–91) had hypercapnic ARF due to chronic obstructive lung
disease (COLD); 7 (6M, 1F, mean age 75, range 73–84 ) had
cardiogenic hypercapnic acute pulmonary edema (cAPE); 7 (5M, 2F,
mean age 50, range 25–72) had severe pneumonia (SP), 2 with
hypercanic ARF. End-points were the following: pH >7.35, RR
<24 bpm, VT >7 ml/kg, reduced dyspnea, diminished signs of
muscle fatigue, SpO2 >90%. NPPV was considered successful if
the patient was not intubated and mechanically ventilated. NPPV
was considered unsuccessful if the patient was intubated and
mechanically ventilated, became intolerant of mask or died.
BiPAP Respironics® ventilators (S/T-D 20, S/T-D 30, Vision), were
used to administer NPPV, as pressure support ventilation, by nasal
or facial masks. All patients were given standard medical therapy,
as required by the underlying disease.
Results: NPPV was successful in 14 of 18 COPD patients (77.7%),
in all 7 patients with cAPE (100%) and in 3 of 7 patients with SP
(42.8%). Failure in 4 COLD patients was due to mask intolerance
in three cases and to sudden death in one case. Four patients with
SP (three seriously immunocompromised) died. COLD patients
were ventilated for 3 to 62 h (mean 21.5 h), cAPE patients for 4 to
15 h (mean 7.4 h) and SP patients for 12 to 148 h (mean 59.7 h).
Ventilation was longer in SP patients who obtained a therapeutic
benefit (mean 112 h) than in SP patients who did not (mean 23 h).
Conclusion: With the limits of this observational study, we
conclude that NPPV has been shown to be an effective support
therapy for COLD patients with acute exacerbation and for
hypercapnic severe cAPE patients. The use of NPPV in patients
with SP was less effective and warrants ulterior study to be
validated, according to literature.
Noninvasive mechanical ventilation in asthma crisis: an alternative ventilatory therapy to endotracheal
A Esquinas, D González, A Carrillo, M Del Baño, M Rodríguez, F García and P Jara
Intensive Care Unit, Hospital M Meseguer, Murcia, Spain
Crit Care 1999, 3 (suppl 1):P25
Oxygen therapy by mask venturi (OMV) in asthma crisis (AC)
could not be avoided,, and urgent endotracheal intubation (ETI)
is the lifesave procedure recommended. Sometimes in a selected
population noninvasive ventilation (NMV) may avoid ETI and his
deleterious effects (barotrauma, infections, etc).
Objective: We describe our first experience in treatment of acute
respiratory insufficiency in (AC). Period of study 1995-98.
Setting: Polyvalent ICU.
Method: Inclusion criteria: Borg dysnea score: 5 ; respiratory rate:
>30 rpm, PaO2 <60 mm Hg ( FIO2 0.5%). ETI: apnoea or unstable
breathing pattern, or severe dysnea. Continuous cardiorespiratory
Results: Time of NMV: 5 ± 3 h levels of IPAP: 12 ± 3 EPAP
6 ± 3 cmH2O; Global respiratory rate: 38 ± 10; pH: 7.36 ± 0.02;
pCO2: 45 ± 7 mmHg paO2: 49 ± 26 mmHg. NMV intolerance
(12.5%). Complications: NMV group: skin nose lesion n = 3; ETI
group: neumothorax n = 2.
Poster abstracts 13
Neumothorax n = 2
Conclusion: NMV in asthma crisis refractory to (OMV) is a safe
alternative to ETI, and could be avoided in selected patients
(50%). Borg Dysnea score index and respiratory rate at 3 h: 38 ± 6
to 25 ± 6 rpm in NMV group are the best early clinical predictors.
Noninvasive positive-pressure ventilation in acute respiratory distress syndrome: preliminary results
T Principi, S Pantanetti, P Carletti, E Adrario and P Pelaia
Department of Medical and Surgical Emergency, University of Ancona
Crit Care 1999, 3 (suppl 1):P26
The NIV in acute respiratory failure of a previously healthy lung
is not much widespread but much discussed. We report the first
data about four patients, who have been accepted in our ICU due
to acute respiratory failure post-trauma and treated with
ventilatory support via face mask like NIV. All patients were negative to
pre-existing lung disease and got thoracic trauma with multiple
costal fractures and bony fractures. We used the mechanical
ventilator Adult Star (Infrasonic, Inc., San Diego USA). All the patients
were co-operating and without neurological deficiency. The NIV
has been applied for 2 days and alternated with spontaneous
ventilation through Venturi mask after 24 h.
Results: the analyzed data show an improvement of PaO2 in all
patients, already after the first hours of treatment as well as a
respiratory rate reduction.
Discussion: The NIV has to be considered as a conventional
ventilation’s kind also by acute hypoxemic respiratory failure. The
admission’s criteria of the patients to this kind of ventilation is
however important. In conclusion, we can affirm that the NIV has
an important advantage compared to the conventional ventilation,
that is a shorter stays in the intensive care unit, associated to a
reduction of pneumonia related to endotracheal intubation.
57.6 ± 11.1 126.9 ± 14.4a 121.7 ± 17.9a 121.7 ± 17.9a 125.4 ± 3.9a
125.4 ± 3.9a 130.7 ± 29.9a 116.2 ± 7.2a 114.7 ± 12.3a
19 ± 1.1a 17.7 ± 0.8a,b
ANOVA One Way rep. P < 0.001. Tukey: asignificantly diff. vs. basal; bvs. 1 h.
Noninvasive mechanical ventilation (NIMV) in weaning failure: could be an alternative approach?
A Esquinas, D González, A Carrillo, M Del Baño, M Rodríguez, F García and P Jara
Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain
Crit Care 1999, 3 (suppl 1):P27
Setting: Polyvalent ICU.
A trial with noninvasive ventilation (NIMV) could be a safe
alternative option in some selected unweanneable patient, after a
period of invasive approach of weaning with: 1) Endotracheal tube
(ET) or 2) Traqueostomizated with a ‘T’ oxygen or Pressure
Support Ventilation (PSV) trials.
Subjects: We show a cases series where NIMV have been applied
as an alternative weaning technique in three difference clinical
situations of unweanneability: 1) Post-extubation failure n = 12,
2) Decanulation in traqueostomizated n = 1, and 3) Elective extubation n = 3.
Methods: Inclusion criteria: acute respiratory insufficiency in a
period (0–48 h): respiratory rate >30 rpm, increase accessory
respiratory muscular activity, hypoxemia PaO2 <60 mmHg at mask
venturi (FIO2: 0.5) after a period of ‘T’ piece or PSV and almost
four consecutive weaning failure trials. Excluded: hemodynamic
instability (SAT <90 mmHg), uncooperative patients, and
excessive secretions., IPAP/EPAP cmH O to achieve: >10 ml/Kr and
decrease in dysnea Borg score. Continuous cardiorespiratory
Results: Unweanneable population n = 16. Average age: 61 ± 20,
male n = 12; APACHE II score: 21 ± 3, time of NIMV: 72 ± 12 h.
Postextubation – NMV
Decanulation – NIMV
Extubation – NIMV
n = 12
n = 1
n = 3
n = 16
NIMV was effective in reduce dysnea Borg scores (4 to 2),
gasometric alterations and avoid reintubation 8/12. Causes of
exclusion: secretions 23%, hemodynamic instability 15%. Complications:
skin lesion n = 2, gastric distension n = 1.
Conclusion: 1). A trial with a NMV as a weaning alternative
technique is a safe alternative in selected patients with showed a
persistent weaning failure. 2). Reduction in ICU stay, mortality, with
a great comfort and few complications compare to others method.
Airway pressure release ventilation (APRV) enhances cardiac performance in patients with acute lung injury
(ALI)/adult respiratory distress syndrome (ARDS)
LJ Kaplan, H Bailey and V Formosa**
Medical College of PA-Hahnemann University, Departments of Surgery, *Emergency Medicine, **Pulmonary Medicine 3300 Henry Avenue,
Philadelphia, PA 19129, USA. Tel:(215) 842-7558; Fax; (215) 843-1095; E-mail:
Crit Care 1999, 3 (suppl 1):P28
Purpose: To determine whether APRV can safely enhance
hemodynamics in patients with ALI/ARDS.
Methods: Patients with ALI/ARDS were ventilated in pressure
control (PCV) with both upper and lower inflection points
eliminated from the hysteresis curve; all patients had a pulmonary
artery catheter. Ventilator settings achieved a pCO2 of 35–45 torr
and a pO2 of >60 torr. Patients were then changed to APRV. Data
included: age, diagnosis, ventilator settings, hemodynamic
profiles, ABG, lactate, and medications. Data (means ± SD) were
compared using a Student’s t-test; significance assumed for
P < 0.05.
Results: Mean age was 58 ± 9 years (n = 12) and mean Lung Injury
Score was 7.6 ± 2.1. Temperature (PCV 100.8+1 v APRV 100.6+1F;
P > 0.5) and PaO2/FIO2 (PCV 168 ± 24 v APRV 182 ± 18; P > 0.05)
were similar. Diagnoses were pneumonia (22%), abdominal sepsis
(45%), trauma (33%), bacteremia (18%) and transfusion related
lung injury (1%). Peak airway pressures fell from 38 ± 3 (PCV) to
25 ± 3 cmH O (APRV, P < 0.05); mean pressures fell from 18 ± 3
(PCV) to 12 ± 2 cmH O (APRV; P > 0.05). Paralytic use (PCV 74%
v APRV 4%; P < 0.05) and sedative use significantly declined
(PCV 100% v. APRV 68%, P < 0.05). Pressor use decreased
substantially (PCV 92% v ARPV 45%, P < 0.05). Lactate levels
remained unchanged (PCV 2.2 ± 0.6 v APRV 1.8 ± 0.8 mmol/l;
P > 0.05). Cardiac index rose from 3.2 ± 0.4 (PCV) to
4.6 ± 0.3 l/min/m2 BSA (APRV; P < 0.05) while DO2I increased by
36% (P < 0.05). CVP declined from 18 ± 4 (PCV) to 12 ± 5 cmH O
(APRV; P > 0.05).
Conclusion: APRV may be used safely in patients with ALI/ARDS
and decreases the need for paralysis and sedation compared to
PCV. APRV increases cardiac performance with decreased pressor
use and CVP in patients with ALI/ARDS. Further study of ARPV
is warranted to discover its impact on resource utilization and
Pulmonary function in children who were on long-term mechanical ventilation due to neonatal respiratory
I Vidmar, J Primozic, S Grobovsek Opara and M Grasselli
University Medical Centre, Division for Paediatric Surgery and Intensive Care, Zaloska 7, SI-1525 Ljubljana, Slovenia
Crit Care 1999, 3 (suppl 1):P29
Context: Children with a history of neonatal respiratory disease
that required mechanical ventilation, who develop subsequent
bronchopulmonary dysplasia, often have abnormal pulmonary
function. The extent to which the neonatal respiratory disease
alone is involved is not clear.
Objective: To evaluate the association between neonatal
respiratory disease without bronchopulmonary dysplasia on discharge
and pulmonary function later in childhood.
Design: Case–control study.
Setting: Ambulatory follow-up of former intensive care patients at
a university medical centre.
Poster abstracts 15
Table. Pulmonary function tests: mean ± standard deviation
VC (n = 18) ml
*Significant difference (P < 0.01)
FEV1 (n = 18) ml
DLCO (n = 18) (mmol/min)/kPa
Rt (n = 16) kPa/l/s
TGV (n = 15) ml
Participants: Eighteen children aged 11–15 years with a history of
neonatal respiratory disease were randomly recruited, regardless
of gestational age or cause of disease. Inclusion criteria: mechanical
ventilation for >14 days; high inspired oxygen fraction for >2 days
(FiO2 >0.4). Exclusion criteria: presence of bronchopulmonary
dysplasia or other acute or chronic pulmonary disease at the time of
this investigation. Eighteen controls matched for age, sex and
height were recruited from children of the hospital staff. All were
healthy at birth and had no pulmonary disease at the time of this
investigation. All parents gave informed consent.
Pulmonary function tests: Vital capacity (VC); forced expiratory
volume in the first second (FEV1) with and without challenge by
the bronchoconstrictor methacholine; diffusing capacity (DLCO);
airway resistance (Rt) with and without methacholine challenge;
and thoracic gas volume (TGV).
Main outcome measures: Variables of pulmonary function in the
cases. Differences between the cases and controls were compared
using the paired-sample t-test.
Results: Both FEV1 and Rt differed significantly (P < 0.01)
between children who had had respiratory disease as neonates
(cases) and controls. There were no significant differences in VC,
DLCO and TGV (Table).
Differences in VC and FEV1 between cases and controls after
methacholine challenge were not significant; however, this
analysis is of limited value because only eight or nine matched pairs
underwent these tests.
Conclusion: A mild degree of airway obstruction is apparent in
children 11 to 15 years after neonatal respiratory disease, even in
the absence of bronchopulmonary dysplasia or other pulmonary
Does the size of the ventilator tidal volume affect the incidence of post operative pneumonia?
SK Appavu, TR Haley, A Khorasani and SR Patel
Division of Surgical Critical care, Cook County Hospital and the Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
Crit Care 1999, 3 (suppl 1):P30
After major abdominal or thoracic surgery, the patient may
develop rapid shallow ventilation because of splinting, pain or
heavy sedation. This may lead to the development of post
operative atelectasis and pneumonia. Hence, it seems reasonable to
expect that the administration of large tidal volumes (VT) during
post operative mechanical ventilation will prevent or decrease the
incidence of post operative pulmonary complications including
that of pneumonia. Whether or not this is true is yet to be
determined. Therefore, we performed the following prospective study.
We hypothesized that large VT mechanical ventilation after major
operations resulted in a lower incidence of post operative
Adults admitted to the surgical intensive care unit for post
operative mechanical ventilation after major abdominal or thoracic
surgery were placed on one of two VT regimens: 9 ml/kg (group 1)
or 14 ml/kg up to a maximum of 1000 ml (group 2). Patients who
were not placed on the correct VT regimen and those whose tidal
volumes were changed during the study were excluded. Standard
ICU monitoring was instituted. In addition, ventilator
performance, peak inspiratory pressures, blood gases and daily chest
Xrays were monitored. The incidence of post operative pneumonia
was recorded. Results were analyzed by SPSS statistical software.
Results: Forty-nine patients completed the study, 29 in group 1
and 20 in group 2. Their mean age was 52.7 years. There were 28
males and 21 females. Thirteen of 49 patients (26.5%) developed
post operative pneumonia. A comparison of the two groups is
Females VT (ml) vent (h) Pneumonia
Conclusion: Post operative ventilation with large tidal volumes
does not reduce the incidence of pneumonia.
Bronchoscopy and BAL in mechanically ventilated patients in an ICU at a university teaching hospital
R Strauss, M Sander, A Müller, M Wehler, C Ernst and EG Hahn
Department of Medicine I, University Erlangen–Nuremberg, Krankenhausstr. 12, D-91054 Erlangen/Germany. Tel: 0049-9131-8533885
Fax: 8536909; E-mail:
Crit Care 1999, 3 (suppl 1):P31
Introduction: Bronchoscopy is an important diagnostic and
therapeutic tool in modern intensive care medicine. In ventilated
patients it can lead to hemodynamic instability and can
compromise the gas exchange .
Method: We evaluated in a prospective study from 3/1997 to
9/1998 indications, complications and side effects of bronchoscopy
in a 12 bed medical ICU. The vital signs of the patients were
monitored continuously by ECG, invasive blood pressure and
SaO2 measurement. A BGA was performed 5 min before and
5/30/120 min after the examination.
Results: One hundred and fifty-one bronchoscopies were
performed in 103 patients (63 male, median age 60 years, median
APACHE II-Score 27.5). The indications were bacteriological
examinations in 113/151 (75%), respiratory toilet in 29/151 (19%),
oxygenation problems in 11/151 (7%). Less common indications
were atelectasis, intubation and biopsy. A BAL was performed in
111/151 (74%) cases. The median PaO2/FiO2-ratio (PFR) was 292
mmHg 5 min before bronchoscopy and 254/182/193 mmHg
5/30/120 min afterwards. In the subgroup with BAL the median
PFR was 295 mmHg 5 min before, 5/30/120 min after examination
261/181/194 mmHg. The PFR was in the critical range <80 mmHg
before bronchoscopy in 5/151 (3%) and 5/30/120 min after the
examination in 5/151 (3%), 9/151 (6%) and 7/151 (5%) cases. In
patients with BAL the corresponding figures were 2/111 before
and 3/111, 6/111, 4/111 after bronchoscopy. A decrease of the PFR
between the beginning and 30 min after finishing bronchoscopy
by more than 50 mmHg was observed in 59/151 (39%) cases for all
patients, in 50/111 (45%) for the BAL subgroup. During 5/151
(3%) procedures serious complications were observed. An increase
of the blood pressure (215/120 mmHg max.) after local application
of noradrenalin and a high peak pressure during ventilation (>45
Torr) did not need therapy. A tachyarrhythmia absoluta was
treated by cardioversion. A decrease of systolic arterial blood
pressure (min. 67 mmHg) during sedation, could be stabilised by
volume substitution and dopamine infusion. Bundle-branch block
like ventricular complexes were observed on the ECG monitor in
one case, which were accompanied by a blood pressure decrease.
After an interruption the ECG showed sinus rhythm and the
hemodynamic stabilised again. In a 24 h period after bronchoscopy
the patient died because of an acute myocardial infarction.
Conclusion: Bronchoscopy is a safe procedure in critical ill
mechanically ventilated patients. Even in patients with BAL, in
the most cases only a slight decrease of the PFR could be
observed. The lowest PFRs were observed 30 min after
bronchoscopy, 90 min later the PFR was almost back to the starting
level. Critical PaO2 values were only seen in rare cases.
Complications could be handled in all cases. The death of one patient in a
24 h range after bronchoscopy was probably caused by the
underlying disease and is to be seen only in temporal coincidence.
Clinical presentation and prognostic factors in fat embolism syndrome
GD Puri, VK Arya and P Chari
Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012
Crit Care 1999, 3 (suppl 1):P32
Fat embolism occurs in most of the patients following long bone
fractures but 1–5% of these present clinically as fat embolism
syndrome. The recorded data of 64 patients having uncomplicated
long bone fractures without head and chest injuries admitted to
our ICU with diagnosis of FES over a period of 3 years was
evaluated to determine factors effecting management and prognosis.
Forty-two patients belonged to subacute and 29 to fulminant FES
group depending upon their clinical status at the time of ICU
Majority of FES patient had fracture femur and presented with
respiratory distress as initial symptom. Lung injury score was
1.34 ± 0.64 in subacute and 3.36 ± 0.44 in fulminant group
(P < 0.01). Patients with fulminant FES had more number of
abnormal laboratory parameters. Eighteen patients (43%) in
subacute and all patients in fulminant group required ventilation.
There was significant delay from FES presentation to ICU
admission for subacute FES patients requiring ventilatory support than
the patients improving with conservative therapy alone (P < 0.05).
One patient in subacute (2.3%) and 10 patients in fulminant FES
group (45.5%) died. The compliance of respiratory system (Crs) at
the start of intermittent positive pressure ventilation was
significantly less in fulminant as compared to subacute FES patients
(P < 0.05). Most of the ventilated patients had initial improvement
in Crs with ventilation but only those patients who made
continuous improvement in Crs beyond 48 h of ventilation ultimately
maintained oxygenation and survived in both the groups. We
conclude that early ICU admission and supportive therapy is
important determinant of morbidity in FES. Patients with more number
of abnormal laboratory parameters and those in whom Crs and
oygenation index does not improve even after 48 h of adequate
ventilatory support are unlikely to improve by conventional
ventilatory support alone and need to be shifted to other modalities of
Acute respiratory distress syndrome in a University Hospital ICU in Japan
High-frequency oscillatory ventilation (HFOV) in bronchiolitis patients
H Yukioka and K Nakatani*
Division of Critical Care Medicine and *Department of Anesthesiology and Intensive Care Medicine, Osaka City University Medical School, 1-5-7
Asahi-machi, Abeno-ku, Osaka 545-8586, Japan
Crit Care 1999, 3 (suppl 1):P33
Objective: To determine prognostic factors for and the outcome of
acute respiratory distress syndrome (ARDS) in our ICU.
Method: The American–European consensus conference
definition  was used for ARDS diagnosis. Thirty-three (2.1%) of 1588
patients admitted to the ICU met the criteria for ARDS.
Mechanical ventilation with PEEP was performed for all patients with
ARDS. Steroid pulse therapy (60%), nitric oxide inhalation (21%),
surfactant replacement (9%), and neutrophil elastase inhibitor
administration (24%) were also used. For determination of
prognostic factors of ARDS, mean pulmonary arterial pressure (mPAP),
pulmonary vascular resistance (PVR), and multiple organ
dysfunction score (MODS)  excluding the Glasgow Coma Score were
measured and compared with outcome.
Results: There were 22 men and 11 women aged 61 ± 12 years.
The mortality rate of ARDS was 73%. Sepsis was the main cause
of ARDS accounting for 73% of cases. All ARDS patients with
septic shock (n = 9) and with sterile shock  (n = 4) died. The
patients with shock had higher MODS compared to those without
shock with mortality rate 55%. There were no significant
differences in mPAP and PVR between survivor and nonsurvivors.
ARDS patients who had high MODS, especially those with low
PaO2/FIO2 and high pressure-adjusted heart rate, 5 days after the
onset of ARDS had a poor prognosis.
Conclusion: Shock and MODS, but not pulmonary hypertension,
are important as prognostic factors for ARDS.
ELIM Duval*, AJ van Vught*, PLJM Leroy*† and RJBJ Gemke*
*Ped. Int. Care Unit, Wilhelmina Kinderziekenhuis,PO Box 18009, 3501 CA Utrecht, The Netherlands and †Department of Pediatrics, University
Hospital Ghent, Belgium
Crit Care 1999, 3 (suppl 1):P34
Respiratory syncytial virus (RSV) is nowadays the leading cause of
bronchiolitis and viral pneumonia in children. Although the course
is often benign, some children need prolonged hospitalisation and
mechanical ventilation or even ECMO if conventional mechanical
ventilation (CMV) fails.
HFOV is currently considered to be contraindicated in obstructive
airway disease with prolonged time constants due to the risk of
dynamic airtrapping. This could give rise to circulatory and
ventilatory compromise and barotrauma. Nevertheless, bronchiolitis
patients are sometimes put on HFOV after deterioration on CMV.
We report 9 patients with RSV bronchiolitis and pulmonary
overdistention (small airway disease) successfully treated with
HFOV after deterioration on CMV. Although marked
hyperinflation was present in all our patients prior to transition, no airleaks
developed during HFOV. In one patient the oxygenation index
(OI) increased after start of HFOV. Nitric oxide was added and
oxygenation improved immediately. All patients survived without
residual lung disease.
In distinct to current opinion, we showed that small airway disease
can safely and successfully be managed with HFOV. Ventilatory
strategy should be directed to open up the small airways and keep
them open with sufficiently high mean airway pressures (‘the
open airway strategy’ similar to the ‘open lung strategy’ in diffuse
alveolar disease). Permissive hypercapnia may be used to reduce
pressure swings as much as possible, leading to less shear stress on
lung tissue, without influencing airway recruitment. Further
dynamic airtrapping can be prevented with the use of longer
expiratory than inspiratory times and with prevention of spontaneous
breathing. An increasing OI at 48 h may be an indicator of failure
of HFOV and alternative treatments should be considered. NO
might be such an option to avoid ECMO.
The importance of prone position ventilation in ARDS for the improvement of oxygenation index
J-C Lewejohann, H-J Düpree, J Gleiß, S Lewejohann, E Muhl and H-P Bruch
Med. Univ. of Luebeck, Dept. of Surgery, Ratzeburger Allee 160, 23538 Luebeck, Germany. E-mail:
Crit Care 1999, 3 (suppl 1):P35
Introduction: In acute respiratory distress syndrome (ARDS)
change from supine (SP) to prone position can improve gas
exchange by recruiting alveoli situated in dorsal dependent
regions and by alteration of ventilation/perfusion ratio. The aim of
this study was to investigate the effect of prone position (PP) after
application of high fractional inspired oxygen (hFiO2), inverse
ratio ventilation (IRV), positive end exspiratory pressure (PEEP)
as well as kinetic therapy (KT) and hemofiltration (HF) did not
lead to a breakthrough in treatment of severe ARDS.
Methods: We studied 22 consecutive patients with severe ARDS
(mean age 64 ± 11.16 [SE] years) in a clinical follow-up design. All
patients received hFiO2, IRV and PEEP before starting prone
position, while 15 obtained HF (Prisma®, Hospal) and 3 KT
(Rotorest®). Prone position was commenced 82 h median time
(range 6 to 417 h) after onset of severe ARDS at a mean PaO2/FiO2
ratio of 98.02 ± 6.11 (SEM) mmHg. We compared individual
oxygenation index (PaO2/FiO2) before and after start of prone
position with linear regression analysis (Excel® regression-procedure;
Results: In the stage of supine position neither treatment with
hFiO2, IRV, PEEP nor HF and KT led to an improvement of
oxygenation index. After starting prone position ventilation 20 of 22
patients showed a significant increase of the oxygenation index
(responder: Y[SP] = [–46.11 ± 3.41] × X + [194.03 ± 3.78];
Y[PP] = [25.00 ± 3.05] × X + [170.36 ± 2.68]; [mean ± SEM]; P < 0.05),
while 2 patients showed no improvement of oxygenation index
(slope of regression SP/PP: 42.96/–22.70 and –11.63/–19.33). Renal
failure of these two non-responders was not treated by HF.
Improvement of oxygenation index was independent of duration
in supine before the begin prone position (range 6 to 417 h). In
one patient PP was started actually after 417 h of treatment at our
Intensive Care Unit.
Conclusion: Starting prone position seems to mark a U-turn for
oxygenation for the majority of patients with severe ARDS, while
application of high fractional inspired oxygen, inverse ratio
ventilation, positive end exspiratory pressure as well as kinetic therapy
and hemofiltration do not necessarily improve oxygenation. The
timing of this non invasive technique primarily depends on the
decision to turn the patient from supine to prone. We recommend
prone position in ARDS as soon as possible to reduce lung injury
and complications resulting of mechanical ventilation.
The effect of the pulmonary time constant on the cough peak flow rate at two different inflation pressures: a
bench test model
JS Wills and RP Mahajan
University Department of Anaesthesia and Intensive Care, Queen’s Medical Centre, Nottingham NG7 2UH, UK
Crit Care 1999, 3 (suppl 1):P36
Supramaximal flow is characteristic of the cough manoeuvre and is
thought to be the result of dynamic compression of collapsible
airways. We investigated the effect of changing the pulmonary
time constant on the peak flow rate produced by an in vitro cough
manoeuvre. We used a prototype artificial cough generator and a
simplified lung-airway model. The model consisted of a compliant
bag with a resistor (internal diameter 3 mm to 7 mm) that emptied
through a collapsible tube. The resulting range of emptying time
constants (420 to 2800 ms) included those found in vivo (500 to
2000 ms). The lung-airway model was inflated to one of two
pressures (31 cmH O or 55 cmH2O) and then compressed within a
glass container to a pressure of 45 cmH2O. A
mechanically-operated glottis opened rapidly and the resultant flow was measured
by a pneumotachograph. The cough peak flow rate (CPFR) was
Time constant (ms) 420
recorded for 20 cough manoeuvres for each configuration and the
values of the mean and standard deviation are shown in the Table.
The results from this bench-test model suggest that the
pulmonary time constant has a profound effect on the magnitude of
the cough peak flow rate.
Computer simulation: a guideline in ventilator setting in severe lung disease
L Uttman, S Sigurdsson and B Jonson
Departments of Clinical Physiology and Anaesthesiology, University Hospital, Lund, Sweden
Crit Care 1999, 3 (suppl 1):P37
Mechanics and gas exchange can in be studied with a
computercontrolled ventilator. The physiological profile obtained describes
the Pel/V diagram, inspiratory and expiratory resistance versus
volume and the expired volume of CO2 versus tidal volume. When
setting PEEP, frequency, I:E ratio, and minute ventilation or
inspiratory pressure the physician needs to assimilate the information of
the physiological profile and all clinical information to assure an
adequate gas exchange at a non-traumatic ventilation. In
ALI/ARDS harm can be caused both by ventilation at too low lung
volumes and by ventilation at high volumes. In COPD the task is
to ventilate at the lowest possible volume and airway pressure.
The complexity of the physiology and ventilator settings makes it
impossible to figure out what is the ideal pattern of ventilation in
order to reach the immediate therapeutic goals defined by the
physician. However, on the basis of an adequate mathematical
physiological profile, a computer can by simulation prognosticate
what would be the consequences of alternative modes of
ventilation. Through repeated simulations the physician can search a
mode of ventilation that leads to his goals.
Computer simulation can be used to: a) increase the
understanding of various patterns of ventilation in disease. b) predict the
consequences of alternative settings in a particular patient.
In left diagram the total pressure in the ventilator (Pvent), the
tracheal pressure (Ptr) and the alveolar, i.e. the elastic pressure, Pel,
Poster abstracts 19
Current ventilator setting
Alternative ventilator setting
is shown for a patient with critical obstructive lung disease. Under
current setting (volume control 10 l/min, Ti = 25%, Tpause = 10%,
RR = 16, PEEP = 4 cmH2O) the PaCO2 of 9.2 kPa was deemed
acceptable. The pressures were, however, very high. By repeated
simulations it was possible to identify a setting which dramatically
would reduce the pressures without changing PaCO2.
Clinical evaluation of a new closed loop ventilation mode: adaptive supportive ventilation (ASV)
RS Campbell, RP Sinamban, JA Johannigman, FA Luchette, SB Frame, KDavis Jr and RD Branson
University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA
Crit Care 1999, 3 (suppl 1):P38
Introduction: ASV (Galileo, Hamilton Medical, Inc.) is a mode of
mechanical ventilation (MV) with a closed loop algorithm to
determine and adjust ventilator settings. ASV may adjust
mandatory breath rate, I:E ratio, and inspiratory pressure of mandatory
breaths. Target minute ventilation (VE) is determined by ideal
body weight (IBW) and clinician selected Percent Vent (% Min
Vol). Galileo assesses the pt by measuring dynamic compliance
and expiratory time constant. With IBW and %Min Vol settings,
optimal settings for rate, Ti, VT, and VE are determined. We
compared MV with ASV to MV with physician determined vent
settings during the initiation of MV.
Methods: Ninteen post-operative pts requiring MV were studied.
Vent settings by physician were noted and each pt was placed on
those settings or ASV randomly. IBW was determined from
standardized tables and %MinVol was set to 100%. PEEP and FiO2
were determined by staff and held constant. ABG’s and
cardiopulmonary variables (f, VT, VE, Ti, PIP, Paw, HR, MAP, and VCO2)
were measured and recorded after 30 min on each mode. Data
were compared using student’s t-test.
Results: 19 pts (14 male) were studied. Initial ‘test breaths’ during
ASV were well tolerated. Mean IBW was 88.8 Kg. Mean age was
54.3 years. Table 1 reveals set and measured ventilator parameters
for both study periods. PIP and VT were lower during ASV.
Respiratory rate was higher during ASV. VE, TI, and Paw were unchanged
between study periods. Mean values for PEEP and FiO2 were 7.3
and 0.48, respectively. Table 2 reveals ABG measurements, CO2
production, and VD/VT ratio. There were no clinically relevant
differences in ABG’s or VCO2 between study periods. VD/VT was
lower during ASV. No pt suffered any adverse events from
derangements in ventilation or acid-base balance. One pt with
ARDS receiving 17 cmH O PEEP was hypoxemic during ASV
(PaO2 57.2). Table 3 reveals heart rate and mean arterial pressure
during each study period. There were no clinical changes to any
measured vital sign between the two study periods.
Discussion/conclusion: Upon initiation of mechanical ventilation,
the precise VE requirement of the pt may not be known.
cians use rough estimates and clinical experience to determine VE,
respiratory rate, VT, and Ti. Determination of vent settings made
by the machine have been suggested (Intern Care Med 1996,
22:199). Our results suggest that ASV as startup mode of
ventilation is acceptable and comparable to physician determined
ventilator settings. Gas exchange during ASV is equivalent to physician
determined ventilation. VT during ASV is more consistent with
‘lung protective’ strategy (7.8 ml/kg) than was conventional VT
(9.7 ml/kg). Mechanical ventilation with ASV is more efficient as
evidenced by lower VD/VT and may be safer as a result of lower VT
Poster abstracts 111
catecholamines used were recorded. Blood samples were
centrifugated and sera stored at –20°C. Levels of protein S100 were
measured using a commercial immunoluminometric assay (Sangtec
100®, Byk Sangtec Diagnostica, Dietzenbach, Germany) according
to the guidelines of the manufacturer. Reference level was
<0.3 mg/l. Cerebral recovery was evaluated by the five-point
cerebral performance category (CPC) on ICU demisson .
Results: Mean age was 66 yrs, median 67, range 35–78 years, 9/17
(65%) were male. 14/17 (82%) survived and were evaluated by the
CPC. 5/13 (38%) met Category 1 criteria (conscious and
alert/normal function), 2 met CPC 2 (conscious and alert/moderate
disability, 2 met CPC 3 (conscious with severe disability), 4 met
CPC 4 (comatose), 1 met CPC 5 (brain death). In 16/17 patients
an elevated S100 was measured with a mean value of 5.13 mg/l,
range 0.5–15.4, median 3.8 mg/l, with a maximum 1 h after CPR in
13/16 patients. In all patients of category 1 normal or slightly
elevated levels (0.1–0.7 mg/l) were found, returning to normal within
a few hours. In category C the highest S100 values (8.8/12.1 mg/l)
of surviving patients were found, in contrast to category D with
moderate elevated levels (1.7–5.4 mg/l). Patients who died had
S100 values of 4.7–15.4 mg/l. No correlation was seen between pH,
base excess, serum lactate on admission, catecholamine dosis
needed during CPR and neurological outcome.
Conclusion: S100 seems to be a sensitive marker of cerebral injury
due to diffuse hypoxia after CPR. Normal S100 values excluded
severe cerebral damage. Normal or slightly elevated levels of S100
(£0.7 mg/l) are correlated with good neurological outcome, but high
S100 values do not necessarily predict an unfavourable prognosis.
S Leonard, ADJ Watts, K Parmar*, J Wendon† and B Hunt*
Dept. of Anaesthesia and †Liver Failure Unit King’s College Hospital and *Dept. of Haematology, St Thomas Hospital, London, UK
Crit Care 1999, 3 (suppl 1):P223
Introduction: Encephalopathy and irreversible cerebral injury may
occur in ALF. S100 is a CNS-specific protein that is a marker of
cerebral injury [1,2]. We investigated S100 protein in patients with
ALF who underwent OLT.
Methods: After IRB approval blood samples were taken in 10
patients age 20–51 years with ALF. Blood was taken before OLT
(A), during the anhepatic phase (B), 30 min after reperfusion (C),
and on days 1 (D) and 4 (E) post-OLT. The blood was centrifuged
and serum stored at –70°C. S100 was analysed using an
Results: Serum S100 (X ± SEM) was elevated prior to OLT
(normal <0.12 mg/l). By day 4 post-OLT S100 had fallen in all
patients except one. This patient subsequently died.
Conclusion: Serum S100 is elevated in ALF and encephalopathy.
We observed a rise in S100 during OLT in these patients. The role
of S100 as a marker of neuronal injury in ALF and OLT warrants
P224 S100: a potential marker of cerebral trauma
M Simenacz and M Vucevic
Academic Unit of Anaesthesia, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK
Crit Care 1999, 3 (suppl 1):P224
Introduction: Head injuries are associated with a high level of
morbidity and mortality. The aim of this study was to examine if
S100, a calcium binding protein localised in astroglial cells of the
central nervous system, can be used as a marker of head injury and
to predict survival outcomes from severe head injury.
Methods: After informed consent and local ethics approval, 12
severe head injured patients (GCS £8) were included. All patients
were treated according to standardised head injury protocols.
Serial serum samples were taken over a period of 48 h together
with various other physiologic measurements. Plasma
concentrations of S100 were analysed using a radioimmunometric assay —
Results: The mean S100 in patients who survived was 1.1 mg/l and
in those who died 0.79 mg/l. Six of the 12 patients in the study
Serum S100 (mg/l) after severe head injury
Time after admission (h)
Conclusion: Plasma S100 concentrations increase in severe head
injuries. The reference value is less than 0.2 mg/l and this was
exceeded in both patients who survived and those who died.
Serum S100 levels could not be correlated with mortality.
M Pugh, K Bresland and M Vucevic
Academic Unit of Anaesthesia, Leeds General Infirmary, Leeds, LS1 3EX, UK
Crit Care 1999, 3 (suppl 1):P225
Aims of study: A retrospective review of the treatment and
outcome of neurosurgical patients admitted to the ICU in the
years 1990 and 1996 to assess the effect of the introduction of the
routine use of percutaneous tracheostomy and vasoconstrictor
Results: See Table.
Discussion: The use of tracheostomies and vasoconstrictors has
increased during this period of study. Tracheostomy has no effect
on mortality whereas vasoconstrictor usage appears to result in an
increase in mortality.
Total patients admitted
Mean age (years)
Tracheostomies performed (%)
Days until tracheostomy
Use of vasoconstriction (%)
Logistic regression on mortality (odds ratio):
Exp (B) = 0.76
Exp (B) = 5.46
95% CI (0.40–1.46)
95% CI (2.87–10.41)
L Bargues, JP Ducourau, P Morizet, G Boussignac and JM Saïssy
Service Anesthésie-Réanimation, HIA BEGIN, Saint Mandé, France
Crit Care 1999, 3 (suppl 1):P226
Introduction: During experimental cardiac arrrest, precordial
compression associated to the unique use for ventilation of constant
flow insufflation of air at the distal end of a modified endotracheal
tube provided the same ventilatory results but better
hemodynamic effects than manual ventilation . Because of these results
and the simplicity of the technique, a study concerning humans
beings and using oxygen during cardiopulmonary resuscitation
(CPR) has been realized.
Methods: After ethic committee approval, adult out-of-hospital
cardiac arrests (shocked arrests excluded) were randomized in two
groups: control group (C) treated by conventional CPR with active
compression-decompression (ACD) and manual ventilation after
intubation, Constant Flow Insufflation group (CFI-CPR) treated
with ACD and flow rate of 15 l/min through small capillaries of
Boussignac tube (Vygon, Ecouen, France). CPR continued for 30
min at the most. As soon as spontaneous circulation returned
(SCR), arterial gazometry was made and all patients were
mechanically ventilated. Statistical analysis was performed by c2 and
Mann-Whitney tests. A P < 0.05 was considered statistically
significant. Results were expressed as mean ± SD.
Results: Thirty patients were included in C group, 34 in CFI-CPR
group. There were no differences in mean age (65 ± 3 vs 62 ± 3
years) or delayed CPR activation (6 ± 2 vs 7 ± 3 min). SCR was
observed in 8 patients of C group after 13 ± 6 min and in 6 patients
of CFI-CPR group after 14 ± 6 min (NS). The results of arterial
gazometries for both group are shown in the Table.
Poster abstracts 113
CFI-CPR 6.86 ± 0.08 103 ± 18
237 ± 80 18.2 ± 2.4 95 ± 3
14.2 ± 1.5 92 ± 3
Arterial gazometry, no statistically differences
Conclusion: Comparable values of arterial gazometry were
observed after CFI-CPR or standard CPR. This easier technique
is as efficient as manual ventilation in terms of oxygenation during
the early phase of cardiac arrest. Further studies are required to
determine if CFI-CPR improve prognosis.
P227 Airway management during cardiopulmonary resuscitation (CPR) by training nurses
V Dörges, H Ocker, C Sauer and P Schmucker
Department of Anaesthesiology, University Hospital of Lübeck, Ratzeburger Allee 160, D-23562 Lübeck, Germany. Tel: +49 451/500-4057;
Fax: +49 4509/71068; E-mail:
Crit Care 1999, 3 (suppl 1):P227
A experimental model of a patient was designed to grade the
success of ventilation using the Guedel airway/face mask
(GA/FM), Laryngeal mask (LM) or Combitube (CT) in CPR. It
consisted of a manikin head, training lung (Dräger®: compliance
50 ml/cmH2O, resistance 16 cmH2O/l/sec), lower esophagial
sphincter pressure (LESP) 7 cmH O and a simulated stomach .
Sixteen training nurses were shown the correct use of each device.
The volunteers than used each device for a 2-min ventilation. For
a successful ventilation a tidal lung volume of >200 mls had to be
achieved within 180 s. Peak pressures in the esophagus, lung and
gastric 2-min volumes were recorded. Each volunteer was graded
from 1 (excellent) to 4 (bad), on the success of airway insertion,
quality of the seal and visible adequacy of ventilation. The
volunteers could deliver an adequate tidal lung volume with the
GA/FM in 7–102 s (median: 24 s); LM in 18–92 s (median: 37 s),
and 46–180 s (median: 74 s) with the CT. In the GA/FM group
there were three failures, and two in the CT group. Analysis of the
success of airway insertion, sealing and adequacy of ventilation
shows a significant advantage with the LM or CT (P < 0.0001)
against the GA/FM. There was no difference between the LM
and CT. The 2-min lung volume delivered with the GA/FM ranged
from 4.2–13.4 l (mean: 8.0 l), with peak LESP of 9–27 cmH2O
(mean: 16.4 cmH2O) causing a gastric inflation of 2.5–13.6 l (mean:
6.6 l). The 2-min lung volume with the LM was 11.7–44.1 l (mean:
25 l), peak LESP of 0–22 cmH O (mean: 7.9 cmH2O) and gastric
inflation of 0–6.2 l (mean: 1.4 l). For the CT the 2-minute lung
volume ranged from 12.3–41.5 l (mean: 27 l), peak LESP of 0 and
without gastric inflation. Our results show the significant risk of
gastric distension when using the GA/FM. Adequate lung
ventilation of >5 l/min delivered with the GA/FM could be achieved only
by 4 volunteers. The LM might provide the best alternative for
airway management during CPR by nursing staff with a 100%
success rate on adequacy of ventilation. A training program on the
LM might further reduce the risk of gastric inflation.
P228 Does emergency transportation induce a stress-response in probationers
V Doerges, S Dix, H Ocker, A Kühl and P Schmucker Department of Anaesthesiology, University Hospital of Lübeck, Ratzeburger Allee 160, D-23562 Lübeck, Germany
Crit Care 1999, 3 (suppl 1):P228
Introduction: Common opinion is that emergency transportation is
a stressful event for patients. The question is if simulated
emergency transportation might be a useful model to measure the
levels of stress-responsive with a high ecological validity.
Methods: After approval by the local ethical committee 32 male
probationers (age 18–40) were randomized into two groups
(‘strain’, ‘control’). The following values were taken:
plasma-hormones (epinephrine E, norepinephrine NE, cortisol C) and
CVSvalues (BP, MAP, HR). The ‘strain’-group was carried downstairs
from a third floor flat and taken into an ambulance for an
emergency transport. Blood samples were taken in the flat after
informing the probationer (A), at the ground-floor (B) and at the end of a
15 min emergency transportation under defined conditions (C).
The CVS-values were recorded continuously . The
‘control’group had to sit on a chair for 5 min and afterwards to lay on a
stretcher for 15 min. The blood samples were done at equivalent
times. The results were evaluated by a two-factor variance
analysis with repetition of the values for the factor measuring time.
Results: Our study shows that a simulated emergency
transportation induces stress. Differences in stress-responses depending on
the period of the simulated emergency transport were found. The
increase of E, NE, C and HR during the transport of the
probationer down the stairs was significant (P < 0.001); no significant
alterations could be shown in the ‘control’ group. The emergency
transport in the ambulance appears to be clearly less of a strain to
the patient. This was shown by a significant decrease of HR, E
and NE levels (P < 0.001) compared to the downstairs part.
Conclusion: More attention should be focused on the period of
emergency transport from on-scene to the ambulance to influence
positively the most stressing event. Further studies concerning
sedation before transportation appear to be necessary.
P229 Road traffic accident related morbidity and mortality as seen in an emergency department
E Pikoulis, F Karlis*, C Theos†, P Koulouvaris, A Geranios*, S Kiose‡, A Tsamatropoulos† and S Mantonakis
Second Department of Surgery, *Department of Intensive Care, †First Orthopedic Department, ASCLEPEION Voulas, Vasileos Pavlou 1,
16673,Voula, Athens, Greece. ‡Department of Hygiene and Epidemiology, University of Athens Medical School, Greece
Crit Care 1999, 3 (suppl 1):P229
Introduction: Trauma remains the leading cause of death in the
first four decades of life. Trauma-related costs is accounted for by
accident injuries and the resultant disabilities, lost wages, medical
expenses, insurance administration costs and most importantly
loss of life become a great national issue in Greece. The purpose
of this study is to report in epidemiological manner certain official
information regarding prenosocomial events of all traffic accidents
in the Southern area of Athens (1 000 000 inhabitants) within a
year. The records were a co-operative and cross-matched result
from the following services involved : The Department of Surgery
and Intensive Care, ‘ASCLEPEION’ Hospital of Voulas, Athens
and Department of Hygiene and Epidemiology, Athens
University Medical School.
Patients and methods: From January 1997 to January 1998, 3211
trauma victims were to 1300 traffic accidents. 2173/3211 (67.7%)
were males and 1038/3211 (32.3%) females. The mean age of
victims was 39 years (range 14–90 years). In more than 70% of the
cases the cause of accident was reported as being ‘human error’
regarding the driver of vehicle.
Results: The two most common incidents of the casualties were
collision and deviation. 57/3211 (1.8%) victims died either
immediately or during transportation to our hospital. From the victims
43 (75.44%) were males and 14 (24.56%) females. The mean age
of victims was 54 years (range 12–82 years). The most frequent
fatal accident time were the hours between 14:00–24:00 (28
victims = 49.12%). April and July were the most fatal months (8
victims each = 14%).The primary use of Abbreviated Injury
Scoring system (A.I.S.) on those who reached the Hospital alive
classified 518 cases (16.13%) as having mild injuries and 2693
cases (83.87%) as having medium and/or severe injuries.
Morbidity and mortality among the population of Greece were
33238 and 2139 respectively within the above period.
Conclusion: Nevertheless newspapers, radio and TV pay more
attention to the narcotic and other causes victims than that of the
car accidents which is the main reason of deaths among the young.
We can conclude that the suitable prehospitalized care of the
injured victims and the rapid assessment and resuscitation at the
Trauma Centers are the cornerstones of the current treatment and
improve the outcome of the injured significantly.
P230 Sports activity after severe polytrauma: results of a prospective study
RJ Stiletto, P Nowacki* and M Baacke
Department of Trauma Surgery/ICU, Philipps-University Marburg, Badinger Str. 35033 Marburg/Lahn, Germany,
*Department of Sports Medicine, Justus Liebig University Gießen, Germany
Crit Care 1999, 3 (suppl 1):P230
Background: There is only a small body of literature dealing with
the problem of sports activity after survived severe polytrauma.
Having in mind that most of these patients are in the age group
between 18 to 40 years, sports activity after survived polytrauma is
a decisive factor of their quality of life.
Materials and method: In a prospective trial we evaluated the
sports activity and sports performance of a group of 50 polytrauma
patients (ISS >15) after a minimum time of 6 months following
their discharge from hospital. The characteristics of the group
were as follows (mean values): age 28.5 years, follow-up time 18
months, sex: male 40, female 10 patients. The ISS was 50. Cause
of injury was in 96% a MVA, in 4% a fall from great height. The
APACHE II on the first day was 17. The patients’ time on
respirator was 7 days. The stay on ICU was 11, and the stay in hospital 26
days. The sports activity and performance were evaluated
according to a standardized score in all patients who practiced sports
before the trauma. In addition, a performance test with
spiroergometry and serum lactate samples could be performed in seven
Results: During the 6 months after discharge from hospital four
patients died. The sports status of these patients could not be
evaluated. Forty-six patients (92%) were available for further
evaluation. The pre- and post-traumatic status of their sports is listed
in Table 1. Sports performance and participation levels in
differ10 = 21.7%
21 = 45.6%
36 = 78.2%
25 = 54.34%
ence activities were evaluated in the 36 patients who practised
sport before the trauma. The results are listed in Table 2.
Conclusion: According to our results a decrease in activity and
performance levels is obvious in the post trauma patient group. More
than 70% of the patients practising sports before the trauma had to
reduce their activity level. 23.86% had to quit their former
activities. However, more than 50% of the patients were able to practice
sports after their trauma.
1 = 2.1%
Poster abstracts 115
P231 Discomfort, awareness and recall of patients in the intensive care: still a problem?
ICU, King Hussein Medical Centre, PO Box 1115, Amman 11821, Jordan
Crit Care 1999, 3 (suppl 1):P231
Introduction: During surgery, anaesthetists take extra care to
prevent awareness of any patient who is having any kind of
operation done, mainly under general anaesthesia either by using
inhalational or intravenous medications, but patients in the ICU,
mainly those on ventilatory support, with intubation and sedation,
pass through a lot of psychological stress and frustration, which
most of the times is not documented in the genera intensive care,
and has never been done in our unit.
Aim of this study: In this study at our general ICU, we tried to
have a proper assessment of this problem in order to avoid it in the
future, and to get a proper consensus regarding its existence and
Methods: Seventy patients between the ages 20–60 years, were
interviewed 1 day after discharge from the ICU, about their
memory of events during their stay. Patients with head injury,
CNS infection or those who were disoriented at the time of
interview were excluded from the study. The remaining 55 patients
were oriented to place and time.
Intravenous opiates (morphine, pethidine) were used for analgesia
as required, while sedation was achieved using midazolam and
morphine infusions in appropriate doses as decided by the
attending doctors and nurses.
Questions asked were generally about patients’ memory of events
and about their distressing experiences regarding pain, anxiety,
dreams, fear, noises, causes of discomfort and others which will be
displayed in the results section.
The same questions were repeated 5 days later.
Results: The sample of patients were representative of our regular
ICU admissions in their age group, APACHE II score and
duration of stay.
The most distressing and commonest experiences recalled were:
anxiety (68%), discomfort from endo-tube (60%), fear (54%), pain
(52%), discomfort from N/G tube (48%), difficulty in
communicating (33%), dreams and hallucinations (31%), discomfort from
physiotherapy (24%), noise (15%), insomnia (13%), thirst (10%),
some of these like anxiety, fear, dreams, hallucinations and
insomnia had continued since discharge in 6% of patients. None of the
studied experiences correlated with age, sex, or with the
APACHE II score. On interviewing the patients 5 days later, there
were no significant changes in their responses.
Conclusion: Our sedation and analgesia in the ICU is not enough
to prevent unpleasant experiences, mainly those related to patient
More work is still needed, i.e. using sedation scores to improve
our sedation and analgesia in the ICU.
P232 Sedation of patients in intensive care units by midazolam (MDZ): clinical and biological evaluation
D Chatellier, C Poisson, L Tronchon, D Thévenin, H Robert, P Odou, C Barthélémy and M Luyckx
Réanimation Médicale Polyvalente Centre Hospitalier du Docteur Schaffner 99, route de la Bassée 62307 Lens, France
Crit Care 1999, 3 (suppl 1):P232
Aim: To assess if the clinical scoring of sedation (Ramsay scale),
the administered dose of MDZ, the serum levels of MDZ from
the beginning to the end of sedation are related to clinical
parameters (body area), biological data (creatinine clearance, liver
enzymes, protidemia), and pharmacokinetic parameters
(elimination half-life T1/2).
Patients and methods: The study was conducted with 31 patients
(70 ± 10 year-old ; IGS II = 41 ± 14). The objective was to reach a
score of sedation of 2 up to 4. Sedation of patients was initiated
with an intravenous bolus of MDZ (B = 0.1 mg/kg) and maintained
with MDZ at the rate (H1 = 0.08 mg/kg/h). If needed, the dose of
MDZ was gradually increased: H = 1/2B + 1,5H ; H = 1/2B + 2H1
2 1 3
(if H3 was insufficient, sufentanil was added (0.17 mg/kg/h and
0.34 mg/kg/h)). Waking up of patients was monitored by the
beginning of respiratory weaning. Liver enzymes, protidemia and
creatinine clearance are evaluated every day and 24 h after the end of
sedation.The serum levels of MDZ and its metabolites were
measured by HPLC and RRA every 8 h during the first day; then
every 24 h, before and after each change of posology and finally
every 4 h after the end of sedation for 24 h. The correlations
between the different parameters monitored were evaluated by a
Results: No correlation between time to awakening (22 ± 21h) and
duration of sedation (96 ± 57 h) or clinical parameters or biological
data was observed. In a similar way, score of sedation, posology
and serum levels of MDZ were not correlated. The
pharmacokinetic parameters of MDZ were : T1/2 = 11.77 ± 4.8 h, clearance =
8.6 ± 4 l/h, Vd = 149 ± 98 l, concentration at steady state =
1008.7 ± 395 ng/ml. The unique parameter modulating the time to
awakening was T1/2 of benzodiazepinique total activity (T1/2 =
12 ± 4.96 h) with 7 patients.
total activity (h)
P233 Cardiovascular effects of dexmedotomidine for ITU sedation: UK results of a multi-centre study (St George’s,
University College, St Thomas’s and Bristol Royal Infirmary Hospitals)
CJ Bradshaw, RM Venn, R Spencer, D Brealey, E Caudwell, M Singer, D Treacher, SM Willatts and RM Grounds
St George’s Hospital, Blackshaw Road, London, SW17 0QT, UK
Crit Care 1999, 3 (suppl 1):P233
Introduction: A multi-centre study examining the safety and efficacy
of the novel sedative agent dexmedetomidine, a highly selective
alpha-2 agonist, possessing analgesic and sympatholytic properties.
Methods: One-hundred and nineteen post-operative patients who
required sedation and ventilation for at least 6 h on the ITU were
enrolled. Ninety-eight completed the randomised,
placebocontrolled, double-blind study (81 cardiac and 17 general surgical)
in four centres in the UK, but all patient data was used in the
safety analysis. Within 1 h of return from theatre, the study drug
was started with a loading dose of 1 mg/kg for 10 min, followed by a
maintenance infusion of 0.2–0.7 mg/kg/h to maintain a Ramsay
sedation score of ³3 and was continued for 6 h after extubation
(maximum duration 24 h). Rescue sedation and analgesia was
provided with midazolam and morphine respectively. Heart rate,
systolic, diastolic pressures and central venous pressures were
recorded at 10 min intervals for the first 30 min and then hourly.
Results: Patient demographics were comparable as were Ramsay
sedation scores between the two groups. The average
dexmedetomidine infusion rate was 0.35 mg/kg/h whilst intubated and
0.15 mg/kg/h after extubation (range 0–0.7 mg/kg/h). Data was
collated for the initial 6 h of the infusion and for the period pre- and
post-extubation ± 4 h, hence, allowing for the variation in the
duration of intubation in the data analysis. Once adequately sedated the
patients receiving dexmedetomidine achieved greater
cardiovascular stability as compared to the placebo group, with a significantly
lower and less variable heart rate (P = 0.0001), this was clearly
demonstrated in the period around extubation when mean heart
rate in the dexmedetomidine group was 75 (SEM ± 2.0), versus 92
(± 2.9) in the placebo group. Diastolic blood pressure showed a
similar trend with a reduction of 5 mmHg in the dexmedetomidine
group, but no sustained significant differences in systolic arterial
pressure or central venous pressures. Of the 66 patients who
received dexmedetomidine, 16 had transient episodes of
hypotension (MAP <60 or >30% reduction from pre-infusion BP) and/or
bradycardia (HR <50), mainly during the loading dose, of which
three patients required temporary interruption of the infusion and
three others required termination of the infusion.
Summary: Dexmedetomidine may improve cardiovascular stability.
P234 Ovarian hyperstimulation syndrome (OHSS) at a maternity hospital
V Lappas, P Myrianthefs, C Ladakis, S Pactitis, A Carousou, J Stamatiou and G Baltopoulos
Athens University School of Nursing Intensive Care Unit at ‘Agioi Anargyroi’ Cancer Hospital of Kifissia, Nea Kifissia 14564, Greece,
Department of Intensive Care Unit of ‘IASO’ Maternity Hospital at Athens, Marousi 15123, Greece
Crit Care 1999, 3 (suppl 1):P234
Background: Ovarian hyperstimulation syndrome (OHSS) is a
clinically important entity due to assisted conception which occurs
in about 1–10% of in vitro fertilization (IVF) cycles with serious
complications such as deep vein thrombosis, hypovolaemia,
haemorrhage, respiratory distress and hepato-renal failure.
Objective: The aim of this study was to describe our experience
with OHSS at ‘IASO’ Maternity Hospital.
Materials and methods: The last year seven patients with age
30 ± 2.4 (X ± SEM) were admitted in our ICU due to severe
ovarian hyperstimulation syndrome complications.
Results: Signs and symptoms (Table 1) and labs (Table 2) were
due to third space fluid shift (increased capillary permeability)
with evidence of hypovolaemia, haemoconcentration and
Ultrasound examination of the abdomen showed ascites, pelvic
fluid and enlarged ovaries (in our patients >11 cm in diameter) in
all patients and chest X-ray revealed hydrothorax in five patients
(71%). Ovarian hyperstimulation syndrome clinical feature is due
to exaggerated ovarian response characterized by marked
elevation of serum oestradiol levels and the presence of a large number
of follicles (>20).
Management and outcome: All patients had bed rest, fluid
input–output control, adequate fluid intake, high protein oral
intake, human albumin solutions iv and LMWH sc (nadroparin
Abdominal distension or pain
WBC × 103/ml
Poster abstracts 117
calcium 3000 iu). Two patients had paracentesis of hydrothorax
because of dyspnea or discomfort. Hospital and ICU stay was
8 ± 3.3 and 5 ± 1.9 days, respectively. All patients recovered
without developing any life threatening complications and were
discharged in good condition.
Conclusions and discussion: Ovarian hyperstimulation syndrome
is a serious clinical condition  which may be complicated by life
threatening events in up to 0.5–2% [1,2]. Early recognition and
management until normalization of oestradiol serum levels
provide good outcome with mortality rate 0.0025% .
P235 Anticoagulation: hitting the target after cardiac surgery
CD Booth and CL Nelson
Pharmacy Department, Leeds General Infirmary, Leeds, UK. E-mail:
Crit Care 1999, 3 (suppl 1):P235
Introduction: A pharmacy led anticoagulant service has recently
been introduced to dose and monitor warfarin in all cardiothoracic
inpatients at the Leeds General Infirmary. This abstract presents
an audit of locally produced guidelines for the induction of
warfarin in cardiothoracic patients.
Aim: To improve the anticoagulant process for cardiothoracic
patients by using the experience of clinical pharmacists to
produce guidelines for induction of warfarin.
Results: An audit was undertaken and data was collected on 89
patients. Sixty patients (67%) received a warfarin loading dose
according to the local guidelines. Fifteen (71%) of the 21 patients
with mechanical valves had an acceptable INR on day four. Only
one patient (5%) had a high INR, and 5 (24%) had a low INR. Of
the 39 ‘low risk’ patients (tissue valves, coronary endarterectomies
and A.F), 21 (54%) were within the acceptable range on day 4
whilst four (10%) were high and 14 (36%) were low.
In a group of 29 patients where guidelines were not followed
(dosing decisions were made by junior surgeons), only 8 patients
(28%) had an acceptable INR on day four, 16 (55%) had a low
INR and 5 (17%) had a high INR.
Discussion: This study has shown that the locally developed
guidelines can be used to safely initiate warfarin in cardiothoracic
patients immediately following cardiac surgery. In the future we
intend to undertake an analysis to produce maintenance dose
guidelines which are specific to cardiothoracic patients. A
combination of these two guidelines should optimise the dosing of
warfarin in cardiothoracic patients and contribute to an overall
improvement in their care.
P236 A prospective study of thrombocytopenia and prognosis in intensive care
A De Weerdt, S Vanderschueren, M Malbrain*, D Vankersschaever, E Frans, A Wilmer and H Bobbaers
Department of General Internal Medicine, Medical Intensive Care Unit, University hospitals, Herestraat 49 3000 Leuven, Belgium and
*Department of Intensive Care, Ste-Anne St-Remi Hospital, Boulevard Jules Graindor 66, 1070 Brussels, Belgium
Crit Care 1999, 3 (suppl 1):P236
Introduction: To study the incidence and prognosis of
thrombocytopenia in an adult critically ill population, 329 patients
consecutively admitted during a 5-month period to the medical intensive
care unit (ICU) of a university hospital (212 patients) and a
medical-surgical ICU of a regional hospital (117 patients), were
prospectively surveyed. The primary outcome measure was ICU
Results: One hundred and thirty-six patients (41.3%) had at least
one platelet count < 150×109/l. These patients displayed a higher
APACHE (Acute Physiology and Chronic Health Evaluation) II,
SAPS II (new Simplified Acute Physiology Score) and MODS
(Multiple Organ Dysfunction Score) at admission, longer ICU stay
(8 versus 5 days median (interquartile range)) and a higher
mortality rate (crude odds ratio, OR = 5.0, 95% confidence interval, CI
2.7–9.1) than those who never developed thrombocytopenia
(P < 0.0005 for all comparisons). Bleeding incidence rose from 4.1%
in non-thrombocytopenic patients to 21.4% in patients with
minimal platelet counts between 101 and 149×109/l (P = 0.0002),
and to 51.9% in patients with minimal platelet counts <100×109/l
(P < 0.0001). 19.5% of the study population died in the ICU
following the index admission. Eighteen of 193 patients (9.3%) who
never became thrombocytopenic died, versus 31 of 89 patients who
were thrombocytopenic at admission (OR = 5.2, 95% CI 2.7–9.8,
P < 0.0001) and versus 15 of 47 patients (31.9%) who developed
thrombocytopenia later on during ICU stay (OR = 4.6, 95% CI
2.1–10.0, P = 0.0002). In addition we found that a drop in platelet
count to £50% of admission was associated with higher death rates
(OR = 6.0, 95% CI 3.0–12.0, P < 0.0001). In a linear regression
analysis, adjusting for admission APACHE II, SAPS II and MODS,
admission thrombocytosis and the occurrence of bleeding, nadir
thrombocytosis remained significantly related to ICU mortality.
Conclusion: Thrombocytopenia is a simple and readily available
risk marker for ICU mortality, independent of and complementary
to established severity of disease indices. Both a low nadir
thrombocytosis and a significant fall of platelet count predict a poor vital
outcome in adult ICU patients.
P237 Platelet function and inflammatory markers in septic patients
U Leonhardt, F Zeiger, M Koksch and L Engelmann
University Leipzig, Department of Internal Medicine I, Philipp-Rosenthall-Str. 27, 04103 Leipzig, Germany
Crit Care 1999, 3 (suppl 1):P237
Background: In septic patients disseminated intravascular
coagulation is a severe complication whereby an altered platelet
function appears contributory. Clinical outcome depends on an early
diagnosis and sufficient therapy. In the present study the
association of platelet function to inflammatory markers indicating
disease severity was investigated.
Methods: Inflammatory markers C-reactive protein, procalcitonin,
interleukin-6 and interleukin-10 were measured using standard
methods in 18 patients fulfilling clinical, inflammatory and
hemodynamic criteria of sepsis. Platelet activation marker P-selectin
was flow cytometrically analysed ex vivo and after stimulation
using 5 mmol/l ADP and 10 mmol/l TRAP-6.
Results: Flow cytometrically measured platelet function was
tightly associated with inflammatory markers. Pre-activation of
platelets in the circulation was significantly correlated to plasma
levels of procalcitonin (P < 0.023), whereas in vitro induced
reagibility after ADP- and TRAP-6 stimulation correlated well with the
plasma concentration of the C-reactive protein (P < 0.001;
P < 0.012). Furthermore, a close relation of IL-6, but not of IL-10,
plasma levels to TRAP-6 stimulated P-selectin expression was
observed (P < 0.033).
Conclusion: Platelet function was demonstrated to be tightly
associated with the inflammation process in septic patients. Whether
this finding may be a useful marker for disease severity and the
development of a disseminated intravascular coagulation should
be clarified in prospective studies.
P238 Retrospective study of patients with haematological malignancies admitted in an intensive care unit
F Faria, P Alves, E Gonçalves*, A Martins, L Viterbo*, F Viseu* and A Aguiar
Intensive Care Unit and *Onco-haematology Unit, Instituto Português de Oncologia, Porto, Portugal
Crit Care 1999, 3 (suppl 1):P238
Introduction: The development of aggressive schemes of
chemotherapy predisposes haematological patients to various
lifethreatening complications. The admission of neutropenic patients
into an intensive care unit (ICU) is still controversial mainly if
they have multiple organ dysfunction (MOD) and /or if
mechanical ventilation is required.
Objective: Analyses from patients with haematological
malignancies admitted in a medico-surgery ICU of an oncology hospital.
Patients and methods: Retrospective observational study on
patients with haematological malignancies admitted in ICU from
October/96 to October/98, coming from Paediatric Department
(PD), Onco-Haematological Unit (OHU) and Bone Marrow
Transplantation Unit (BMTU). We analysed the patient data, namely
the underlying malignancy, the reason for admission, the type and
number of organ dysfunction (including neutropenia and
requirement of mechanical ventilation), the time in ICU, acute
physiology, age, chronic health evaluation (APACHE II) and
sepsis-related organ failure assessment (SOFA).
Results: Between October/96 and October/98, 46
onco-haematological patients were admitted in the UCI (56 inpatients) with
ages from 9 months to 70 years old, 23 female/23 male: 6 came
from PD (13%), 29 from OHU (63%) and 11 from BMTU (24%).
Underlying haematological malignancy: Non Hodgkin Lymphoma
(34%), Acute Myeloid Leukaemia (21%), Chronic Myeloid
Leukaemia (15%), Hodgkin Disease (15%), Acute Lymphoid
leukaemia (11%), Multiple myeloma (4%). Six of the 46 patients
were excluded because of the short time in ICU (£12 h). Six
patients were readmitted. The mean time of stay was 8.2 days.
The reasons for ICU admission were: acute respiratory failure
(54%), multi-organ dysfunction (MOD; 14%), post-surgery (14%),
septic shock (8%), tumour lysis syndrome (6%), hypovolemic
shock (2%) and neurological dysfunction (2%). The ICU mortality
was 52.5%, being 76% of them neutropenic patients with MOD
and requiring invasive ventilation. 89% of the patients coming
from BMTU died.
Conclusion: The main risk factors to dead in an ICU are the
number of organ dysfunction at admission, the requirement of
invasive ventilation, BMT, APACHE II ³20 and SOFA ³15.
P239 Prognostic value of the bone marrow in severe sepsis/septic shock
R Milheiro, E Lafuente, A Bártolo, A Sousa, C Gonçalves, J Fernandes, M Martins, J Leão, F Santos and P Carvalho
Intensive Care Unit, Hospital de Senhora de Oliveira, 4810 Guimarães, Portugal
Crit Care 1999, 3 (suppl 1):P239
Introduction: Peripheral haematological changes are one of the
sepsis diagnosis criteria. However, there are only a few studies
concerning the effects of severe sepsis/septic shock in bone
marrow of the adult patient.
Objectives: Characterise the bone marrow haematological changes
in severe sepsis/septic shock patients and to evaluate the
prognostic value of the marrow cell differential count (myeloid,
lymphoreticular, erythroid series).
Materials and methods: Prospective study of 29 patients with the
diagnosis of severe sepsis/septic shock of different etiologies. Age,
SAPS II in the first 24 h, organ dysfunctions according to SOFA,
organ failure according to Knaus and the final outcome were
considered in the present study.
Poster abstracts 119
The bone marrow of each patient was studied and a differential
count considering the myeloid, lymphoreticular and erythroid
series was made. The patients were separated according to final
outcome (dead and alive) and the bone marrow differential counts
were compared between the two groups applying t Student test.
Results: See Table.
Conclusion: In the present study significant statistical correlation
was found between lymphoreticular count and mortality. We can
conclude that bone marrow evaluation has had a prognostic value
in this patient group.
Dead (n = 17)
Alive (n = 12)
Myeloid series (%)
Lymphoreticular series (%) 10.6 ± 4.5
Erythroid series (%)
Mortality rate 58.86%
P240 Monitoring of plasma lipid peroxide level after abdominal aortic reconstruction in humans
MS Ryszka, P Guzik*, T Zujewski*, K Rzetecka*, M Kempa*, A Wykrêtowicz*, B Sawarzyñska-Ryszka, R Szulc and H Wysocki*
Institute of Anaesthesiology and Intensive Therapy, University School of Medical Sciences, Poznañ, Poland; *Division of Cardiology, Intensive Therapy,
University School of Medical Sciences, Poznañ, Poland
Crit Care 1999, 3 (suppl 1):P240
Aortic reconstructive surgery is associated with post-ischemic
reperfusion and oxidative stress. It is expected that oxidative
stress should be self-limiting during healing process in the
postoperative period. Lipid hydroperoxides (LHP) are one of oxidative
stress markers therefore we evaluated changes in LHP level in the
course of uncomplicated healing in patients who underwent
abdominal aortic reconstruction. Ten male patients, aged 56–74
years (mean 65.5 ± 6.01) with abdominal aortic aneurysm or
aortoiliac occlusive disease were submitted to aortic grafting operation.
LHP concentration was measured in blood samples collected via
central line prior to (P), at the end of (E) and 1 h, 24 h, 48 h and
72 h after surgery. The results are presented as mean ± SEM.
*Nonparametric one-way ANOVA–Kruskal–Wallis test
LHP concentration was significantly increased at the end of
surgery and started to decrease just after 1 h later reaching the
initial level within 48 h. The obtained results indicate limitation of
the oxidative stress in the course of uncomplicated healing. The
results also suggest that LHP level can be used for monitoring of
oxidative stress activity in humans.
P241 Deep leg veign thrombosis in multiply injured patients: an underestimated problem? Results of a prospective
clinical study with 50 patients
RJ Stiletto, K Giannadakis and R Leppek*
Department of Trauma Surgery/ICU and *Department of Radiology Philipps-University Marburg, Baldinger Str. 35033 Marburg/Lahn, Germany
Crit Care 1999, 3 (suppl 1):P241
Introduction: Too little is still known about the incidence rate of
thromboembolic complications in polytrauma patients after ICU
treatment, as only a small amount of data is available on this topic.
The majority of the studies published to date that have been
performed to assess the incidence rate of thrombosis in multiply
injured patients only refer to the clinical symptoms of a venous
thrombosis. A systematic screening-examination for the
assessment of the incidence rate of thromboembolic complications in
the above-mentioned patient collective has not yet gained
acceptance as a routine method in clinical practice.
Material and method: Between January 1996 and December 1997,
50 polytrauma patients were included in a prospective clinical
study. Including criteria were: an initial ISS-score >16, a stay on
the ICU of at least 72 h and a time on the respirator of at least 72 h.
All patients were examined for a deep veign thrombosis by using a
standardized protocol and by means of a colour-coded duplex
(ccd) sonography. In cases in which the clinical or/and sonographic
examination yielded results of a suspected veign thrombosis, a
phlebography was performed. In cases of a suspected pulmonary
embolism a pulmonary angiography was performed. The
colourcoded duplex sonography was used before the patients were
mobilized or transfered to an other ward (generally after 15 days).
Results: If not indicated otherwise numbers are given as median.
The age of the 38 male and 12 female patients was 38.6 years.
The severity of trauma was characterized by an ISS-score of 39.5
points. Eight patients died of a multiorgan-failure during their
stay on the ICU. The autopsy findings reveal that no patient died
of the of a veign thrombosis or a pulmonary embolism. Of the
remaining 42 patients, 8 patients (19%) showed deep leg veign
thrombosis in the ccd. In three of these patients (7%) also a
pulmonary embolism occurred.
Conclusion: Having in mind the results of our study the incidence
rate of thromboembolic complications in polytrauma patients
seems to be much higher as expected in comparison to the
published results of other authors.
P242 Obstructive shock in pulmonary embolism: thrombolytic therapy and survival
S Pivetti, E Aluffi, L Bonino, S Valpreda, R Urbino, B Tartaglino, F Navone, C Antro and V Gai
Medicina d’Urgenza e P.S. Medicina, E.D., Az. Osp. ‘ S. Giovanni Battista’ diTorino, Torino, Italy
Crit Care 1999, 3 (suppl 1):P242
Study objectives: Shock due to massive pulmonary embolism (PE)
shows a variable prevalence in literature, without general agreement
about thrombolytic therapy effectiveness. Objective of the study was
to appreciate prevalence and main clinical features of obstructive
shock (OS) in patients with PE admitted to our departement, and to
evaluate thrombolytic therapy effectiveness (BAPE regimen).
Methods and results: 236 PE cases were treated from March 95
until June 98 ; 24/236 suffered OS (10.2%, 14 F, 10 M, mean age 69
years). In 91.6% of OS we found one risk factor, at least, and in 62%
two or more risk factors. 3/24 patients presented with cardiac arrest,
7/24 showed RBBB and 5/24 S1Q3T3 pattern on EKG, 9/24 showed
a normal EKG. Echocardiography, performed in 66% of patients,
detected in all cases an enlarged and hypokinetic right ventricle;
venous duplex ultrasound, performed in 70% of cases, detected DVT
in 70.5%; perfusion radionuclide lung scan, performed in 70.5% of
cases, showed a high probability pattern in 94%. D-dimer was
altered in all cases; ABG analysis showed hypoxemia in all cases.
13/24 patients with OS were given thrombolysis according to
BAPE regimen (rTPA 0.6 mg/kg over 15 min); 11/24 patients with
OS were not given thombolysis because of absolute
contraindications. Thrombolytic therapy decision-making rested on clinical
data, on echocardiography in 38% of case and on echocardiography
and lung scan in 61% of cases. Intra-hospital overall death-rate was
37.5% (9/24 patients); all 13 patients given thrombolysis were
alive at discharge, whereas, 9/11 (81.8%) patients not given
thrombolysis died in the hospital.
Conclusion: We found OS in 10.2 % of PE cases; 13 patients given
thrombolysis all were alive and showed stable hemodynamic
parameters at discharge, whereas 9/11 patients not thrombolysis
given died during hospital stay. This outlines the need of an
expeditious clinical and instrumental diagnosis as a tool of
decisionmaking, especially about thrombolytic therapy. Moreover, we
found a 100% sensibility of D-dimer, hypoxemia as detected by
ABG analysis, echocardiography and perfusion radionuclide lung
F Guarracino, D De Cosmo, D Penzo, M Tedesco, A Bossi and R De Stefani
Department of Cardiothoracic Anaesthesia and ICU, Umberto I Hospital, Via Circonvallazione 50, 30171 Mestre (VE), Italy
Crit Care 1999, 3 (suppl 1):P243
Introduction: Aortic valve prosthesis determine a transvalvular
gradient (Dp) with changes in aortic flow that can affect left
ventricular geometry and function, implanted prosthesis and aortic
route. In order to improve prognosis a new prosthesis has been
proposed , the so called ‘stentless valve’ (SV), whose main
characteristic is the absence of the supporting ring. Aim of our study was
to evaluate if such valve could influence early postoperative
course in ICU.
Methods: Forty patients, age 67 ± 11 and EF 56 ± 14, undergoing
aortic valve replacement were enrolled. Nineteen patients, 12
with aortic stenosis (AoS) and seven with insufficiency (AoI)
underwent SV implantation (group S); 21 patients, 13 with AoS
and eight with AoI, received mechanical valve (group M).
Anaesthesia with remifentanil and propofol, moderate hypothermia
(30°C) and anterograde blood cardioplegia were used. In all cases
mechanical ventilation (MV) and intubation time, need for
inotropic support and blood loss were registered during ICU stay.
Results: No differences were found in duration of MV (125 ± 30 min
in group S versus 136 ± 12 min in group M, P > 0.05) and intubation
(3 h in group S versus 3.4 h in group M, P > 0.05) in patients with
aortic stenosis. In patients with AoI MV and intubation time was
shorter in group S (respectively 140 ± 25 min versus 155 ± 18 min in
group M, P < 0.05; 3.9 h versus 4.5 h in group M, P < 0.05). No
differences were observed in blood loss between two groups, nor in
dopamine dosage (5.4 mg/kg/min versus 6.6 mg/kg/min, P < 0.05).
Discussion: Our results show no differences in early postoperative
outcome in patients with AoS when treated with mechanical or
SV. Vice versa SV seems to improve ICU course of patients with
AoI, with regard to duration of MV and intubation. Other studies
with echocardiography are necessary to clear if these differences
can be due to a lower aortic transvalvular gradient of SV.
P244 High risk patients in major thoracic surgery
G Della Rocca, F Ruberto, F Pugliese, L Pompei, C Coccia, MG Costa and P Di Marco
Istituto di Anestesiologia e Rianimazione, Dir Prof A. Gasparetto, University of Rome ‘La Sapienza’ Via del Policlinico n°155-00161 Rome, Italy
Crit Care 1999, 3 (suppl 1):P244
Lung resections are correlated to high mortality (4–6%) and
morbidity (20–40%) that can increase in high risk patients.
Objectives of this study is to analyze preoperative risk factors,
in a group of high risk patients undergoing thoracotomy for
lung cancer and to assess the relationship with postoperative
P245 Outcome of systemic rheumatic disease patients admitted in intensive care unit
B Bouffandeau, B de Cagny, V Jounieau, F Tinturier, Y Domart, PY Lallement, H Gayet and A Fournier
Unité de Réanimation Néphrologie, hôpital sud - 80054 Amiens, France
Poster abstracts 121
1 PE, 1 resp
1 MI (died), 1 resp
Table. Preoperative risk factors and perioperative
Age + cardiovascular
Age + respiratory
Age + cardiovascular + other
Age + respiratory + other
Age + cardiovascular + respiratory
Cardiovascular + other
Respiratory + cardiovascular
Methods: From January 1996 to December 1997 43 patients,
undergone pulmonary resection for lung cancer, were considered at
high risk and enrolled in this study according to one or more of the
following including criteria: age older than 70 years; previous
cardiovascular disease; poor pulmonary function (FEV1 <65%
predicted values, PaO2 <65 mmHg or PaCO2 >42 mmHg); chronic
systemic disease. Patients clinical data are reported in the Table.
Anesthetic technique was the same for all patients. All the patients
were monitored with EKG, pulse oxymetry (Nellcor N200),
invasive arterial pressure, pulmonary artery catheter when necessary
and in-end expiratory gas analysis. Preoperatively an epidural
catheter was inserted in T6-T11 space. Anesthesia was maintained
with isoflurane 0.5% vecuronium and fentanyl combined with
epidural analgesia (bupivacaine 0.5% and fentanyl). A continuous
infusion through the epidural catheter of morphine 20 mg in 250 ml
normal saline 0.9% at 5 ml/h was used for postoperative pain relief.
Surgical procedures included: 33 lobectomy, 4 bilobectomy, 3
sleeve resections, 2 pneumonectomy. Relationship among different
preoperative risk factors and postoperative complications were
performed with c2 test and corrected with Fisher’s exact test.
Results: Mean age was 69 yrs (range 50–83 years). All patients
were extubated in the operative room at the end of surgical
Complications occurred in 25.5% of patients (11/43): 3
arrhythmias, 2 myocardial infarctions, 2 pulmonary edema, 2 acute renal
failures, 2 pulmonary complications (prolonged air leakage)
(Table). The perioperative mortality rate was 4.6% (2/43). The
mean length of staying in hospital was 11 days for all patients, 12.5
for respiratory group, 9.6 for cardiac group, 10.9 for age group.
Conclusion: In our experience lung resections in high risk patients
have low mortality and morbidity. Therefore, age over 70 years
Crit Care 1999, 3 (suppl 1):P245
Objective: The aim of this study was the determination of short
and longterm outcomes and prognostic factors for patients with
systemic rheumatic diseases (SRD) admitted to intensive care
units (ICU) in a retrospective case series study of SRD patients
admitted in six French ICU in community and teaching hospital
between January 1992 and July 1996.
Main results: A total of 60 SRD patients were included with
diagnostic of infection (40%), acute exacerbation of SRD (16.7%),
iatrogenic complication (16.7%), cardiovascular complication
(15%), and miscellaneous (11.7%). The death rate in intensive
care units was 26.7% (16/60). Multivariate analysis (Cox model)
identified two factor predicting poor MICU outcome: age above
65 years (relative risk [RR], 3.3; 95% confidence interval [CI],
1.9–5.8) and Tran organ failure indices (RR, 2.2; 95% CI, 1.7–2.8).
The mean overall survival time after admission to ICU was 18.8
months. The 1-year survival rate was 61.1%, and the 2-years
58.8%. Multivariate analysis (Cox model) identified two factors
predicting poor long term outcome: age above 65 years (RR 4.0;
95% CI 2.7–6.0), and need of mechanical ventilation (RR, 6.5;
95% CI, 4.2–10.1) (Fig).
MI, myocardial infarction; PE, pulmonary edema; RF, renal failure
alone has no longer to be considered a limiting factor in patients
undergoing surgery for lung cancer. High risk patients need a very
careful preoperative evaluation of cardiovascular and pulmonary
function in order to avoid perioperative complications and to
reduce the morbidity. An appropiate surgical and anesthetic
technique, and postoperative pain relief improves outcome in high risk
Figure. Survival of patients with SRD in intensive care unit,
influence of mechanical ventilation.
Conclusion: We conclude that this SRD patients should be
admitted to the ICU on the same basis as other patients. In this
population neither the diagnostic of the underlying disease, nor the use
of immunosuppresive therapy did influence the short and long
outcome. Long-term survival depended only on the age and the
need of mechanical ventilation.
Critical Care 1999, Vol 3 suppl 1
P247 Time and type of admission to a surgical intensive care unit
P Haraldsen and R Andersson
Department of Surgery, Lund University Hospital, S-221 85 Lund, Sweden
Crit Care 1999, 3 (suppl 1):P246
Surgical intensive care consumes considerable facilities and the
associated costs are high. The present study aimed at evaluating
longterm outcome of patients treated due to abdominal sepsis in
the surgical intensive care unit from January 1983 to December
1995 by a follow-up from June to August 1997 of patients
surviving the hospital stay. The patients were interviewed by telephone
and also completed a ‘quality-of-life’ form. Out of 210 patients
(mean age 65 years) 151 survived the hospital stay. At follow-up,
another 45 patients were deceased, 41 patients were not reached
MW Sebastian, WJ Fulkerson and NW Knudsen
Duke University Medical Center, Durham, NC, USA
Crit Care 1999, 3 (suppl 1):P247
Introduction: Duke University Medical Center (DUMC) is a
tertiary care hospital with a Level 1 (USA) Trauma Center
Designation. Increasing level of patient acuteness, high census levels,
decreasing resident staffing and financial concerns have led to
intensive care unit (ICU) organization and staffing changes. ICU
care is being redefined at DUMC via pursuit of a multidisciplinary
approach to the treatment of critically ill patients. As part of this
initiative, analysis of Surgical Intensive Care Unit (SICU)
admissions was performed for January through March 1998. This
analysis showed that 45% of admissions occurred when there was no
attending in house. To fulfill the missions of patient care,
education, research, cost-containment, optimal bed utilization and
appropriate reimbursement for services, we instituted
around-theclock board-certified intensivist coverage in the SICU.
Continuing analysis of admission distribution confirms that half of
admissions occur at night and breakdown of type of admission
indicates that these admissions are the patients most requiring
active resuscitation and supervision of resident management.
and another 17 patients declined to participate. Thus, the
followup included 48 patients. At discharge from hospital, 54% of the
patients returned directly home and 67% returned to their regular
work after a median sick-leave of 10 weeks. When comparing a
quality-of-life score, an impairment of median scores (P < 0.01)
was found, although the patients subjectively appreciated quality
of life not to have changed significantly. 49% claimed full
recovery. Hospital mortality was 28% attributable to multiple organ
dysfunction and total mortality over the time period was 50% and
rarely associated with abdominal sepsis. Thus, recovery following
abdominal sepsis treated in the surgical intensive care unit is good
and motivates efforts performed during the acute phase.
Results: There are approximately 115 admissions per month to
this 16 bed ICU for a total of 575 admissions for the study period.
From 6 PM to 6 AM, 276 (48%) admissions occurred encompassing
88% of trauma patients and 79% of floor transfers. The time
distribution was constant for each month and the incidence of
postoperative, direct admission, and floor transfer was also constant from
month to month, while the incidence of trauma admissions was
higher in July and August.
Methods: To determine time and type of SICU admissions we
retrospectively reviewed the SICU database from July through
November 1998. Time of arrival was divided into 12-h blocks
beginning at 6 AM and 6 PM. Patients were divided into four
categories: postoperative, direct admission, trauma and floor transfer.
Conclusion: Fifty percent of admissions to the DUMC SICU
occur during off-hours when traditionally there has been no
attending level in-house supervision. The high percentage of
trauma and floor transfers during off-hours validates this
reorganization of ICU staffing and around-the-clock supervision.
P248 Preliminary data: PIM and Prism in infants and children post cardiac surgery in a UK PICU
GD Jones, M Hatherill and IA Murdoch
Paediatric ICU, Guys Hospital, London SE1 9RT, UK. Tel: 0171 955 2564; Fax 0171 955 2563
Crit Care 1999, 3 (suppl 1):P248
Objective: To describe the predictive and calibration capabilities of
PIM and PRISM in infants and children following cardiac surgery.
Design: Between December 1997 and November 1998, 250
consecutive infants and children were studied. No child died in
theatre. There were; 53 patients <1 month, 75 from 1 month–1
year and 122 >1 year. Median age 11.43 months (range 0.02–229).
Survivors were defined by ICU discharge.
Results: Crude mortality was 6% (15/250) all deaths occurred in
children <1 year old. Median age of death (range) was 0.33 months
(0.02–11.83). Median time (range) to death was 53 h (2–264).
Table. Observed vs (predicted) deaths and area under the ROC curve for PRISM and PIM
Poster abstracts 123
Calibration using the Hosmer-Lemeshow goodness of fit test,
showed a c2 16.15, df 8, significance 0.04 for PRISM and c2 17.05,
df 8, significance 0.03 for PIM. Using a cut off at P = 0.5, sensitivity
and specificity for PRISM was 98.3% and 33.3%, and 99.2% and
26.7% for PIM.
compares favourably with the original work by Shann et al. 
(0.87 vs 0.83). Therefore we would concur with their conclusion
that PIM is accurate enough to describe the risk of mortality in
groups of children, and has the added advantage of needing less
data collection than PRISM.
Conclusion: Neither PRISM, nor the new scoring system PIM are
well calibrated for predicting individual mortality. However,
despite the small numbers, the area under the ROC plot for PIM
P249 Does intensive care improve outcome?
CD Gomersall, PY Tan, GM Joynt, TA Buckley and E Wong
Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
Tel. 44 171 886 1248; Fax. 44 171 886 6360; E-mail.
Crit Care 1999, 3 (suppl 1):P249
Introduction: ‘Does intensive care improve outcome?’ is a
question of fundamental importance. It is unlikely to ever be answered
conclusively, because of ethical constraints on performing a
controlled study of two groups randomised to ICU admission or no
ICU admission. It is possible however, to assess ICU admission as
an independent predictor of survival when considered alongside
other possible predictors.
Method: Prospective cohort study of all adult patients referred for
emergency admission to the only adult ICU of a university
hospital during a 3-month period. Because of the limited number of
alternative ICU beds patients refused admission are not
transferred to an ICU in another hospital. Exclusion criteria were:
direct ICU transfers from other hospitals, patients referred when
the ICU was full, patients with acute burn injury and cardiac
surgery patients. (The latter two groups were excluded from the
original MPM II derivation and validation sets). MPM II0 score
was calculated for each patient and the following data were
collected: sex, referring specialty, APACHE II diagnostic weighting,
admission or refusal of admission to ICU and hospital survival.
MPM II0 consists of 14 physiological and diagnostic variables and
is the only severity scoring system available at ICU admission.
Logistic regression analysis using a forward stepwise conditional
method was performed using SPSS for Windows. Variables
included as possible predictors of survival were sex, MPM II0,
APACHE II diagnostic weighting, ICU admission, and
interactions between admission and MPM II0, and admission and
APACHE II weighting.
Results: Three hundred and eighty-three patients were studied of
whom 229 were admitted. Low MPM II0, low APACHE II
diagnostic weighting and admission to ICU were found to be
independent predictors of hospital survival with a hospital survival
odds ratio for ICU admission/ refusal of 2.41 (95% CI: 1.48–3.93).
Discussion: This result demonstrates that admission to ICU is an
independent predictor of survival when compared with available
likely predictors. It is unlikely that the association between
admission and survival is due to selective admission of those patients
more likely to survive as the association was independent of
severity of illness, type of illness and sex. Our results therefore strongly
support a positive answer to the question ‘Does admission to ICU
S Grmec, S Piberl and V Gasparovic*
EMS, PHU Maribor, Ul. Talcev 9, Maribor 2000 Slovenia, *Division of Intensive Care Medicine, University Hospital Centre Zagreb, Kispaticeva 12,
1000 Zagreb, Croatia
Introduction: Due to the numerous prehospital descriptive scoring
system it is uncertain whether they are efficient in the description
of how serious illness are and furthermore whether they can have
prognostic role in the estimation of the illness outcome (what is
their validity in connection with the prognostic scoring system
Methods: In prehospital setting were collected from each patient
postintervention values of the MEES and GCS. The APACHE II
score were recorded on the day of admission to hospital. This
study was undertaken over a 2 year period (January 1996 to
October 1998) and included 286 consecutive patients
hospitalized for nontraumatic coma. Patients less than 16 years old were
not included. There were 168 men and 118 women. Their age
varied from 16 to 87 years with a mean 51.8 ± 16.9. Sensitivity,
specificity and correct prediction outcome measured by the
c2method in four severity scores. The Youden Index was also
obtained. The best cutoff point in each scoring system was
determined by the Youden index. The difference in Youden index was
calculated by Z score. A P value <0.05 was chosen to reject the
null hypothesis. For each score receiver operating
characteristically curve (ROC) were obtained. The difference in ROC was
calculated by Z score.
Results: For prediction of mortality, the best cutoff points are 19
for APACHE II; 18 for MEES and 5 for GCS. The Youden index
has best cutoff point at 0.63 for APACHE II, 0.61 for MEES and
0.65 for GCS. Correct predictions outcome (%) was for APACHE II
79.9 ± 1.6; for MEES 78.3 ± 1.9 and for GCS 81.9 ± 1.5. The area
under ROC is 0.86 ± 0.02 in the APACHE II; 0.85 ± 0.06 in the
MEES and 0.88 ± 0.03 in the GCS. There was no statistical
differences among APACHE II, MEES and GCS in terms of correct
prediction outcome. Youden index and the area under ROC (P < 0.05).
Conclusion: APACHE II is not much better than prehospital
descriptive scoring system (MEES and GCS). APACHE II and
MEES may not replace the role of GCS in the prediction
mortality in nontraumatic coma. For the assessment of mortality the
GCS score provides the best indicator for these patients
(simplicity, less time-consuming and effective information, especially in
an emergency situation).
P251 Application of prognostic score to patients following cardiac arrest
MV de la Torre-Prados, A García-Alcántara A, A Poullet-Brea, C Reina-Artacho and A Soler-García
Servicio Medicina Intensiva HU Virgen de la Victoria, 29016-Málaga, Spain
Crit Care 1999, 3 (suppl 1):P251
Introduction: The use of prognostic scores in continuous form
may help in decision-making in the post-resuscitation phase
following cardiac arrest.
Objective: To evaluate the clinical efficacy of a prognostic score
 on intrahospital mortality of patients suffering extrahospital
Material and method: A 6 month prospective study carried out on
37 patients in the Emergency Unit of a 650 bed hospital
(attending to a total of 74 000 patients per year). A score of 0–6 based on
cardiac rhythm at time of arrest was applied (cardiac rhythm
different to ventricular tachicardia without pulse or ventricular
fibrillation = 3). Glasgow score at the time of admission (4 or 5 = 1 and 3
= 2) and type of cardiopulmonary resuscitation received up to
arrival of Emergency Assistance (no first aid from qualified
personnel at time of arrest = 1).
Results: Average age was 61.8 ± 14.9 years (29–84), with sex
distribution of 59.4% male and 40.5% female.
Conclusion: 1 The application of this score may prove useful in
clinical practice to evaluate the continuity of life-support. 2
Neurological assessment is the most valuable clinical variable for
prognosis in the follow-up phase. 3 As in other studies, age is not a
determining factor in intrahospital mortality following cardiac
arrest. 4 Median arterial pressure shows a difference of some 20
points between the surviving and non surviving groups. 5
Mortality among males is significantily greater than females after
receiving CPR. 6 The type of assistance received prior to arrival of
health services is of significant value in the survival chain.
1. Lancet 1995, 346:417-421.
MAP, Median arterial pressure hospital admisssion. *Significant difference between groups, Chi Square. **t test.
P252 Outcome of children with near drowning requiring treatment in PICU
P253 Prognosis related to organ dysfunction in intensive care unit
D Gionis, M Moustaki, Z Beka, A Tsoutsou, E Ourani and J Papadatos
‘P&A Kyriakou’ Children’s Hospital, PICU
Crit Care 1999, 3 (suppl 1):P252
A number of near drowned children needed admission to a PICU
due to the severity of their condition. The aim of this review is to
illustrate the epidemiology, the clinical features, the management
and the outcome of near drowned children admitted to our PICU.
For this purpose, we reviewed the charts of near drowned children
admitted to our unit during the last 11 years. The study
population consisted of 11 children (7 boys and 4 girls) aged 2.5–12.5
years (mean age 7.2 years, SD4,1, SE1.3). At the same period a
five-fold number of near drowned children were hospitalized in
pediatric wards. The submersion site, among our patients, was sea
in 6 cases, a swimming pool in 3, a pond in 2 cases. Ten children
were transferred from district hospitals where they had initially
received advanced life support. 6/10 children were transferred
intubated. 4/10 children were in cardiac arrest after the accident,
3/4 had been given basic life support at the accident site and
subPS Martins and S Blecher
Hospital Santa Marcelina, São Paulo, Brazil
Crit Care 1999, 3 (suppl 1):P253
Objective: To develop a model for assessing severity of organ
dysfunction (OD) among patients on the first 24 h of Intensive Care
Unit (ICU) stay, using a score to determine the probability of ICU
Design: Prospective cohort study.
Setting: General medical and surgical ICU in a tertiary teaching
hospital in City of São Paulo, Brazil.
Patients: Three hundred and seventy-eight consecutive,
unselected patients over the period from March to October of 1996:
developmental sample. Three hundred patients over the period
from February to June of 1997: validation sample.
Outcome measure: Patients vital status at ICU discharge. None
intervention was considered.
Statistical analysis: APACHE II score was calculated for all
patients. A Lowess Regression model, using the variables that
demonstrated P £ 0.10 in the univariate analysis was made to
idenARF, Acute renal failure
sequently 2 of them were intubated on their arrival at the nearest
district hospital. 1/4 was intubated in the nearest hospital where
he was transferred with brain death without having received
appropriate basic life support for about 30 min. 2/3 children who
initially were apnoeic and comatose, required intubation. The
remaining 4 children had respiratory distress and irregular
respiration but only one needed intubation. 8/11 patients have clinical
and roentgenographic features of pulmonary oedema. The
intubated children remained on mechanical ventilation from 12–36 h.
Convulsions occurred in 3 children. In 1/11 patients there were
signs of high intracranial pressure with good response to mannitol
administration. 10/11 patients survived and discharged from
hospital after 3–6 days of hospitalization overall. The patient who was
admitted with brain death, never recovered. All survived children
had no neurological sequalae on their follow up 2–5 years later.
Our results emphasize that even the most severe cases of near
drowning have a favorable outcome, provided that the victims are
given basic life support at the accident site.
tify the level of severity of each variable. The variables were then
entered into a multiple logistic regression analysis resulting in a
probability of ICU mortality equation. The Goodness-of-fit test
was used to evaluate model calibration; discrimination was
evaluated using area under the receiver operating characteristic curve
(ROC), in the developmental and validation samples.
Main results: OD was considered in five systems: neurologic,
pulmonary, renal, cardiovascular and hematologic, plus the presence
of chronic disease. The points were assigned from 1 to 4 according
to the levels of severity (Table). The results showed good
calibration (P = 0.96; C = 2.33; dF = 8 and P = 0.90; C = 3.01; dF = 10)
respectively in the developmental and validation samples, and
good discrimination (ROC curve of 0.81 and 0.82, respectively).
Conclusion: Cardiovascular dysfunction was the most severe organ
dysfunction, followed by pulmonary, renal and neurologic
dysfunction. Hematologic dysfunction and the presence of chronic
disease were less severe. This model can be used as end point in
epidemiologic studies of organ dysfunction in our ICU when the
points are summed according to the horizontal lines (severity
within an organ system), or as a predictor of death when the points
are summed vertically, once the b is the same for all variables.
P254 Characteristics of patients with sepsis and multiple organ failure in the UK
L Shaikh, H Stuart, A Rhodes and RW Chang for the RIP Users Group
Dept of Intensive Care, St George’s Hospital, London, SW17 0QT, UK. Fax 0181 7679748
Crit Care 1999, 3 (suppl 1):P254
All severe sepsis and multiple organ failure patients
Introduction: This study examined the characteristics and ICU
outcome of patients admitted with severe sepsis and compared
them with patients who develop severe sepsis after admission to
Method: The Riyadh Intensive Care Program (RIP) database
1989–1996 contains 28 094 complete demographic data, daily
APACHE II and TISS scores from 21 UK ICUs. 2790 patients
retrospectively satisfied the criteria of severe sepsis and multiple
Results: See Table.
Conclusion: The timing of development of severe sepsis and
multiple organ failure appears to be an important factor for outcome
with a significantly higher mortality among those admitted with
sepsis. The admission APACHE II score and the score on the day
of development of sepsis were lower among those who developed
sepsis. This may be attributable to these patients already being in
the ICU environment and thus receiving closer monitoring and
more timely intervention. This finding may be of importance in
the design of future trials to evaluate new treatment modalities.
Apache II on 1st
day of sepsis (SD)
1162 (41.6%) 1628 (58.4%)
60.2 (16.7) 58.5 (17.7)
61.5 (15.9) <0.001
23.2 (7.5) <0.001
24.7 (7.2) <0.001
2.4 (0.7) <0.001
Differences between those admitted with and those that
Admission Apache II (SD)
Day of sepsis Apache II(SD) 25.8 (7.2)
No organ failure (SD)
L Shaikh, H Stuart, A Rhodes and RW Chang for the RIP Users Group
Dept of Intensive Care, St George’s Hospital, London, SW17 0QT, UK. Fax 0181 7679748
Crit Care 1999, 3 (suppl 1):P255
Introduction: No large, well-controlled, trial has been able to
demonstrate a statistically significant and reproducible benefit of
experimental treatment in severe sepsis and multiple organ
failure. This study was done to determine the factors that have to
be controlled for in future design of clinical trials in sepsis.
Method: 2790 patients from the RIP database satisfied the criteria
of severe sepsis and multiple organ failure. Logistic regression
APACHE II Score
Number of organ failures
APACHE II Score
APACHE II Score
APACHE II Score
Poster abstracts 127
analysis was carried out to determine the factors that influenced
ICU outcome. The CHAID model of an expert system
AnswerTree (SPSS, UK) was also used to derive decision rules
that govern the outcome of these patients.
Results: Of the eight independent variables entered into the
logistic regression analysis four in order of importance were selected:
APACHE II score on the day of development of sepsis, treating
centre, number of organ failures, age. The area under ROC was
0.75. The level and branches of the decision rules by the expert
system is shown in the Figure on the previous page. The
difference in outcome for all the nodes is P < 0.0001
Conclusion: As the area under the curve of the ROC = 0.75, one is
unlikely to use logistical regression analysis to risk stratify patients
for future trials of severe sepsis; however, expert systems can
delineate statistical significance and patterns which influence
outcome in a complex trial population.
P256 Does SOFA and TISS scores correlate in long term ICU patients?
I Novak, P Hora, M Bilek, M Suchy, R Rokyta and V Sramek
ICU, Medical Dpt I, Charles Uni Hospital Plzen, Alej Svobody 80, CZ-30466 Plzen, Czech Republic. Tel: +420-19-710 3 165;
Fax: +420-19-522 566; E-mail:
Crit Care 1999, 3 (suppl 1):P256
Introduction: SOFA score is a useful tool for monitoring of organ
function in ICU patients . TISS score is used for measuring of
workload in intensive care . We studied if there is any link
between SOFA and TISS scores in long term ICU patients (i.e.
patients staying in the ICU >3 days).
Materials and methods: Daily SOFA and TISS scores of ICU
patients admitted between July and November 1998 who stayed
in the ICU >3 days were retrieved from data collection system. An
experienced ICU doctor has collected SOFA scores into this
system daily. Pooled scores for the whole group, for ICU survivals
(S) and nonsurvivals (NS) separately and the scores on the first
day of ICU stay were analysed.
Results: Sixty-two patients (i.e. 42% out of total admissions; age
60.0 ± 14.7 years) fulfilled the inclusion criteria and stayed in the
ICU for the mean of 11.9 ± 10.8 days). ICU mortality was 30.6%
(19 patients). Significant correlation was found for pooled SOFA
and TISS scores (r2 = 0.52, P < 0.0001) and it was more pronounced
in survivals (S) than in nonsurvivals (NS) (r2 = 0.52, P < 0.0001 and
r2 = 0.19, P < 0.0001, respectively). Significant link between the
two scores was already present on the first day of ICU stay
(r2 = 0.54, P < 0.0001).
Conclusion: In long term ICU patients a significant correlation is
present between organ failures (scored by SOFA) and workload
(measured by TISS). This link is already present on the day of
admission and later on is more pronounced in survivals possibly
because in NS the care is more often witheld or withdrawn.
1. Vincent JL et al.: Use of the SOFA score to assess the
incidence of organ dysfunction/failure in the intensive
care units: Results of a multicenter, prospective study.
Crit Care Med 1998, 26:1793-1800.
2. Dickie H et al.: Relationship between TISS and ICU cost. Intensive Care Med 1998, 24:1009-1017.
P257 Daily SOFA scoring for ICU patients?
P Hora, M Bilek, M Suchy, R Rokyta, I Novak and V Sramek
ICU, Medical Dpt I, Charles Uni Hospital Plzen, Alej Svobody 80, CZ-30466 Plzen, Czech Republic. Tel: +420-19-710 3 165;
Fax: +420-19-522 566; E-mail:
Crit Care 1999, 3 (suppl 1):P257
Introduction: SOFA might be a useful tool for monitoring of organ
function in ICU patients . We evaluated optimal frequency of
SOFA acquisition in long term ICU patients (i.e. patients staying
in the ICU >3 days).
Materials and methods: Daily SOFA scores of ICU patients
admitted between July and November 1998 who stayed in the ICU >3
days were retrieved from the data collection system. An
experienced ICU doctor has collected SOFA scores into this system
daily. Original daily SOFA score flow charts and adapted
(simplified) SOFA score flow charts (SOFA on days 1, 4, 7, 10, 14, 21, 24,
28 etc.; i.e. values of unlisted days expressed as trends between
data collection days) were compared for individuals and the whole
group of patients. Data are presented as means ± SD; P < 0.05 was
Results: Sixty-two patients (i.e. 42% out of total admissions; age
60.0 ± 14.7 years) fulfilled the inclusion criteria and stayed in the
ICU for the mean of 11.9 ± 10.8 days. ICU mortality was 30.6% (19
patients). Original and adapted data did show equal values for the
whole group of patients (MANOVA group by time effect 0.98 at
Day 4, 62 patients and 1.00 at Day 7, 36 patients). Out of total 736
ICU days, in 374 there was theoretical possibility of data
difference (adapted SOFA scores). Significant difference (defined as
DSOFA >2) between original and adapted values was found in 64
cases (17.1%) In 30 cases adapted values were higher then original
Conclusion: SOFA score collected 2–3 times a week describes
sufficiently characteristics of long term ICU patients. Significant
individual data might be lost when SOFA score is not collected on
U Janssens, C Graf, J Graf and P Hanrath
Medical Clinic I, University Hospital of RWTH Aachen, Pauwelsstraße 30, D-52057 Aachen, Germany
Crit Care 1999, 3 (suppl 1):P258
Objectives: The SOFA (sepsis-related organ failure assessment)
score describes quantitatively the degree of organ dysfunction.
Although primarily not designed to predict outcome any
assessment of morbidity must be related to mortality to some degree.
We therefore investigated whether an increasing SOFA score is
associated with a higher hospital mortality in patients (pts) of a
medical intensive care unit (ICU).
Methods: All consecutive pts who stayed >24 h in ICU were
included in this prospective study between 11/97 and 2/98. SOFA
score and SAPS II were determined after 24 h. Discrimination
power of the scores for survivors (S) and non-survivors (NS)
[hospital mortality] was assessed by the area under the Receiver
Operating Characteristic (AUROC) curve.
Results: 303 pts (216 male [71.3%], 62 ± 12 years, length of ICU
stay 3.7 ± 4.7 days, SOFA 2.5 ± 2.9, SAPS II 26 ± 12.6) were studied.
Hospital mortality was 14.5%. SOFA score for NS was significantly
higher than for S (5.9 ± 3.7 vs. 1.9 ± 2.3, P < 0.05). The AUROC was
0.82 ± 0.04 for the SOFA score and 0.77 ± 0.04 for SAPS II.
P259 Statistical modeling of prognostic indices
Figure. Mortality (%) versus SOFA score.
Conclusion: SOFA score discriminates well between S and NS
24 h after admission. Respiration, liver and coagulation showed an
increasing mortality rate with a higher SOFA score for each organ.
Although the SOFA score was primarily designed for use in septic
patients it may be also applied for pts of a medical intensive care
J Livianu, S Blecher, JMC Orlando and JO Proença
Hospital Municipal Jabaquara-Rua Francisco Paula Ribeiro 562, São Paulo, Brazil
Crit Care 1999, 3 (suppl 1):P259
Introduction: Severity scoring models can provide accurate
outcome prediction but their performance is very influenced by
variations in patient case-mix. Therefore, none of the usual
scoring systems (APACHE II, SAPS II and MPM 24) fitted to this
ICU: they had good discriminatory power but poor calibration.
Logistic regression analysis of their variables was performed to
identify the most predictive association to ICU mortality.
Methods: Data of 823 consecutive patients (pts) admitted to the
ICU were prospectively collected. Pts who stayed less than 24 h at
the ICU or were burn or had less than 16 years old were excluded.
For pts with several admissions, only the first ICU admission was
considered. The remaining 709 pts were divided in two groups:
418 (59%) pts constituted the development set and 291 (41%) pts
became the validation set. After calculating the scoring indices,
their variables and respective weights were separately analysed.
Variables with P value <0.05 at univariate analysis were included
as independent variables at logistic regression and vital status at
ICU discharge was considered as dependent variable.
Results: There were 67% male and 33% female pts; median age
was 46 years old, postoperative care took up 330 (46.7%) cases, of
which 275 (83%) were emergency surgery. Trauma was the
admission cause for 200 (28%) pts. ICU mortality rate was 25.1% and
APACHE II, AII; SAPS II, SII; MPM 24, M24, OR, odds ratio
Glasgow coma scale
Points assigned as
hospital mortality 33.7%. APACHE II was 16.7 ± 8.4 and SAPS II
was 33.5 ± 16.5. Through statistical modeling, an hibrid model was
generated, with variables and points from the three indices. With
this model, the prediction obtained was: development set with
discrimination ROC = 0.89 and calibration goodness-of-fit C = 1.68
and validation set with ROC = 0.84 and goodness-of-fit C = 7.72.
Conclusion: Hemodynamic instability, infection, impaired renal
function, respiratory failure and coma were the best predictors of
death. Early identification of patients at major risk may allow
treatment with more resources and interventions, in order to
improve survival. Furthermore, this study shows that suitable
statistical management may be useful to customize and enhance the
prognostic accuracy of the currently available scoring systems.
P260 The determination of the duration of the nursing activities in the intensive care unit and the therapeutic
intervention scoring sysem (TISS)
N Kýlýçaslan and G Kocaman
Dokuz Eylül University School of Medicine, Ýzmir, Turkey
Crit Care 1999, 3 (suppl 1):P260
The purpose of this study was to calculate nurse/patient radio by
using TISS-28, and to assess time allocation to nursing activities in
the intensive care unit. In this study the TISS scores of 416
patients were calculated in the intensive care unit 10 weeks long
using the TISS-28 form. In order to determine the duration of the
nursing care activities due to nursing care categories the work
sampling method was used. A sampling matrix for 10 weeks was
created and the nursing care activities were observed 7 days a
week for two day shifts (08.00–16.00). The data collection
instruments were, the ‘TISS-28’ and ‘Work sampling form for intensive
care unit nursing activities’. The TISS-28 point for ICU was 40.41
for day shift. One TISS-28 point equals 11.88 min of the 480 min
in each shift. Related literature shows that nursing care activity for
one day makes 40–50 TISS score. The percentage of nursing time
spent on nursing activities in the ICU was calculated by using
work sampling. Results indicated that 44.25 % of nurses time was
spent in activities in TISS-28; 12.87% in activities not in TISS-28;
25.8% in indirect patient care, 6.21% in organnizational activites,
10.64% in personnel activities and 0.15% in other activities. It is
shown that category one represents TISS-28 and that the increase
in TISS score results in the increase in nursing care activity
duration. These result show that the TISS-28 can be useful to
determine the patient/nurse ratio in intensive care units.
Miranda DR, Rijk AD, Schaufeli W: Simplified Therapeutic
Intervention Scoring System: The TISS-28 items: results
from a multicenter study. Critical Care Medicine 1996,
Cullen DJ, Cývetta JM; Briggs BA: Therapeutic Intervention
Scoring System: a method for guantitative comparison of
patient care. Crit Care Med 1974, 2:57.
Hendrickson G, Doddato T, Kovner C: How do nurses use their
time? JONA 1990, 20:3.
Urden DL, Roode JL: Work sampling (a decision-making tool
for determining resources and work redesigning). JONA
P261 Fast-track intensive care procedure after cardiac surgery in the 9th decade
N Huebner, W Rees*, M Boeckelmann, S Rittel*, H Warnecke* and U Christmann
Dept. Anesthesiology, *Dept. Cardiac Surgery, Schuechtermann Klinik, Ulmenallee 11, 49214 Bad Rothenfelde, Germany
Crit Care 1999, 3 (suppl 1):P261
Objective: Outcome with fast track intensive care medicine after
cardiac surgery in patients older than 80 years.
Methods: Between 7/96 and 7/97, 86 cardiac operations (3.7%)
have been performed in patients older than 80 years out of an
overall number of 2349 cardiac operations. Preoperative NYHA
Status was III in 36.1% and IV in 46.5% of the old patients. LVEF
was 49%, LVEDP 16 mmHg. Additional desaeses were: diab. mell.
23.3%, renal insufficiency 11.6%, cerebral stroke 10.5% and
myocardial infarction 37.2%. Performed cardiac operations have
been: CABG (61.6%), AVR (23.3%), CABG and AVR (12.8%),
MVR (1.2%), CABG and MVR (1.2%) and REDO operations
(4.6%). Mean time on ECC was 84 min and overall operation time
was 169 min (mean). Anesthesia was conducted as balanced
anesthesia with early extubation as a main aim.
Results: Patients were extubated 6 h ( median ) after surgery,
shortest duration of ventilation was 30 min. Mean stay on ICU was 2.6
days and mean time of hospitalisation was 9.4 days.
30-day-mortality was 3.4% in the old patients and 2.2% in the overall population.
Conclusion: Fast-track procedure after cardiac surgery in the
octanarian is feasible with even better results and without any
additional risk than conventional intensive care procedure.
P262 Prognosis and functional capacity a year after a myocardial infarction on elderly 80-year-old patients
L Lorente, M Martin, R Medina, JJ Valencia, J Mujika and A Jimenez
Intensive Care Unit, Clinica La Colina, Santa Cruz de Tenerife, Spain
To analyse differences between sex, localization and developed or
no Q wave.
Design: Retrospective analysis.
Patients: All patients of ³80 years admitted between 1.1.94 and
31.10.97 with a myocardial infarction.
Evaluation of evolution curve: The study was done through
telephonic interview. We analysed mortality at the reception (REC), 1,
3, 6, 9 and 12 months (M). Was used a daily activity scale (DAS)
with five factors (walking, dressing, bathing, cleaning and eating)
with a punctuation from 0 to 2 every activity (0 = total dependence,
1 = partial dependence and 2 = independence), with a range 0 to 10.
Statistical analysis: The statistical significance of the variables was
tested by Fisher’s test of t Student test. Values less than 0.05 were
considered statistically significant.
Results: We included 112 patients, 54 (48.21%) male and 58
female. The localization of the myocardial infarction was anterior
(Anter) in 71 cases (63.39%) and inferior (Infer) in 41, and 87
patients (77.67%) developed Q wave. At the reception 41
(36.60%) patients dead and 16 patients dead at the following 12
months (accumulated mortality at year = 50.89%). Q wave and
anterior myocardial infarction had more mortality, with P < 0.001
and P < 0.05 respectively. At year, the survivors had a mean DAS
8.72 ± 1.89. It was higher in non-Q wave (P < 0.05) and males
(P < 0.05).
The evolution is shown in the Table.
Conclusion: Though the mortality between elderly 80 years old
patients with myocardial infarction is high, they have an
acceptable functional capacity (more in males and non-Q-wave
Patients with MI
P263 Very old patients (older than 85 years) at a medical ICU: indications, interventions, outcome
J Reiger and G Grimm
IInd Medical Department General Hospital, A-9020 Klagenfurt, St. Veiterstrasse 47, Austria
Crit Care 1999, 3 (suppl 1):P263
Objective: The part of elderly people in the population has been
increasing during the last decades. In 1995, 16% of the
MiddleEuropean population have been older than 65 years, up to the year
2010 there should be an increase up to 22%. German
investigations have shown, that a 1/3 of the population older than 65 years
are suffering from 3–4 chronic diseases, 98% of the population
older than 80 years from one chronic disease.
Through those facts the number of old patients admitted to ICUs is
increasing. Aim of following paper was to objective the treatment and
outcome of very old patients (over 85 years) at a medical ICU of a
general hospital over an 18-month period (1997-01-01 to 1998-06-30).
Results and outcome: 899 patients had been admitted to the ICU
during the study period, 48 (5.3%) older than 85 years. At
admission the APACHE II-score ranked between 19 and 32. Indications
had been mainly cardial (27), metabolic (8), gastrointestinal (6),
outside CPR (5) and acute respiratory failure (2). 11 patients had
been mechanical ventilated (1–8 days, mean 2.7 days), 6 patients
received a cardiac pacemaker, 5 underwent endoscopical
interventions, 4 thrombolysis (AMI, 100 mg Alteplase ‘front loaded’), 2
patients PTCA/IABP and one female patient ACBG.
Duration of stay had been 3.8 days (overall 3.9 days), mortality
27.7% (overall 14.8%).
Conclusion: Comorbidity and mortality had been higher in
patients older than 85 years compared to all patients. 6 month after
the ICU stay 24 patients (68.5%) were still alive. With good
quality of life. Despite higher mortality very old patients benefit
from ICU stay and interventions.
P264 Quality control with autopsy on a medical intensive care unit
J Roosen, E Frans, A Wilmer, S Vanderschueren and H Bobbaers
Department of Medical Intensive Care, U.Z. Gasthuisberg, Leuven, Belgium
Postmortem examination is considered as the golden standard for
the evaluation of clinical diagnosis. However due to several
reasons (costs, permission of family members), few medical
centers continue to perform autopsy as a means of quality control.
From 1995 to 1996, we performed an autopsy study in a medical
intensive care unit of a university hospital: 93% of the 140
deceased patients in our medical ICU underwent an autopsy, 100
consecutive patient files were studied.
The clinical diagnosis were made by internists, specialized in
intensive medicine; the diagnosis on autopsy were made by a
pathologist. According to the criteria of Goldman, the clinical
and autopsy findings were categorized into major and minor
diagnoses. A missed diagnosis on clinical grounds was classified as a
class I error (if detected before death, this would probably have
caused a therapeutic change with possible altered outcome) or as a
class II error (if known before death, this diagnosis would not have
led to a change in therapy).
In 16% of the patients, a class I missed diagnosis was detected
(cardiac tamponade, myocardial infarction, fungal pneumonia); in
9%, a class II missed diagnosis was detected (most frequently
tumors). Sometimes the diagnosis was missed due to a
combination of severe, acute problems (e.g. development of cardiac
tamponade after insertion of a venous catheter during hemorraghic
shock), or due to a lack of sensitive and specific investigational
methods (fungal pneumonia is frequently suspected in
immunocompromised patients, but is often difficult to confirm), or due to
logistic transportation problems in the hemodynamically unstable
patient (e.g. retroperitoneal hemorrhage is not always detectable
on bedside echography; for diagnosis, CAT-scan is needed).
Conclusion: Even in the era of increasing diagnostic possibilities,
due to improved medical technologies in the ICU, postmortem
examination still remains useful in detecting unexpected
diagnoses, missed in the premortem clinical evaluation. Our
observations suggested the need for constant alertness and an aggressive
investigational planning in patients with unexplained shock or
P265 Quality of life before and after medical intensive care
M Wehler, R Strauß, A Bost, A Geise, A Müller, M Meyer* and EG Hahn
Department of Medicine I and *Institute of Medical Statistics and Documentation, University of Erlangen-Nuremberg, 91023 Erlangen, Germany
Introduction: We prospectively analysed changes in the quality of
life (QOL) in patients before and 6 months after admission to a
medical intensive care unit (ICU).
Patients and methods: All patients admitted to the ICU were
eligible for inclusion. Patients <18 years and those who died or were
discharged within 24 h of admission were excluded, QOL
measures were collected during interview during the first 24 h of ICU
stay and 6 months after admission using a questionnaire especially
designed for ICU patients developed by the Spanish Group for
Epidemiological Analysis of Critical Care Patients . Baseline
QOL referred to the 2 months prior to admission and were
compared with measures at 6 months using Wilcoxon matched-pairs
test, P < 0.05 was considered statistically significant.
Results: During the first 12 months of the study period 326
patients met the study criteria; mean age was 58 ± 17 (± SD) years,
median 60, range 19–95 years, 55% were male. Mean ICU length
of stay was 10.4 ± 15.1 days, range 2–127 days. Mean APACHE II
score was 23 ± 10, range 0–51. Mean TISS score after 24 h was
33 ± 14, range 0–69. Mortality rates were: ICU 24%, hospital 6%,
9% within the following 6 months after hospital discharge. Up to
now 147 patients completed the questionnaire after 6 months, six
patients (1.8%) were lost to follow-up. Relative to baseline a
significant worsening was noted in the subscale of normal daily
activities (P = 0.013). No significant changes were seen in total QOL
score (P = 0.25) an the subscales of physiologic basic activities
(P = 0.06) and emotional state (P = 0.09). No correlation existed
between APACHE II scores and QOL (r = 033).
Conclusion: Six months after ICU treatment patients had a
significant decrease in the level of their daily activities. Basic physiologic
activities and emotional status are not significantly altered. 90% of
the long-term survivors were living at home and all previously
occupied patients were able to return to their previous profession.
1 Fernandez RR, et al.: Intens Care Med 1996; 22:1034-1042.
P266 Withdrawal of intensive care in the patient’s home
P Williams and S Mann
ICU, Middlemore Hospital, Otahuhu, Auckland, New Zealand
Death should be managed as vigorously as life saving. Historically
intensive therapy is withdrawn in the intensive care unit, but we
would like to present four cases where intensive care treatment
was withdrawn at home. The staff of the Intensive Care Unit at
Middlemore Hospital have taken four patients home, on
ventilatory and inotropic support, and withdrawn care when the patient
was settled in their home, surrounded by family. This is felt to aid
in the grieving process, and in many cases is culturally desirable.
The cases thus far are subarachnoid haemorrhage, massive
intracerbral bleed and intractable septic shock. From our
experience we recommend that certain selection criteria are observed.
There is a need for the patient and family to live locally, support is
required from the local general practitioner and district nursing
service, and a clear explanation of the whole process must be
understood by all family members prior to leaving the intensive
care unit. A palliation plan must be commenced prior to leaving
the intensive care unit.
Dept Anaesthesia & Pain Management, The Alfred, Commercial Road, PRAHRAN, VIC, Australia, 3181. Tel: 613 9276 2851; Fax: 613 9276 2813;
Crit Care 1999, 3 (suppl 1):P267
Three hundred and sixty-seven (67%) of questionnaires on ethical
issues distributed to members of the Australian and New Zealand
Intensive Care Society were returned and included for analysis.
The questionnaire was similar to a questionnaire that had been
distributed to members of the European Society of Intensive Care
Medicine, but adapted and augmented for local use, and provides
a useful comparison of how issues are considered in Australasia.
Intensive Care beds are a limited resource, and availability
restricts admissions. Nonetheless, 76% of respondents admitted
patients with a poor prognosis for survival. There was high (82%)
concordance of what was felt should be done and what was done
in clinical scenarios. Respondents considered that they provided
high information to patients, including in the event of iatrogenic
complication. In terms of end-of-life decisions, 35% of
respondents wrote that they would involve the family in discussions (not
an option available for selection): this appeared to be a pragmatic
approach to dealing with relatives. Withdrawal of treatment was
considered to be different to withholding treatment by 43% of
respondents. 34% of respondents would change a
do-not-resuscitate order that had been previously instituted. 15% of respondents
considered that an Ethics Consultant would assist in their
practice, with 95% supporting the inclusion of ethics teaching during
P268 Withholding and withdrawing life support: national French prospective study
E Ferrand, R Robert, P Ingrand and the LATAREA group
Service de Réanimation Médicale CHU, Poitiers 86021 Poitiers cedex, France
Introduction: Controversies still exists regarding indications of
WH and WD, ethical similarity or difference between WH and
WD, the way to withhold or to withdraw treatments and what
should be the family implications in these decisions
were older and had higher SAPS 2 than the remaining patients.
Decisions of withhold or withdraw were more frequent in patients
with previous chronic diseases or cardiac arrest before admission
in ICU. Futility and the poor expected quality of life were the
most frequently cited reason for WH or WD. Decision to not
ventilate the patient was the most frequently reported withheld
treatment (n = 214; 15%). Vasopressors were either not started or
limited in their dosage in 196 patients (14%). The most frequently
withdrawn life support treatment were vasopressors (19%).
Extrarenal epuration was discontinued in 67 patients (7%). Lowering
FiO2 to 21% was indicated in 155 patients (14.5%), discontinued
ventilation was ordered in 101 patients (9.4%) and extubation was
performed only in 34 patients (3.1%). Withdrawal of hydration was
rarely performed (n = 16 ; 1.5%). 1176 out of the 7309 (16.1%)
included patients died. 628 out 1176 died (53%) after support was
withheld or withdrawn. Most of the time WH or WD was decided
by the medical team. A unique M.D. was involved in the decision
in 37 (12%) of cases. Paramedic (nurses) opinions was taken in
account for the decision in 482 (59.7%). Family was involved in
the process in less than 50%.
Results: Treatments were withheld or withdrawn in 807 out 7309
(11%). WH and WD were indicated in 336 patients (4.6%) and 471
patients (6.4%) respectively. ICU patients undergoing WH or WD
1. Goldman L , Sayson R , Robbins S et al.: The value of the autopsy in three medical eras . N Engl J Med 1983 ; 308 : 1000 - 1005 .
P267 Results of an ethical questionnaire distributed to members of the Australian and New Zealand Intensive Care Society