Proceedings of Réanimation 2017, the French Intensive Care Society International Congress
Ann. Intensive Care
Proceedings of Réanimation 2017, the French Intensive Care Society International Congress
0 Réanimation polyvalente, CHU Habib Bourguiba, Sfax, Tunisia Annals of Intensive Care 2017 , 7(Suppl 1):P144
1 Réanimation polyvalente, Faculté de médecine de Sfax , Sfax , Tunisia
2 P144 Post traumatic cerebral thrombophlebitis: prospective study about 15 cases Chtara Kamilia
3 Inserm cic 1435/urgences/samu, Centre Hospitalier Universitaire de
4 P148 Staphylococcal community‐acquired urinary tract infection in the emergency department: a sign for acute infective endocarditis? Thomas Lafon
5 Urgences/samu, Centre Hospitalier Universitaire de Limoges , Limoges , France
6 Service de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges , Limoges , France
7 Limoges , Limoges , France
8 Inserm cic1435/ service de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges, Limoges, France Annals of Intensive Care 2017 , 7(Suppl 1):P148
9 Bactériologiev‐irologie‐hygiène/umr‐s 1092, Centre Hospitalier Universitaire de Limoges , Limoges , France
10 Service de maladies infectieuses, Centre Hospitalier Universitaire de Limoges , Limoges , France
11 Réanimation polyvalente adulte, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France Annals of Intensive Care 2017 , 7(Suppl 1):P157
12 Unité de microbiologie clinique et dosages des anti‐infectieux, Groupe Hospi‐ talier Paris SaintJ‐oseph , Paris , France
13 Réanimation, Groupe Hospitalier Paris SaintJ‐oseph , Paris , France
14 P157 Clinical impact of extended‐spectrum
15 lactamase producing Enterobacteriaceae colonization on pneumonia in ICU Caroline Schimpf
16 Department of biology, Centre d'Assistance Médicale Urgente, Tunis, Tunisia Annals of Intensive Care 2017 , 7(Suppl 1):P160
17 Department of intensive care and toxicology, Centre d'Assistance Médi‐ cale Urgente , Tunis , Tunisia
18 P160 Carbapenemase‐producing Enterobacteriaceae: experience of a Tunisian intensive care unit Amira Ben Jazia
19 Réanima‐ tion médicale, CHU Farhat Hached. Research Laboratory N° LR14ES05. Faculty of Medicine, Sousse, Tunisia com Annals of Intensive Care 2017 , 7(Suppl 1):P172
20 Réanimation médicale , CHU Farhat Hached, Sousse , Tunisia
21 P172 Effects of early use of diuretics in patients at risk of acute renal failure and oliguria Narjess Ben Aicha
22 Service de réanimation, centre d'assistance médicale‐urgente, Tunis, Tunisia Annals of Intensive Care 2017 , 7(Suppl 1):P176
23 Department of intensive care and toxicology, Centre d'Assistance Médi‐ cale Urgente , Tunis , Tunisia
24 P176 Early versus late‐onset ventilator‐associated pneumonia: causative pathogens and resistance profiles Hend Ben Lakhal
25 Neuro‐ muscular reference centrer, Cliniques universitaires Saint‐Luc, Université catholique de Louvain , Brussels , Belgium
26 Institute of neuroscience, Université catholique de Louvain , Louvain‐la‐Neuve , Belgium
27 Intensive care unit, Cliniques universitaires Saint‐Luc, Université catholique de Louvain , Bruxelles , Belgium
28 O81 Physical therapy during the early course of sepsis is safe and preserves skeletal muscle mass Cheryl Hickmann
29 Department of physical medicine and rehabilitation, Cliniques universitaires Saint‐Luc, Université catholique de Louvain , Brussels , Belgium Annals of Intensive Care 2017 , 7(Suppl 1):O81
Introduction Head injury is a rare but possible etiology of cerebral
thrombophlebitis. The diagnosis should be considered especially in
front of open head injuries extended to venous sinuses. The MR
angiography is the gold standard for early diagnosis.
Patients and methods This is a descriptive prospective study of all
trauma patients hospitalized in the intensive care unit of the
University Hospital Habib Bourguiba Sfax over a period of 6 years between
January 2010 and June 2016 and in whom the diagnosis of cerebral
venous thrombophlebitis has been confirmed by angiography CT or MR
Results During the period study, 15 patients were included. The
median age of patients was 29 [17–49] years. All patients were male,
victims of poly trauma following an accident of traffic. In admission,
SAPSII was 31 [24–52] and SOFA was 4 [2–8]. We have noted the
presence of a serious head injury in 15 patients, extended open skull
fractures of the venous sinus in 9 patients. A related chest trauma was
present in 12 patients and abdominal trauma in 4 patients, trauma
of the pelvis and/or members were present in 7 patients. All patients
underwent mechanical ventilation. The diagnosis of cerebral venous
thrombosis was confirmed by cerebral angiography CT in 9 patients
and cerebral MR angiography in 6 patients. 7 patients have presented
secondary pulmonary embolism. All patients did not show a
contraindication against anticoagulation at diagnosis of thrombophlebitis. The
thrombophilia (antithrombin III, protein C and S, homocysteine, and
antiphospholipid, gene mutation factors II and V) as well as for
antineutrophil cytoplasmic antibodies were negative in all patients. The
outcome was favorable in 13 patients. Two patients were died due to a
state of refractory septic shock.
Discussion Post traumatic cerebral thrombophlebitis is a rare
thrombotic vascular disease. It must be mentioned especially
with presence of extensive skull fractures in open sinuses. Venous
MR angiography is the gold standard. The treatment is based on
anticoagulation curative dose. Its prescription can be complicated in
these cases associated with traumatic intracranial hemorrhage.
Conclusion Head injury is a rare but possible etiology of cerebral
thrombophlebitis. Other prospective studies are needed to better
understand the path physiology and the prognosis of these
Pain measurement in mechanically ventilated patients
with traumatic brain injury: behavioral pain tools
versus analgesia/nociception index—preliminary results
Ali Jendoubi1, Ahmed Abbes,1, Houda Belhaouane,1, Oussama Nasri,1,
Layla Jenzri,1, Salma Ghedira2, Mohamed Houissa2
1Anesthesia and Intensive Care, Charles Nicolle Teaching Hospital, Tunis,
Tunisia; 2 Intensive care, Charles Nicolle Hospital, Tunis, Tunisia
Correspondence: Ali Jendoubi ‑
Annals of Intensive Care 2017, 7(Suppl 1):P145
Introduction Pain is highly prevalent in critically ill trauma patients
especially those with a traumatic brain injury (TBI). Behavioral
pain tools such as the Behavioral pain scale (BPS), and critical
care pain observation tool (CPOT) are recommended for sedated
non-communicative patients. The analgesia nociception index
(ANI) assesses the relative parasympathetic tone as a surrogate
for antinociception/nociception balance in sedated patients. The
primary aim is to evaluate the effectiveness of ANI in detecting pain
in TBI patients. The secondary aim was to evaluate the impact of
Norepinephrine use on ANI effectiveness, and to determine the
correlation between ANI and BPS.
Patients and methods We performed a prospective observational
study in 21 deeply sedated TBI patients. Exclusion criteria were
nonsinus cardiac rhythm; presence of pacemaker; atropine or isoprenaline
treatment; neuromuscular blocking agents and major cognitive
impairment. HR, blood pressure and ANI were continuously recorded
using the Physiodoloris® device at rest (T1), during (T2) and after the
end (T3) of the painful stimulus (tracheal suctioning).
Results In total, 100 observations were scored. Patients’ characteristics
were resumed in Fig. 1. ANI was significantly lower at T2 (Med (min–max)
54.5 (22–100)) compared with T1 (90.5 (50–100), p < 0.0001) and T3 (82
(36–100), p < 0.0001). Similar results were found in the subgroups of
patients with (65 measurements) or without (35) Norepinephrine.
During procedure, A negative linear relationship was observed between ANI
and BPS (r2 = −0.469, p < 0.001). At the threshold of 50, the sensitivity
and specificity of ANI to detect patients with BPS ≥ 5 were 73 and 62%,
respectively with a negative predictive value of 86%.
Conclusion ANI is effective in detecting pain in deeply sedated
critically ill TBI patients, including those patients treated with
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Fig. 1 Baseline demographic and clinical characteristics. Values
are expressed as mean ± standard deviation (SD); n (%) or median
[interquartile range]. EDH extradural haemorrhage SDH subdural
haemorrhage, SAH subarachnoid hemorrhage
The prognosis of cervical spine trauma in elderly subjects
in surgical intensive care
Kamal Belkadi1, Ma Bouhouri2, Youness Harti3, Afak Nsiri2, Khalid Khaleq4,
Driss Hamoudi2, Rachid Harrar2
1Anesthesie reanimation, chu ibn rochd, Casablanca, Morocco; 2Reanima‑
tion des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco;
3Anesthésie réanimation, CHU Ibn Rochd Casa, Casablanca, Morocco;
4Service d’accueil des urgences, Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Kamal Belkadi ‑
Annals of Intensive Care 2017, 7(Suppl 1):P146
Introduction The aim of our study was to assess the prognostic factors
of cervical spine trauma in elderly subjects admitted in the surgical
intensive care unit.
Patients and methods We conducted a retrospective, and
singlecenter study over 16 years (January 2000–January 2016) in Ibn Rochd
hospital, we included all patients aged over 65 years with isolated
cervical spine trauma, operated and non-operated, admitted in
surgical intensive care, the death risk factors were searched by uni and
Results 198 patients were collected, the average age was
69.4 ± 3.9 years, with a male predominance 70.2%, the main causes
were road accidents (50.5%) and fall (34.3%), 68.2% had a complete
form (Frankel A), 75.7% were operated. The death rate in our study was
55%. The prognostic factors in univariate analysis were: hypertension,
heart disease, fall injury, surgical delay >10 h; independent factors of
death in multivariate analysis: heart disease and fall injury.
Conclusion The cervical spine trauma in elderly patients hospitalized
in intensive care unit is poor prognosis.
Interest of the urine antigen testing for Legionella pneumophila
in the management of severe acute pneumonia: practice survey
and analysis of performance in intensive care unit
Camille Thieffry1, Frédéric Wallet2, Erika Parmentier‑Decrucq 1, Raphaël
Favory1, Daniel Mathieu1, Julien Poissy1
1Pôle de réanimation, hôpital salengro, C.H.R.U. ‑ Lille, Avenue Oscar Lam‑
bret, Lille, France, Lille, France; 2 Centre de biologie pathologie génétique,
Centre Hospitalier Régional Universitaire de Lille, Lille, France
Correspondence: Julien Poissy ‑
Annals of Intensive Care 2017, 7(Suppl 1):P147
Introduction Legionnaire’s disease is a rare but severe acute
pneumonia with a difficult definitive diagnosis. Legionella’s urine
antigen testing is a quick, sensitive and specific test, widely prescribed
in the case of an acute and severe community-acquired pneumonia.
However, its overall contribution to the diagnosis of atypical
pneumonia remains unknown in daily practice. The aims of this study
were to evaluate the usefulness of this test in a “real life” utilization and
to identify potential clinical markers of legionnaire’s disease in order
to optimize its prescription. Legionnaire’s disease is a rare but severe
acute pneumonia with a difficult definitive diagnosis. Legionella’s
urine antigen testing is a quick, sensitive and specific test, widely
prescribed in the case of an acute and severe community-acquired
pneumonia. However, its overall contribution to the diagnosis of
atypical pneumonia remains unknown in daily practice. The aims of
this study were to evaluate the usefulness of this test in a “real life”
utilization and to identify potential clinical markers of legionnaire’s
disease in order to optimize its prescription.
Patients and methods We conducted a retrospective, monocentric
and observational study. All the prescriptions of the urine antigen
testing where monitored in the intensive care department and the
emergency room admitting severe patients, in our University Teaching
Hospital, from January 1st 2013 to December 31st 2015. Qualitative
variables were compared by a Fischer’s exact test, and quantitative
variables by a Mann–Whitney test. All tests were bilateral, and p ≤ 0.05
was considered as significant. ROC curves were determined for the
variables of interest.
Results During the period of the survey, 1142 urinary tests were
performed in 1002 patients. Three tests were positive for 0.26% of
patients. Only 569 patients suffered from an actual pneumonia.
Other patients suffered mostly from acute bronchitis (137 cases),
and exacerbation of chronic obstructive pulmonary disease
(123 cases). The characteristics of the 3 patients suffering from
legionnaire’s disease differed significantly compared to the other
kinds of acute pneumonia for: the need for invasive mechanical
ventilation (100 vs 34.96% of patients; p = 0.043), PaO2/FiO2
ratio (107.5 vs 274.5; p = 0.0107), duration of mechanical ventilation
(27.5 vs 2.5 days; p = 0.0062), natremia (129.5 vs 138 mmol/l;
p = 0.0125), Creatine Phospho-Kinase level (16,125 vs 106UI;
p = 0.0225) and Serum Glutamat Oxalacetat Transaminase (251 vs
35UI; p = 0.0157). We determined ROC curves for these last biological
variables. Natremia: better threshold = 131, Se/Sp = 100/84.2%,
AUC = 0.92. SGOT: better threshold = 191, Se/Sp = 100/89.6%,
AUC = 0.9. CPK: better threshold 195, Se/Sp = 100/66.5, AUC = 0.88.
Discussion Urine antigen testing for Legionnaire’s disease appears to
be over-prescribed in many cases with a very poor level of positivity
in our cohort. However, it could be limited to patients exhibiting a
pneumonia, and among them to patients with the classical biological
perturbations described in this disease, which have excellent
diagnostic performance. This targeted strategy would present an
important benefit in term of costs.
Conclusion Our results show that a better selection in the patients
who could benefit of this test is mandatory. Simples markers in routine
testings could help the clinician to adapt his prescription, optimizing
this test’s efficiency.
Introduction Urinary tract infection is a frequent cause of admission
at the Emergency Department (ED). Most prevalent bacteria are
usually gram-negative bacilli and Staphylococcus aureus (Sa) is rarely
evidenced (2.5%) except in hospital-acquired infections due to urinary
catheter . Bacteriuria can be observed in Sa infective endocarditis
(IE) because of the metastatic properties of Sa. We hypothesized
that presence of Sa in the urine could be related to Staphylococcal
bacteremia associated with unsuspected IE and not only the
expression of a “usual” urinary tract infection.
Patients and methods This is a descriptive single-center study
conducted over a 10 year-period in the Teaching Hospital of Limoges.
All patients admitted to the ED with Sa (both MSSA and MRSA) isolated
from their urine cultures were retrospectively analyzed. Data were
collected from the database of the microbiology department and the
patient medical charts. We secondarily searched if a Sa IE had been
documented in patients with Sa isolated from their blood cultures in
order to establish a link between IE and presence of Sa in the urine. We
used modified Dukes criteria as diagnostic criteria of IE .
Results Between 2005 and 2015, 420,000 patients were admitted
in the ED. Out of the 204 records analyzed, 174 patients whose urine
culture grew Sa were excluded because they had a urinary catheter
(n = 75) or sterile blood cultures (n = 99). Finally, 30 patients were
studied (17 men; median age: 73 years; diabetes: n = 7; mitral valvular
disease: n = 2, aortic valvular disease: n = 2) (Table 1). Reasons for
admission were markedly heterogeneous and fever accounted for 14
cases. Echocardiography was performed in 25 patients with a median
delay of 6.5 days (range: 0–23 days) and IE was confirmed in 21 of
them. Only three cases of IE have been diagnosed in the ED because
of a fever and valvular murmur (n = 2) but no patient was admitted
to the ED for IE suspicion. Other initially suspected diagnoses were
prostatitis, pneumonia or appendicitis and not related to any type
Table 1 Patients characteristics
Congenital heart valve defect
Skin and eye petechiae
of infection in 26% of the cases. The origin of Sa bacteremia was
cutaneous in 67% of the cases. During the hospital stay, 70% of the
patients presented secondary sites of Sa infection in addition to the
urinary tract (arthritis, splenic abcess, cerebral hematoma). Among 21
patients presenting with an IE, 8 died within 7 days, and total hospital
mortality reached 50%.
Conclusion This case series suggests that IE should be ruled out when
Sa bacteriuria is evidenced, irrespective of the clinical presentation.
This could question the reality of isolated community-acquired urinary
tract infections due to Sa.
The infectious tricuspid endocarditis in ICU: clinical features,
management and outcome
Amira Jamoussi1, Amira Ben Jazia1, Takoua Marhbène1, Dhouha Lakh‑
dhar1, Jalila Ben Khelil1, Mohamed Besbes1
1Medical icu, Hospital Abderrahmen Mami De Pneumo‑Phtisiologie,
Correspondence: Amira Jamoussi ‑
Annals of Intensive Care 2017, 7(Suppl 1):P149
Introduction Since the outbreak scourge of intravenous drug
addiction in Tunisia, we are witnessing the emergence of cases of
infectious tricuspid endocarditis (ITE). This pathology should be
studied because it requires specific medical and surgical management.
The aim of the study was to describe the clinical features, management
and outcome of ITE in intensive care unit.
Patients and methods This was a retrospective study from January
2009 to December 2014. We enrolled patients who were hospitalized
in intensive care unit and had ITE. We recorded baseline characteristics,
management and outcome.
Results During the study period, we collected 10 cases of ITE making
an incidence rate of 3 cases for 1000 patient admissions. They were
divided into 8 men and 2 women. The median age was of 37.5 years.
The main reasons of ICU admission was acute respiratory failure (80%),
among them 5 required mechanical ventilation. Hemodynamic failure
was present in 3 cases.
The median SAPS II was of 33 [19–90]. The median APACHE II was of
17 [7–53]. Different contributing factors were identified: intravenous
drug abuse (6 patients), a central venous catheter (1 patient) and a
pacemaker (1 patient).
All patients underwent transesophageal echocardiography showing
one or several vegetations on native tricuspid valve. No associated left
endocarditis was found.
Blood cultures were positive in 8 cases of which 5 contained 2
different micro-organisms. The identified micro-organisms were:
Meticillin Resistant Staphylococcus aureus (n = 6), Meticillin Sensitive
Staphylococcus aureus (n = 3), coagulase-negative staphylococcus
(n = 2), Enterobacter cloacae (n = 1), and candida famata (n = 1).
Occurring complications were hospital-acquired infections (n = 5),
septic pulmonary embolism (n = 4), withdrawal syndrome (5 cases),
acute renal failure (n = 2) and atrioventricular block (n = 2).
Medical treatment consisted of a double antibiotic treatment. Surgical
treatment was required in 7 patients: tricuspid valve replacement by
bioprosthesis (6 cases) and valvuloplasty (1 case).
The average length of stay was of 31.3 days [2–56]. ITE had recurred on
bioprotheses in two patients after intravenous drug resumption; they
underwent surgery again and one of them died.
In hospital mortality was of 30%. The outcome was favorable in 7
Conclusion The ITE in ICU is a severe disease with frequent
complications and in hospital mortality reaches 30%. The most frequent
incriminated micro-organism is Meticillin Resistant Staphylococcus aureus.
It often requires medical and surgical treatment. Intravenous drug
addiction remains the most common cause and worsens the
prognosis by the risk of recurrence.
Microbiological mapping of community‑acquired intra‑abdominal
infections (IAI) and indicator of local antibiotherapy
appropriateness with French national guidelines
Julien Goutay1, Caroline Blazejewski2, Isabelle Joly‑Durand 3, Isabelle
Pirlet4, Marie Pierre Weillaert5, Sebastien Beague2
1Interne en anesthésie réanimation, C.H. Régional Universitaire de Lille
(CHRU de Lille), Lille, France; 2Réanimation polyvalente, Hospital Center
De Dunkerque, Dunkerque, France; 3Equipe opérationnelle d’hygiene,
Hospital Center De Dunkerque, Dunkerque, France; 4Service de chirurgie
digestive, Hospital Center De Dunkerque, Dunkerque, France; 5Labora‑
toire, Hospital Center De Dunkerque, Dunkerque, France
Correspondence: Julien Goutay ‑
Annals of Intensive Care 2017, 7(Suppl 1):P150
Introduction French guidelines for community-acquired IAI underline
the importance of establishing antibiotherapy protocols based
on regular analysis of microbiological data; and of systematic site
infection cultures to determine microbial sensitivity to antibiotics.
Our study describes microbial population involved in our
communityacquired IAI and defines an annual follow-up indicator of probabilistic
antibiotherapy inadequacy to microbial sensitivity.
Materials and methods We conducted a retrospective, monocentric,
observational study from January the 1st 2014 to December the 31st
2015. All community-acquired IAI in adults were included. Exclusion
criteria were: cirrhosis and peritoneal dialysis. Initial probabilistic
antibiotherapy and total antibiotherapy duration were left to the
discretion of the physician in charge. Results of intra-abdominal
cultures (IAC) were analyzed. Three microbial groups were defined:
(A) A-group: wild-type bacteria strains treated with adequat
antibiotherapy; (B) B-group: antibiotic resistant bacteria treated with
adequat antibiotherapy; (C) C-group: multi-drug resistant bacteria
treated with inadequat antibiotherapy. A Chi square analysis was
performed on SPSS software (IBM).
Results 98 community-acquired IAI were included: 54 (55%) had
positive IAC with 133 bacteria; 34 (35%) didn’t have intra-abdominal
swab; 10 (10%) had sterile cultures. Predominant strains were
Gramnegative bacteria (76/133 (57%)). More represented bacteria were
Escherichia Coli (50/133 (38%)) and Bacteroïdes fragilis (16/133 (12%)).
127/133 (95%) bacteria belong to A- and B-groups. B-group importance
increased significantly between 2015 and 2016. C-group characteristics
were comparable over the 2 years. Initial antibiotherapy was inadequate
with French guidelines in 38/98 (39%) cases and with microbial
antibiotic susceptibility in 6/133 (4.5%) cases (C-group). Average
antibiotherapy duration was 11.3 days. Antibiotic treatment duration
was too long according to French guidelines for 65/98 (67%) patients.
Discussion Our microbial population in community-acquired IAI is
similar to national studies with a lowest resistance rate (C-group under
10%). Probabilistic antibiotherapy proposed by French guidelines is
appropriated to our microbial ecology. Antibiotherapy duration is
unconformed with guidelines in 67% cases. Peroperative swabs are
frequently missing (35%). Non-compliance with French guidelines
highlights the importance to formalize our local procedure. This
formalization at any stage (surgical, medical and biological cares)
seems essential to improve our standard of care. C-group rate could be
used as a real-time feedback to adapt our protocol continuously.
Conclusion The goal of our study is to improve local standard of care
by offering a formalization of community-acquired IAI management
procedure. C-group rate seems to be a good follow-up indicator of
probabilistic antibiotherapy inadequacy to microbial sensitivity,
allowing an optimization of our protocol in real-time.
1. Montravers et al. Recommandations Formalisées d’Experts «Prise en charge des infections intra‑abdominales», Octobre 2015.
The resumption of peritonitis in surgical intensive care unit
Ma Bouhouri1, Kamal Belkadi2, Soufi Aziz1, Khalid Khaleq3, Afak Nsiri1, Driss
Hamoudi1, Rachid Harrar1
1Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca,
Morocco; 2Anesthesie reanimation, chu ibn rochd, Casablanca, Morocco;
3Service d’accueil des urgences, Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Kamal Belkadi ‑
Annals of Intensive Care 2017, 7(Suppl 1):P151
Introduction The resumption of peritonitis is a serious complication of
abdominal and pelvic surgery. It’s a medical and surgical emergency,
the prognosis depends on the speed, the quality of the care, and the
underlying terrain and etiology.
Patients and methods We conducted a descriptive analytic
retrospective study over a period of 5 years (January 2011–June 2016)
60 cases of peritonitis hospitalized in surgical intensive care unit.
Results The average age of our patients was 44.36 years with a sex
ratio of 1.5 (36H/24F). The most frequent risk factors were: factors
relating to the ground, and factors related to the initial peritonitis.
Clinical signs were dominated by fever (75%), abdominal pain (52%).
The period of the average recovery was 8.2 days. The decision of the
surgical revision was based on a clinical, biological and radiological
40 patients in our series, 67% of cases were taken on clinical and
biological criteria while 15 patients 25% were taken on radiological
criteria. In 8% of the remaining cases, the potential severity of the clinical
and biological state in association with an inconclusive ultrasound, led
The therapeutic treatment was based on a perioperative resuscitation,
treatment of organ failure, empirical antibiotic therapy and by midline
laparotomy surgery. Bacteriological samples performed
intraoperatively allowed to have the following bacteriological profile:
predominance of BGN (79%) dominated by E. coli (28%) followed by Klebsiella
pneumoniae (21%), Acinetobacter and Enterococcus baumanii (12%).
The multimicrobien character was found in 55%. The E. coli–Klebsiella
pneumoniae association was the most frequent (37%).
The anastomotic dehiscence was the direct cause of the most common
surgical revision found intraoperative (62%). The average hospital stay
was 8 days. The mortality rate was 61%. The main prognostic factors in
our study emerged in the univariate analysis were: kidney failure, the
number of organ failure, a TP <50% the needs of ventilation and the
use of catecholamines.
Discussion Mortality is variable depending on the studies, between
25 and 60%.
Conclusion The diagnosis often difficult. Only effective and early
therapeutic management reduces mortality remains high in recent
years despite the various advances in the field of surgery and
Prognostic factors in intra abdominal sepsis: a prospective study
Reda Hafiane1, Khalid Khaleq1, Khalid Hattabi2, Mohamed Aziz Bouhouri1,
Afak Nsiri1, Driss Hammoudi1, Abdelaziz Fadil2, Rachid Al Harrar1
1Service de réanimation des urgences chirurgicales, CHU IBN ROCHD de
Casablanca, casablanca, Morocco; 2Service des urgences viscérales, CHU
Ibn Rochd de casablanca, Casablanca, Morocco
Correspondence: Reda Hafiane ‑
Annals of Intensive Care 2017, 7(Suppl 1):P152
Table 2 Main prognostic factors in intra abdominal sepsis
Pesence of clammy skin
Hemodynamic instability 26
Use of vasoactive drugs
Community acquired intra abdominal sepsis: concerning 302
Reda Hafiane1, Khalid Khaleq1, Khalid Hattabi2, Mohamed Aziz Bouhouri1,
Afak Nsiri1, Driss Hammoudi1, Khalid Zerouali3, Abdelaziz Fadil2, Rachid Al
1Service de réanimation des urgences chirurgicales, CHU IBN ROCHD de
Casablanca, casablanca, Morocco; 2 Service des urgences viscérales, CHU
Ibn Rochd de casablanca, Casablanca, Morocco; 3Service de microbiol‑
ogie, CHU Ibn Rochd de casablanca, Casablanca, Morocco
Correspondence: Reda Hafiane ‑
Annals of Intensive Care 2017, 7(Suppl 1):P153
Introduction Intra abdominal sepsis is a dangerous condition causing
a high mortality rate even with surgery and post operative care
The aim of the study is to assess the bacteriological and
epidemiological profile of this population.
Patients and methods It’s a prospective observational study
performed during 6 months (02/2016–08/2016) in visceral emergency
Inclusion criteria: adults admitted with intra-abdominal infectious
disease diagnosed with biological and radiological means.
Exclusion criteria: post operative peritonitis and deceased patients
before their admittance.
Studied parameters: demographic data (gender, age…), the time
management, co morbidities, number of organ failure, intraoperative
incidents and postoperative evolution.
Results During this period, we admitted 302 patients, the mean age:
41.14 ± 17 years. Male predominance was noticed in our population:
Main emergencies are reported in the attached Table 3. Concerning
the bacteriological profile: we had 121 positive samplings.
Enterobacterias were the most frequent strain. E coli was predominant:
43%, Enterococcus faecalis: 25%, Streptococcus (viridians and
acidominimus): 14%, we had 1 case of Acinetobacter baumanii resistant
to imipenem. 6 cases of yeasts were found (Candida albicans).
Antibiotic use was: Ampicilline: 44%, Ceftriaxone 41%, metronidazole:
76% and tazocilline: 4%.
Discussion In our context, community acquired intra abdominal
sepsis leads to a high death rate. We noticed relevant parameters: a late
time management, high gravity scores, some surgical procedures not
directed by supervisors. Therefore, we have to establish therapeutic
protocols tailored to each disease in order to improve patients’
management and help to reduce the mortality rate.
Conclusion Early diagnosis and care for intra abdominal sepsis
represent a major way to prevent complications. Bacteriological proof is
necessary to adjust post operative antibiotherapy.
Introduction Intra- abdominal sepsis represents a life threatening
condition. Its manifestations are non specific and can quickly lead
to multi organ failure if not treated correctly. Patient’s assessment
is essential in order to adjust the therapy. The aim of our study is to
highlight the prognostic factors in this situation.
Patients and methods It’s a prospective observational study
performed during 6 months (02/2016–08/2016) in visceral emergency
Inclusion criteria: adults admitted with intra-abdominal infectious
disease diagnosed with biological and radiological means.
Studied parameters: demographic data, co morbidities, number
of organ failure, type of anesthesia, intraoperative incidents and
evolution. Results were analyzed using SPSS software, prognostic
factors were extracted with univariate then multivariate analysis.
Significant results were noted.
Results During this period, we admitted 302 patients, the mean age:
41.14 ± 17 years. Male predominance was noticed in our population:
69.9%. The mortality rate was: 13.2%.
The main prognostic factors were reported in the attached Table 2.
Discussion Many significant prognostic factors were identified:
Age, existence of hemodynamic failure with renal involvement, long
operative time and the use of vasoactive drugs.
A high hemoglobin level at the admission was a protective factor.
The presence of respiratory distress, the sex and the presence of yeasts
were not significant factors in our study.
Conclusion Intra abdominal sepsis is causing quickly a multi organ
dysfunction syndrome leading to death. Therefore, our priority is to
stop this sepsis with the help of the surgeon and the efficient use of
Table 3 Main emergencies with epidemiological profile
Peptic perforation peritonitis
intestinal perforation peritonitis
Conformity of antibiotic prescribing in emergency room
Fatma Kaaniche Medhioub1, Rania Allela2, Najla Ben Algia3, Samar Cherif4
1Faculté de médecine de Sfax, Sfax, Tunisia; 2Hopital régional mahres, Fac‑
ulté de médecine de Sfax, Sfax, Tunisia; 3Intensive care, hopital régional
Gafsa, Sfax, Tunisia; 4Intensive care, hopital régional mahres, Sfax, Tunisia
Correspondence: Fatma Kaaniche Medhioub ‑
Annals of Intensive Care 2017, 7(Suppl 1):P154
Introduction The development of bacterial resistance is a major
public health problem due to unreasonable use of antibiotics. The
introduction of appropriate antibiotic therapy has a positive impact
on patient survival and a significant economic impact. The objective
of this study is to evaluate the compliance of antibiotics prescribed in
Patients and methods Prospective study conducted on 1 year
(01/01/2015–31/12/2015). We have included patients admitted to
the emergency with hyperthermia (>38°), hypothermia (<36°) or two
criteria of systemic inflammatory response syndrome. Were collected
in the emergency department: history, presence of prior antibiotic
therapy, demographic and clinical characteristics at admission,
prescription of antibiotics in emergencies and its modalities and
the discharge diagnosis. During hospitalization were collected: the
introduction, modification or discontinuation of the antibiotic, the
reasons for this change and certainty diagnosis. The compliance
analysis of antibiotic therapy was performed by an expert group
(two infectiologists, a bacteriologist and an emergency doctor) with
regard to the current recommendations. Two groups were defined and
compared: group of patients receiving complies antibiotic therapy and
group with antibiotics considered improper. The criteria associated
with non-compliance were sought.
Results Four hundred and twenty-two patients were enrolled. The
final diagnosis retained an infectious etiology in 356 patients (84%).
The mean age was 62.4 ± 18 years. Blood cultures were taken in 370
cases (87.7%). Infectious sites were most often lung (52%) and urine
(32%). Severe sepsis was diagnosed in 14 patients (3.3%). A complies
prescription was found in 335 patients (79.4%). Antibiotic therapy
was started in 302 patients (71.5%) at the emergency and classified
complies with 234 (55.4%). Among the 68 patients (16.1%) with an
illegal antibiotic, it was continued in 24 (35.3%) during hospitalization.
Among 120 patients (28.4%) did not receive antibiotics, this attitude
was classified complies in 115 patients (95.8%). Non-compliance was
related to the presence of antibiotics in the last 3 months and the
presence of renal failure.
Conclusion Particular attention should be paid to the antibiotic
prescription in patients subject to prior exposure to these. Dose
adjustments should be respected in cases of renal failure. Regular
evaluation of the antibiotic prescription in the emergency is necessary.
Pulmonary resections’ bacterial cartography
Mohamed Taoufik Slaoui1, Souhail Boubia2, Y. Hafiani1, A. Khaoudi1, R.
Cherkab1, W. Elallam1, C. Elkettani1, L. Barrou.1, M. Ridaii2
1Anesthesia service surgical resuscitation, chu ibn rochd, Casablanca,
Morocco; 2 Thoracic surgery, chu ibn rochd, Casablanca, Morocco
Correspondence: Mohamed Taoufik Slaoui ‑
Annals of Intensive Care 2017, 7(Suppl 1):P155
Introduction The study of the bacterial cartography in thoracic
surgery is extremely important for the treatment of post-operative
infections due to the severity of the underlying pathology, the fragility
of patients after surgery in addition to the choice of the empiric
Materials and methods We led a prospective study following all the
patients who underwent a pulmonary resection surgery for a period
of 7 months from January to July 2016, jointly with the microbiology
department, CHU Ibn Rochd, Casablanca. The bronchial secretions
were collected by a protected distal bronchial sample using a
(Combicath) after the intubation.
Results During the period of the study, 92 patients underwent a
pulmonary resection, 65% for a neoplastic pathology.
The medium age was 43 years ±8 and 58% of our sample were
male. 48% of our patients had smoking habits and 16 of them had
pulmonary tuberculosis, 12 had repeated respiratory infections.
The antibiotics used in pre-operative: 58% of beta-lactams; 22% of
fluoroquinolones; 5% of macrolides.
Moreover, 60% of our patients were classified ASA1.
Of the 92 obtained samples, 22 were positive (23.9%). The most
frequently observed germs were the Acinetobacter baumannii (8.7%),
Pseudomonas aeruginosa (6.5%), Klebsiella pneumoniae (4.3%),
Staphylococcus aureus (4.3%). The Acinetobacter baumannii was the
most resistant germ (60% sensibility to carbapenem).
These patients were followed until their D30 after surgery, 12 of them
developed a post-operative pneumonitis with 4 cases of
multi-resistant Acinetobacter Baumanii, 2 of which deceased.
Conclusion Pneumonitis after pulmonary resection are common and
severe that’s why it is necessary to establish a global prevention
strategy mainly based on general patricians and pneumologists’ awareness
concerning the choice of the prescribed antibiotics, in order to avoid
the spread of multi-resistant germs.
Introduction Infection is a major cause of morbidity and mortality
in burned. The bacterial ecology varies among centers. Despite the
progress in the management of severe burned, mortality remains very
high. The aim of this study is to establish the pathogenic profile of AB
in this population.
Materials and methods Single-center retrospective study of
7 months, including any serious burned hospitalized for more than
48 h in intensive care, and who benefited from bacteriological samples
during his stay.
Infectivity was retained on a range of clinical and biological arguments
(CDC criteria) changed). They excluded all burned died for
noninfectious causes, and patients with isolated settlement.
Results Sixty-two (72) patients were infected by the AB during
our study period. The sex ratio (M/F) was 1.7 and the mean age was
39 ± 23 years. Nosocomial pneumonia was present in 61.11% of cases.
Urinary tract infection was present in 18.05% of cases. Bacteremia was
present in 12.5% of cases. Skin infection was present 8.33% of cases.
The resistance profile was marked by 100% of cases of resistance to
third-generation cephalosporins (C3G), 88% of cases of resistance to
fluoro-quinolones (FQ), 74% of cases of resistance to imipenem and
64, 28% of cases of resistance to tigecycline.
Conclusion The incidence of infection with Acinetobacter baumannii
in our unit remains high compared to that of intensive care units.
Colonization and infection by the AB are significantly associated
with increased length of stay, and mortality, and given the gravity of
hospitalized patients, failure to comply with hygiene and abusive use
of antibiotic prophylaxis.
Introduction ESBL are enzymes mostly found in Enterobacteriaceae
and confer resistance to all beta lactams antibiotics except cefoxitin
and carbapenems. Recently, a significant increase in the rate of
ESBLrelated infections in ICU makes difficult the choice of empiric antibiotic
therapy, especially in patients colonized by extended-spectrum
β-lactamase producing Enterobacteriaceae (ESBLe) . Notably,
very few data are currently available regarding the role of ESBLe
colonization on further pneumonia involving the same bacteria .
The aim of our study was to describe the incidence of ESBLe infections
among ESBLe-colonized ICU patients.
Patients and methods This study was conducted retrospectively from
January 1st 2011 to May 1st 2016, in our intensive care department. All
admitted ESBLe-colonized patients who develop an infection during their
ICU stay have been included in the study. The only exclusion criterion was
an antibiotic treatment for an ESBLe infection at ICU admission.
Results During the period of the study, 386 stays were associated with
an ESBLe colonization in 384 patients. 148 infections were diagnosed in
patients colonized by ESBLe, among which 78 pneumonias. In 18 cases
(23%) the ESBLe was involved in the pulmonary infection (PN-ESBLe+)
and was the only responsible bacterium in 66% of cases. The ESBLe
was the same in screening and pneumonia in 15 cases (83%). The
PN-ESBLe+ was associated with septic shock in 9 (50%) cases, acute
respiratory distress syndrome in 2 (11%) cases and neurologic failure
in 7 (39%) cases. Episodes were ventilator-associated pneumonia in
56% (10 cases) of PN-ESBLe+ and 52% (31 cases) of PN-ESLBe-. The
most common pathogens involved were Escherichia coli, Klebsiella
pneumoniae, and Enterobacter cloacae in both groups. Comparing
groups (PN-ESBLe+ or PN-ESLBe−), only the notion of prior antibiotic
therapy within 30 days (OR 3.9 [1.07–18.3]; p = 0.03) and colonization
by ESBL Klebsiella pneumoniae (OR 4.04 [1.02–16.1]; p = 0.04) were
more frequent in PN-ESBLe+. At least one empiric antibiotic was
effective on the ESBLe in 83% of cases. In vitro antibiotic susceptibility
tests demonstrate 100% efficiency of the association of piperacillin/
tazobactam and amikacin on ESBLe involved in pneumonia.
Mortality at day 28 was 24% for PN-ESBLe+ and 44% for PN-ESBLe−.
Hospital mortality was 53 and 38% respectively (p = NS).
Among 70 extra-pulmonary infections, ESLBe take part in 30 (43%)
cases. The involvement of ESBLe was significantly lower in pneumonia
than in other infections (p = 0.01).
Discussion Due to the single center character of our study, results
cannot be extrapolated to the whole ICU population. Nevertheless, the
observed incidence of colonizing ESBLe in our study is close enough
from others studies. This point consolidates reflection about ICU
pneumonia empiric treatment.
Conclusion The involvement of colonizing-ESBLe in ICU pneumonia is
rare in our population and significantly lower than in other infections.
Identified risk factors for PN-ESBLe + are a prior antibiotic therapy
within 30 days and colonization with K. pneumoniae. Alternative
associations to carbapenem remain efficient in all cases of pneumonia
in our ICU and should probably be kept in mind.
Introduction Immediate adequate treatment of ICU-acquired Gram
negative bacilli (GNB) bloodstream infections (BSI) improves patients’
prognosis. Risk factors of resistance of GNB-BSIs should be better
Materials and methods Data from a large French national ICU
network were explored during a 10-year period (2005–2014). Patients
with a GNB-BSI were included and were divided into two groups
according to the resistance (R) profile (BSI due to a R isolate or not).
The following three groups were considered: (1) all GNB-BSI including
Pseudomonas spp., Acinetobacter spp., Stenotrophomonas spp. and
Enterobacteriacae (Eb) for which the following R were considered:
ticarcillin (Pseudomonas spp., Acinetobacter spp., Stenotrophomonas
spp.); ceftazidime (cefta) (P. aeruginosa (PA), Acinetobacter spp.,
Stenotrophomonas spp.), third generation cephalosporin (3GC) (Eb)
and imipenem (all GNB, during the period 2011–2014 only), (2) PA
cefta R from 2005 to 2014 and (3) Eb species resistant to 3GC from
2005 to 2014. Univariable hierarchical logistic models with two levels
(random center and region effects) were used to select variables
associated with resistance using a p value threshold of 0.2. Selected
variables were further introduced in multivariable analyses using a
hierarchical model with two random effects.
Results From 265,035 patients admitted in an annual median of 158
French ICUs, 9553 experienced an ICU-acquired (>48 h.) BSI, 5062
(53%) BSI due to GNB, including 1764 (35%) BSI due to R isolates.
PA was identified in 1167 (23%) BSIs (480 (41%) R) and Eb in 3298
(65%) BSIs (1226 (34%) R). The median annual incidences of R GNB
BSIs/10,000 ICU patients were: 68 for all R GNB BSI, 41 for Eb 3GC-R BSIs
and 9.2 for PA cefta-R BSI. There was a significant increase of annual
incidence for all GNB R and Eb 3GC-R BSI.
Independent factors associated with all R GNB BSI were: 1) ICU
variables: percentage of patients with an immunosuppression other
than neutropenia (7.9–14%: OR 1.23; 95% CI, [1.04–1.46]; >14%: 1.31
[1.09–1.57]); percentage of resistant GNB the previous year (55–66%:
1.87 [1.59–2.2]; >66%: 2.93 [2.43–3.53]) and 2) patient-variables:
antimicrobial therapy at ICU admission (1.79 [1.55–2.08]); presence of an
invasive device (CVC or intubation) (1.99 [1.25–3.16]) before infection;
and one protective factor: trauma at ICU admission (0.76 [0.65–0.89]).
The year effect was significant both for all R GNB and 3GC-R Eb but
not for R PA. This effect was more pronounced for 3GC-R Eb, with an
increase in the risk of R from 2005 to 2014 (Fig. 2). The duration from
ICU admission to infection was the main risk factor of R for all BGN
and sub-groups (Eb and PA): the probability of having a BSI due to a
R strain increased with the time in ICU before infection (Fig. 3).
ICUbased random effect remains significant indicating major impact of
Fig. 2 Evolution of the risk to have a BSI due to a resistant strain
according to the year of ICU admission
Fig. 3 Days from ICU admission to infection
Limitation The absence of information about antibiotic consumption
may partly explain the remaining significant center random effect in
the final models.
Conclusion The duration from ICU admission to BSI was a main risk
factor for a resistant isolate in GNB BSI. Resistance rates increased
over time, especially for 3GC-R Eb and were highly dependent of local
Sepsis at ICU admission due to extended‑spectrum β‑lactamase
producing enterobacteriaceae among colonized patients:
prevalence, risk factors and prognosis
Keyvan Razazi1, Jérémy Rosman1, Nicolas de Prost1, Guillaume Carteaux1,
Chloe Jansen2, Jean Winoc Decousser3, Christian Brun‑Buisson 1, Armand
1Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 2Cepi, Hos‑
pital Henri Mondor, Créteil, France; 3Microbiologie, Hôpital Henri Mondor,
Correspondence: Jérémy Rosman ‑
Annals of Intensive Care 2017, 7(Suppl 1):P159
Introduction Prevalence of Extended-spectrum
beta-lactamaseproducing Enterobacteriaceae (ESBL-PE) carriers dramatically increases
all over the world with a spread to the community. The increasing
prevalence of ESBL-PE carriage at Intensive Care Unit (ICU) admission
raises important questions on empiric therapy strategies in patients
presenting with infection, which may include the use of a carbapenem
as first-line therapy. Data on ESBL-PE sepsis at ICU admission among
colonized patients are lacking.
Patients and methods We prospectively assessed between 2009
and 2015 the prevalence, risk factors and prognosis of ESBL-PE
sepsis among ESBL-PE carriers at ICU admission. The following data
were collected: demographic characteristics, which included sex,
age, simplified acute physiology score (SAPS II), location before ICU
admission, antibiotic exposure, surgery during the previous year,
presence of underlying disease, Charlson comorbidity index, presence
of indwelling devices and outcomes.
Results A total of 597 patients had ESBL-PE carriage detected at
admission, corresponding to 9.5% of admitted patients. Among these
patients, 325 patients had sepsis at ICU admission. Fifty patients
(15.4%) had ESBL-PE related sepsis at ICU admission. ESBL-PE infection
included 23 (46%) urinary tract infections, 14 (28%) pulmonary
infections, 9 (18%) abdominal infections and 4 (8%) other infections.
All but two ESBL-PE pneumonia cases were hospital-acquired (86%)
while community-acquired ESBL-PE urinary tract infection was not
uncommon (12/36 = 33%).
By multivariable analysis, prior urinary tract disease [OR 3.0 (1.1–8.0)],
hospital-acquired sepsis at admission [OR 2.9 (1.4–5.7)], treatment
with fluoroquinolone within the past 3 months [OR 2.8 (1.2–6.4)]
past ESBL-PE infection [OR 2.8 (1.2–6.5)] were independent predictive
factors for ESBL-PE sepsis at admission, whereas a pulmonary source
of sepsis [OR 0.30 (0.15–0.61)] was protective. The final model showed
a good calibration (chi2 = 3.7, p = 0.45) and discrimination (area under
the curve = 0.85). Patients with ESBL-PE related sepsis had more often
septic shock and bacteraemia at admission. ESBL-PE related sepsis was
also more often associated with more frequent inadequate empirical
therapy (68 vs 87%, p < 0.001). However, mortality did not differ
significantly between patients with ESBL-PE infection and others (20
Conclusion At ICU admission, ESBL-PE related sepsis was relatively
infrequent among colonized patients. Our predictive factors for
ESBL-PE may help choosing empiric therapy for sepsis among ESBL-PE
carriers at ICU admission. The study did not show a significant
association between ESBL-PE infection at admission and mortality.
Introduction Carbapenemase-producing Enterobacteriaceae (CPEc)
are increasingly reported worldwide and constitutes a real challenge
antibiotic for clinicians to preserve the bacterial ecology. Its incidence
has remarkably increased in our intensive care unit during the last
Fig. 4 CPEc increasing from 2011 to 2015
This work aims to focus on the impact of CPEc increasing in our
intensive care unit.
Patients and methods A retrospective and descriptive study
conducted in a Tunisian intensive care unit, including all hospitalized
patients infected by an Enterobacteriaceae. We have determined
annual incidence of CPEc from January 2008 to December 2015.
Results One thousand two hundred and three episodes of
Enterobacteriaceae infections were eligible in 748 patients (324
male/424 female) aged between 14 and 88 years.
The global prevalence of CPEc across study period was 4.48%
(54/1203).The prevalence of CPEc in each site was respectively of
23% in hemocultures, 18% in coproculture, 12% in catheters, 3.3% in
respiratory tract, and 3% in urinary tract.
The overall incidence of (CPEc) increased from 0.69% (1/144) in 2008
to 7.77% (15/193) in 2015 (Fig. 4).
Our study confirms the rapid spread of CPEc in Tunisian hospital
and the urgent need for a well-structured and coordinated national
surveillance plan in order to limit their dissemination.
Extended spectrum beta lactamase producing enterobacteriacae
(ESBL‑PE) infections in ICU
Achille Kouatchet1, Rafael Mahieu2, Emmanuel Weiss3, David Schnell4,
Jean‑Ralph Zahar 5
1Service de Réanimation médicale et Médecine hyperbare, Centre
Hospitalier Universitaire d’Angers, Angers, France; 2Réanimation médicale,
Centre Hospitalier Universitaire d’Angers, Angers, France; 3Département
d’anesthésie‑réanimation, Hôpital Beaujon, Boulevard du Général Leclerc,
Clichy, France, Clichy, France; 4Réanimation médicale, CHU de Strasbourg,
Strasbourg, France; 5Laboratoire de bacteriologiev‑irologie‑hygiene,
Hôpital Avicenne, Bobigny, France
Correspondence: Achille Kouatchet ‑ ackouatchet@chu‑angers.fr
Annals of Intensive Care 2017, 7(Suppl 1):P162
Introduction The ESBL spread has a major consequence in term
of antibiotic choices. Carbapenem antibiotic are regarded as the
most effective treatment. However numbers of authors suggest
that alternatives antibiotics (i.e. noncarbapenems) could be used in
ESBL-PE infections. There are some conflicting data regarding the use
of alternatives in case of ESBL-PE infections. Moreover as far as we
know, there are no data in ICU.
Objectives the aim of this study was to describe ESBL-PE infections in
ICU and therapeutic options chosen in these specific situations.
Patients and methods Prospective multicentric observational
cohort study conducted in volunteers ICU. All consecutive patients
hospitalized in ICU with ESBL-PE infection according to CDC definitions
were included. Severity of illness was defines according to bone
criteria, SAPS II and SOFA. Demographic datas, empirical and definitive
antibiotic therapy (ET and DT), clinical evolution, and outcome were
recorded. In vitro antimicrobial susceptibility testing was performed
by the disk diffusion method or the Vitek 2 system according to the
guidelines of the Antibiogram Committee of the French Microbiologic
Results During the study period 146 patients with ESBL-PE infection
met eligibility criteria with respectively a median age and SAPS II score
of 63 (51–74) and 50 (38–70). The median SOFA Score at first day of
antibiotic therapy and ICU admission were 7 (4–11) and 7 (5–11)
respectively. The most frequent site of infection were respiratory tract
(45%), urinary tract (20%) and abdominal (17%). The most frequent
isolated species were: Escherichia coli (43%), Klebsiella sp (37%) and
Enterobacter sp (18%). Respectively 50, 23 and 27% patients had
septic shock, severe sepsis and sepsis according to Bone criteria.
Among ESBL-PE, 98.6% were carbapenem and 46.5 were BLBI
sensitive. Among the whole population, 47 (48%) patients received a
carbapenems as ET. 66 (68%) received a DT with carbapenems and 31
(32%) patients received an alternative DT. The most frequent reasons
for maintaining carbapenems as DT were: Antibiotic susceptibility
tests (38% of cases), severity level (33% of cases) immunosuppression
(8% of cases). The Median length of ICU stay after infection was
respectively 12 (6–27) and 11 (7–16) days for carbapenems and
alternatives DT (p = 0.1). The D28 mortality was 24% for patients with
carbapenems DT and 24% for patients with alternatives DT (p = 0.02).
Surprisingly, there were no differences between the 2 groups
(carbapenems vs alternatives) in term of severity.
Conclusion Alternatives are frequently used for ESBL-PE infections in
ICU. In our cohort 31 (32%) patients received antibiotics other than
carbapenems regardless of the severity.
enterobacteriaceae cross‑transmission in the absence of private
room in intensive care unit
Margaux Artiguenave1, Paktoris‑Papine Sophie 1, Florence Espinasse2,
Faten El Sayed3, Aurélien Dinh4, Cyril Charron1, Guillaume Geri5, Antoine
Vieillard‑Baron 1, Xavier Repessé1
1Réanimation médico‑chirurgicale, Assistance Publique ‑ Hôpitaux de
Paris, Hôpital Ambroise Paré, Boulogne‑Billancourt, France; 2Equipe
opérationnelle d’hygiène hospitalière, Assistance Publique ‑ Hôpitaux de
Paris, Hôpital Ambroise Paré, Boulogne‑Billancourt, France; 3Service de
microbiologie, Assistance Publique ‑ Hôpitaux de Paris, Hôpital Ambroise
Paré, Boulogne‑Billancourt, France; 4Equipe mobile de microbiol‑
ogie, Assistance Publique ‑ Hôpitaux de Paris, Hôpital Ambroise Paré,
Boulogne‑Billancourt, France; 5Réanimation Médicale, Hôpital Cochin,
Correspondence: Xavier Repessé ‑
Annals of Intensive Care 2017, 7(Suppl 1):P163
Introduction Multidrug micro-organisms are responsible for longer
hospitalisations and poorer outcomes in intensive care unit (ICU).
The transmission of extended-spectrum beta-lactamase producing
enterobacteriaceae (ESBL-PE) is prevented by the application of
additional contact precautions, mainly relying on isolation in a
private room and hand hygiene with waterless alcohol-based
solution. Contact isolation cannot be achieved in our 12-bed ICU only
composed of two twin bedrooms. We aimed at reporting the ESBL-PE
acquisition in this peculiar architectural form of ICU and at studying
the impact of twin bedrooms on ESBL-PE cross-transmission.
Patients and methods An observational and non-interventional study
was prospectively conducted in the 12-bed ICU of a university hospital
Ambroise Paré (Boulogne-Billancourt, France). Inclusion criteria were:
(1) adult patients and (2) a period of hospitalisation allowing the
patient to be nursed by at least two paramedical teams. Characteristics
of patients at admission (age, sex, SAPSII) and clinical data during
hospital stay (duration of mechanical ventilation, duration of ICU
stay, outcome) were prospectively collected. Microbiological data
concerning ESBL-PE imported and acquired carriage were monitored
by rectal swabs collected at admission and once weekly every Monday
for the whole duration of the ICU stay. ESBL imported carriage was
defined as a first screening positive for ESBL whereas ESBL acquired
carriage as a negative first screening at admission followed by at least
one positive rectal swan. Mechanistic of a potential cross-transmission
was studied following a three-step process consisting in (1) identifying
patients considered as possible ESBL sources (index patients) for
transmission, (2) classifying each ESBL strain according to the CTXm 1
and 9 groups and (3) diagnosing potential cross-transmission by gene
sequencing of remaining cases of possible transmission.
Results From June 2014 to April 2015, 550 patients were admitted
in the ICU, among which 470 followed the inclusion criteria. The rate
of ESBL colonization at admission was 13.2% (n = 62), mainly with
Escherichia coli. Two hundred and twenty-one non-colonized patients
were screened at least twice. The incidence of ESBL acquisition was
4.1% (9 patients on 221), also mainly with Escherichia coli. Mortality
did not differ between ESBL carriers and non-carriers. In univariate
analysis, ESBL acquisition was associated with the Injury Global
Score II (IGSII) and the Sequential Organ Failure Assessment (SOFA)
at admission, the need for catecholamine and the ICU length of
stay (LOS). In multivariate analysis, ICU LOS and IGSII at admission
were the strongest risk factor for ESBL acquisition. The nine
ESBLacquired carriers had one to three index patients defined as a patient
hospitalized who shared at least 1 day hospitalization. The CTXm
grouping of the ESBL strains excluded a cross-transmission for 4
patients. The gene sequencing did it for 3 others and confirmed a
cross-transmission in only two patients (0.8%). The cross-transmission
emanated from the same source of a CTXm 1 ESBL-producing E. coli.
This patient shared 1 day in a different unit with the first acquired
carrier and 2 days in the same unit with the other. No case of
crosstransmission in the same room was observed.
Conclusion The rate of 13.2% of ESBL carriage on admission was
comparable to other rates in French ICUs (15%). Despite the absence
of contact isolation, the incidence of ESBL acquisition was 4.1% which
is actually lower than transmission rates previously published in other
ICUs. A cross-transmission concerned two ESBL-acquired carriers
only and resulted from the same index patient during short shared
hospitalizations of 1 day in a different unit and 2 days in the same unit.
Our results question whether the contact isolation in private rooms
plays a major role for the prevention of ESBL cross-transmission in ICU,
although the external validity of our results could be questionable.
Introduction Bacterial resistance to antibiotics is a common problem
worldwide. In South America, this prevalence is reported to be the
highest in the world. However, in French Guyana, there is no data on
the epidemiology of colonization and infection caused by extended
spectrum B-lactamase producing enterobacteriaceae (ESBL-PE). We
conducted this study to investigate the prevalence of colonization
with ESBL-PE and subsequent ICU acquired infection in French Guiana.
Materials and methods A 24 months (January 2014 to December
2015) observational study in a 14 beds ICU in a general hospital. Our
unit, is the sole and the referral one of all French Guiana department.
Results Over the study period, 670 patients were admitted to ICU
and 603 of them (90%) were hospitalized more than 48 h. The mean
occupancy rate was 82.5 ± 20.6% and the mean colonization index
(with ESBL-PE) was de 37 ± 18.1%. The mean age was 43.4 ± 21.1 years.
The sex-Ratio (M/F) was 1.3. The mean IGS II calculated at admission
to ICU was 44.6 ± 24.2. The most recorded organ failures at admission
to ICU were respiratory and hemodynamic ones (56.7 and 37.2%
respectively). At admission to ICU, 44.2% of patients presented active
infection and 57.3% received antibiotics. Multidrug resistant (MDR)
bacteria carriage was found in 88 patients (13.4%) at ICU admission and
was acquired in ICU in 89 other patients (13.4%). The most isolated MDR
bacteria at admission were ESBL producing E coli and K. pneumoniae.
However, the most isolated MDR bacteria during ICU stay were ESBL
producing K. pneumoniae and E cloacae. During the ICU stay, 98
patients (14.6%) had presented 147 episodes of ICU acquired infections
(ICU-AI). Over the 177 patients carrying MDR bacteria, 159 (89.8%)
carried ESBL-PE and 66 developed ICU-AI. ESBL-PE caused 21.2, 37.5,
20, and 66.7% of 1st, 2nd, 3rd and 4th ICU-AI episodes respectively.
Statistical analysis didn’t show any link between ESBL-PE carriage and a
first episode of ICU-AI caused by ESBL-PE.
Conclusion Our study show a high prevalence of ESBL-PE bacteria
carriage at admission in our ICU. ESBL-PE carriage was not associated
to higher prevalence of ICU-AI caused by the same microorganism.
This finding can help to reduce the inappropriate use of carbapenems
in such conditions.
On‑line hemofiltration versus conventional hemofiltration
in septic shock patients: clinical safety and effectiveness
Kaouther Dhifaoui1, Zied Hajjej1, Amira Fatnassi1, Walid Sellami1, Iheb Lab‑
bene1, Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospi‑
tal of Tunis, Tunisia, Tunis, Tunisia
Correspondence: Zied Hajjej ‑
Annals of Intensive Care 2017, 7(Suppl 1):P165
Introduction The implementation of hemofiltration (HF) as a renal
replacement therapy in septic shock patients requires the supply
of large quantities of replacement solutions. These solutions are
either industrially prepared in autoclaved expensive plastic bags
(conventional hemofiltration, CHF) or continuously provided
in unlimited amounts at the dialysis machine directly from the
water treatment plant to form the replacing solutions (on-line
hemofiltration, OLHF).The aim of our study was to evaluate the safety
and effectiveness of on-line hemofiltration compared to conventional
hemofiltration in septic shock patients.
Patients and methods The investigative protocol was approved
by the Institutional Ethics Authorities and all patients or their legally
authorized representatives provided written informed consent.
It was a prospective, randomized, clinical study, including septic
shock patients with acute renal failure. Patients were randomized
to receive either on-line hemofiltration (n = 8) or conventional
hemofiltration (n = 25) for renal replacement therapy during 4 days.
Hemodynamic monitoring was conducted by conventional devises,
including: electrocardiogram and a radial arterial catheter for invasive
arterial pressure every 6 h during period study. We collected serum
samples also every 6 h (urea, potassium and sodium levels, troponin,
hemoglobin, platelets, C-reactive protein and lactates).
Results The evolution of heart rate (HR), mean arterial pressure
(MAP), biological markers were comparable between the two groups
over time except a significant decrease in MAP in the OLHF group
compared to CHF group only at H6 (P = 0.008) and H12 (P = 0.015)
and a significant decrease in C-reactive protein level in the OLHF
group at H48 (P = 0.02).
Conclusion On-line hemofiltration seems to be a safe and reliable
method of renal replacement therapy in septic shock patients. It may
be associated with attenuated pro-inflammatory cytokine profile
Usefulness of biological testing during renal replacement therapy
in ICU patients
Fahmi Dachraoui1, Sabrine Nakkaa1, Abdelwaheb M’ghirbi1, Ali Adhieb1,
Dhouha Ben Braiek1, Kmar Hraiech1, Ali Ousji1, Islem Ouanes1, Hammouda
Zaineb1, Saousen Ben Abdallah1, Lamia Ouanes‑Besbes 1, Fekri Abroug1
1Réanimation polyvalente, CHU Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Fahmi Dachraoui ‑
Annals of Intensive Care 2017, 7(Suppl 1):P166
Introduction Clinical and biological monitoring of efficacy and safety
of RRT sessions is thought useful and in many ICUs biological testing
at mid RRT session and at its end is routinely performed. The aim of the
present study is to evaluate the impact of laboratory tests performed
during RRT session on clinical decision making and treatment alteration.
Patients and methods Retrospective study including all consecutive
patients hospitalized in the medical ICU of the University Hospital
Monastir, Tunisia between January 2015 and September 2016,
requiring intermittent hemodialysis performed in the ICU. For each
patient we collected demographic characteristics (age, sex, SAPS III,
diagnosis, comorbidities), indication of the RRT, clinical and biological
parameters before, during and at the end of RRT session. Based on
the patient monitoring records during each RRT session we identified
therapeutic interventions started before the end of the RRT session in
the light of the results of laboratory tests performed during the session
(usually in the middle the session): infusion of glucose, potassium,
transfusion, extension of the session.
Results During the study period, 370 patients were admitted to the
ICU. Of these 24 patients required acute hemodialysis. The median age
of these patients were 54 years (IQR = 31), 53% of them were female.
The main comorbidities were hypertension, diabetes, chronic renal
failure (CRF) with preserved diuresis, respectively in 55, 38 and 36%.
¾ of the patients included were in septic shock and had median SAPS
III score of 92 (IQR = 34). Anuria, pulmonary oedema, hyperkalemia,
and acidosis indicated RRT sessions respectively in 47.1, 24.5, 8.8, 9.8
and 9.8%. Results of laboratory tests performed during RRT sessions
prompted a specific attitude in the following rates: infusion of glucose
in 35.7%, addition of potassium in 22%, and extension of the session
Conclusion The practice of laboratory tests during the RRT sessions
seems useful since it could impact clinical decision making in more
than one-third of sessions.
Feasibility of regional citrate anticoagulation
for membrane‑based therapeutic plasma exchange in ICU
Simon Klein1, Mattéo Miquet1, Jean‑Marc Thouret 1, Vincent Peigne1
1Réanimation, Centre Hospitalier Métropole‑Savoie, Chambéry, France
Correspondence: Vincent Peigne ‑
Annals of Intensive Care 2017, 7(Suppl 1):P167
Introduction Therapeutic plasma exchange (TPE) is crucial for
the management of auto-immune diseases like thrombotic
thrombocytopenic purpura or myasthenia gravis. TPE is performed
either by centrifugation, with specific machines which are not
routinely available in ICUs, or by using specific plasma separation
membranes with widely spread in ICUs hemofiltration machines.
Regional citrate anticoagulation for TPE is well established with
centrifugation but has been seldom described for membrane TPE. We
are reporting the experience of our ICU in this field.
Patients and methods Retrospective study including all patients
who received TPE with citrate regional anticoagulation between 2013
and 2016 in an 18-bed ICU. TPE is performed solely in the ICU in our
Results 26 patients were included. TPE was required for thrombotic
microangiopathy (13 patients), vasculitis (6 patients), hyperviscosity
syndrome (2 patients), Guillain–Barré syndrome (2 cases) and others
(3 patients). Mean SAPS2score was 32 [standard deviation (SD) 16.6].
281 TPE were performed, with a mean number of 10.5 (SD 11.5; range
2–57) TPE per patients. Coagulation of the circuit of TPE occurred in 10
(38%) patients. Coagulation of the circuit occurred in 10.3% (29/281) of
the TPE. Minor adverse events have been reported in two patients: one
had a rash during the first TPE (no recurrence during the 56 next TPEs)
and the other had paresthesia during the first two TPEs (the calcium
infusion was increased and there had been no recurrence during
the 25 next TPEs). No serious adverse events related to citrate were
Conclusion Regional anticoagulation with citrate allowed us to
perform TPE in 26 patients, without significant adverse events. The
rate of circuit coagulation was 10.3% per TPE.
Modelization of the cost‑effectiveness of anti‑thrombin to reduce
the incidence of membrane thrombosis during continuous
Vincent Peigne1, Jean‑Louis Daban 2, Mathieu Boutonnet2, Bernard Lenoir3
1Réanimation, Centre hospitalier Métropole Savoie, Chambéry, France;
2Réanimation, Hôpital d’Instruction des Armées Percy, Clamart, France;
3Département d’anesthésie‑réanimation, Hôpital d’Instruction des
Armées Percy, Clamart, France
Correspondence: Vincent Peigne ‑
Annals of Intensive Care 2017, 7(Suppl 1):P168
Introduction A reduced incidence of membrane thrombosis after
injection of Anti-thrombin (AT) has been reported in septic patients
with acquired deficit in AT undergoing continuous hemofiltration.
As this strategy was routinely performed in our unit until 2012, we
investigated its cost-effectiveness.
Patients and methods Data about the use of hemofiltration,
the consumption of AT and hemofiltration devices during 2011
(period with routine use of AT) and 2012 (period with use of AT
only if a membrane thrombosis occurred) were extracted from the
administrative database of the institution. A decisional tree was built
to modelize the impact of AT on the consumption of hemofiltration
devices and blood products. The decisional tree took into account
the probability of membrane thrombosis with and without AT and
the probability of transfusion after membrane thrombosis. Costs were
obtained from the pharmacy of the institution (AT, hemofiltration
devices) and from the literature (blood products).
Results During 2011, 77 days of hemofiltration were performed,
with the use of 45 doses of AT (23,202€) and 76 hemofiltration
devices (11,632€). During 2012, 76 (−1%) days of hemofiltration
were performed, with the use of 5 (−89%) doses of AT (2578€) and 85
(+10%) hemofiltration devices (13,443€). The mean cost of 1 day of
hemofiltration decreased from 449€ to 211€ with the diminution of
the use of AT.
According to the decisional tree, AT was almost never cost-effective.
The only circumstances associated with a benefit for the use of AT was
the association of a probability of thrombosis with AT inferior to 0.1,
of a probability of thrombosis without AT equal 1, of a probability of
transfusion after thrombosis equal 1 and a cost of transfusion of 424€.
In these extremely favorable circumstances, AT could decrease the
daily cost of hemofiltration of 2.22–19.30€.
Discussion The model has several limits: the losses of utility related
to transfusion and to interruption of hemofiltration due to
thrombosis were not taken into account; the cost of AT measurement was not
estimated; the work load of changing a membrane and of transfusion
after membrane thrombosis was not analyzed.
Conclusion Our results suggest that anti-thrombin is not
costeffective to reduce the costs of hemofiltration related to membrane
Vascular access sites for acute renal replacement in intensive
Amira Ben Jazia1, Amira Jamoussi2, Takoua Merhbene3, Dhouha Lakh‑
dhar4, Jalila Ben Khelil2, Mohamed Besbes2
1Medical ICU, Hospital Abderrahmen Mami De Pneumo‑Phtisiologie,
Ariana, Tunisia; 2Réanimation médicale, Hôpital Abderrahmen Mami,
Ariana, Tunisia; 3Réanimation respiratoire, Hôpital Abderrahmen Mami de
pneumo‑phtisiologie, Ariana, Tunisia; 4Service de réanimation médicale,
Centre d’assistance médicale‑urgente, Tunis, Tunisia
Correspondence: Amira Ben Jazia ‑
Annals of Intensive Care 2017, 7(Suppl 1):P169
Introduction Several temporary venous catheterizations are
sometimes required for acute renal replacement therapy (RRT) in the
intensive care unit (ICU). This study compares catheterizations in the
femoral and jugular veins in terms of patient safety.
Materials and methods This was a descriptive retrospective review of
dialysis sessions (DS) records monitoring performed in patients older
than 17 years hospitalized in medical intensive care unit between April
2011 and December 2015.
A study of dialysis catheter, was conducted in critically ill adults
requiring RRT was performed.
Catheter insertion site, catheter age and urea reduction ratio (URR)
Results URRs were analyzed from 330 dialysis sessions (n = 64
patients). The mean rate of URRs was 52.8 ± 12.4. Only 31.4% of
dialysis sessions (DS) were efficient with URR ≥ 60.
This study analyzed 64 patients who underwent two different sites of
catheterization: the femoral and jugular site.
The mean age of cathéters was 1.613 days.
No significant difference (P = 0.18) in the efficiency of (DS) was
detected between sessions performed through femoral (n = 225; 68%)
and jugular (n = 105; 32%) dialysis catheters.
Conclusion Femoral and internal jugular acute vascular access sites
are both acceptable for RRT therapy in the ICU. The effectiveness of
(DS) in the ICU is low (31.4%). An analysis of predictive factors of
inefficiency of (DS) is expected to improve our results.
Renal replacement therapy protocol with regional citrate
anticoagulation: observational study of efficacy with a new
post‑filter ionized calcemia target
Celine Derreumaux1, Thierry Seguin1, Jean‑Marie Conil 1
1Réanimation polyvalente, Hopital Rangueil, Toulouse, France
Correspondence: Celine Derreumaux ‑
Annals of Intensive Care 2017, 7(Suppl 1):P170
Introduction In Intensive Care Unit (ICU), some patients suffering from
acute kidney injury need renal replacement therapy (RRT). It requires
the circuit anticoagulation, this could be done by a regional citrate
method. Today, this is a recommended approach for the everyday care,
even if the technique isn’t widespread yet . The ionized calcemia
dosing through the filter (“post-filter” ionized-calcemia) is used to
monitor the technique efficacy, with a target of 0.25–0.35 mmol/L
showing a good filter anticoagulation.
The objective of our study was the assessment of efficacy and safety
of our regional citrate anticoagulation protocol, with a less restrictive
post-filter ionized calcemia target (0.3–0.6 mmol/L). The main goal was
the analysis of the circuit lifespan, considering a lifespan above 24 h, as
well as the search of some clinical and biological factors affecting the
technique efficacy. Moreover, we analyzed the side effects incidence
of the protocol (hypernatremia, metabolic alcalosis), and their
consequences. The study received the scientific ethical agreement
of University Hospital of Toulouse, and is registered with number
Patients and methods 57 patients, admitted to one of the two
University Hospital ICUs of Toulouse, needing a continuous RRT
method, without any need for systemic heparin anticoagulation, and
without severe hepatocellular failure, were included in the study. 103
filters included over a 1-year period were analyzed.
Results Results show a mean filter lifespan of 48 h, with a lifespan
above 24 h for 85.4% of all filters. Coagulation was the cessation
reason for 29.1% of filters, most of them before 24 h of the filter use.
A value of post-filter ionized calcemia at day 1 below 0.54 mmol/L
was the main factor influencing a filter lifespan above 24 h. An age
older than 51 and a SAPS II severity score below 80 were other factors
conditioning a filter lifespan of more than 24 h. Side effects of citrate
were rare and didn’t have any clinical impact among our patients.
Discussion These results suggest that citrate used for anticoagulation
in RRT could have an additional anti inflammatory effect through
the induced hypocalcemia, as well as an energetic gain which could
lead to a renal protection against ischemia–reperfusion mechanism
. Moreover, these results call into question the need of post-filter
ionized calcemia dosing for the monitoring of citrate anticoagulation
efficacy, since the method safety is monitored by the total-to-ionized
Conclusion During continuous RRT in ICU, a regional citrate
anticoagulation protocol with a non-restrictive post-filter ionized
calcemia target seems to be efficient and could reduce side effects.
These results need to be confirmed with a randomised control study.
Impact of the use of an oXiris filter versus an AN69ST filter on the
duration of hemofiltration in intensive care
Charlotte Kelway1, Valery Blasco1, Cyril Nafati1, Karim Harti1, Laurent Reydellet1, Jacques Albanese1 1RPPF, Hopital de la Timone, Marseille, France
Correspondence: Charlotte Kelway ‑
Annals of Intensive Care 2017, 7(Suppl 1):P171
Introduction Continuous veno-venous haemofiltration (CVVH) is
used to treat acute kidney injury in critically ill patients. To optimize
its efficiency, CVVH requires effective anticoagulation. Systemic
anticoagulation with standard heparin, the most used, can lead to
major bleeding complications. Hemofilters that are able to adsorb
heparin molecules on their surface such as AN69ST and oXiris
membranes represent an alternative. The objective of this study was
to compare these two types of filters in terms of duration, efficiency,
dysfunctions and cost.
Materials and methods From October 2012 to May 2014, we
conducted a retrospective, observational, and non-interventional
study. All patients admitted in the intensive care unit needing CVVH
were included. The primary endpoint was the filter lifespan: AN69ST
versus oXiris. The secondary endpoint was the filter efficiency
(urea reduction ratio: URR). The main analysis did not consider the
anticoagulation type. We conducted a subgroup analysis taking into
account the use or not of an anticoagulation.
Results 181 sessions in 93 patients were carried out using 386 filters
representing 10,706 h of treatment. The mean AN69ST filter lifespan
was 27 ± 20 h and 28 ± 22 h for oXiris filters (p > 0.05). There is no
significant difference in terms of duration between the two filters.
The subgroup analysis taking into consideration the use or not of
anticoagulation did not show any difference either. The mean URR
was 48 ± 23% in the AN69ST group and 44 ± 25% in the oXiris group
(p > 0.05). Concerning the dysfunctions, there were no significant
difference between the two filters. One hundred and seventy-six
AN69ST filters were used for a total cost of 24,288 euros. Two hundred
and ten oXiris filters were used for a total cost of 39,060 euros.
Conclusion The AN69ST and oXiris lifespans are not significantly
different. They were as efficient in terms of blood epuration and had
as many dysfunctions. The use of an oXiris filter rather than an AN69ST
to extend the circuit’s lifespan in the same clinical conditions is not
justified considering the extra cost generated.
Introduction Because oliguria is a poor prognostic sign in patients
with acute renal failure (ARF), diuretics are often used to increase urine
output in patients with or at risk of ARF. From a pathophysiological
point of view there are several reasons to expect that loop diuretics
could have a beneficial effect on renal function. However, a review
of literature shows that the use of loop diuretics in patients with ARF
has been associated with inconclusive results despite the theoretical
To assess the adjunctive effect of diuretics, to alter the progression to
kidney injury or failure, in patients at risk for acute renal failure.
Patients and methods This is a retrospective chart review of
consecutive patients who developed ARF with oliguria in the intensive
care unit. Chart abstractors were well trained residents. Two chart
reviewers (senior intensivists) studied all the charts. An explicit
protocol was used to precise all needed definitions. Uniform handling
of data was ensured especially for conflicting, missing or unknown
data. Oliguria was defined as urine output lower than 0.5 ml/kg/h for
at least 3 h.
RIFLE score was assessed before and after urinary output
normalisation. Therapeutic intervention to optimize pre-renal perfusion was
described. Mean arterial blood pressure (MBP) before and after
therapeutic initiation, oliguria duration, delay from oliguria onset to diuretic
administration, delay from diuretic administration to urinary output
normalisation were measured.
Results 23 patients were studied over a 2 years period. They were 63
[24, 87] median (IQR) aged, with diabetes mellitus, 22%; hypertension,
47.8%; cardiac failure, 32% and chronic respiratory failure, 43%.
Chronic and obstructive kidney diseases were excluded. Median SAPS
II was 37 [23, 75]. 80% were on mechanical ventilation.
RIFLE score before diuretics administration was assessed at oliguria
onset as (patients without risk, zero; R, 69%; I, 17%; F, 10%; L, 4%; E,
zero). Fluid resuscitation after oliguria onset was administered in 77%
and vasopressors in 80%. Median (IQR) delay from oliguria onset to
diuretic administration was 5 [0.5, 22] h while optimization of
prerenal hemodynamic disturbances was already achieved.
The median (IQR) MBP before and after therapeutic intervention was
respectively, 74 [46, 100] and 95 [69, 110] mmHg. Median (IQR) delay
from initiation of therapeutic intervention and MBP improvement was
1.5 [0, 3] h. The delay from diuretic administration to urinary output
normalization was 3 [0.5, 27] h.
After resumption of diuresis, RIFLE score was assessed as (patients
without risk, 74%; R, 17%; I, 8%; F, 1% L, zero; E, zero) (Fig. 5). Increased
Fig. 5 Progression of RIFLE score classes respectively from baseline to
after therapeutic intervention
serum creatinine level, above 1.5 fold normal range, was observed
only in 6 (26%) patients.
Conclusion Rapid optimization of pre-renal hemodynamic
disturbances associated with short delay administration of diuretics
could significantly alter the progression to kidney injury or failure in at
risk acute renal failure ICU patients.
Epidemiology and risk factors of Acinetobacter baumannii
ventilator associated pneumonia
Walid Sellami1, Zied Hajjej1, Soumaya Ben Yedder2, Walid Samoud1, Bous‑
selmi Radhouene1, Bousselmi Mariem3, Iheb Labbene1, Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hos‑
pital of Tunis, Tunisia, Tunis, Tunisia; 2Department of critical care medicine
and anesthesiology, Military hospital of tunis, tunisia, Tunis, Tunisia, Tuni‑
sia; 3Department of critical care medicine and anesthesiology, Military
Hospital of Tunis, Tunisia, tunis, Tunisia
Correspondence: Walid Sellami ‑
Annals of Intensive Care 2017, 7(Suppl 1):P173
Introduction The ventilator associated pneumonia (VAP) is a common
and severe complication of assisted ventilation. It’s the leading cause
of nosocomial infections in intensive care unit and remain responsible
for a high morbidity and mortality because of the emergence of
multidrug resistant (MDR) bacterial agent such us Acinetobacter baumannii
(AB). The aim of this study was to determine the incidence, risk factors
and prognosis of AB VAP.
Patients and methods Retrospective study extending over a 5 year
period (January 2010–January 2016) that included all patients over
18 years and ventilated more than 48 h and developing AB VAP.
Patients were divided into two groups: one consisting of patients
who developed VAP to AB and the second developed VAP to another
Results One hundred and forty patients developed VAP. The incidence
rate of AB VAP was 15.3% with a density of incidence of 20.3 per 1000
ventilator days. Age, male gender, the time between hospitalization
and mechanical ventilation and the medical pathology were risk
factors for developing AB VAP. AB was resistant to ceftazidime in
100%, to imipenem in 65%, tobramycin in 70% and netilmycin in
35.3%, rifampin in 85% with a sensitivity to colistin in 100% of cases.
The resistance of this germ to imipenem increased from 35% in 2010
to 88.5% in 2016. The evolution of patients with AB VAP developed
frequently septic shock compared to other patients (44 vs 19.3%;
p = 0.038). The AB VAP mortality was higher (50 vs 33%; p = 0.03).
Conclusion The increasing incidence of multi-drug resistant AB VAP is
responsible for a high morbidity and mortality. So we need to identify
risk factors and to strengthen the means of prevention of hand
contamination and cross transmission during invasive procedures.
Incidence and risk factors of central line associated bloodstream
infections and its risk factors in a Tunisian medical intensive care
Nesrine Sma1, Asma Ammar2, Khaoula Meddeb1, Asma Ben Cheikh2, Hend Ben Lakhal1, Jihene Ayachi1, Ahmed Khedher1, Nesrine Fraj1, Mes‑ saouda Khelfa1, Yamina Hamdaoui1, Imed Chouchene1, Nabiha Bouafia2, Mohamed Boussarsar3
1Réanimation médicale, CHU Farhat Hached, Sousse, Tunisia; 2Hospital
hygiene unit, Farhat Hached Hospital, Sousse, Tunisia; 3Medical intensive
care unit, Farhat Hached Hospital. Research Laboratory N° LR14ES05.
Faculty of Medicine, Sousse, Tunisia
Correspondence: Mohamed Boussarsar ‑ hamadi.boussarsar@gmail.
Annals of Intensive Care 2017, 7(Suppl 1):P174
Introduction Central line associated bloodstream infections (CLABSI)
are among the serious hospital-acquired infections. The aim of this
study is to determine the incidence of CLABSI, the pathogens and the
risk factors that play a role in the development of BSI among patients
followed in a Tunisian medical intensive care unit.
Patients and methods All patients admitted for more than 48 h
were included in the study over a 1-year period in an 8-bed medical
ICU. The enrollment was based on clinical and laboratory diagnosis
of BSI. Blood samples were collected from catheter hub of all patients
for culture, followed by identification and antibiotic sensitivity
testing of the isolates. For all subjects, age, sex, underlying diseases,
SAPS II score, ICU length of stay, invasive procedures and their
durations (mechanical ventilation, central catheterization, urinary
catheterization) were recorded. Risk factors were evaluated by a
multivariate logistic regression model.
Results Among a total of 237 admissions from September 15th
2015 to September 15th 2016, 163 (68.7) patients were eligible. One
hundred twenty-five (76) patients had a central line. A total of 27
episodes of CLABSI were assessed in 23 (18.4) patients. The mean
SPASII of patients with CLABSI was 33 ± 15.4. Their mean CHARLSON
index was 1.8 ± 1.7, median duration of catheterization was 4 [1.5–
7] days and 8 (34.8) had more than one catheterization attempt. The
rate of CLABSI was 19.2/1000 catheter.days. Gram positive bacteremia
was determined in 13% of BSI patients. Of these isolates, 3 were
Staphylococci. Gram negative bacteremia was determined in 35%
of these isolates, 4 were Acinetobacter baumannii, 3 were Klebsiella
pneumonia and 1 was Proteus mirabilis and in 56% of cases BSI
was diagnoses clinically. A univariate analysis identified
ventilatorassociated pneumonia, sedation, and longer interval between onset of
CLABSIs and the duration of catheterization as risk factors of CLABSIs.
In multivariate analysis, the independent factors of CLABSI which
are the duration of catheterization (OR, 1.06; 95% CI, [1.003–1.139];
p = 0.042) and catheterization attempt number (OR, 1.99; 95% CI,
[1.18–3.37]; p = 0.01). Thirteen (56.5) patients developed septic shock
and they all died.
Discussion The rate of CLABSI in our ICU (19.2/1000 catheter.days)
was higher compared with the mean rate of CLABSI in ICU reported by
the NNIS system surveillance for 2004, which is 3.9/1000 catheter.days
. Duration of catheterization, frequent manipulation of catheter,
catheter location, catheter type, underlying diseases, suppression of
immune system, and types of fluids administered through the catheter
are significant risk factors in development of BSIs . In our study both
duration of catheterization and number of attempts are independent
factors for CLABSI.
Conclusion In a monocenter cohort, CLABSI had a moderate density
rate but are associated with poor outcome. Identifying the risk factors
is necessary to find solutions for this major health problem.
Introduction According to some studies, field-intubated patients
have 1.5–3 times greater risk of ventilator associated pneumonia
(VAP). Endobronchial intubation (EI) can be unrecognized by the
physicians and may result in complications such as atelectasis which in
turn could increase the risk of VAP. The aim of our study was to confirm
Patients and methods This monocentric retrospective study included
all consecutive patients >18 years who underwent an out-of-hospital
tracheal intubation before their admission to the intensive care unit
(ICU) between January 2012 and December 2015. Exclusion criteria
were suspected aspiration or pneumonia on admission, patients who
died within the first 5 days of ICU stay, extubation in less than 48 h
and underlying disease making radiological interpretation difficult
for VAP diagnosis. VAP were divided into early onset (<7 days) and
late onset (≥7 days) events and were independently diagnosed by
two experienced intensivists who had no access to the initial chest
X-ray performed to check the position of the tracheal tube, based on
the Clinical Pulmonary Infection Score. Onset of ventilator associated
tracheobronchitis (VAT) was also noted. Inadvertent endobronchial
intubation was determined by another independent physician based
on the interpretation of admission chest X-ray.
Results 397 patients were intubated out-of-hospital. Of the 284
patients excluded, 104 had an extubation in less than 48 h, 114 were
died within the first 5 days, 22 had a suspicion of pneumonia, 28 a
suspicion of aspiration and 8 an underlying disease making radiological
interpretation difficult. Of the 121 patients included, 28 (23.1%) had an
EI upon admission. No significant difference was observed between
the EI and non-EI group for gender, age, SAPS2, comorbidities and
diagnostic category (cardiorespiratory arrest, trauma, coma and
cardiorespiratory failure). Early-onset VAP were diagnosed in 43% in the EI
group and in 29% of non-EI patients (p = 0.085). Adding early onset
VAT, the respiratory infection rate was 61% in the EI group and 44% in
the non-EI group (p = 0.061) (Fig. 6). Late-onset VAP were observed
in 8.6% in the non-EI group and 7.1% in the EI group, without
difference between groups (p = 0.403). There was no inter-group difference
in the duration of ventilation, duration of ICU stay and ICU mortality.
Staphyloccocus aureus was the most prevalent pathogen in patients
with early-onset VAP (23.1%, only one strain was methicillin-resistant).
Conclusion This study found a high rate of inadvertent prehospital
endobronchial intubation with a higher incidence of early-onset VAP.
These results support the implementation of specific procedures to
decrease the incidence of EI.
Introduction Ventilator-associated pneumonia (VAP) is associated
with increased hospital stay and high morbidity and mortality in
critically ill patients. The classic dichotomy between early and late
onset VAP is no longer helpful available. The aims of this study were to
determine the incidence of multidrug-resistant pathogens in the first
episodes of VAP and to assess potential differences in bacterial profiles
of subjects with early-onset versus late-onset VAP.
Patients and methods Retrospective cohort study over a period
of 18 months including all patients who had a first episode of VAP
confirmed by positive culture. Subjects were distributed into 2 groups
according to the number of intubation days: early-onset VAP (<5 days)
or late-onset VAP (≥5 days).The primary endpoint was the nature of
causative pathogens and their resistance profiles.
Results Sixty patients were included, 29 men and 31 women. The
average age was 38 ± 16 years. The IGS 2 at admission was 40.5 [32; 44]
APACHE 19 [15; 22]. Monomicrobial infections were diagnosed in of 46
patients (77%).Two different bacteria were isolated in 14 cases (13%).
A. baumannii was the most frequently isolated in 53% (n = 32) of
patients; followed by P. aeruginosa in 37% (n = 22), Enterobacteriaceae
in 28% (n = 17) and S. aureus in 5% (n = 3). The isolated bacteria were
multidrug-resistant in most cases (58/60). The VAP group comprised 36
episodes (60%) of early-onset VAP and 24 episodes (40%) of late-onset
VAP. A. baumannii was isolated in 47% of early VAP (n = 17) versus 62%
of late VAP (n = 15) (p = NS), P. aeruginosa in 36% of early VAP (n = 13)
versus 37% of late VAP (n = 9) (p = NS) and Enterobacteriaceae in 30%
of early VAP (n = 11) versus 25% of late VAP (n = 6) (p = NS). For the
resistance profile of the different pathogens isolated, there was no
difference between early and late onset VAP.
Conclusion According to new data from the literature, there were no
microbiological differences in the prevalence of potential
multidrugresistant pathogens or in their resistance profiles associated with
early-onset versus late-onset VAP.
Introduction The bacterial nosocomial infection is a major cause of
morbidity and mortality in burned. The bacterial ecology in an ICU has
a major impact in terms of morbidity and mortality, particularly in the
center of burned or length of stay of patients is increased compared to
a general intensive care.
Materials and methods We conducted an observational study spread
over 7 months in ICU for severe burned burnt including any who
have spent more than 48 h with nosocomial infection (modified CDC
criteria), and in which all biological and bacteriological samples were
taken. The different types of infections studied were: skin, urinary,
lung and bloodstream infections. They excluded all patients belatedly
supported or having stayed in other healthcare facilities.
Results One hundred twenty (120) patients showed nosocomial
infection during this period. The sex ratio (M/F) was 1.7 and the mean
age was 39 ± 23 years. Bacteremia was present in 44.84% of cases,
followed by the urinary tract infection that was present in 21.21% of
cases, followed by the cutaneous infection in 10.30% of cases, and
last pulmonary infection in 9% of cases. Infection was polymicrobial
in 14.5% of cases. The main bacteria identified were: Acinetobacter
baumanii (43.45%) of which 74% is resistant to imipenem,
Enterobacteriaceae (31.5%), Pseudomonas aeruginosa (24%) of which
83.25% is resistant to ceftazidime and 68.2% is resistant to imipenem,
Enterococcus (16%) and Staphylococcus Aureus (14.29%).
Conclusion The incidence of nosocomial infection is very high
compared to literature. The rate of resistance to common antibiotics
is very high. A drastic management of antibiotics in our context, the
selection of patients and the frequent use in the operating room for
skincare allow a better management of these patients.
Ventilator acquired pneumonia: diagnosis treatment
and bacterial ecology in a Moroccan intensive care unit
Hanane Ezzouine1, Mahmoud Kerrous1, Saad El Haoui1, Soufiane Ahdil1,
1Anesthesiology and intensive care department, University Teaching
Hospital IBN Rushd‑Casablanca, Casablanca, Morocco
Correspondence: Hanane Ezzouine ‑
Annals of Intensive Care 2017, 7(Suppl 1):P178
Introduction The management of ventilator acquired pneumonia
is a diagnostic and therapeutic challenge. Antibiotic therapy is a key
link. The objective of this work is to study the epidemiological, clinical
patients who developed VAP during their stay in the Medical Intensive
Care Unit of the CHU Ibn Rushd in Casablanca and are features of the
bacterial ecology of VAP during the 2015.
Patients and methods It is a retrospective descriptive study and
analytical spread over 1 year, from January 2015 to December 2015.
Were included all patients with pneumonia Ventilator, with or without
bacteraemia, after hospitalization for more than 48 h. Were collected
clinical, biological, radiological, bacteriological and scalable patients
Results The average age of the patients was 42.19 years with a sex
ratio (M/F) 1.47 APACHE II score average was 16.4, the average SAPSII
was 31.12 and the average was 2.39 SOFA. 86.5% of patients were
intubated on admission in intensive care. 3.5% were intubated within
less than 5 days notice after admission and the average time to onset
of VAP was 3.76 days. The VAP were early in 68.4% of cases. The average
hospital stay of patients being 19.63 days. 73.68% in the sample used
in our patients was bronchial aspiration. The most offending germs are
27.2% Acinetobacter baumannii, Pseudomonas aeruginosa 16.3%. 100%
of patients received empirical antibiotic therapy chosen according to
the ecology of the service. 77.4% died. 43.8% of deaths were directly
related to VAP.
Conclusion Ventilator acquired pneumonia is main problem in our
ICU. The bacteriological ecology must be usually known. In our unit
Acinetobacter baumanii is the main germ associated.
Determinants and prognostic factors of Acinetobacter baumannii
Khalid Abidi1, Tarek Dendane1, Ssouni Oussama1, Jihane Belayachi2, Naou‑
fal Madani2, Redouane Abouqal2, Amine Ali Zeggwagh1
1Medical intensive care unit, Mohamed V University Hopital Ibn Sina,
Rabat, Morocco; 2Service des urgences médicales hospitalières ‑ ibn sina
– université mohamed v – rabat, Hopital Ibn Sina, Rabat, Morocco
Correspondence: Tarek Dendane ‑
Annals of Intensive Care 2017, 7(Suppl 1):P179
Introduction Acinetobacter baumannii (AB) ventilator-associated
pneumonia (VAP) is common in critically ill patients. The aims of
this study were to describing the epidemiological characteristics of
AB-VAP, to identify risk factors for acquisition and factors predictive of
a poor outcome.
Materials and methods A retrospective-prospective study was
conducted at the Medical Intensive Care Unit of the University
Hospital Ibn Sina, Rabat-Morocco from January 2013 to December
2015. They were included in the study that all patients developed VAP
with identified germ. For identification of risk factors of acquisition of
AB VAP, two groups of patients were compared: patients with AB VAP
versus patients with VAP caused by other germs. To identify factors
associated with mortality, two other groups were compared: Survivors
Results 122 patients presented VAP among which 60 were caused
by Acinetobacter baumannii. Among isolates of AB, 8.3% were drug
susceptible, and 16.7% were multidrug-resistant while 75% were
extensively drug-resistant. They were Independent risk factors for
acquisition of AB VAP in multivariate analysis: the presence of a central
venous catheter before the occurrence of VAP, duration of prior
hospitalization ≥4 days and ICU duration of stay ≥5 days. The mortality rate
of AB VAP was 85%. The independent risk factors for poor outcome in
multivariate analysis were: duration of antibiotic treatment >7 days,
the reintubation and the presence of a previous hospitalization.
Discussion Our data were similar to those of the literature with a high
incidence of VAP due to the AB (49%) and a high rate of resistance to
this bacterium particularly to carbapenems. However, and compared
to the literature, the VAP AB were responsible for a death rate much
Conclusion Our data were similar to those of the literature with a high
incidence of VAP due to the AB (49%) and a high rate of resistance to
this bacterium particularly to carbapenems. However, and compared
to the literature, the VAP AB were responsible for a death rate much
Ventilator‑associated pneumonia in the elderly: a study of the
Hatem Ghadhoune1, Anis Chaari2, Guissouma Jihene1, Hend Allouche1,
Insaf Trabelsi1, Habib Brahmi1, Mohamed Samet1, Hatem El Ghord1
1Réanimation médicale bizerte, Faculté de médecine de Tunis, Bizerte,
Tunisia; 2Intensive care unit, King Hamad University Hospital, Muharraq,
Correspondence: Hatem Ghadhoune ‑
Annals of Intensive Care 2017, 7(Suppl 1):P180
Introduction Ventilator-associated pneumonia (VAP) is common in
critically-ill patients. In fact, 10–20% of patients requiring invasive
mechanical ventilation develop this complication. The onset of VAP
has been reported to be associated with increased mortality. However,
data related to critically-ill elderly patients are scarce. The aim of this
study is to assess the prognostic impact of VAP in critically-ill elderly
Patients and methods Mono-center, retrospective study conducted
from 01/012014 to 30/09/2015. All old patients (age ≥65 years)
requiring mechanical ventilation were included. Two groups were
compared: Patients who developed VAP (VAP (+) group) and those
who did not develop VAP (VAP (−) group).
Results During the study period, 86 patients were included. The
causes of admission in the intensive care unit (ICU) were shock
(n = 30), acute respiratory failure (n = 41) and disturbed level of
consciousness (n = 15). Diabetes mellitus, hypertension and chronic
obstructive pulmonary disease were the most common comorbidities
(44.2, 32.6 and 40.7% respectively). Mean age was 73.3 ± 6.5 years.
Sex-ratio (M/F) was 1.8. Mean APACHE(II) score was 24 ± 9. The mean
duration of mechanical ventilation was 10 ± 15 days. Thirty patients
(34.9%) developed VAP. ICU-mortality was significantly higher in the
VAP (+) group (90 vs 55.4%; p = 0.001). Multivariate analysis identified
two independent factors predicting ICU mortality: Shock on admission
(OR = 22.7, CI 95% [5.1–101.2], p < 0.001) and VAP (OR = 5.7, CI 95%
[1.2–28.1], p = 0.033).
Conclusion VAP is common in critically-ill elderly patients and is
associated with worse outcome. Therefore, preventing its onset is of
increased health-care costs. Among pathogens responsible of VAP,
Acinetobacter baumannii which is characterized by its ability to spread in
the hospital environment and to acquire resistance leading sometimes
to therapeutic impasses is associated with a particularly high mortality
Objective To describe the epidemiological characteristics of A.
baumannii VAP, to determine their prognosis and identify factors
associated with mortality.
Patients and methods It is a monocentric observational study
conducted over a period of 13 years in a Tunisian intensive care unit
(ICU) including mechanical ventilated patients for more than 48 h with
confirmed A. baumannii VAP.
Results One hundred and twenty-three patients were included
in the study. A. baumannii was responsible for 31% of VAP in our
ICU. The VAP were late in 59% of cases. More than 90% of isolates
pathogens were resistant to ticarcillin, piperacillin, piperacillin–
tazobactam, ceftazidime and ciprofloxacin. Sixty percent of germs
were sensitive to imipenem. Resistance to imipenem has increased
consistently from 0% at the beginning of the study to 88% in 2015.
All pathogens were susceptible to colistin. A. baumannii VAP was
complicated by septic shock in 63% of cases. The median duration
of mechanical ventilation and of ICU stay were 17 (IQR: 11–25) and
25 days (IQR: 17–41) respectively. The use of parenteral nutrition
was the only factor associated with the occurrence of A.
baumannii VAP resistant to imipenem (odds ratio 2.27, 95% CI [1.07–4.80],
p = 0.033). ICU mortality was 45%. It was higher in patients with A.
baumannii VAP resistant to imipenem (55 vs 39%, p > 0.05). In the
multivariate analysis, the age, the use of renal replacement therapy
and the occurrence of VAP relapse have been identified as factors
associated with mortality.
Conclusion A. baumannii resistance to imipenem became
threatening. The use of parenteral nutrition was the only factor associated with
the occurrence of A. baumannii VAP resistant to imipenem. The choice
of empiric antimicrobial for VAP caused by this pathogen must take in
consideration the epidemiologic data of each country and each ICU.
A. baumannii VAP was associated with high mortality. The age, the use
of renal replacement therapy and the occurrence of VAP relapse have
been identified as predictive of poor outcome.
Admission in intensive care unit for severe adverse drug event:
Julien Arcizet1, Bertrand Leroy1, Caroline Abdulmalack2, Catherine Ren‑
zullo1, Maël Hamet2, Jean‑Marc Doise 2, Jérôme Coutet1
1Pharmacy unit, C.H. Chalon sur Saône William Morey, Chalon‑sur‑Saône,
France; 2Intensive care unit, C.H. Chalon sur Saône William Morey,
Correspondence: Julien Arcizet ‑ julien.arcizet@ch‑chalon71.fr
Annals of Intensive Care 2017, 7(Suppl 1):P182
Introduction Adverse drug events (ADE) remain a serious public
health problem. They represent between 0.16 and 15.7% of hospital
admissions and between 0.37 and 27.4% of intensive care unit (ICU)
admissions. They are defined as any injury related to a drug, and
include both adverse drug reactions, expected or not, but also
underuse, overuse and misuse, unintended or undesired, preventable or not.
Indeed, mortality from iatrogenic event would rise between 2.0 and
28.1%, whereas these ADE that resulted in ICU hospitalization could be
prevented in 17.5–85.7% of cases. These unplanned admissions
overload ICU, limit access to health care for other patients and have serious
economic consequences for the health system. It is therefore
necessary to study these ADE to know their main causes and attempt to find
a solution to avoid them.
The main objectives of our study were to clinically and pharmaceutically
analyze and stratify the different ADE leading to hospitalization in our ICU.
Patients and methods This is a monocentric prospective study,
between June 2014 to January 2016, in medico-surgery ICU. From
all admissions, we had included patients admitted in our hospital for
involuntary ADE (plausible, likely and very likely causal). We had
collected clinical aspects (Failure mode, IGSII score, mortality in ICU) and
pharmaceutical aspect (number of drug, offending drugs) at daily
medical staff meeting.
Results On 1545 admissions, 154 patients were hospitalized for
unintended ADE. The average age was 70 years old [26; 95], with a
men/women ratio equal to 1.8. The clinical severity IGSII score found
was 51 [13; 120]. Average length of stay in ICU was 5.5 days [1; 28] on
average in this unit. The main reasons of admission were: hematologic
failure (in particular hemorrhagic) (29.9%), metabolic failure (19.5%),
renal failure (11.0%), neurological failure (11.0%) and sepsis (10.4%).
Respiratory, hepatic, hemodynamic failures and hypersensitivity
reactions represented respectively less than 10% of cases. 34 patients
(22%) included died during their stays in ICU. On average, 7.6 drugs
were found in the usual treatment of the patient. 32.5% of this
population had a known cognitive disorder and 62% of them
selfmanagement of their treatment. The main drugs involved were:
furosemide (16.9%), metformin (13.0%), perindopril (9.1%), lysine
acetylsalicylate (8.4%), warfarin (8.4%) and fluindione (7.8%). The most
common drug families involved were: drugs of the cardiovascular
system (33.8% of cases), anticoagulants and antiplatelet agents
(31.8%), antidiabetics (16.9%) and psychotropic (13.6%).
Conclusion Hospitalizations in ICU for ADE are still too common
despite their preventability for most cases. Many patients with known
cognitive disorder manage their treatment themselves and this is
probably one of the reasons of iatrogenic events. Anticoagulants
and antiplatelet agents, by side effects, misuse, underuse or overuse
are very often involved. The onset of kidney failure from dehydration
and the continuation of nephrotoxic and antidiabetic treatment also
remain one of the most common causes. Consequently, it is necessary
to continue and develop primary, secondary and tertiary prevention
strategies to prevent their appearance, to limit their consequences
and to reduce recidivism.
Chaigar Mohammed Cheikh1, Zakaria Quechar1, Hanane Ezzouine1,
Introduction Intensive care unit (ICU) is usually identified as a
place of acute care, concentrated over a short period. For many
reasons, a prolonged stay in the ICU has a pejorative connotation
for the intensivist physician. The aim of our study is to describe the
epidemiological, clinical, paraclinical profile of patients hospitalized for
a long time in ICU (over 15 days) and to identify the main prognostic
factors and those that can predict the duration of stay in ICU.
Patients and methods We conducted a retrospective study, over a
period of 5 years and 6 months (January 2010 to June 2015), enrolling
patients whose length of stay was greater than or equal to 15 days in
medical ICU of the UH Ibn Rochd of Casablanca. Statistical analysis was
performed using SPSS 21.0.
Results We enrolled 151 patients witch correspond to 8.2%
of all admissions. The sex ratio was 1.6, the average age was
(43.2 ± 18.5 years). The majority of patients (75%) were transferred
from the emergency department. Medical pathology was the main
motive of admission (82.1% of cases). Means of severity scores were
calculated as follows: APACHE III (56.2 ± 22.9), IGS III (40 ± 9.6), OSF
(0.6 ± 0.7). The average length of stay was (42.2 ± 59.7 days). The
incidence of nosocomial infection was 82.8%, the average day of
onset was 9.34 ± 8.7 days. Pneumonia, bacteremia and vascular
catheter infections were the main sites, Gram-Negative Bacilli
were the most frequently identified, dominated by Acinetobacter
baumanii (27.9%). Mechanical ventilation (91.4%) and vascular
catheterization (84.1%) are the most used invasive devices. Antibiotics
(92.1%), sedation (91.4%) and vasopressors (60.9%) were the main
administrated treatments. The outcome was favorable in 37.7% of
cases. Hemodynamic instability (64.2%) and respiratory complications
(61.6%) were the complications most frequently observed, septic
shock occurred in 49% of cases. Mortality rate was 55%. In univariate
analysis, the variables that have emerged as risk factors of mortality
were: sex, length of hospitalization, severity scores (APACHE III, IGS
III, OSF), the Charlson comorbidity score adjusted to age, traumatic
pathology, the occurrence of nosocomial infection, septic shock,
hemodynamic instability, neurological worsening, use of vasopressors,
and tracheostomy. In multivariate analysis: nosocomial infection
(p = 0.04), hemodynamic worsening (p = 0.03), use of vasopressors
(p < 0.01) and antibiotics (p < 0.01) appeared to be risk factors of
Conclusion Although patients hospitalized in ICU for more than
15 days are few, they represent a serious problem of care and an
important part of the activity of intensive care (bed occupancy, care
Admissions and readmissions to the intensive care unit
of patients with hematologic malignancies: a 5 years
Magalie Joris1, Dimitri Titeca Beauport1, Loay Kontar1, Delphine Lebon2,
Bérengère Gruson2, Michel Slama1, Jean‑Pierre Marolleau 2, Julien Maizel1
1Réanimation médicale, Centre Hospitalier Universitaire, Amiens, France;
2Hématologie clinique et thérapie cellulaire, Centre Hospitalier Universi‑
taire, Amiens, France
Correspondence: Magalie Joris ‑ joris.magalie@chu‑amiens.fr
Annals of Intensive Care 2017, 7(Suppl 1):P184
Introduction Despite an improvement in prognosis of patients
with hematologic malignancies for the last decade, mortality of
such patients admitted to the intensive care unit (ICU) remains high.
Yet, it seems that a first ICU stay does not modify prognosis of the
malignancy. Until now, there is no data on readmission in the ICU of
such patients and its effect on short and long term prognosis impact.
Patients and methods This retrospective, single-center study
conducted on a 5 years period in the medical ICU from our university
hospital included 265 patients with hematological malignancies
admitted for a first stay. Objectives were to evaluate the ICU, day 28
and 6 months mortality, to identify prognostic factors associated with
mortality within uni- and multivariate analysis, to evaluate readmission
rate within the 60 days after discharge, to indentify the admission risk
factors associated with ICU readmission and the prognosis factors
associated with mortality during the second ICU stay.
Results The mean age was 58.6 ± 14.8 years, with a male–female
ratio of 1.55. The most represented malignancies were acute
leukemia (40.8%) and non-Hodgkin lymphomas (26.8%); 16.2%
were hematopoietic stem cell transplant recipients. 54% of patients
had newly diagnosed malignancy, 20.8% were in complete
remission (CR), 11.7% had stable disease or partial remission and
13.6% had progressive disease. 46.4% of patients presented with
severe neutropenia at the time of ICU admission. The main
lifethreatening complications precipitating ICU admission were acute
respiratory failure for 43.8%, sepsis for 51.7%, acute kidney injury
for 14%, neurological disturbance for 18.1% and preventing tumor
lysis syndrome for 15.8%. 11.3% presented with hemophagocytic
lymphohistiocytosis (HLH). 34.3% of patients received non-invasive
ventilation, 46.8% mechanical ventilation (MV), 54.3% needed
vasoactive drugs administration and 40.8% had renal replacement
therapy. ICU, day 28 and 6 months mortality were 39.8, 46.4 and
63.4% respectively. By multivariate analysis poor performance status,
IGS II, HLH, MV and anti-fungal administration were associated
with increased ICU mortality, infections with Pseudomonas were
associated with higher day 28 mortality. Catheter related infections
were associated with better ICU survival and CR was associated with
lower day 28 mortality. 38 of 132 (28.9%) candidate patients for ICU
readmission after a first stay were readmitted within the 60 days
following discharge. Median overall survival was lower in readmitted
versus non readmitted patients. 6 months mortality was 73.8% for
readmitted versus 13.8% for no readmitted patients (p < 0.0001).
The second ICU stay mortality was 60.5% and 6 month mortality
was 78.9%. By multivariate analysis, only MV was associated with
prognosis. The 6 months mortality rate of patients who survived to
the second ICU stay was significantly higher than the patients who
survived to the first admission but were not readmitted (46.7 vs 13.8%,
p = 0.0007).
Conclusion Main features, short and long term mortality and
prognostic factors associated with ICU admission are in lines with
previous studies. Early readmission rate was high with a negative
impact on survival. Despite admission in the ICU of patients with
hematologic malignancies seems not to affect long term prognosis,
early readmission seems to have a pejorative impact on the course of
1. Azoulay E. Outcomes of critically ill patients with hematologic malignancies: prospective multicenter data from France and Belgium—a groupe de recherche respiratoire en réanimation onco‑hématologique study. J Clin Oncol. 2013;31:2810–18.
Prognosis of lung cancer patients admitted to ICU
Julie Gorham1, Lieveke Ameye,2, Thierry Berghmans,1, Marianne Paes‑
mans2, Jean‑Paul Sculier, 1, Anne‑Pascale Meert 1
1Intensive Care and Thoracic Oncology, Institute Jules Bordet, Brussel,
Belgium; 2Data centre, Institute Jules Bordet, Brussel, Belgium
Correspondence: Anne‑Pascale Meert ‑
Annals of Intensive Care 2017, 7(Suppl 1):P185
Introduction Lung cancer is among all types of cancer, the most
common solid tumour admitted in intensive care . Recent studies
showed that the prognosis of patients with lung cancer during
intensive care unit (ICU) stay has improved . The aim of our study
was to determine the causes of ICU admission of lung cancer patients,
their prognosis and to identify factors predicting hospital mortality
and survival after hospital discharge.
Patients and methods We conducted a retrospective study including
all patients with lung cancer admitted for a medical or surgical
complication in the intensive care unit of a cancer hospital between
September 1, 2008 and December 31, 2013. mbol’ > . Recent
studies showed that the prognosis of patients with lung cancer during
intensive care unit (ICU) stay has improved . The aim of our study
was to determine the causes of ICU admission of lung cancer patients,
their prognosis and to identify factors predicting hospital mortality
and survival after hospital discharge.
Results During this period, 212 ICU admissions occurred in 180
patients with lung cancer. The majority of them were men (64%),
had non small cell lung cancer (80%) and metastases at the time of
admission (81%). 54% received an antineoplastic therapy during the
month preceding the ICU admission. 47 patients (26%) died during
hospitalisation with 36 deaths in the intensive care unit and 11 in
the hospital ward after ICU discharge. The three main reasons of
admissions were: cardiovascular problems (32%), respiratory failure
(29%) and neurological (16%) complications. The SAPS II score (OR
1.07; 95% CI 1.04–1.11) as continuous covariate and the presence
of respiratory complications (OR 4.00; 95% CI 1.76–9.07) were the
2 factors independently affecting hospital mortality in multivariate
analysis. Median overall survival since ICU admission was 3.7 months
(95% CI, 2.8–4.4). Median overall survival for patients discharged
alive from ICU was 4.8 months (95% CI, 3.9–5.6 months). Considering
patients discharged alive from the hospital, only the presence of
metastases was a statistically independent prognostic factor in
multivariate analysis (HR 2.3; 95% CI 1.44–3.65).
Discussion The prognosis of patients with lung cancer admitted in ICU
improved probably due to a better selection of these patients eligible
for intensive care. As already observed in general cancer patients’
population, prognosis factors for hospital mortality are related to the
acute complications but survival after hospital discharge is dependent
from the cancer stage.
Conclusion Lung cancer patients are admitted in critical care in over
half of the cases for cardiovascular and respiratory complications. The
hospital mortality rate of these patients admitted in ICU was 26%.
However survival after hospital discharge remains low and dependent
of the cancer metastatic status. ICU admission should be considered
for patients with lung cancer.
Introduction Admission of cancer patients with poor prognosis
in intensive care units (ICU), like acute myeloid leukemia (AML)
resistant to the first course of induction chemotherapy, continue
to be controversial. The ICU trial may be an alternative in this case
to ICU refusal. The ICU trial is a full-code ICU admission followed by
reappraisal of the level of care. The objective of this study was to find
variables available at ICU admission and at day 3 in order to predict
prognosis of critically ill medical patients with relapsed acute myeloid
Patients and methods Retrospective monocentric study of
consecutive patients with a relapsed AML admitted to the 30 beds
medical ICU of an academic hospital. We evaluated hematological
treatments, organs supports and mortality in ICU.
Results Between 2002 and 2014, 24 patients with relapsed AML were
admitted in the ICU. At admission, patients were 54 years old, IGS 2:
64 ± 24, Lactates: 4.9 mmol/L (±4.7). Eight patients underwent bone
marrow transplant (BMT). Five patients had graft-versus-host disease
(GVHD). 12 patients were admitted for septic shock, 7 patients for acute
respiratory failure, 2 for cardiac arrests, 1 for coma, 1 for acute kidney
injury and 1 for hemorrhagic shock. BMT was significantly associated
with higher mortality [Odds ratio (0R) 13.0 (95% confidence interval
(95% CI) 1.7–99, 43)—p: 0.02]. 7 BMT patients died in ICU. Neutropenia
[OR 0.33 (95% CI 0.05–1.87)—p: 0.4] and GVHD (OR 2.0 [95% CI 0.07–
51.6)—p: 1.0] were not able to predict mortality in ICU. The first day
in ICU: 15 patients were under mechanical ventilation, 17 patients
need vasopressor perfusion and 3 patients dialysis. Mortality in ICU
was 37%. 4 patients died from acute illness before day 3. Among the
24 patients admitted in ICU, none of the life-sustaining interventions
at admission were associated with mortality: invasive mechanical
ventilation [OR 9.14 (95% CI 0.9–92.4) - p: 0.08], vasopressor perfusion
[OR 6.2 (95% CI 0.6–62.2)—p: 0.18] and renal replacement therapy
[OR 4.8 (95% CI 0.3–65.8)—p: 0.27]. On day 3, life supports were not
associated with higher mortality: invasive mechanical ventilation [OR
3.7 (95% CI 0.32–41.1)—p: 0.35], vasopressor perfusion [OR 2.0 (95%
CI 0.27–14.7)—p: 0.64] and renal replacement therapy [OR 1.2 (95% CI
Conclusion Mortality in ICU was 37% in patients with relapsed AML. In
fact, temporary full-code ICU management in patients with relapsed
AML seems to be appropriate. None of the life-sustaining interventions
at admission and on day 3 were able to predict survival. An ICU trial of
3 days might not be enough to appraise precisely the outcome. Bone
marrow transplant was associated with a high mortality in our study.
In case of relapsed AML with BMT, ICU management is still challenging.
Mortality analysis of the chronically critically ill patients: an
epidemiological prospective study
Severine Couffin1, David Lobo2, Nicolas de Prost3, Nicolas Mongardon4,
Gilles Dhonneur5, Roman Mounier2
1Surgical intensive care, Hospital Henri Mondor, Créteil, France; 2Anes‑
thesia and surgical intensive care, Hospital Henri Mondor, Créteil, France;
3Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 4Service
de réanimation médicale, Hôpital Cochin, Paris, France; 5Anesthesia and
intensive care medicine, CHU Henri Mondor, Créteil, France
Correspondence: Severine Couffin ‑
Annals of Intensive Care 2017, 7(Suppl 1):P187
Introduction The growing population of chronically critically-ill
patients has a poor prognosis despite all the resources mobilised .
Our primary objective was to analyse the prognostic value of different
definitions used to describe them. Our secondary objective was to
look for early clinical and biological factors that could be associated
with the in-hospital mortality.
Patients and methods We conducted an epidemiological prospective
study in 3 intensive care units (neurosurgical, cardiosurgical and
medical) of a large French teaching hospital (Henri Mondor, Créteil).
We included all the patients hospitalized for at least 7 days. We tested
5 definitions: the prolonged mechanical ventilation, the definition
taken up by Kahn et al. , the prolonged length of stay, the persistent
critical illness and the persistent inflammation-immunosuppression
and catabolism syndrome. Two biological examinations were
performed: upon entering the study and 1 week later. The study
endpoint was the in-hospital mortality.
Results Thirty patients were included between April and July
2016. Among them, only 40% matched the definition of prolonged
mechanical ventilation, which is still the most used in the literature.
Further, it was not associated with the mortality, but the prolonged
length of stay was, with 59% of these patients, that did not survive to
their hospital stay. Other parameters that were significantly different
between the patients who died and those who survived were an
advanced age, an elevated IGS II score at hospital admission, an
elevated SOFA score at study entry, a late healthcare-associated
infection and several biological variables: a high C reactive protein, low
albumin and prealbumin and a poor percent of monocytes expressing
HLA-DR, all measured at day 7.
Conclusion The in-hospital mortality of chronically critically-ill is still
high. A prolonged length of stay is the only definition who may be
helpful to identify the patients with the poorest outcome. Among the
early factors associated with mortality, we found a late
healthcareassociated infection and a low percent of monocytes expressing
HLADR, pointing to the value of studying the immune system of these
Introduction As a result of demographic transition, the proportion of
«very elderly» (≥90 years) patients is increasing worldwide and more
of these patients are nowadays admitted to intensive care units (ICU).
Among physicians the discussion about appropriateness of these ICU
admissions still remains controversial mostly due to questionable
outcome, limited resources and costs. The aim of the study was to
determine and evaluate the clinical characteristics and outcome in a
very old population admitted to a medical ICU in an urban teaching
Patients and methods We present here a monocentric, retrospective
and observational study. We reviewed the charts of all patients
(≥90 years) admitted to a medical ICU between 2000 and 2015
(16 years). We collected epidemiological, clinical and biological
parameters and all therapeutic measures during the ICU stay. A
longterm survival follow-up was also performed. Two hundred eighty-four
patients were included for statistical analysis. Multivariate Cox regression
was also performed to identify risk factors for 28-day outcome.
Results A total of 284 patients were included, which represented
1.8% of admissions to the ICU during the period of the study. The
mean age was 92.6 ± 2.1 years, the sex ratio was 0.41. Most of patients
(41%) were admitted from the Emergency Department. 20% of these
admitted patients suffered of previous dementia. The mean Charlson
comorbidity score was 7.7 ± 1.7 and the mean McCabe score was
1.33 ± 0.5. The admission diagnosis in the ICU was mainly respiratory
distress (51%), septic shock (11%), cardiac arrest (10%) and coma (8%).
The mean SAPS-II score within 24 h of ICU admission was 55.9 ± 21.7.
Half of these patients required support by mechanical ventilation
(mean duration 7.3 days) and vasoactive drugs and 6% of patients
received renal replacement. ICU and in-hospital mortality rates were
38 and 44% respectively. Overall survival at 6 months after hospital
discharge was 33%. Multivariate regression revealed necessity of
catecholamines and mechanical ventilation as independent risk
factors and urinary sepsis as protective factor for 28-day outcome.
In fine, for 34% of these patients, a limitation of active treatment was
decided (on average after 2 days of stay). For all others there was no
justification for limiting care because of a well-established treatment
plan (with family, GP, ICU team).
Conclusion The proportion of elderly patients remains low, but they
are increasingly being treated in intensive care units. Nevertheless, the
in-hospital mortality is high compared to the average mortality in our
ICU over the same period (20%). The prognosis is often not as poor as
initially perceived by physicians. The indication for ICU treatment in
our study was mostly justified; in the setting of consistent patient care
and good clinical practice. It remains therefore appropriate to discuss
every single ICU admission of elderly patients without any
restriction related to age. Thus, the ongoing cluster-randomized trial of ICU
admissions for the elderly patients (ICE-CUB 2 study) is deeply awaited
to confirm or not these results .
The hemorrhage postpartum: inventory
Setti‑Aouicha Zelmat 1, Djamila‑Djahida Batouche 2, Fatima Mazour3,
Belkacem Chaffi4, Nadia Benatta5
1Réanimation, etablissement hospitalier spécialisé 1er novembre, oran,
Algeria; 2Réanimation pédiatrique, Centre Hospitalier et Universitaire
d’Oran, Oran, Algeria; 3 Anesthesie ‑réanimation chirurgicale, EHS 1er
Novembre, oran, Algeria; 4Service de gynéco‑obstétrique, EHS 1er
Novembre, oran, Algeria; 5Cardiologie, Centre Hospitalier et Universitaire
d’Oran, Oran, Algeria
Correspondence: Setti‑Aouicha Zelmat ‑
Annals of Intensive Care 2017, 7(Suppl 1):P189
Introduction Regardless of the route of delivery, the postpartum
hemorrhage (PPH) is defined as blood loss ≥500 ml after childbirth,
and severe PPH as blood loss ≥1000 ml. PPH is the leading cause of
maternal mortality in Africa. The aim of this prospective study was to
assess the quality of the initial management of PPH in Algeria in Oran
EHU and to determine the factors of care with the severity of this
Patients and methods We conducted a prospective cohort study
between April 2014 and September 2014 at the EHU ORAN. All
women who delivered vaginally and showed HPP including the
suspected cause was uterine atony were included. The severe PPH
was defined as bleeding that required invasive surgical treatment
(hysterectomy, arterial ligation), a transfusion, a transfer to an
intensive care unit or death of the patient. The quality of care was
evaluated using objective criteria defined by a delay of diagnosis and
care and mortality.
Results Among the 466 women who delivered vaginally during
the study period, 23 had a PPH, link with uterine atony alleged at
diagnosis, 18 of which presented signs of severity. In 41% of cases,
the delay in diagnosis of PPH was less than 30 min; 70% of women
received oxytocin within 10 min after diagnosis. The tranexanique
acid was used in 1 case. The examination of the cervix, uterine
exploration and uterine massage was performed in 67, 99 and
97%, respectively. The failure of first line treatment involved 24%
of patients. Among them, the time between the diagnosis of PPH
and administration of blood derivatives was greater than 1 h in a
third of cases. The administration of oxytocin delay exceeds 10 min
multiplied by 2.5 the risk of severe PPH. However we had 2 deaths in
Discussion In our study the optimal period of care was not adequate,
obtaining blood derivatives in our institution remains among the
factors aggravating Among the main risk factors for PPH, uterine
atony was the main source of complication. Bleeding postpartum
aggravated in our two patients has led to the deaths from late
diagnosis and care that was not optimal. These hemorrhages PP is
the leading cause of mortality: 21% of obstetric deaths (25% in the
confidential survey 1996–1997) .
A hysterectomy was indicated after failure to conservative treatment.
The death rate is estimated at 8% following a disorder complicated
hemostasis of disseminated intravascular coagulation (DIC). In some
series, the mortality rate is estimated between 2 and 4% .
Conclusion The management of PPH in obstetrics gynecology service
The EHU Oran was not optimal. The issue of timing of diagnosis and
initial treatment is crucial. Solutions must be sought locally to ensure
this results comfort the possibility of therapeutic regulation of free
circulating mtDNA to prevent septic organ dysfunction related to
Conclusion Exogenous mtDAMPs can induce endothelial dysfunction
in mice. The mtDNA-RAGE axis is a key component of the signaling
pathway involved in this dysfunction.
Introduction The use of dynamic parameters to assess fluid
responsiveness was supported by cyclic changes in stroke volume
induced by mechanical ventilation. However, these parameters have
several limits. Venous to arterial carbon dioxide difference inversely
related to cardiac index. Consequently, fluid administration would be
beneficial if carbon dioxide gap increases.
Objective To investigate whether carbon dioxide gap predicts fluid
responsiveness in patients with acute circulatory failure.
Patients and methods We conducted a prospective study in
the medical intensive care unit of Hospital Taher Sfar at Mahdia,
between March 2013 and April 2016. Patients with circulatory
failure and who required mechanical ventilation were included.
We measured the variation of cardiac index between baseline
and after volume expansion of 500 ml of saline fluid. The PiCCO2
was used to measure cardiac index. Response to fluid challenge
was defined as a 15% increase in cardiac index. Before and after
fluid administration, we recorded carbon dioxide difference and
Results Among 68 included patients, 33 (49%) were responders.
The causes of acute circulatory failure were septic shock (n = 45),
cardiogenic shock (n = 11), and Hypovolemia (n = 12). Carbone
dioxide gap was significantly higher in responders group (8 ± 7 vs
4 ± 4 mmHg, p = 0.019). The area under the ROC curve for carbon
dioxide gap was 0. 68 (95% CI 0.55–0.80). The best cutoff value was
6 mmHg (Sensibility = 46%, specificity = 80%, positive predictive
value = 52% and negative predictive value = 60%). The area under the
ROC curve for delta carbon dioxide was 0.54 (95% CI 0.4–0.68).
Conclusion In this study, baseline carbon dioxide gap was not
universal indicator to predict the fluid responsiveness in patient with
Incidence and prognostic impact of new onset supraventricular
arrhythmia in patient with septic shock
Walid Sellami1, Zied Hajjej1, Soumaya Ben Yedder1, Walid Samoud1, Iheb
Labbene1, Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospi‑
tal of Tunis, Tunisia, Tunis, Tunisia
Correspondence: Walid Sellami ‑
Annals of Intensive Care 2017, 7(Suppl 1):S85
Introduction Supraventricular arrhythmia (SVA) is commun in
intensive care unit (ICU). Its incidence seems to be higher in patients
with sepstic shock. Sepsis-associated myocardial dysfunction promote
the occurrence of SVA by constituting an arrythmogenic substrate or
under the effect of inotropic drugs.
The aim of this study is to assess the incidence and prognostic impact
of SVA in patients with septic shock.
Patients and methods We retrospectively studied all patients with
new onset SVA suffering from septic shock in non cardiac surgical ICU.
Myocardial dysfunction was evaluated by transthoracic echography
(TTE) after an adequate cardiac resuscitation using intravenous fluids
expansion and adjunctive vasoactive agents. SVA was detected by the
electrocardiogram scope. During the study period clinical and biologic
characteristics, hemodynamic tolerance (vasopressors doses, arterial
pressure changes), current treatment (such as corticoid), duration of
mechanical ventilation, duration of vasopressor requirement and
hospital mortality were collected.
Results Sixty patients were included in the study. The SVA occurred
in 28 patients, with an incidence of 46%. The median time to onset
was 2 days. Cardioversion was performed for 15 patients with an
effectiveness of 80%. Clinical and biological characteristics were similar
between the groups with and without SVA: SAPS 2 and SOFA score
at the beginning of septic shock, the existence of ARDS and cardiac
biomarkers (NT-proBNP, troponin). However, renal failure and the use of
corticoid in septic shock were more frequent in the group with SVA. The
maximum doses of vasopressor agent were not significantly different
between the groups with or without SVA. Myocardial dysfunction in
sepsis defined by the left ventricle ejection fraction (LVEF) less than
45% (or the need for inotropic drug for LVEF > 45%) was not associated
with the occurrence of SVA (+SVA group: n = 8; −SVA group: n = 6;
p: 0.57). SVA was poorly-tolerated, observed by a significant decrease
in mean arterial pressure and a significant increase in norepinephrine
doses within 1 h of the start of SVA. The occurrence of SVA was
associated with longer duration of use of vasopressor agent and a
longer duration stay in ICU (+SVA group: 21 days, −SVA group: 14 days;
p = 0.03). There was no difference in duration of mechanical ventilation
and hospital mortality between the two groups.
Conclusion The occurrence of SVA is common in septic shock, poorly
tolerated hemodynamically and associated with longer duration stay
in the ICU and vasopressor need. Sepsis myocardial dysfunction isn’t
necessarily associated to the occurrence of SVA.
Introduction A short term beneficial effect of prone position on
cardiac index has been shown in 50% of 18 ARDS patients, and was
related to an increase in cardiac preload in preload responsive patients
(1). The aim of this study was to evaluate the long term hemodynamic
response to prone position in a larger series of ARDS patients.
Patients and methods Single center retrospective observational
study performed on ARDS patients hospitalized in a medical ICU
between July 2012 and March 2016. Patients included were adults
fulfilling the Berlin definition for ARDS, undergoing at least one prone
position session, under hemodynamic monitoring by the Picco®
device, with availability of hemodynamic measurements performed
before (T1), at the end (T2), and after the prone position session
(T3). Prone position sessions were excluded if they were performed
>7 days after ARDS onset. The following variables were recorded:
demographic, SAPSII, ARDS severity and risk factor, SOFA score and
cumulative fluid balance at PP onset, delay between ARDS session and
PP session, hemodynamic, arterial blood gas, ventilatory settings,
plateau pressure, catecholamine dose and additional treatments.
Statistical analyses were performed using prone position session as statistical
unit and mixed models taking into account both multiple prone
position sessions by patient and multiple measurements during a prone
position session. p < 0.05 was chosen for statistical significance. Data
are expressed as mean ± standard deviation.
Results 85 patients fulfilled the inclusion criteria over the study
period, totalizing 149 prone position sessions (2 ± 1 sessions per
patient). Patients’ age was 65 ± 11 y, 67% were male, 75% fulfilled
the criteria for severe ARDS, and SAPSII at ICU admission was 64 ± 17.
ARDS risk factors were pneumonia in 63 (74%), aspiration pneumonia
in 26 (31%), and sepsis in 7 (8%) patients. Duration of prone position
sessions was 16 ± 3 h. Hemodynamic measurements were performed
in PP 13 ± 3 h after PP session onset. At session onset, SOFA score was
15 ± 4, and cumulated fluid balance was 2.5 ± 7.1 L. Vasopressor were
used in 87%, inhaled nitric oxide in 22%, and neuromuscular blocking
agents in 91% of the sessions. Hemodynamic and respiratory
parameters before, during and after the prone position sessions are reported
in Table 24.
Cardiac index increased by at least 15%, decreased by at least 15% or
remained stable in 35 (24%), 36 (34%), and 78 (52%) of the sessions,
respectively. As compared to both other groups, PP sessions with
significant increase in cardiac index had the following significant
differences at T1 by univariate analysis: lower cardiac index, lower global
end-diastolic volume, lower cardiac function index, and lower
vasopressor dose. Multivariate analysis is under investigation.
Conclusion Prone position is associated with an increase in global
end-diastolic volume, reversible after return in supine position that
may explain the positive effect of PP on cardiac index observed in ¼
of the PP sessions.
Before PP (T1) End of PP (T2) After PP (T3)
dPmax (mmHg s−1)
Lactates (mmol L−1)
VT (ml kg−1 PBW)
† p < 0.05 versus before PP; ‡ p < 0.05 versus end of PP; * p < 0.05 versus after PP
1. Jozwiak M. Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2013;188:1428–33.
Is the shape of the inferior vena cava a good tool to assess fluid
responsiveness? A pilot study
Hélène Cochet1, Jean Pierre Ponthus1, Virginie Amilien1, Martial Tchir1,
Elise Barsam1, Mohsen Ayoub1, Jean Francois Georger1
1Réanimation polyvalente ‑ surveillance continue, Ctre Hospitalier
Intercommunal de Villeneuve Saint Georges, Lucie et Raymond AUBRAC,
Correspondence: Hélène Cochet ‑
Annals of Intensive Care 2017, 7(Suppl 1):S87
Introduction Make sure that our patient have a good circulatory
condition is a daily challenge for the intensivist. One of the
therapeutics is fluid and one of his purpose is to increase venous
return and then cardiac output. In order to examine that, There are
several tools as the transthoracic echocardiogram wich allows the
visualisation and the study of the respiratory variability from the
inferior vena cava (IVC). Unfortunately there are some situations where
the IVC visualisation is difficult (obesity, gut surgery, emphysema).
The IVC is easily seen by a transhepatic ultrasound in her retrohepatic
section. We make the hypothesis that the shape of the IVC could be
predictive of fluid responsiveness.
Patients and methods We have performed fluid challenge in
patients under mechanical ventilation. The need for fluid therapy is
the intensivist in charge decision. We performed a echocardiogram
and we take two measures of the ICV: major axis and minor axis,
the ICV is measured avec the sus hepatic vena. A elastometry index
(EI) is determined which is the ratio of minor axis to minor axis. The
fluid challenge is 250 ml of isotonic saline then we perform a new
echocardiogram. A Tag is written on the patient to take the same
ultrasound slice. We retain one increase of 15% of the cardiac index
(IC) as a success of the filling. We exclude the presenting patients A
right cardiac insufficiency, an arrhythmia and/or a HTAP. The statistical
analysis is realized with the software R.
Results Between August, 2015 and January, 2016 we included
49 patients. The average age is of 59 years (24–81), IGS2
of 48 (20–84), Ejectionnal Fraction of 48% 35–75) and the S wave
tricuspid is 14 (9–21). The causes of the filling were an oliguria (31%), a
low blood pressure (20%), a low cardiac output (30%), a
hyperlactatémia (9%) and an other cause in 10% of the cases. We find a positive
correlation between the EI and the increase of the IC, also for the area
of the VCI and the respiratory variations of the VCI (p0.05) the other
variables are not predictive (BP, E/e’, E/A). The data are summarized in
the picture 1. ROC curves has been established (Table 25; Fig. 21).
Conclusion It is an alternative and simple technique once acquired.
The limits are essentially established by technical conditions such as
Table 25 Relevant parameters
ICV respiratory variation (%)
Fig. 21 See text for description
the necessity of being very perpendicular at the risk of falsifying the
EI. For now it is just a static index but an ovoïd vena cava (EI: 0.85) may
be predicative of fluid responsiveness. The strangely big size of the VCI
can be attributed to a deformation of the in-depth image because of
the probe but this should not modify in theory the report of EI. It is
a question in the future of testing this parameter at the spontaneous
breathing patient, study his variability with respiration and
strengthening its external validity.
Quality of reporting of fluid responsiveness evaluation studies: a
five year systematic review
Izaute Guillame1, Matthias Jacquet‑Lagrèze 1, Jean‑Luc Fellahi 1
1Anesthésie réanimation, Hopital Louis Pradel, Bron, France
Correspondence: Matthias Jacquet‑Lagrèze ‑
Annals of Intensive Care 2017, 7(Suppl 1):S88
Introduction The Standards for the Reporting of Diagnostic Accuracy
Studies (STARD) statement was developed in 2003 to improve the
quality of reporting of diagnosis studies (1). STARD is a list of 25
essential items, it was updated in 2015 (2). Fluid responsiveness evaluation
is a cornerstone of hemodynamic management of patient with
circulatory failure. Numerous studies have evaluated tools for assessing fluid
responsiveness. The purpose of this work was to evaluate the quality
of reporting of studies assessing fluid responsiveness, using the STARD
Materials and methods We used MEDLINE via PubMed to search
all publication of studies assessing the ability to predict or diagnose
fluid responsiveness in a perioperative or circulatory failure context
between the 1st of January 2004 and the 1st of January 2014. We have
presented herein the last 5 years (2010–2014). Paediatric studies,
publication with no abstract available or in another language than English,
review, meta-analysis, and journals with impact factor less than 2 were
excluded. We have checked these studies for all the 25 STARD
criteria. The rating methodology of each item was discussed and double
checked (GI and MJL). The 2003 and 2015 STARD quality score (SQS)
was the integer of the present item. Univariate and multivariate
analysis were conducted to find out if some characteristic of the studies
were linked with a better SQS. Following items were studied: year of
publication, positive or negative study, location of study, expert team,
funding source, conflict of interest, the use of a new device, instruction
to the author including STARD statement, impact factor of the journal.
Every covariate associated with a p-value lower than 0.20 in the
univariate analysis were used in the multivariate analysis. Statistical analysis
was performed with R software. All the test were two-sided, p < 0.05
was considered statistically significant.
Results After a double screening (GI, MJL) of 430 articles (2010–2014),
97 were selected, then 46 were excluded because of an IF < 2. Fifty-one
studies were selected and reviewed. The mean 2003 overall quality
score was 11.85 on a scale of 0–25, whereas the mean 2015 overall
quality score was 15.34 on a scale of 0–30. The 2003 SQS remained
stable between 2010 and 2014 (p = 0.173). Correlation between 2003
and 2015 SQS was good (r = 0.83; p < 0.001). Some items are
insufficiently reported, especially: participant sampling (adequately reported
in 19.6% of studies), executing and reading the tests (11.7%),
blindness (11.8%) and, the description of test reproducibility (19.1%). Some
items are better reported: technical specifications and/or references to
tests (65.1%), methods for calculating or comparing (90.2%), clinical
and demographic characteristics (82.3%), diagnostic accuracy (90.2%).
Only 16% of the journals studied required authors to use STARD. A
high Impact factor and the year of the study were the items associated
with a better SQS the presence of a conflict of interest was associated
with a lower SQS in univariate analysis. A higher impact factor (> 5),
was the only independent factors statistically significantly (p = 0.037)
associated with higher SQS in a multivariate regression model.
Discussion Our study showed that the SQS were very low. Assessment
of a study depends on quality of reporting. Blindness and participant
sampling are the cornerstone to evaluate such bias as spectrum,
verification, review and selection bias of a study, and were unfortunately
scarcely reported compared to existing data in diagnosis accuracy
reporting. One of the limitation is the 5 years sample of the study. We
have planned to continue the analysis for a 10-year review starting just
after the 2003 STARD publication.
Conclusion Our study showed that several items remain poorly
reported. We recommend systematic use of STARD criteria in the
elaboration and reporting of future studies that evaluates the preload
Neurological impairment in cirrhotic patients admitted to ICU:
hepatic versus drug‑induced encephalopathy
Julie Assaraf1, Simona Tripon2, Maxime Mallet3, Marika Rudler4, Julien
Mayaux5, Dominique Thabut6, Nicolas Weiss7
1Unité de soins intensifs d’hépatogastroentérologie, Pitié‑Salpêtrière Hos‑
pital, Paris, France; 2Unité de soins intensifs d’hépatogastroentérologie,
Hôpital Pitié‑Salpêtrière, Paris, France; 3Unité de Soins Intensifs. Service
d’Hépato‑gastro‑entérologie du Pr Poynard, CHU Pitié Salpétrière, Paris,
France; 4Hepatology and gastroenterology, Pitié‑Salpêtrière Hospital,
Paris, France; 5Réanimation médicale, Hôpital Pitié‑Salpêtrière, Paris,
France; 6Brain Liver Pitié‑Salpêtrière Study Group (BLIPS), Hôpital
Pitié‑Salpêtrière, Paris, France; 7Unité de réanimation neurologique, Hôpi‑
tal Pitié‑Salpêtrière, Paris, France
Correspondence: Julie Assaraf ‑
Annals of Intensive Care 2017, 7(Suppl 1):S89
Introduction Neurological impairment, i.e. encephalopathy, is
commonly observed in patients with decompensated cirrhosis
and/or portosystemic shunts admitted in ICU. Often ascribed to
high plasmatic levels of ammonia, encephalopathy could also be
induced by drugs or infection, due to altered blood–brain barrier
(BBB) permeability. This latter setting is often underdiagnosed and
encephalopathy related to hyperammonemia (so called hepatic
encephalopathy-HE) being pointed out as the culpit of all neurological
symptoms in cirrhotic patients. Quinolones and betalactamins were
recently found in the cerebrospinal fluid of HE patients and it has
been shown that the expression of efflux pumps, responsible for
drugs passing through the BBB, was altered in animal models of HE.
The purpose of this study was to assess the incidence of neurological
impairment, i.e. encephalopathy, in cirrhotic patients hospitalized in
ICU and to analyse its promoting factors, especially ammonia levels,
infection and drug intake.
Patients and methods Between February 2015 and September 2016,
all cirrhotic patients admitted in ICU were prospectively included.
We collected patient’s clinical and biological parameters, especially
ammonia levels, all the ongoing treatments, and seeked for the
presence of evolutive infection defined as an infection considered
as clinically relevant. Cirrhotic patients having encephalopathy and
ammonia levels above 75 μmol/L were considered as having HE.
We performed univariate and multivariate analysis to estimate the
association between ammonia level, infection or drugs intake and the
presence of encephalopathy.
Results 202 cirrhotic patients were included, they were
58 ± 11 yearsold, 71% were men. Etiology of cirrhosis was as followed: alcohol
110 (54%), virus 27 (13%), NASH 19 (10%), mixed 30 (15%), others
16 (8%). 122 patients (60%) displayed neurological impairment, i.e.
encephalopathy at admission, 84 (42%) had ammonia levels above
75 μmol/L, 80 (40%) had evolutive infection and the following drugs
were found: furosemide, hydrochlorothiazide, betablockers, lactulose,
rifaximine, betalactamins, proton pump inhibitors (PPIs), quinolones,
benzodiazepines, morphine derivatives, insulin, anti-epileptic drugs,
corticosteroids and immunosuppressants. In univariate analysis,
patients with encephalopathy had significantly higher Child and
MELD scores, higher ammonia, bilirubin and leukocytes levels, more
evolutive infections, and received more frequently PPIs, lactulose
and quinolones as compared to those who had no encephalopathy.
Patients with encephalopathy took also more frequently an association
of agonist of efflux pumps (e.g. PPIs, betalactamins or quinolones)
(p = 0.0005). In the group of patients displaying low ammonia levels
(less than 75 μmol/L), encephalopathy was significantly increased in
patients having infection (p < 0.0001), taking quinolones (p = 0.0086),
PPIs (p = 0.0196), and betalactamins (p = 0.0438) whereas
ursodeoxycholic acid treatment had a protective effect (p = 0.0299).
Multivariate analysis showed that high ammonia levels (p < 0.0001),
presence of infection (p < 0.0001), and taking quinolones (p = 0.0403)
were independently associated with the presence of encephalopathy.
Conclusion These results highlight the involvement of drugs in the
physiopathology of neurological impairment in cirrhotic patients.
Several drugs that were implicated can modify the activity of efflux
pumps expressed on the BBB. Besides HE, cirrhotic patients are
susceptible to develop drugs-induced encephalopathy regardless
of ammonia level, underlying the necessity to carefully assess every
treatment indication, given their potential neurotoxicity.
Functional outcome of prolonged hypoglycemic encephalopathy
Guilaume Barbara1, Bruno Megarbane2, Laurent Argaud3, Guillaume Louis4, Nicolas Lerolle5, Francis Schneider6, Stéphane Gaudry7, Nico‑ las Barbarot8, Angéline Jamet,9, Hervé Outin10, Sébastien Gibot1, Pierre‑Edouard Bollaert 1
1Réanimation médicale, hôpital central, C.H.U. de Nancy, Nancy, France;
2Service de Réanimation Médicale et Toxicologique, CHU Lariboisière,
Paris, France; 3Réanimation Médicale, Hospices Civils de Lyon ‑ Groupe ‑
ment Hospitalier Edouard Herriot, Lyon, France; 4Réanimation polyva‑
lente, Hôpital de Mercy, Ars Laquenexy, France; 5Réanimation médicale,
Centre Hospitalier Universitaire d’Angers, Angers, France; 6Réanimation
médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg,
France; 7Service de réanimation médico‑chirurgicale, CHU Louis Mourier,
Colombes, Colombes, France; 8Service de réanimation polyvalente,
Centre hospitalier, Saint Brieuc, France; 9Réanimation médicale, CHU de
Poitiers, Poitiers, France; 10Service de Réanimation Médico‑Chirurgicale,
CHI de Poissy/Saint‑Germain‑en‑Laye ‑ Site Poissy, Poissy, France
Correspondence: Pierre‑Edouard Bollaert ‑ pe.bollaert@chu‑nancy.fr
Annals of Intensive Care 2017, 7(Suppl 1):S90
Introduction Little is known about the causes, clinical course and
longterm outcome of prolonged hypoglycemic encephalopathy. We
investigated functional long-term prognosis and identify prognosis factors of
patients admitted in an Intensive Care Unit (ICU) with prolonged
neurological manifestations related to obvious hypoglycemia.
Patients and methods This was a retrospective study conducted in
patients hospitalized from July 1, 2004, to July 1, 2014, in 9 polyvalent
intensive care units in French university and general hospitals.
Participants were adults admitted to the ICU with a Glasgow Coma
Score <8 due to hypoglycemia <0.5 g/l and persistent consciousness
disorders after normalizing blood glucose levels. Patients with possible
other causes of consciousness disorders, previous cognitive disorders,
hypothermia <35 °C or circulatory arrest within 24 h after ICU admission,
were excluded. Follow-up phone call was used to determine the
functional outcome using modified Rankin Scale at 1-year minimum
(mRS) with mRS 0–3 defining good and mRS 4–6 poor outcomes.
Results Forty-nine patients were included. Median age was 55 years.
Causes of hypoglycemia were various, mainly including insulin or
oral antidiabetic drugs abuse (65%) and neuroendocrine carcinoma
(16%). Twenty (41%) patients died in the ICU, and a total of thirty-one
(63%) patients had a poor outcome at 1-year follow-up. Twenty-two
(45%) patients underwent therapeutic limitation, primarily due to no
hope expected for improvement (86%). Among survivors with poor
outcome at ICU discharge (n = 15), one died 10 months later and six
improved their outcome at 1-year follow-up with a median decrease
in mRS of −2 [IQR −2.5 to −1.75], including five patients who finally
reached the good outcome group. Among the patients with good
outcome on ICU discharge, one died, seven further improved their
outcome at 1 year with a median decrease in mRS of −2 [IQR −2.0
to −1.0], whereas one patient deteriorated while remaining in the
good outcome group (from mRS 1–2). On multivariate analysis, only
low mRS prior to ICU admission (OR 2.6; 95% CI = 1.1–6.3; P = .03)
and normal brain imaging (OR 7.1; 95% CI 1.1–44; P = .03) were
significantly predictive of outcome. All patients (n = 15) who stayed
hypoglycemic 480 min or more evolved poorly.
Conclusion Poor outcome was observed in about 60% of this
population of prolonged hypoglycemic encephalopathy. Some patients can
recover satisfactorily over time though we did not identify any robust
factor of good outcome.
Cerebrospinal fluid characteristics during status epilepticus: a
descriptive and prognostic study
Mathilde Holleville1, Stéphane Legriel1, Anne Laure Chateauneuf1, Sébast‑
ien Cavelot1, Gwenaëlle Jacq,1, Jean‑Denis Moyer 1, Jean Pierre Bedos1,
1Réanimation médico‑chirurgicale, C.H. de Versailles, Le Chesnay, France
Correspondence: Mathilde Holleville ‑
Annals of Intensive Care 2017, 7(Suppl 1):S91
Introduction The lumbar puncture is an important tool of the
etiologic investigations during status epilepticus. Scarce data
are available regarding cerebrospinal fluid pleocytosis directly
induced by seizures. We aimed to describe the cerebrospinal fluid
characteristics of the patients admitted to the intensive care unit
for status epilepticus, and to report the clinical, biological and
radiological data of these patients. Furthermore, to determine
whether status epilepticus per se increases the cerebrospinal fluid
pleocytosis, we specifically studied cerebrospinal fluid parameters
after status epilepticus in adult patients after exclusion of the cases
of status epilepticus induced by acute infection or neoplastic disease
of the central nervous system.
Patients and methods This monocentric retrospective study (2005–
2012) included patients of more than 18 years old admitted to the
intensive care unit for status epilepticus and who had a lumbar
puncture. Status epilepticus was defined by a single seizure lasting more
than 5 min or multiple seizures without neurological recovery in
between. A cerebrospinal fluid pleocytosis was defined by a
cerebrospinal fluid cell count of more than 4/mm3. We analyzed demographic,
medical, biological data and outcomes at 3 months and 1 year. The
groups were compared using univariate and multivariate analysis.
Cerebrospinal fluid pleocytosis was considered directly linked to seizures
when etiologic investigations identified causes of status epilepticus
which were not known to induce cerebrospinal fluid pleocytosis.
Results Among 191 patients admitted to the intensive care unit
for status epilepticus, 124 (65%) had a lumbar puncture and were
included. Eight of them had a cerebrospinal fluid pleocytosis of
infectious or neoplastic origin. Among the 116 remaining patients,
97 (84% = group B2) had normal cerebrospinal fluid parameters,
and 19 (16% = group B1) had a cerebrospinal fluid pleocytosis
considered as directly linked to seizures, with a median [Q1–Q3]
cerebrospinal fluid cell count of 8/mm3 [7–20]. No other cerebrospinal
fluid parameters changes were observed in the two groups, unless a
slight increase in the cerebrospinal fluid lactate (mmol/l), but without
significant difference between the two groups (3.1 [2.7–3.4] group B1
vs 2.9 [2.5–3.5] group B2). In the multivariate analysis, only myoclonic
status epilepticus (OR 55.1; CI 95% 6.02–1103.88; p = 0.001) and
leukocytosis at the admission (OR 1.1 per 103/mm3 increment; CI95%
1.01–1.21; p = 0.01) were associated to pleocytosis directly linked to
status epilepticus. The intensive care unit mortality was significantly
increased in patients with pleocytosis directly linked to status
epilepticus (5 (26%) vs 7 (7%), p = 0.02), but hospital mortality was not
significantly different between the 2 groups.
Discussion Overall, we reported a higher rate of lumbar puncture
than those reporting in others studies concerning status epilepticus.
Furthermore the rate of 16% of pleocytosis directly linked to status
epilepticus is slightly higher than in most studies. Unfortunately we
didn’t realize a second lumbar puncture to assess the pleocytosis
normalization during the days following the first lumbar puncture.
The pathophysiological hypothesis of this phenomenon may be that
prolonged/repeated seizures during status epilepticus would induce
a blood–brain barrier dysfunction thereby favoring a cerebrospinal
Conclusion In our study, 16% of status epilepticus without infectious
or neoplastic origin had a cerebrospinal pleocytosis directly linked
to status epilepticus. This pleocytosis was significantly associated
with myoclonic seizures and blood leukocytosis. These data may
help to interpretation of cerebrospinal fluid pleocytosis during status
Synek score and NSE to predict poor neurological outcome
after cerebral anoxia and therapeutic hypothermia
Dimitri Titeca Beauport1, Magalie Joris1, Philippe Merle2, Loay Kontar1,
Antoine Riviere1, Bertand De Cagny1, Thierry Soupison1, Michel Slama1,
1Réanimation médicale, Centre Hospitalier Universitaire, Amiens, France;
2Explorations fonctionelles du système nerveux adulte, Centre Hospitalier
Universitaire, Amiens, France
Correspondence: Dimitri Titeca Beauport ‑ titeca.dimitri@chu‑amiens.fr
Annals of Intensive Care 2017, 7(Suppl 1):S92
Introduction Neurological prognostication from cardiac arrest
survivor is a current concern. EEG patterns and NSE dosage are two
important prognostic factors. NSE threshold for prediction of poor outcome
appear controversial, in part, because of variability in dosage timing
and measurement techniques. Synek Score is routinely used in our
center to classify comatose patients in post cardiac arrest. The aim of
this study was to assess the prognostic value of NSE and Synek
classification to predict poor neurological outcome.
Materials and methods We conducted a retrospective monocentric
study in our medical intensive care unit between November 01, 2013
and August 31, 2016. All patient having at least one EEG and H48-72
NSE dosage available were included. Patients dead from post cardiac
arrest shock, stroke, moribund, spontaneous awaking, or missing data
were excluded. Electroencephalograms were prospectively classified
by electrophysiologist according to the Synek score and NSE were
performed within H48-72 post cardiac arrest.
Results Among 162 cardiac arrest survivors, 70 were retrospectively
analyzed. All patients received sedation with midazolam and
sufentanil and mild therapeutic hypothermia for 24 h. Forty-eight were
classified as poor outcome (CPC ≥ 3) and 22 as good outcome (CPC 1–2).
Serum NSE levels above 46 µg/l was associated with a poor
neurological outcome with sensitivity of 75%, specificity of 100% and AUROC at
0.95. The Synek score ≥3 was also strongly associated with poor
neurological outcome with sensitivity of 91.5%, specificity of 90.9% and
AUROC at 0.95.
Conclusion In the limits of this study, Synek score ≥3 on first EEG and
H48-72 NSE > 46 µg/l are two strong predictor of poor neurologic
outcome. The prognostic value of the association of the NSE and the
Synek score to predict a poor neurological outcome remain to be
Introduction Traumatic Brain Injury (TBI) is a major public health
problem. It is the leading cause of death and disability in young
subjects. One of the principles of the TBI management is prevention
of secondary cerebral insults including maintaining perfusion and
cerebral oxygenation, control of intracranial pressure (ICP). An increase
in ICP above 20 mmHg is associated with poor outcome. Cerebral
hypoxia can occur with normal level of ICP and cerebral perfusion
pressure (CPP).Monitoring of regional partial pressure of brain tissue
oxygen (PbtO2) is a safe and reliable method for measuring cerebral
Patients and methods A retrospective single-center
observational study was conducted between January 2012
and December 2013, aimed to study the influence of PbtO2
with severe TBI patients outcome at 6 months through
Glasgow Outcome Scale (GOS). The hourly values of ICP, PbtO2
and CPP were recovered on daily monitoring sheets. We compared
two groups according to their GOS. During the study period, 66
patients underwent a monitoring ICP and PbtO2.
Results The mean age was 33.7 ± 14.1 years. 78.8% were men.
The initial Glasgow score was 6.6 ± 3.7. The mean Simplified Acute
Physiology Score (SAPS II) was 43.4 ± 11.2 and Injury Severity
Score (ISS) 30.5 ± 9.7. At 6 months, 7 patients had died (GOS1).
Forty patients had a good outcome: GOS 4–5 (Group 1). Sixteen
patients had poor outcome: GOS 2–3 (Group 2). In Group 2, there
are significantly more PbtO2 hourly values below 10 mmHg at Day0
(5.5 ± 6.4 vs 2.3 ± 3, 2 in Group 1, p = 0.025); and more PbtO2
hourly values greater than 20 mmHg at Day0 (8.4 ± 7.0 vs 4.8 ± 4.9,
p = 0.045).
Conclusion PbtO2 less than 10 mmHg or greater than 20 mmHg at
Day0 is associated with poor outcome at 6 months in the severe TBI.
The PbtO2 allows a more individual approach of monitored TBI.
Introduction Organ donation in patients after a decision to withdraw
life-supportive therapies (WLST) (Maastricht 3 condition: M3) have
been performed in our hospital since May 2015. We report here main
characteristics of donors, data on M3 procedure and results on renal
Patients and methods All potential donors were included in a
survey from May 2015 to June 2016, according to the French national M3
protocol defined by the French Organ Procurement Agency (Agence
de la Biomédecine:ABM) .The demographical, clinical and biological
characteristics of the donors, the different deadlines and times of the
protocol and data of renal transplantation were collected and analyzed.
Table 26 Characteristics of the donors, deadlines of the
protocol and transplant recipients
Characteristics of potential donors (n = 28)
Age in years, mean [range]
CrCl by Cockroft‑ Gault, mean (ml/mn) [range]
Length of stay in ICU, mean (day) [range]
Deadlines of the protocol (n = 13)
Time from extubation to death, mean (min) [range]
Warm ischemia time, mean ‘min) [range]
Duration of vessel cannulation, mean (min) [range]
Duration of normothermic regional perfusion, mean
Duration of cold storage, mean (min)
Characteristics of transplant recipients (n = 26)
Age in years, mean [range]
Length of stay in transplant unit, mean (day) [range]
Duration before creatinine <250 μmol/L after
transplantation, mean (day) [range]
Serum creatinine (μmol/L) at the hospital discharge,
Delayed Graft Function, n (%)
Results 28 patients had inclusion criteria. Patients were admitted in
intensive care unit for cardiac arrest (68%), strokes (14%), traumatic
brain injury (14%), ARDS (4%). Of them, 15 procedures (54%) were
stopped (6 refusals of organ donation, 4 medical contra-indications
discovered with additional exams, 1 failure of vessel cannulation, 4
deaths more than 3 h after extubation). 28 kidneys were harvested
and 26 transplantations performed (1 renal cancer discovered during
procurement surgery).The characteristics of the donors, deadlines of
the protocol and transplant recipients are reported in the Table 26.
Conclusion The French programm Maastricht 3 offered a new
possibility of organ donation in our hospital. Thanks to these donors, the
number of renal grafts increases and the preliminary results on transplant
recipients are encouraging in line with the preliminary report of the
ABM. Nevertheless, it is necessary to follow the transplant recipients
and extend the procedure to new centres.
Is chronic obstructive pulmonary disease a risk factor
for microaspiration in intubated critically‑ill patients?
Thècle Degroote1, Emmanuelle Jaillette1, Farid Zerimech2, Balduyck
Malika2, Saad Nseir1
1Centre de réanimation, Centre Hospitalier Régional Universitaire de Lille,
Lille, France; 2Laboratoire de biochimie et biologie moléculaire, Centre
Hospitalier Régional Universitaire de Lille, Lille, France
Correspondence: Thècle Degroote ‑
Annals of Intensive Care 2017, 7(Suppl 1):S96
Introduction Microaspiration of gastric and oropharyngeal
contaminated secretions occurs frequently in intubated critically-ill patients,
and plays a major role in the pathogenesis of ventilator-associated
pneumonia (VAP). At basic state, patients with chronic obstructive
pulmonary disease (COPD) have an increased risk of microaspiration
(due to gastro-esophageal reflux disease, pharyngo-laryngeal
dysfunction…), this risk may even be more important under mechanical
ventilation. The main purpose of this study is to determine if COPD is
a risk factor for global abundant microaspiration (GAM) in intubated
Materials and methods We gathered data about two prospective
multicentric randomized trials focused on microaspiration in intubated
patients. Data about COPD were retrospectively collected in order to
complete previous data. Microaspiration of gastric and oropharyngeal
secretions was respectively determined by quantitative measurements
of pepsin and salivary amylase in all tracheal aspirates during the first
48 h after intubation. GAM was defined as the presence at significant
level of pepsin (>200 ng/ml) and/or salivary amylase (>1685 UI/L) in at
least 30% of the tracheal aspirates. In order to find GAM independent
risk factors, we realized an univariate and multivariate analysis of the
Results Out of 448 patients included in the studies, 415 were
analyzed among which 95 patients with COPD. 360 patients (87%) had
GAM. Neither COPD diagnosis, nor spirometric severity nor specific
therapeutics were associated with GAM. Risk factors for GAM in
univariate analysis were the age, diabetes, low score in Glasgow Coma
Scale (GCS), and no recourse to paralytic agents or vasopressors. After
multivariate analysis, age was identified as independant risk factor for
GAM (OR [IC 95%] = 1.03 [1.01–1.05], p < 0.001); whereas high score
in GCS (OR [IC 95%] = 0.93 [0.86–0.99], p = 0.03) and use of paralytic
agents (OR [IC95%] = 0.46 [0.23–0.90], p = 0.02) were associated with
less occurrence in GAM. GAM was not associated with any increase of
length of mechanical ventilation, length of ICU stay, VAP incidence or
Discussion In this study, we found some relevant risk factors for
microaspiration (age, low score at GCS) consistent with literature on
the subject. Patients with paralytic agents had less GAM which may
be due to higher PEEP, higher cuff pressure and less enteral nutrition
because of the severity of the underlying diseases.
Conclusion This study did not show any increased risk of
microaspiration in intubated COPD patients, whatever stage of COPD.
Microscopic examination and quantitative culture of protected
brush specimen in suspected episodes of ventilator acquired
pneumonia: effect of prior antimicrobial treatment
Jean‑François Llitjos 1, Marlène Amara2, Guillaume Lacave3, Jean Pierre
Bedos3, Béatrice Pangon2
1Réanimation Médicale, Hôpital Cochin, Paris, France; 278150, Hospital
Center De Versailles, Le Chesnay, France; 3Réanimation médico‑chirurgi‑
cale, Centre Hospitalier de Versailles, Le Chesnay, France
Correspondence: Jean‑François Llitjos ‑
Annals of Intensive Care 2017, 7(Suppl 1):S97
Introduction Protected specimen brush (PSB) is considered to be one
of the standard methods for the diagnosis of ventilator-associated
pneumonia (VAP). To our knowledge, there is no study assessing effect
of prior antibiotherapy on direct examination, bacteriological culture
and concordance of direct microscopy and culture.
Patients and methods All consecutive episodes of suspected VAP
were retrospectively evaluated between January 2014 and December
2014 in a 20-bed intensive care unit. Patient’s characteristics and
preexisting conditions were abstracted from the medical charts.
After assessment of VAP probability using the clinical pulmonary
infection score (CPIS), PSB were performed in patients with a
CPIS of 6 or more. Based on antibiotic treatment in patients when
bacteriological specimens were obtained, two groups were defined:
no antibiotic group and antibiotic treatment started before PSB group.
Two independent bacteriologists retrospectively reviewed direct
examination and culture of PSB to assess bacteriological concordance,
defined as non-concordant when direct examination and culture
were different, concordant when direct examination and culture were
similar and partially concordant when either direct examination or
culture were comparable but with other microorganisms lacking in
one or the other method.
Results During this 12-months period, among 73 mechanically
ventilated patients, 116 episodes of suspected VAP with PSB were
evaluated. We found 60% of PSB (n = 70) performed without antibiotic
treatment and 40% of PSB (n = 46) performed under antibiotherapy.
We found no significant differences in patient’s demographics,
characteristics, and severity between both groups. Patients received
antibiotics for the following reasons: aspiration pneumonia (n = 12), peritonitis
(n = 8), VAP (n = 7), community-acquired pneumonia (n = 4), septic
shock of unknown origin (n = 4), pyelonephritis (n = 3), meningitis
(n = 2), acute pancreatitis (n = 2) and others (n = 4). The median
duration of mechanical ventilation in the antibiotic receiving group and in
the group without antibiotics was 7.5 days (IQR; 5–12 days) and 9 days
(IQR: 5–22), respectively. When PSB was performed under antibiotic
treatment, direct examination was positive in 26% (n = 12), culture
was positive in 28% (n = 13) and those methods were concordant, non
concordant and partially concordant in 93% (n = 43), 4% (n = 2) and
3% (n = 1), respectively. On the other hand, when PSB was performed
without antibiotics, direct examination was positive in 65% (n = 46),
culture was positive in 62% (n = 43) and those methods were
concordant, non concordant and partially concordant in 71% (n = 50), 18%
(n = 12) and 11% (n = 8), respectively. In univariate analysis, we found
a significantly higher proportion of negative direct examination and
negative culture in the antibiotic group (p > 0.001). Moreover, these
methods were significantly more frequently concordant (p = 0.01),
with a higher rate of both negative microscopic exam and culture
when compared to the no antibiotic group (76%, n = 33 vs 38%,
n = 18). Surprisingly, among the 13 patients previously treated with
antibiotics with positive culture, 38% (n = 5) of the microorganisms
showed antibiotics sensitivity.
Discussion Whether prior antibiotic treatment may induce false
negative of false positive treatment is a well-recognized phenomenon, the
precise effect of antibiotics on direct examination and quantitative
culture is not well assessed in VAP. Moreover, despite recent
development of clinico-radiological score, diagnosis of VAP remains difficult,
with no gold-standard. Therefore, bacteriological guided therapy is of
particular importance. We found PSB realization under antibiotic
treatment is associated with a lower rate of positive direct examination and
culture and suggest performing these bacteriological samples without
antibiotherapy. Some authors have suggested lowering the diagnostic
threshold point of this bacteriological technique in order to preserve
its accuracy. However, we can postulate that microorganisms
responsible of superinfection in mechanically ventilated patients treated with
antibiotics may be resistant and therefore the PSB could be positive.
Conclusion In patients with a high pre-test probability of
ventilatoracquired pneumonia, recent introduction of antibiotics significantly
reduced the diagnostic accuracy of protected brush specimen by
reducing rates of positive direct examination and culture. Further
studies should evaluate if antibiotic discontinuation may revert this effect.
Implementation and impact assessment of a “ventilator‑bundle”
at the university clinics of Kinshasa: before and after study
José Mavinga1, Joseph Nsiala Makunza2, M E Mafuta3, Yves Yanga1, Amisi
Eric1, Jp Ilunga1, Ma Kilembe1
1Anesthesia and Reanimation, Cliniques universitaires de kinshasa,
Kinshasa, Democratic Republic of the Congo; 2Anesthésie‑Réanimation,
Hôpital Privé d’Athis‑Mons ‑ Site Caron, Athis‑Mons, France; 3Scool of
public health, Université de Kinshasa, Batiment administratif, Kinshasa,
Democratic Republic of the Congo
Correspondence: José Mavinga ‑
Annals of Intensive Care 2017, 7(Suppl 1):S98
Introduction In 2005, an international consensus conference took
stock of the various measures to be implemented for the prevention
of ventilator acquired pneumonia (VAP) . These measures are often
gathered in groups of 3 or 5 under the term of “ventilator-bundle.”
The effectiveness of these “bundles” was poorly evaluated in African
Objective To establish a VAP prevention program and assess its
impact on morbidity and mortality of patients under mechanical
ventilation in our service.
Patients and methods Prospective, mono centric, quasi-experimental
before-after study. It took place in the intensive care unit of the
University Clinics of Kinshasa in the Democratic Republic of Congo (DRC).
This service is equipped with 8 beds and a respirator for two beds.
The observational period (phase1) was carried out from February 1st
to December 31st, 2014 and the intervention period (phase2) from
February 15st, 2015 to February 15st, 2016. All consecutive patients
intubated and mechanically ventilated for more than 48 h were
included. Five preventive measures were held: hand hygiene, the
elevation of the head of the bed at 30°–45°, the daily lifting of sedation,
oral decontamination with chlorhexidine and control cuff pressure of
the endotracheal tube. Compliance with this bundle was assessed by
direct observation without the knowledge of caregivers. The
diagnosis of “VAP” was held before a clinically modified sore (m CPIS) >6. The
main outcomes were the incidence of VAP and mortality. The protocol
for this study was approved by the Ethics Committee of the School of
Public Health of the University of Kinshasa, under the approval
We have had non conflict of interest in this study.
Results We included 44 patients in the phase1 and 58 patients
in the phase2. Baseline characteristics of patients were similar in
both groups. Compliance with all the measures has been improved
between the two period from 0 to 32.75%. The incidence density
decreased from 33.74 to 18.05 VAP per 1000 ventilator days between
observational and interventional period, but the all-cause mortality
was almost equal in the 2 groups (88.6 vs. 86%).
Discussion With the implementation of our bundle, observance of
the team were improved in the second group, compared to the first
and the incidence density decreased from 33.74 to 18.05 VAP per 1000
ventilator days between both period. This result is consistent with the
littérature. Sure enough, many studies show the same effect of VAP
prevention with a decrease of nearly 50% of the incidence density of
VAP, after implementation of a «ventilator –bundle .
Conclusion The implementation of a “ventilator bundle,” has
significantly reduced the incidence of VAP in our service. In the contrary, our
study failed to demonstrate a reduction in mortality.
Introduction With an increasing incidence and high mortality rates,
sepsis is a public health issue. There is growing evidence that sepsis
induces long lasting alterations of transcriptional programs through
epigenetic mechanisms that may lead to protracted inflammation,
organ failure, sepsis-induced immune suppression (SIIS), secondary
infections and death. We hypothesized that epigenetic changes
contribute to the pathophysiology of SIIS. To test this hypothesis,
we studied the effects of histone deacetylases (HDAC) inhibition
with trichostatin A (TSA) in a double-hit murine model of SIIS and
Materials and methods C57BL/6 mice were treated with TSA (2 mg/
kg ip) or saline serum (CTL) 30 min before induction of sepsis by cecal
ligation and puncture (CLP). Surviving mice underwent intratracheal
instillation of 1.5 × 106 CFU of Pseudomonas aeruginosa 8 days after
CLP. We evaluated the effect of TSA on survival and cellular responses
to the primary and secondary infections. Cellular responses in
the blood, spleen and BAL were assessed by flow cytometry after
CLP (Days 1, 3 & 8) and after pneumonia (4 & 12 h). We also studied
lymphocyte apoptosis and dendritic cells (DC) expression of CD40,
CD86, and MHCII. Bacterial clearance was assessed in the BAL and
in the blood 4 and 12 h after pneumonia. Continuous variables
represented as mean ± SD were compared using Student t test.
Kaplan–Meier curves were compared by the log rank test. P < 0.05
indicated statistically significant differences.
Results Whereas treatment with TSA did not change survival after
CLP, TSA improved survival after tracheal instillation of P. aeruginosa
(P = 0.009, Fig. 22).
Fig. 22 See text for description
TSA-treated mice had significantly higher absolute DC, T and
B-lymphocytes counts with reduced lymphocyte apoptosis after
CLP. Four hours after secondary pneumonia, TSA-treated mice had
significantly higher DC counts and improved bacterial clearance in the
BAL, with reduced systemic dissemination of P. aeruginosa.
Conclusion HDAC inhibition with TSA improves survival in our murine
model of secondary pneumonia, improves bacterial clearance and
attenuate cellular features of SIIS. These results suggest that
sepsisinduced epigenetic changes contribute to the advent of SIIS.
Comprehensive characterization of epigenetic changes associated with
SIIS might allow us to identify new therapeutic targets to reprogram
immune cells in sepsis and avoid SIIS.
Nosocomial infections in intensive burn care unit
Amel Mokline1, Achraf Laajili1, Helmi Amri1, Imene Rahmani1, Nidhal
Mensi1, Lazheri Gharsallah1, Sofiene Tlaili1, Bahija Gasri1, Rym Ham‑
mouda1, Amen Allah Messadi1
1Burn care department, Trauma and burn center, Tunis, Tunisia
Correspondence: Amel Mokline ‑
Annals of Intensive Care 2017, 7(Suppl 1):S100
Introduction Nosocomial infections (NI) are common in burn patients
due to the loss of the first line of defense against microbial invasion,
immunocompromising effects of burn injury, and invasive diagnostic
and therapeutic procedures. The objective of this study was to identify
the incidence of nosocomial infection (NI), the pathogens and their
antibacterial patterns, and prognosis of these burn patients.
Patients and methods A retrospective study was conducted in a 20
bed intensive burn care unit during 6 months. Patients were eligible
for the study, if they met the following criteria: total burn surface area
(TBSA) > 10%, length of ICU stay ≥48 h, and infected in accordance
with the criteria of the National Nosocomial Infections Surveillance
(NNIS) and the criteria of the SFETB [1–2]. In this study, NIs were
classified into four main groups: pneumonias, bloodstream infections (BSI),
catheter related infections (CRI), and urinary tract infections (UTI). For
included patients, skin levy, blood cultures, urine and sputum cultures
were drawn during fever or clinical features of sepsis.
Results During the 6-month study period, 190 patients were
admitted to the ICU, 47 patients were included (24.7%). 32 were male and 15
female. The mean age was 41 ± 19 yr. The mean TBSA was 41 ± 24%.
63% were admitted from another hospital. Burn injuries were due to
domestic accidents in 53% and self immolation in 25%. The mean
length of ICU stay was 16 ± 14 days. 47 patients acquired 58 NIs
(36.2% BSI, 20.5% pneumonia, 10.3% CRI and 10.3% UTI. There was
no bacteriological documentation of NI in 22.5% of cases. NIs occured
4 days post burns. The most three isolated pathogens were:
Acinetobacter spp. (31%), P. aeruginosa (22.5%) and extended spectrum
betalactamase-producing Enterobacteriaceae (17%). The most frequently
administered antibiotics were polymyxin/carbapenem/teicoplanin
combination (21%), polymyxin/carbapenem combination (15%) and
carbapenem/tigecycline combination (15%). In our study, mortality
rate was 50%.
Conclusion Nosocomial infection occured in 24.7% of cases in
burn patients, caused by Acinetobacter spp, P. aeruginosa and
Enterobacteriaceae BLSE. So, eradication of infection in burn patients
require effective surveillance and infection control in order to reduce
mortality rates, length of hospitalization and associated costs.
Predictors of treatment failure for patients with pneumonia
caused by Staphylococcus aureus methicillin‑sensitive in a intensive
care unit: a retrospective study
Pierre‑Antoine Allain 1, Nathallie Gault2, Catherine Paugam‑Burtz 1, Arnaud
1Anesthesiology and critical care, Hospital Center University Beaujon
(AP‑HP), Clichy, France; 2Unité d’épidémiologie et recherche clinique,
Hospital Center University Beaujon (AP‑HP), Clichy, France
Correspondence: Arnaud Foucrier ‑
Annals of Intensive Care 2017, 7(Suppl 1):S101
Introduction Infection of the lower respiratory tract is the most
common cause of infection in intensive care unit (ICU) (1). Although the
attributable mortality of ventilator associated pneumonia remains
debated, the recurrence of these infections is always associated with
a significant morbidity (2). Staphylococcus aureus methicillin-sensitive
(SAMS) is one of the most frequently germs involved in ICU
pneumonia especially in trauma patients. The aim of the study was to establish
the risk factors associated with microbiological treatment failure of
pneumonia, caused by SAMS.
Materials and methods we retrospectively identified 185 patients
who developed a first episode of ventilator associated pneumonia
caused by SAMS during a 6 years-period (2009–2014). The primary end
point was the microbiological treatment failure defined as a second
episode of pneumonia caused by SAMS corresponding to either a
persistent or a recurrence of the pneumonia (Fig. 23). The primary aim of
Fig. 23 See text for description
the study was to identify factors associated with a treatment failure, the
secondary objective was to identify factors associated with the
occurrence of second episode (i.e. persistent, recurrence, superinfection
and/or relapse of pneumonia caused by any bacteria) during or after
treatment of the first episode caused by SAMS. Definition of outcomes
was based after analysis of current concepts available in the literature.
Factors associated with primary and secondary objectives in
univariate analysis (p-value < 0.20), or clinically relevant ones, were entered
in a multivariate logistic regression. The final selection was performed
using the stepwise selection based on the Akaike criterion.
Results Fifty-nine patients (33.3%) developed a second episode of
pneumonia and among them, 30 (16.6%) were considered as a
microbiological failure. In a multivariate analysis, the association of
oropharyngeal flora (FOP) with the SAMS (OR, 3.86; 95% CI, 1.33–11.11;
p = 0.011) and the need of emergency surgery (OR, 5.26; 95% CI, 1.39–
35.2; p = 0.035) were predictive of a microbiological failure. Empirical
antibiotic therapy with amoxicillin-clavulanic acid (OR, 2.28; 95% CI,
1.15–4.51; p = 0.017) and performing emergency surgery (OR, 3.60;
95% CI, 1.34–9.65; p = .011) were predictors of a second episode of
pneumonia caused by any bacteria.
Conclusion In this retrospective, monocentric study, the co presence
of orophryngeal flora and the need of emergency surgery were
associated with microbiological failure of pneumonia caused by SAMS
Ventilator‑associated pneumonia: never enough, never give up!
Sahar Habacha1, Bassem Chatbri1, Aymen M’rad1, Youssef Blel1, Nozha
Brahmi1, Yousra Bourbiaa2, Lamia Thabet2
1Departement of intensive care and toxicology, Centre d’Assistance
Médicale Urgente, Tunis, Tunisia; 2Biology departement, Trauma Center,
Ben Arous, Tunisia
Correspondence: Sahar Habacha ‑
Annals of Intensive Care 2017, 7(Suppl 1):S102
Introduction Ventilator-associated pneumonia is a major iatrogenic
problem since it is a cause of hospital morbidity, mortality and
increase of health care costs. It has been studied many times, but
data’s revision is always necessary. Our study aimed to describe
epidemiology of ventilator-associated pneumonia and identify local
Materials and methods We carried out a prospective study in an
intensive care unit. Were included patients intubated for more than 48 h, from
April 2015 to May 2016, and presenting signs of ventilator-associated
pneumonia (fever, abundant and purulent secretion, increase of FiO2
greater than 0.2, signs on chest-X ray) with positive culture of
endotracheal aspirate. Were excluded patients with germ colonization.
Results A total of 268 patients were ventilated for more than 48 h.
Among them thirty-four patients aged of 39 ± 18.5 years presented
54 episodes of ventilator-associated pneumonia (that is 1.58 ± 0.85
episodes per patient). The mean SOFA score was 5.2 ± 1.8. The
main reasons of mechanical ventilation were loss of consciousness
secondary to poisoning (20%), respiratory distress (20%) and status
epilepticus (12%). The mean duration of stay was 62.5 days with
extremes at 7 and 180 days. The average time between hospitalization
and suspicion of ventilator-associated pneumonia was 5.9 ± 2.7 days.
The average value of the Clinical Pulmonary Infection Score at
suspicion was 5 ± 1.26. The average time between recurrences was
16.8 days with extremes at 4 and 39 days. The culture of endotracheal
aspirate identified two pathogens in 11%. It reveled Acinetobacter
baumanii in 35% in which 63% were imipenem resistant, Pseudomonas
aeroginosa in 33%, Klebsielle pneumoniae in 22%, Staphylococcus
aureus methicillin resistant in 7%. Extended spectrum β-lactamases
bacteria were found in 10% and carbapenemases producers in 12%.
Empirical antibiotherapy was always association of imipenem and
colistin. It was necessary to adapt it to antibiograms in 33/54.
Ventilator-associated pneumonia was complicated by septic shock in
28% and acute respiratory distress syndrome in 24%. Patients evolved
to healing in 63% of episodes (n = 34), to superinfection in 26%
(n = 14) and to death in 9% (n = 5). Pseudomonas aeruginosa was the
most frequent germ in superinfection (7/14), Acinétobacter baumanii
was the most pathogen associated to death (3/5).
Conclusion Ventilator-associated pneumonia is an iatrogenic disease
that threatens lives. It’s in part avoidable. Preventive measures have to
be implemented to reduce its frequency, consequences and costs.
Comparative performance of different automated weaning
modes: a network meta‑analysis
Arthur Neuschwander1, Looten Vincent2, Chhor Vibol1, Yavchitz Amelie1,
Matthieu Resche‑Rigon 2, Jean Mantz1, Romain Pirracchio1
1Anesthésie réanimation, Hôpital Européen Georges‑Pompidou (AP‑HP),
Paris, France; 2Biostatistiques, Hôpital Saint‑Louis (AP‑HP), Paris, France
Correspondence: Arthur Neuschwander ‑ arthur.neuschwander@gmail.
Annals of Intensive Care 2017, 7(Suppl 1):S103
Introduction Mechanical ventilation (MV) weaning is a crucial step in
critically ill patients. MV duration is associated with an increased risk
of ventilator associated events, even though its specific impact on
mortality has never been clearly demonstrated (1). Automated closed
loop systems might help the weaning process. A recently published
meta-analysis has reported a reduction in MV duration when using an
automated weaning mode as compared to non-automated mode (2).
However, the different automated modes have not been compared
to each other. The objective of this network meta-analysis was to
compare the performance of the three major automated weaning
modes, i.e. the Automode°, the Smartcare° and the Adaptative
Support Ventilation (ASV°) for MV weaning in critically ill and
postoperative adult patients.
Materials and methods We included all randomised control trials
that compared automated closed loop weaning applications either
to another automated application or standard care, including
weaning according to a written weaning protocol or nurse driven
protocols. The three modes of automated modes included in the study
were ASV°, Smartcare° and Automode°. The primary outcome was the
duration of MV weaning, defined as the time between randomization
and a successful extubation. We also planned subgroup analyses in
the ICU and the post-operative populations. The quality of the
studies was assessed independently by two blinded investigators, using
the evaluation recommended by the Cochrane Collaboration. A
network Bayesian meta-analysis using random effect models and based
on aggregate data from the included studies was performed using
the gemtc package (R project, Vienna). This trial was declared in
PROSPERO in August 2015 (CRD42015024742).
Results Search of databased identified 776 articles; 233 were screened
for eligibility after removal of duplicates. Abstract analysis led to the
exclusion of 191 articles with a final full text analysis of 42 randomised
Fig. 24 Bayesian NMA with random effect
control trials. Ultimately, 15 trials were included in the analysis,
representing 1424 ventilated patients. Nine studies included patients in the
post-operative period while six were conducted in ICU. The automated
mode was ASV° (A) in 9 studies, Smartcare° (C) in 4 studies and
Automode° (B) in 2 studies. All studies reported the duration of MV
weaning as defined in our protocol. In all studies, the control group was
standard care with a weaning process driven either by nurses or
physicians. In 12 studies (75%) a written weaning protocol was used in the
control group. All ICU studies used sedation protocols based on
sedation scores, none of them including systematic daily sedation
interruption. Each one of the automated application was associated with a
significant reduction in the duration of MV as compared to the control.
When comparing all different modes using the network meta-analysis
framework, ASV° appeared to be the best automated mode when it
pertains to reducing the duration of mechanical ventilation weaning
(Fig. 24). Subgroup analysis showed similar results in the
post-operative and the ICU populations.
Conclusion Compared to standard weaning practice, the 3 major
automated weaning modes significantly reduced the duration of MV
weaning in critically ill and post-operative adult patients. ASV° was
associated with the most significant effect when compared to the
two other automated modes (Smartcare°, Automode°). Further
physiological respiratory studies would help to understand the underlying
mechanisms accounting for the superiority of ASV.
Impact of proportional assisted ventilation on dyspnea
and asynchrony in mechanically ventilated patients
Côme Bureau1, Maxens Decavèle1, Sébastien Campion2, Roukia
Ainsouya2, Marie‑Cécile Niérat 2, Julien Mayaux3, Hélène Prodanovic3,
Mathieu Raux4, Thomas Similowski1, Alexandre Demoule1
1Réanimation médicale, inserm umr_s 1158 neurophysiologie respiratoire
expérimentale et clinique, Pitié‑Salpêtrière Hospital, Paris, France; 2Inserm
umr_s 1158 “neurophysiologie respiratoire expérimentale et clinique”,
Pitié‑Salpêtrière Hospital, Paris, France; 3Unité de réanimation et de
surveillance continue, service de pneumologie et réanimation médicale,
Pitié‑Salpêtrière Hospital, Paris, France; 4Département d’anesthésie‑réani‑
mation et urm_s 1158, Hôpital Universitaire Pitié‑Salpêtrière, Paris, France
Correspondence: Côme Bureau ‑
Annals of Intensive Care 2017, 7(Suppl 1):S104
Introduction During mechanical ventilation, mismatch between
respiratory muscles activity and the assistance delivered by the
ventilator results in dyspnea and asynchrony and is commonly observed in
intensive care unit (ICU) patients. Proportional Assisted Ventilation
(PAV) is a ventilatory mode that adjusts the level of ventilator
assistance to the activity of respiratory muscles estimated by an algorithm.
To date, PAV has been mostly studied in patients without severe
dyspnea or asynchrony. We hypothesized that, compared to pressure
support ventilation (PSV), PAV will prevent severe dyspnea or asynchrony.
Patients and methods Were included ICU mechanically ventilated
patient exhibiting severe dyspnea or asynchrony with PSV. Three
conditions were successively studied: 1) PSV on inclusion (Baseline),
2) PSV after optimisation of ventilator settings in order to minimize
dyspnoea and asynchrony (Optimisation), and 3) PAV. Ten-minutes
recording were performed with each condition. The intensity of
dyspnea was assessed by the Visual Analogic State (VAS, only in patients
able to communicate) and by the Intensive Care Respiratory Distress
Operating Scale (IC-RDOS) for all the patients. The electrical activity
(EMG) of extradiaphragmatic inspiratory muscles was measured. The
Table 27 Breathing pattern, dyspnea score and preva‑
lence of asynchrony according to condition
Fig. 25 Electromyographic of activity parasternal muscles. *p < 0. 05
compared to basal condition
prevalence of asynchrony was quantified by the visual inspection of
the airway flow and pressure traces.
Results 34 patients were included, 74% male, aged 66 [58–78] years,
SAPS2 57 [39–66], mechanically ventilated for 6 [4–9] days. The tidal
volume (Tv) was higher in the Optimisation and PAV than in the Basal
condition (Table 27). The respiratory rate(RR) was lower with PAV than
in the other conditions. The dyspnea-VAS was lower with Optimisation
and PAV than with the Basal conditions. The IC-RDOS was lower with
PAV than with the two other conditions. The asynchrony index was
lower with PAV than with the two other conditions. Parasternal EMG
activity was lower with PAV and Optimisation (Fig. 25).
Conclusion In ICU patients receiving mechanical ventilation with PSV
and exhibiting severe dyspnea or asynchrony, the optimisation of
ventilator settings with PSV and the PAV mode decrease in the simiar
way the severity of dyspnea and the prevalence of patient-ventilator
Thomas Similowski1, Martin Dres1
Annals of Intensive Care 2017, 7(Suppl 1):S105
Introduction In intensive care unit (ICU) patients, diaphragm
dysfunction is associated with adverse clinical outcomes. Ultrasound
measurements of diaphragm thickness (Tdi), excursion (EXdi) and thickening
fraction (TFdi) have been proposed as estimators of diaphragm
function, but have never been compared to phrenic nerve stimulation.
Our aim was to describe the relationship between Tdi, EXdi, TFdi and
diaphragm function evaluated using the change in endotracheal
pressure after phrenic nerve stimulation (Ptr,stim), and to compare their
Patients and methods Ptr,stim and ultrasound variables were
measured in mechanically ventilated (MV) patients <24 h after intubation
(“initiation of MV”, under assist-control ventilation, ACV) and at the
time of switch to pressure-support ventilation (“switch to PSV”).
Diaphragm dysfunction was defined as Ptr,stim <11 cmH2O.
Results 112 patients were included. At initiation of MV, Ptr,stim
was not correlated to Tdi (rho = −0·13, p = 0·28), EXdi (rho = 0·10,
p = 0·66) or TFdi (rho = −0·03, p = 0·80). At switch to PSV, TFdi and
EXdi were correlated to Ptr,stim, (rho = 0·87, p < 0.001 and 0·45,
p = 0·001, respectively), but Tdi was not (rho = −0·09, p = 0·45). At
switch to PSV, a TFdi <29% could reliably identify diaphragm
dysfunction (sensitivity and specificity of 85 and 88%, respectively), but Tdi
and EXdi could not. This value was associated with increased duration
of ICU stay and MV, and mortality.
Conclusion Under ACV, neither Tdi, EXdi nor TFdi were related to
Ptr,stim. Under PSV, TFdi was strongly correlated to diaphragm
strength and, when decreased, was associated with poorer outcome.
End‑tidal carbon dioxide during spontaneous breathing trial
to predict extubation failure: a single center prospective
Faten May1, Keyvan Razazi1, François Bagate1, Guillaume Carteaux1, Nico‑
las de Prost1, Armand Mekontso Dessap1
1Réanimation médicale, Hôpital Henri Mondor, Créteil, France
Correspondence: Faten May ‑
Annals of Intensive Care 2017, 7(Suppl 1):S107
Introduction In spite of recent research and progress in weaning
protocols, extubation failure still occurs in 10–20% of patients and
is associated with poor outcomes, with a mortality rate of 25–50%.
Many risk factors for planned extubation failure have been suggested,
including hypercapnia at end of spontaneous breathing trial (SBT).
However, performing arterial blood gases at the end of SBT is not
routinely recommended whereas EtCO2may be routinely monitored
during a low pressure support SBT. The aim of this prospective
observational study was to determine the clinical usefulness of EtCO2
to predict extubation failure.
Patients and methods We recorded clinical data and EtCO2
during a successful 1 h low level pressure support SBT (at the
beginning, after 5 min and at the end of the trial). Patients ventilated
through tracheostomy and unplanned extubations were excluded.
Extubation failure was defined as death or the need for reintubation
within 72 h (1) after extubation; this delay was prolonged to 7 days
(2) in case of noninvasive ventilation after extubation, which was
systematic in older patients or those with cardiorespiratory disease,
as per our weaning protocol. Multivariable logistic regression analysis
was performed to identify independent variables associated with
Results One hundred and fifteen ventilated patients were enrolled
in our study from July 2015 to June 2016. The median age of these
patients was 63 [52–75] years, their median Simplified Acute
Physiology Score (SAPS) II was 48 [38–61] points and 42.5% (n = 49)
were female. Seventeen (15%) patients had chronic obstructive
pulmonary disease. Reintubation rate was 15% (n = 18). EtCO2
at the end of SBT was similar between patients with failed and
successful extubation: 38 [29–41] vs. 35 [30–40] mmHg, p = 0.9. EtCO2
at other time points as well as its changes during the SBT were also
similar between groups. The three variables predicting extubation
failure in the multivariable logistic regression model were a past medical
history of cirrhosis, acute respiratory distress syndrome before
weaning and lower minute ventilation at the end of SBT.
Conclusion EtCO2 during a successful SBT seems useless to predict
outcome of extubation.
included by center was 27 (11–72). The flow chart of the study is
shown in Fig. 26. Incidence of extubation failure was 10.4% (157 of
1514 intubation-procedures). Incidence of airway failure, weaning
failure and mixed failure were respectively 4.6% (70 of 1514), 5.2% (78 of
1514) and 0.6% (9 of 1514).
Conclusion Extubation failure at 48 h occurred in 10.4% of the 1514
extubation procedures recorded, 44% due to airway failure, 50% to
weaning failure and 6% to mixed airway and weaning failure. Specific
risk factors will be determined using this multicenter database.
A multicenter prospective observational study of 1514 extubation
procedures in 26 intensive care units: the FREE‑REA study
Samir Jaber1, Hervé Quintard2, Audrey De Jong1, for the FREE‑REA study
1DAR B, Hôpital Saint Eloi, Montpellier, France; 2Réanimation polyvalente,
Hôpital Saint‑Roch, Nice, France
Correspondence: Audrey De Jong ‑
Annals of Intensive Care 2017, 7(Suppl 1):S109
Introduction Airway management in intensive care unit (ICU)
patients is challenging . “Airway failure”, defined as the inability to
breathe without endotracheal tube, differs from “weaning failure”,
defined as the inability to breathe without an invasive mechanical
ventilation. However, most of the studies assessing predictive factors
of extubation failure did not separate airway from weaning failure.
We aimed to describe incidence of extubation failure in critically ill
patients, separating for the first time airway from weaning failure, in a
prospective multicenter observational study.
Patients and methods A prospective, observational, multicenter study
was conducted in 26 French ICUs. All adult patients consecutively
extubated in ICU were included. An ethics committee approved the study
design (code UF: 9242, register: 2013-A01402-43). The study was
registered on clinicaltrials.gov (identifier no.NCT 02450669). Clinical
parameters were prospectively assessed before, during and after extubation
procedure. Extubation failure was defined as the need to reintubate
less than 48 h after extubation. Extubation failure could be due to
airway failure, weaning failure or mixed airway and weaning failure.
Results From December 2013 to May 2015, 1514
intubation-procedures were studied in 1465 patients from 26 centers. 49 patients (3.2%)
were intubated twice. The median number of intubation-procedures
Fig. 26 Flow chart of the FREE‑REA study
Efficiency and safety of total plasma exchange in critically ill
cirrhotic patients with acute on chronic liver failure admitted
to the ICU
Ilias Kounis1, Faouzi Saliba1, Stephane André1, Marc Boudon,1, Philippe
Ichai1, Aline Younes1, Lionel Nakad1, Audrey Coilly1, Teresa Antonini1,
Rodolphe Sobesky1, Eleonora De Martin1, Didier Samuel1
1Centre hépato‑billiaire, APHP Hôpital Paul‑Brousse, Villejuif, France
Correspondence: Faouzi Saliba ‑
Annals of Intensive Care 2017, 7(Suppl 1):S110
Introduction Acute on chronic liver failure (ACLF) have been recently
defined by an acute decompensation of a chronic liver disease
associated to organ failure and a high mortality rate. Few authors
reported on the use of total plasma exchange (TPE) in patients
with the current definition of ACLF. The aim of this pilot study was
to evaluate the efficiency and safety of TPE in critically ill cirrhotic
patients admitted with ACLF in the ICU.
Patients and methods A prospective cohort of cirrhotic patients
admitted to the ICU between February 2015 and February 2016. TPE
was performed using a plasma filter (TPE2000, Hospal®) on a CVVHDF
machine (Prismaflex®, Baxter®) connected to the patient with a
femoral double lumen 13F catheter. The plasma volume exchanged per
session was 1.3–1.5 of the total plasma volume. Ratio and type of fluid
replacement were 50% with 5% albumin solution followed by 50%
with fresh frozen plasma. Clinical and biological parameters, and the
following scores MELD, SOFA, CLIF-SOFA, CLIF-OF and Child Pugh were
evaluated prior, after TPE session and 7 days distant of treatment.
Results Seven male patients with a mean age of 50.6 ± 7.7 years
comprised the study and had a total of 20 TPE sessions. The etiology
of cirrhosis was alcoholic (n = 6) or post-HCV (n = 1). The reasons of
ACLF were acute alcoholic hepatitis (n = 2), variceal bleeding (n = 2)
and sepsis (n = 3). Prior to TPE, the mean scores of SOFA, CLIF-SOFA,
CLIF-OF, MELD and Child-Pugh were respectively 9.4, 12, 11.7, 37.6
and C12.5. Mean total bilirubin prior and after TPE sessions was
reduced from 392.3 ± 117.8 µmol/l to 244.9 ± 93.2 µmol/l
(reduction of 37.5%; p = 3.81E−6); at day 7, mean total bilirubin was still
lower at 333 ± 132 µmol/l (p = 0.1). Mean INR prior and after TPE
improved from 5.54 ± 3.38 to 2.32 ± 0.80 (reduction of INR of 58.1%,
p = 4.76E−5) and at day 7 of treatment at 4 ± 1.64 (reduction of 43%,
p = 0.125). Mean GGT levels reduced by 28.5% (p = 0.01). Mean
platelet counts (50.8 ± 19.5 G/L) reduced by 10.2% (p = NS). The
probability of survival at 10, 28 and 90 days was 42.8, 28.6 and 14.3%. One
patient was transplanted and still alive. Tolerance during sessions was
good similar to CVVHDF. Two side effects related to the femoral
catheter were observed (bacteremia and hemorrhagic shock post catheter
Conclusion This preliminary study of TPE in ACLF showed a marked
reduction of liver enzymes and improvement in coagulation
parameters with a relative good safety. A specific caution should be
undertaken regarding catheter related complications. TPE worth to be
evaluated in large trials in ACLF’ patients, with a liver transplant
project, and a lesser degree of organ failure.
Management of enteral feeding during extubation in the
intensive care unit: a multi‑center retrospective study in 11
French intensive care units
Mickael Landais1, Noemie Hubert2, Mai‑Anh Nay 3, Johann Auchabie4,
Bruno Giraudeau5, Reignier Jean6, Arnaud W Thille7, Stephan Ehrmann8
1Service de réanimation médicale, CHU Hôtel‑Dieu Nantes, Nantes,
France; 2Réanimation, C.H.U de Caen, Caen, France; 3Réanimation
médicale polyvalente, Hôpital de La Source, CHR Orléans, Orléans,
France; 4Réanimation médicale, Centre Hospitalier Universitaire d’Angers,
Angers, France; 5Unité de biostatistiques, Hôpital Bretonneau, Tours,
France; 6Réanimation médicale, CHU Hôtel‑Dieu Nantes, Nantes, France;
7Réanimation Médicale, CHU de Poitiers, Poitiers, France; 8Réanimation
polyvalente, CHRU Hôpitaux de Tours, Tours, France
Correspondence: Mickael Landais ‑
Annals of Intensive Care 2017, 7(Suppl 1):S111
Introduction Extubation is a key moment for the patient on his way
to recovery. Extubation failure concerns 10–20% of ICU patients and
is closely linked to nosocomial pneumonia. The practice concerning
enteral feeding interruption at time of extubation has not been
investigated. Fasting before extubation may prevent aspiration and
development of nosocomial pneumonia. Thus, fasting and gastric
content suctioning before extubation may be reasonably considered
as a mean to reduce this burden. Fasting before extubation may
prevent aspiration and development of nosocomial pneumonia.
Thus, fasting and gastric content suctioning before extubation may
be reasonably considered as a mean to reduce this burden. However,
fasting, as recommended before elective general anesthesia is likely to
be ineffective in the setting of extubation in the ICU, due to patients’
gastroparesis and prolonged gastric stasis. Beyond the potentially
unnecessary burden in terms of paramedical workload, fasting
may have some side effects such as caloric deficit, hypoglycemia,
or delayed extubation. Given the current lack of objective data
concerning the clinical practice of feeding/fasting and gastric tube
suctioning before extubation in the ICU, we undertook this descriptive
study to assess current practice.
Materials and methods We conducted a retrospective, multicenter
study in eleven intensive care units in the west of France over a
1 month timespan. All patients extubated were included and data
about enteral feeding during the peri-extubation period as well as
extubation failure and nosocomial that pneumonia occured within
7 days were recorded. Data observed in the eleven participating
centers were completed with a short email survey concerning
declarative practice performed among 43 intensive care units.
Results During the study period, 162 patients were included. Overall,
25 patients (15%) failed extubation and needed reintubation within
the 7 days following planned extubation. Pneumonia was
significantly more frequent reintubated patients than the other (36 vs. 4%,
p < 0.01). Hundred patients (62%) received enteral feeding at the time
of extubation. Compared to patients who did not receive enteral
feeding, those patients had a higher disease severity (SAPSII score 50, [41;
63] vs. 45 [35; 52], p < 0.01; longer duration of mechanical ventilation
7 [4; 13] vs. 1.5 [1; 3] days, p < 0.01). Accordingly, those patients had a
higher rate of extubation failure (21 vs. 7%, p = 0.01) and pneumonia
(13 vs. 3%, p = 0.05). Among the 100 patients receiving enteral
feeding, fasting was implemented before extubation for 64 patients (64%).
Median fasting duration before extubation was 6 h [2; 13]. Despite a
higher severity of disease of patients undergoing fasting before
extubation (SAPS II of 50 [42; 66] vs. 48 [31; 60], p = 0.05). The rate of
extubation failure was similar between the fasting patients and the others:
15 of 64 patients (23%) versus 6 of 36 (17%) of the patient (p = 0.60).
Similarly, the incidence of pneumonia was not different between
groups (n = 9 (14%) vs. n = 4 (11%), p = 0.76). After extubation, the
fasting patients experienced a longer delay until feeding resumption
as compared to non-fasting patients (21 h [6; 42] vs. 8 [5; 22]), but this
difference did not reach statistical significance. Overall gastric content
suctioning before extubation was not commonly performed; before
extubation: 30% of the fasting patients and 26% of the non fasting
Among the 11 participating centers, while some centers imposed
a fasting period before extubation to all their patients, some did it
infrequently. However, no center never imposed fasting, illustrating
between and within center heterogeneity.
This heterogeneity was confirmed on the larger scale declarative email
survey (88% response rate amont 43 units) which showed that only
44% of the units had a written standardized operational procedure for
extubation. Survey respondents reported to practice fasting before
extubation “Always”, “Frequently” and “Never or Rarely” in respectively
71, 21 and 8% of cases.
Conclusion Both practices, fasting as well as pursued nutrition until
extubation are commonly performed in ICUs, with little
standardization of practice. Safety seems equivalent, as no clinically significant
difference in terms of reintubation rate and pneumonia were observed.
Thus, the equipoise condition appears met to undertake a trial
evaluating feeding strategies in the peri-extubation period.
More than half the patients receiving non‑invasive ventilation are
Nicolas Terzi1, Michaël Darmon2, Jean Reignier3, Stephane Ruckly4, Maïté
Garrouste‑Orgeas 5, Elisabeth Gratia1, Alexandre Lautrette6, Elie Azoulay7,
Bruno Mourvillier8, Laurent Argaud9, Laurent Papazian10, Marc Gainnier11,
Dany GoldgranT‑oledano 12, Samir Jamali13, Anne Sylvie Dumenil14, Carole
Schwebel15, Jean‑François Timsit 16, OUTCOMEREA study group
1Service de réanimation médicale, Clinique de Réanimation Médicale,
Grenoble, France; 2Réanimation Médicale, CHU Saint‑Etienne ‑ Hôpital
Nord, Saint‑Étienne, France; 3Réanimation médicale, CHU Hôtel‑Dieu
Nantes, Nantes, France; 4Reanimation, Hôpital Bichat‑Claude Ber ‑
nard (AP‑HP), Paris, France; 5Réanimation, Fondation Hopital Saint
Joseph, Paris, France; 6Réanimation médicale, CHU Gabriel‑Montpied,
Clermont‑Ferrand, France; 7Réanimation médicale, Hôpital Saint‑Louis,
Paris, France; 8Réanimation Médicale et Infectieuse, GH Bichat Claude
Bernard, Paris, France; 9Réanimation Médicale, Hospices Civils de Lyon
‑ Groupement Hospitalier Edouard Herriot, Lyon, France; 10Service de
réanimation‑détresses respiratoires et infections sévères, Hôpital Nord,
Marseille, France; 11Réanimation des urgences médicales, Hôpital de la
Timone, Marseille, France; 12Réanimation polyvalente, Centre Hospitalier
Général, Gonesse, France; 13Réanimation médicale, Centre Hospitalier Sud
Essonne, Dourdan, France; 14Réanimation chirurgicale, Hôpital Antoine
Béclère, Clamart, France; 15Réanimation médicale, C.H.U. Grenoble, Greno‑
ble, France; 16Réanimation médicale et infectieuse, Hôpital Bichat‑Claude
Bernard, Paris, France
Correspondence: Nicolas Terzi ‑
Annals of Intensive Care 2017, 7(Suppl 1):S112
Introduction Noninvasive ventilation (NIV) has become a cornerstone
for the supportive therapy of acute respiratory failure (ARF). Survival
benefits in chronic obstructive pulmonary disease (COPD) and cardiac
patients have been demonstrated. Although ARF and COPD patients
are at risk of malnutrition that adversely affects patient outcomes, few
data are available regarding the management of nutritional support in
non-invasively ventilated patients. We sought to describe nutritional
management in patients receiving NIV as the first line therapy for ARF.
Secondary objectives were to assess the impact of early nutrition use
on the need for invasive mechanical ventilation, occurrence of
ICUacquired pneumonia, length of stay, and death.
Patients and methods We conducted an observational study from
the multicenter French database fed by 20 French ICUs. Our
institutional review board approved this study. Adult medical patients
admitted to the ICU and receiving NIV for more than 2 days were included.
Exclusion criteria were patients admitted after surgery, readmitted in
ICU, patients with neuromuscular disease and treatment-limitation
decisions on admission. Four groups of patients were defined
according to nutrition received during the first 2 days of NIV: (1) No nutrition;
(2) Enteral nutrition: patients who received enteral nutrition with or
without parenteral nutrition; (3) Parenteral nutrition only (3) Oral
The impact of nutrition on day-28 mortality was assessed through
the use of a Cox model adjusted on clinically relevant covariates. The
impact of nutrition on other secondary end-point i.e. ICU-acquired
pneumonia occurrence, need for invasive mechanical ventilation were
assessed using a Fine & Gray models. Patients were censored after
28 days of follow-up. Choice among collinear variables was performed
considering clinical relevance, rate of missing variables and
reproducibility of definitions. Results were given as hazard ratio (HR) for Cox
models and subdistribution hazard ratios (sHR) and 95% confidence
intervals (CI). The impact on duration of stay was estimated by a
multivariate Poisson regression. P values less than 0.05 were considered as
significant. Statistical analysis was performed using SAS 9.4 (Cary, NC).
Results During the study period, 16,734 patients were included in
the database and 1075 met inclusion criteria. Among them, 622
received no nutrition; 28 received enteral nutrition, 74 received
parenteral nutrition only, and 351 received oral nutrition only. Overall, 86
patients developed ICU-acquired pneumonia (8%), 158 required
invasive mechanical ventilation (14.7%) and 161 died before day-28 (15%).
Median length of stay was 6 days [4; 9].
After adjustment for confounders, type of nutrition support was
associated with an increase day-28 mortality (P = 0.02). Compared to oral
nutrition, enteral nutrition was associated with an increase day-28
mortality [sHR 2.91, 95% CI 1.44–5.89; P = 0.003] whereas parenteral
nutrition and no nutrition did not influence this outcome. The type
of nutrition was not associated with the occurrence of ICU-acquired
pneumonia (P = 0.18). However, patients who received enteral
nutrition experienced more frequently ICU-acquired pneumonia
[sHR = 3.00, 95% CI 1.08–8.37; P = 0.036] as compared to oral
nutrition patients. Ventilator free days within the 28 days were negatively
associated with the type of nutrition (P < 0.0001). Compared to oral
nutrition, parenteral and enteral nutrition were negatively
associated with ventilator free days within the 28 days [RR per day = 1.48,
95% CI 1.22–1.78; P < 0.0001 and RR per day = 1.77, 95% CI 1.37–2.30;
P < 0.0001]. Delta PaCO2 measured between the first 2 days was not
associated with any type of nutrition.
Conclusion More than half the patients receiving NIV were fasting
within the first two NIV days. Oral nutrition was prescribed for
onethird of them and was well tolerated. Lack of feeding or
underfeeding had no impact on mortality and ventilator free days within the
28 days. However, enteral nutrition was associated with an increased
occurrence of ICU-aquired pneumonia and a higher mortality rate.
Nutritional support in patients receiving temporary
extracorporeal life support: a retrospective cohort study
Arthur Bailly1, Laurent Brisard1, Philippe Bizouarn1, Thierry Lepoivre1,
Johanna Nicolet1, Jean Christophe Rigal1, Jean Christian Roussel2, Ber‑
1Réanimation ctcv transplantation thoracique, CHU de Nantes ‑ Hôpital
Nord Laennec, Saint‑Herblain, France; 2Chirurgie ctcv transplantation tho‑
racique, CHU de Nantes ‑ Hôpital Nord Laennec, Saint‑Herblain, France
Correspondence: Laurent Brisard ‑ laurent.brisard@chu‑nantes.fr
Annals of Intensive Care 2017, 7(Suppl 1):S113
Fig. 27 Daily proportion of target energy delivered on first 8 days
Introduction The optimal nutritional intake in patients receiving
temporary extracorporeal life support (ECLS), including extracorporeal
membrane oxygenation (ECMO) venovenous (VV) or venoarterial (VA),
remains controversial. Enteral nutrition (EN) is suspect to increase risk
of gastrointestinal (GI) intolerance and intestinal ischemia. So, total
parenteral nutrition (TPN) is often preferred. The purpose of this study
is to describe the nutrition practices for critically ill patients receiving
ECLS and identify opportunities for improving nutrition therapy in this
Patients and methods Retrospective analysis of patients requiring
ECMO-VA or ECMO-VV between 2010 and 2014 in the cardiac surgery
intensive care unit of the University Hospital of Nantes. Nutritional
support was daily monitored with parenteral intake (glucose, lipid
and propofol, protein and albumin, parenteral nutrition) and enteral
nutrition until ECLS weaning. Two groups were compared during ECLS
period: no enteral nutrition delivered (none or TPN) (ANEC, n = 73)
and at least once enteral nutrition delivered (NEC, n = 50) including
EN alone and supplemental parenteral nutrition (SPN). Primary
outcome was incidence of GI intolerance and risk factors. Secondary
outcomes were nutritional adequacy (calculated as overall of calories and
protein delivered divided by the theoretical amount requirements:
20 kcal/kg/d and 1.2 g/kg/d) and clinical outcome. Data are reported
as median (25th and 75th percentiles) or number (%), and analyzed
with student’s t test for continuous variables and χ2 test for categorical
variables. P < 0.05 was considered as significant.
Results 123 patients were enrolled [age 49 years (38–59), IGS-II 51
(35–67), IMC 24 (22–29)], represented 1009 nutrition days [ANEC = 428
(42), NEC = 581 (58)] with duration of 7 days (5–10) [ANEC = 6 (5–8),
NEC = 9 (6–13); P < 0.001] including 96 ECMO-VA and 27
ECMOVV. None nutrition support and TPN were respectively received
on 42% (n = 428) and 32% (n = 321) of patient days (NEC = 105,
SPN = 155). Patients received median intake of 1188 kcal (751–1784)
[NEC = 1458 kcal (952–2016), ANEC = 990 kcal (605–1389); P = 0.001].
The median ratio of prescribed/required calories per day was 83%
(50–127) [NEC = 105% (61–144), ANEC = 70% (42–101); P = 0.001].
Evolution of daily energy balance is reported in Fig. 27. Digestive
intolerance was reported in 27 patients (54%) including gastric
residual volume considered high for physician in 15 cases (30%). Motility
agents were used in 18 patients(36%). No serious GI complications
or clinical signs of mesenteric ischemia were reported. Risk factors
for GI intolerance were low weight [66 kg (56–75) vs. 80 kg (68.5–86);
P = 0.034] and long duration of circulatory support [8 days (5–9.5) vs.
11 days (6.5–14.5); P = 0.018]. Clinical outcome was similar between
the groups (NEC vs. ANEC; ECMO-VA vs. ECMO-VV).
Discussion TPN was preferably used in this specific cohort of critically
ill patients. Although, the number of patients receiving no nutrition
was high, caloric debt during temporary ECLS was low in comparison
with previous results . Overnutrition was frequent in the NEC group
and would justify implementation of nutrition protocol. Incidence of
GI intolerance remains frequent and could justify systematic used of
motility agents with introduction of EN.
Conclusion Enteral nutrition in patients treated with temporary
extracorporeal life support is feasible and may be improve with systematic
motility agents and implementation of nutritional protocol.
Refeeding hypophosphoremia in a medical critical care unit:
3‑month observational study
Gioia Gastaldi1, Cherifa Cheurfa2, Julien Abily1, Steven Grange1, Dorothée
Carpentier1, Christophe Girault1, Gaetan Beduneau1, Thomas Lescot3,
1Réanimation médicale, Centre Hospitalier Universitaire Rouen, Rouen,
France; 2Anesthésie réanimation, Centre Hospitalier Universitaire Rouen,
Rouen, France; 3Réanimation chirurgicale digestive, Hôpital Saint‑Antoine,
Correspondence: Gioia Gastaldi ‑ gioia.gastaldi@chu‑rouen.fr
Annals of Intensive Care 2017, 7(Suppl 1):S114
Introduction Refeeding syndrome (RS) is a potentially lethal
condition that remains underdiagnosed. It is characterized by severe
electrolyte and fluid shifts associated with metabolic abnormalities
in malnourished patients undergoing refeeding orally, enterally, or
parenterally. Clinical criteria have been proposed for determination
of its risk and reported in the National Institute for Clinical Excellence
(NICE) Clinical Guidelines. Hypophosphoremia (hP) is a prominent
feature of the RS and seems to be the earliest abnormality. Phosphorus
is a vital component of nucleic acids, enzyme systems, and various
Objective To determine the incidence of refeeding
hypophosphoremia (RH) < 0.9 mmol/L, and severe RH < 0.6 mmol/L in a medical
critical care unit.
Patients and methods Monocentric, retrospective and observational
study with patients from FRench-speAking icu Nutritional Survey
study FRANS. Critically ill adults (more than 18 yo) were enrolled if they
were hospitalized for more than 3 days during a 3-month period and
had an artificial nutritional support. Refeeding hypophosphoremia is
defined by the occurrence of hypophosphoremia after refeeding. We
studied the incidence of HR, risk factors, and prognosis.
Results 34 patients were enrolled between 03/01/2015 and
05/31/2015. RH appears in 73.5% and severe RH < 0.6 mmol/L in 35.3%
(Fig. 28). There is no correlation between RS risk factors and RH in our
study. Logistic regression did not permit to identify neither risk factor
nor prognostic modification. There is a lack in phosphoremia
measuring (27.6%), and overfeeding during the first 3 days occurs in 29.4%.
Discussion We define that an hypophosphoremia appearing after
refeeding is a refeeding hypophosphoremia, and we do not consider
others etiologies, such as mechanical ventilation, alkalosis, sepsis,
alcoholism, malabsorptive states, poor intake, some medication. Our cohort is
too small to find some possible correlations with risk factors or prognosis.
Conclusion Refeeding hypophosphoremia is common in our
population. Hypophosphoremia is not an independent predictor of ICU or
in-hospital mortality in critically ill patients. The knowledge of the SRI
requires the follow-up of the phosphoremia during nutrition after
critical illness in particular in the undernourished patients.
Fig. 28 Incidence of hypophosphoremia at admission, the first day,
and refeeding hypophosphoremia
Introduction To determine the possible relationship between 10 days
cumulated proteins (10 days CPD) and energy deficits (10 days CED)
observed in ventilated patients and ICU length of stay, duration of
ventilator support, incidence of infections and 28 days mortality.
Patients and methods Mixed medical or surgical ventilated for at least
2 days adult patients from 5 ICUs from CHU Liège Belgium were enrolled
into the study. They were fed by enteral route with a target of 25 kcal and
1.25 g of proteins by corrected kg of bodyweight and by day. If 50% of
the target was not reached on day seven, parenteral nutrition was added
with the same target. CED and CPD were calculated for 10 days, taking
into account all the sources of nutrition, and was defined as the difference
between the amount of energy or protein intake and the target.
Results From 10/12/2014 till 30/5/2015, 99 patients were followed.
Data from 62 patients could be cumulated on the first 10 days. There
were 45 males, mean BMI was 26.9 ± 6.3; SAPS II score on day 1 was
51.3 ± 15.8, SOFA score at day 1 was 9.1 ± 3.5. They were ventilated
for a median of 18 days (IQR 13–26), median ICU length of stay was
27 days (IQR 19–35). Mean SOFA max calculated for the first 10 days
was 12.1 ± 4.2 and the 28 day mortality was 32.3%. On day 5, only
42% reached the target of 25 kcal/kg and 27% the target of 1.25 g of
protein/kg. Mean 10 days CED was −5555.2 ± 4639.9 kcal and mean
10 days CPD was −350.8 ± 252.3 g. There was a significant negative
relationship between both deficits and the SOFA max (p = 0.0064
for CED and p = 0.0053 for CPD). However, there were no
correlations between any of the deficits and ICU length of stay, duration of
mechanical ventilation, occurrence of infections and 28 days mortality.
Discussion Saps II level, SOFA max level, ICU length of stay, all these
parameters emphasize the high severity of this cohort of patients.
It could indeed been thought that it is in this group of critically ill
patients that the impact of nutrition could be easily demonstrated.
Clear relationships between SOFAmax on day 10 and the 10 days CED
and CPD could be seen. However, both the deficit and the level of
organ dysfunctions could be cause or consequence. Unlike previous
studies, usually performed in less severely ill patients, we did not find
any relationship between CED or CPD and patient’s outcome.
Conclusion Contrary to some recent studies, we found no
relationship between CED and CPE and outcome of patients. Future studies
Cardiopulmonary bypass induces lymphopenia and decreases
lymphocyte proliferation ability: IL‑10 and PD‑L1
as potential therapeutic targets to reduce postoperative infection
Fabrice Uhel1, Mathieu Lesouhaitier1, Murielle Grégoire2, Baptiste Gaudriot3,
Arnaud Gacouin1, Yves Le Tulzo1, Erwan Flecher4, Karin Tarte5, JeanM‑arc
1Réanimation médicale, Centre Hospitalier Universitaire de Rennes, Rennes,
France; 2Biosit and inserm u917, faculte de medecine, université rennes 1,
Centre Hospitalier Universitaire de Rennes, Rennes, France; 3Anesthésier‑éan‑
imation, Centre Hospitalier Universitaire de Rennes, Rennes, France; 4Service
de chirurgie thoracique, cardiaque et vasculaire, Centre Hospitalier Universi‑
taire, Rennes, France; 5Biosit and inserm u917, faculte de medecine, universite
rennes 1, Centre Hospitalier Universitaire de Rennes, Rennes, France
Correspondence: Jean‑Marc Tadié ‑ jeanmarc.tadie@chu‑rennes.fr
Annals of Intensive Care 2017, 7(Suppl 1):S116
Introduction Cardiac surgery with cardiopulmonary bypass (CPB)
is associated with a generalized inflammatory response with
concomitant immune paresis which predisposes to the development of
postoperative infections and sepsis (1). Lymphocytes are essential
agents of innate and adaptive immune responses during infections
or inflammation processes. Lymphopenia has been associated with
immune dysfunction during septic shock, and it has been shown
that low absolute lymphocyte count was predictive of
postoperative sepsis (2). Furthermore, impaired lymphocyte function probably
occurs after CPB. Thus, we investigated mechanisms involved in
postoperative lymphopenia and impaired lymphocyte function after CPB.
The aims of this study were: 1) To describe a potential relationship
between lymphopenia and occurrence of postoperative infections. 2)
To demonstrate that CPB induces lymphocytes apoptosis. 3) To
demonstrate that CPB impaired lymphocyte function (ability to
proliferate). 4) To demonstrate that IL-10, PD-L1 (programmed cell death 1
ligand 1) and Indoleamine 2,3-dioxygenase (IDO) could be interesting
targets to restore lymphocyte ability to proliferate after CPB.
Patients and methods Blood cell counts with differentials obtained
within the first postoperative week were analyzed in 828 patients
undergoing cardiac surgery in 2015. Postoperative lymphopenia was
defined as a lymphocyte count <1.3 × 109 cells L−1. Postoperative
infections were defined following CDC criteria.
Study procedures: The following analysis were performed before (T0)
and 24 h after (T1) cardiac surgery with CPB: Lymphocyte apoptosis;
T-cell proliferation ability following polyclonal stimulation; HLA-DR
and PD-L1 expression on monocytes; plasma IDO activity and IL-10
levels; and the ability of lymphocytes to undergo a clonal proliferation
when stimulated using specific inhibitors of IL-10 and IDO.
The study was approved by our local ethics committee. Patients were
informed of the observational nature of the study and gave their consent.
1. Early lymphopenia after CPB was associated with the occurrence of
postoperative infection: Postoperative infections occured with a median
delay of 6 days. Patients who developed postoperative infections had
a significantly lower lymphocyte count at Day 4, Day 5 and Day 6 than
patients without postoperative infections.
2. CPB induced lymphocyte apoptosis and decreased T‑ cell proliferation ability.
3. CPB during cardiac surgery decreased mHLA‑DR expression.
4. CPB increased IDO activity, PD‑L1 expression and IL ‑10 plasma levels.
5. IL‑10 or PD ‑L1 inhibition of inhibition could restore ability of lymphocytes to proliferate, although IDO inhibitors did not show any effect.
Conclusion We provided new evidences that CPB induces
immunosuppression. We also demonstrated that IL-10 and PD-L1
could be interesting targets to restore ability of lymphocytes to
proliferate. As maintaining MV during CPB decreased plasmatic levels of
IL-10, our study brings new evidences that ventilator strategies could
be of interest to decrease postoperative infections.
Influence of neutropenia on mortality of critically ill cancer
patients: results of a systematic review on individual data
Quentin Georges1, Elie Azoulay2, Djamel Mokart3, M Soares4, Kyeongman
Jeon5, Sandra Oeyen6, Chin Kook Rhee7, Pascale Gruber8, Marlies Oster‑
mann9, Quentin Hill10, Peter Depuydt11, Christelle Ferra12, Alice Muller13,
Virginie Lemiale2, Bourmaud Aurelie14, Michaël Darmon1
1Réanimation médicale, CHU Saint‑Etienne ‑ Hôpital Nord, Saint‑Étienne,
France; 2Réanimation médicale, Hôpital Saint‑Louis, Paris, France;
3Réanimation, Institut Paoli‑Calmettes, Marseille, France; 4Post‑graduation
program, D’Or Institute for Research and Education, Rio de Janeiro,
Brazil; 5Department of critical care medicine and division of pulmonary
and critical care medicine, Sungkyunkwan University, Seoul, Republic of
Korea; 6Department of intensive care, Ghent University hospital, Gent,
Belgium; 7Division of pulmonary, allergy and critical care medicine, Seoul
St. Mary’s Hospital, Seoul, Republic of Korea; 8Intensive care, anaesthesia,
and surgery, The Royal Marsden Hospital, London, United Kingdom;
9Nephrology and intensive care, St Thomas’ Hospital, London, United
Kingdom; 10Hematology, Leeds Teaching Hospital, Leeds, United King‑
dom; 11Department of intensive care, Ghent University Hospital, Ghent,
Belgium; 12Hematology, Catalan Institute of Oncology, Barcelona, Spain;
13Department of critical care medicine and pulmonary medicine, hOSPI‑
TAL DE CLINICAS DE PORTO ALEGRE, Porto Alegre, Brazil; 14Département
de santé publique, Institut de Cancérologie de la Loire Lucien Neuwirth,
Correspondence: Michaël Darmon ‑ michael.darmon@chu‑st‑etienne.fr
Annals of Intensive Care 2017, 7(Suppl 1):S117
Introduction The prognostic impact of neutropenia in
criticallyill cancer patients remains controversial. Hence, several studies
in critically ill cancer patients failed to demonstrate the impact of
neutropenia on outcome . This lack of statistical association might
however, reflect a lack of statistical power.
A previous meta-analysis of aggregated data suggested 11% (95% CI
9–14%) raw increase in mortality in neutropenic patients. The available
data were, however insufficient to allow adjustment with confounders
The aim of this study was to assess the influence of neutropenia on
mortality of critically ill cancer patients using individual data obtained
from studies identified by our systematic review. Secondary objectives
were to assess the influence of neutropenia on mortality of critically
ill patients while taking into account underlying malignancy, use of
G-CSF or changes related to period of admission.
Patients and methods This systematic review and meta-analysis
was performed according to the PRISMA statements. Public-domain
databases including PubMed and the Cochrane database were
searched by using predefined keywords. The research was restricted to
articles published in English and studies focusing on critically ill adult
patients from May 2005 to May 2015.
The methods and objectives of this systematic review were reported in
the PROSPERO database (CRD42015026347).
Selected manuscripts’ authors were then contacted to obtained part
of their dataset.
Mortality was defined as either hospital or day-28 mortality.
This preliminary analysis reports results from the whole dataset before
and after adjustment using logistic regression. Period of admission
and use of G-CSF were then assessed and were a pre-planned analysis.
Results Our initial search yielded 1528 citations and 131 studies were
retained for further analysis. Overall, 9 studies were excluded for
redundancy with other included studies, 5 as containing only
neutropenic patients, and two as containing only palliative patients. Finally
30 datasets (26%) containing sufficient data to allow comparison were
obtained from authors.
Overall, 7356 patients were included in this study, including 1666
patients with neutropenia at ICU admission. Median age was of
60 years (IQR 49–69). Median SAPSII score at ICU admission was
42 (IQR 28–57). Respectively 4101 and 3255 patients had
underlying haematological malignancy and solid tumours, and 438 patients
underwent allogeneic stem cell transplantation. Mechanical
ventilation, vasopressors, and renal replacement therapy were required in
respectively 50.7% (n = 3729), 41.1% (n = 3024) and 16.1% (n = 1174)
of the included patients.
Mortality was of 47.4% in the overall population (n = 3483) and was
higher in neutropenic patients (60.3 vs. 43.6% in non-neutropenic
patients; P < 0.001). Neutropenia was independently associated with
poor outcome when adjusted for underlying malignancy, allogeneic
stem cell transplantation and severity as assessed by organ support
(OR 1.45; 95% CI 1.27–1.65).
Mortality decreased progressively over time in both non-neutropenic
(from 54 to 44%; P < 0.0001) and in neutropenic patients (from 72 to
57%; P < 0.0001). When adjusted for confounders, admission during
a more recent period was independently associated with favourable
outcome and did not change the final model.
Conclusion This preliminary analysis suggests a meaningful survival
in neutropenic critically ill cancer patients despite an independent
association between neutropenia and mortality.
Additional analyses are on-going in order to adjust for study weight,
heterogeneity across studies, assess the influence of neutropenia
duration or G-CSF use, and confirm the influence of neutropenia in a
predefined subgroup of patients.
Cytokinic profiles kinetic in response to Candida bloodstream
Christopher Niles1, Fabien Herbert2, Sylviane Pied2, Séverine Loridant,3,
Nadine François3, Anne Bignon4, Boualem Sendid5, Julien Poissy1
1Pôle de réanimation, hôpital salengro, C.H.R.U. ‑ Lille, Avenue Oscar
Lambret, Lille, France, Lille, France; 2Centre d’infection et d’immunité de
lille equipe 4 ‑ basic and clinical immunity of parasitic di, Institut Pasteur
de Lille, Rue du Professeur Calmette, Lille, France, Lille, France; 3Centre de
biologie et pathologie génétique, laboratoire de mycologie et parasitolo‑
gie, Centre Hospitalier Régional Universitaire de Lille, Lille, France; 4Service
de réanimation chirurgicale, hôpital huriez, Centre Hospitalier Régional
Universitaire de Lille, Lille, France; 5Inserm u995‑2, Universite Lille 2 ‑ Droit
et Santé, Lille, France
Correspondence: Julien Poissy ‑
Annals of Intensive Care 2017, 7(Suppl 1):S118
Introduction Candida bloodstream infections (CBI) are frequent and
increasing in hospitalized patients, especially in intensive care units.
Considering the results of some experimental in vitro and animal
studies, it seems that yeasts belonging to Candida genus are able, so as
to survive, to modulate the immune response of the host by guiding
T cells polarization to Th2 profile. Th1 and Th17 cytokines are known
to be involved in host defense against CBI. However, these data are
mainly experimental or collected after candidemia. The aim of this
study is to precise kinetic of cytokines network during human CBI.
Patients and methods This was an ancillary study of an institutional
project dedicated to pathophysiology of candidiasis. We have included
32 patients with candidemia and 54 controls (27 matched hospitalized
controls and 27 healthy subjects). The sera of cases were gathered
before (almost 5 days before), during and after the isolation of yeasts
from blood culture, defined as day 0 (D0). Quantitative analysis of
28 cytokines by Luminex® technology and of (1,3)-β-d-glucans by
Fungitell® test were performed on 132 samples. The amplitude
of Th profile response was expressed by summing the amount of
the most relevant cytokines for Th1, Th2 and Th17 profiles, in pg/
mL. For each patient, the highest level of response was considered
as 100%. Results are expressed for the population by means of
the results. We then performed univariate analysis (Fischer exact
test for qualitative variables, Mann–Whitney and Wilcoxon test for
quantitative variables, Spearman for correlation; GraphPad Prism V6
software) and a multidimensional analysis by principal component
analysis (PCA; IgorPro software).
Results Patients with candidemia exhibited an increase in
proinflammatory cytokines (IFNγ, TNFα and IL-12), in comparison with the
anti-inflammatory cytokines (IL-4 and IL-10) before D0 (p = 0.034) in
univariate analysis. The ratio between mean values reverses at D2 and
D3 (p = 0.02) and the increase of Th2 response level from D0 to D4
is correlated to the decrease of Th1 response (r = −0.885; p = 0.033)
in univariate analysis and PCA. A pro-inflammatory response (Th1) is
associated with a reduced mortality (RR = 0.58 [0.34; 0.98]) and with a
lower β-D-glucans levels (p < 0.0001).
Discussion We describe here a dynamic cytokine profiles in response
to candidemia. Pro-inflammatory response predominates before D0
and reverses after. This is contradictory to the postulate that an
antiinflammatory background could predispose to invasive candidiasis
in ICU patients and exhibiting a “Post-infectious immune suppression
conditions”. But the relative deficiency in Th1 response compared
to simultaneous anti-inflammatory cytokines secretion observed
after CBI is in accordance with experimental data, suggesting the
modulation of the immune response by Candida. The link between
cytokinic profile and mortality can also raise the hypothesis of an
influence by genetic factors on the regulation and direction of the
immune response and so, the existence of a high-risk population.
Conclusion These data suggest a relation between Candida and the
orientation of the immune response towards a pattern deleterious
for the infected host. This could allow to determine the most relevant
cytokines varying during CBI. They could be used as biomarkers
to identify the patients who could benefit from an early treatment
in a preemptive targeted therapeutic strategy. These data will be
paralleled to genetic background and to circulating Candida derived
molecules to precise the relative part of the host and the pathogen in
this complex interaction.
Neutrophil‑to‑lymphocyte ratio as an independent predictor
of mortality in critically ill cirrhotic patients
Mikhael Giabicani1, Caroline Lemaitre1, Emmanuel Weiss2, Steven
Grange1, Dorothée Carpentier1, Gaetan Beduneau1, Christophe Girault1,
Catherine Paugam‑Burtz 2, Fabienne Tamion1
1Intensive care, Hospital Center University Rouen, Rouen, France; 2Anes‑
thesiology and critical care, Hospital Center university Beaujon (AP‑HP),
Correspondence: Mikhael Giabicani ‑
Annals of Intensive Care 2017, 7(Suppl 1):S120
Introduction Prognosis of cirrhotic patients hospitalized in
intensive care unit (ICU) remains poor. Many studies suggested a negative
impact of systemic inflammation on organ failure and outcome in
cirrhosis(1). In ICUs, cirrhotic patients are widely admitted and revalued
after receiving optimal treatments for 3 days. However, little is known
about how manage these patients after day 3 according to their
prognosis. The blood neutrophil-to-lymphocyte ratio (NLR) as a novel
inflammation index biomarker has been reported to be a predictor of
clinical outcomes in various malignancies and in unselected critically
ill patients(2). NLR has also been identified as a predictor of mortality
in patients with stable liver cirrhosis. To our knowledge, the ability of
NLR to predict outcome in critically ill cirrhotic patients has never been
studied. The aim of this study was to evaluate the usefulness of
inflammatory marker such as NLR for diagnosis of infection and predicting
the outcome in hospitalized critically ill cirrhotic patients.
Patients and methods We performed a retrospective monocentric
study including consecutively cirrhotic patients hospitalized in a
medical ICU from 2010 to 2014. For each patient, clinical and biological data
at admission and day 3 were collected. NLR at admission (“NLRD0”), at
day 3 (“NLRD3”) and the variation of NLR between admission and D3
Fig. 29 Multivariate analysis of factors associated with mortality
(“delta NLR”) were calculated. Statistical analysis used appropriate non
parametric tests and Cox regression for survival analysis. The ability of
the variables to discriminate survivors from non-survivors was
determined using ROC curves. Results are expressed as median (IQR).
Results During the study period, 149 cirrhotic patients were
admitted in ICU. The etiologies of liver cirrhosis were alcoholic in 87%
of cases with severe score: median Child-Pugh score = 9 [7–11],
median MELD score = 25 [18.3–30.8]. Main reasons for ICU
admission were sepsis (40.9%), gastrointestinal bleeding (23.5%) and renal
failure (19.5%). NLRD0 was higher for patients hospitalized for septic
shock (p < 0.001). Patients were followed up for 23 days [5.5–289.5].
90 (59.6%) patients died including 57 (37.7%) deaths in ICU and 18
(12.1%) deaths after ICU discharge during the same hospitalization.
NLR decreased for survivors between D0 and D3 (−4.5 [−9.8 to 0.0])
whereas it increased for non-survivors (+1.2 [−3.1 to +10.1]). In
univariate analysis, for predicting survival, higher values of NLRD3, delta
NLR, MELD score at admission, SOFA score at admission and at day 3
and delta SOFAD0-D3 were significant factors. Predictors of death in
multivariate analysis are shown in Fig. 29. Area under delta NLR ROC
curve was 0.72 (CI = 0.61–0.83).
Conclusion The blood NLR is a novel inflammation index that has
been shown to independently predict poor clinical outcomes. We have
demonstrated that delta NLR is an independent predictor of
mortality in critically ill cirrhotic patients. Delta NLR could help to identify
cirrhotic patients at risk of unfavorable outcome.
1. Salciccioli JD, et al. The association between the neutrophil‑to ‑lympho ‑ cyte ratio and mortality in critical illness: an observational cohort study. Crit Care. 2015;19:13.
2. Gandoura S, et al. Gene‑ and exon‑ expression profiling reveals an exten‑ sive LPS‑induced response in immune cells in patients with cirrhosis. J Hepatol. 2013;58(5):936–48.
Serum procalcitonin is a good diagnostic marker of bacterial
infection in patients with hematologic malignancies in the
Intensive Care Unit
Celine Dupre1, Saad Nseir2, Anne‑Sophie Moreau 1
1Centre de réanimation, C.H. Régional Universitaire de Lille (CHRU de
Lille), Lille, France; 2Centre de Réanimation, Centre Hospitalier Régional
Universitaire de Lille, Lille, France
Correspondence: Celine Dupre ‑
Annals of Intensive Care 2017, 7(Suppl 1):S121
Introduction Diagnosis of infection in immunocompromised patients
can be difficult. However, diagnosing infection is very important,
particularly in critically ill. This study aims to evaluate the benefit of
procalcitonin (PCT) blood level as a diagnostic marker for bacterial
infection in patients with hematological malignancies admitted to the
Intensive Care Unit (ICU).
Patients and methods This retrospective single-center study
included all consecutive patients with acute myeloid leukemia or
high grade lymphoid malignancy admitted to the ICU. Patients were
sorted into three subgroups, according to clinical and microbiological
data: «Infectious disease», «no infectious disease» and «Unknown».
Initial serum PCT and when available at day 3 and day 5 were recorded.
Receiver Operating Characteristic (ROC) curve, sensitivity and
specificity were calculated. Serum PCT was considered as decreasing when
the decrease was ≥25% at day 3 and/or ≥50% at day 5. Mortality rates
in the ICU and at day-90 were also studied.
Results Fifty-four patients were included in the study. At diagnosis,
PCT levels were significantly different between the “Infection
disease” group and the “No infection disease” group (p = 0.002). There
was no difference between the “Infection disease” group and the
“Unknown” group (p = 0.052). For the diagnosis of bacterial
infection, best initial serum PCT threshold was 0.65 ng per milliliter. For
that threshold, sensitivity was 94.6% and specificity was 78.6%. PCT
area under the ROC curve was 0.93 [CI 95% = 0.855–1]. Youden’s J
statistic was 0.73. PCT levels weren’t different between groups
according to the presence of neutropenia or in case of inaugural
disease. There was a significant difference in PCT values between
groups according to the SOFA score (p = 0.027), but not the SAPS2
score. Mortality rate in the ICU and at day-90 were significantly lower
for the patients with decreasing PCT (p < 0.001 and p < 0.001,
respectively). When comparing serum PCT and CRP predictive values, PCT
was significantly a better marker of bacterial infection (Fig. 30).
Discussion We found that serum PCT, with a threshold of 0.66 ng/
mL, is a reliable marker of bacterial infection disease in patients
with aggressive hematological malignancy admitted to the ICU.
Our study confirms the results of a previous study in unselected
immunocompromised patients admitted to the ICU, showing a 100%
sensitivity, a 63% specificity and an area under ROC curve of 0.851
[0.78–0.92] for a threshold of 0.5 ng/mL (1).
The main limitations of our study are its retrospective design and the
small number of included patients.
Conclusion PCT is a reliable marker of bacterial infection in patients
with hematological malignancies admitted to the ICU. PCT kinetic
seems to be an interesting prognostic marker in this population.
Aymen Zayene1, Lucie Portier2, Nathalie De Freitas Caires2, Philippe Las‑
Introduction Endocan is a proteogycan secreted by pulmonary and
renal endothelial cells (Lassalle et al.). Its synthesis is increased in
sepsis and is regulated by Lipopolysaccharide (LPS) and cytokines.
Toll Like Receptors (TLRs) are receptors of innate immunity and
recognize diverse exogenous and endogenous patterns.
In this study, we have compared the effect of 2 TLRs agonists on
regulation of secretion and expression of Endocan by Human
Umbilical Veinous Endothelial Cells (HUVECs).
Materials and methods The stimulation of HUVECs was performed by
2 TLRs agonists: LPS and PolyInossinic Polycytidylic acid (Poly (I:C)).
The secretion of Endocan was evaluated by Enzyme Linked Immuno
Sorbant Assay (ELISA) in the supernatant of stimulated HUVECs.
Real Time Polymerase Chain Reaction (qPCR) study compared the
expression of Endocan in the two groups.
Results The secretion of Endocan by HUVECs is upregulated by LPS
and poly (I:C).
Kinetics of secretion of Endocan was faster with LPS than Poly (I:C).
q PCR study confirmed that Endocan is overexpressed in HUVECs
stimulated with LPS than Poly (I:C).
Discussion TLR 4 is involved in the recognition of LPS (Kawai et al.),
a component of the outer membrane of Gram Negative Bacteria,
respiratory syncytial virus fusion proteins, Steptococcus pneumoniae
TLR 3 was originally identified as recognizing a synthetic analog of
double stranded Ribonucleic Acid (dsRNA), poly(I:c) which mimics viral
In this study, we have found that kinetics of secretion and expression
of Endocan is faster with HUVECs stimlated by TLR 4 agonist than TLR
This results could suggest that Endocan may be not only a marker
of septic shock but could be also a specific marker to recognize the
nature of pathogenic microorganisms in septic shock.
Furthermore, other studies with more TLR agonists could be useful to
confirm these results.
Conclusion Studying the effects of diverse TLRs agonists could make
the plasmatic dosage of Endocan more specific and helpful to
recognize the nature of pathogenic microorganisms in septic shock.
Lung ultrasound: help to the diagnostic and the monitoring
of response to physiotherapy. A case report of pneumonia
Aymeric Le Neindre1, Pascal Selot1, Daniel Ferreiro,1, Maria Bonarek,1,
Stépahen Henriot,1, Julie Rodriguez,1
1Physiotherapy, Hôpital Forcilles ‑ Fondation CognacqJ‑ay, Férolles‑Attilly,
Correspondence: Aymeric Le Neindre ‑
Annals of Intensive Care 2017, 7(Suppl 1):O79
Introduction Lung ultrasound is widely used in intensive care,
ermergency and pneumology medicine, for assessing acute
respiratory pathologies. It is noninvasive, radiation free and rapidly
available at the patient’s bedside and provides an excellent accuracy.
So, lung ultrasound may be an interesting tool for the physiotherapist
as it allows to assess with more accuracy the patient improving the
chest physiotherapy indication and monitoring (1).
As far as we are aware, no study has evaluated the impact of lung
ultrasound on clinical-decision making by physiotherapists in the use
of chest physiotherapy.
This case report highlights the lung ultrasound interest in chest
physiotherapy in patient with lung consolidation.
Patients and methods This was a case report written following the
recommendations of the CARE guideline (2).
The case was a 68-years-old female patient, non intubated,
hospitalized in a respiratory ICU. She was hypoxemic (PaO2 = 59 mmHg and
SaO2 = 89%), with dyspnoea at rest and an increasing radiological
opacity at the right lung base. Hypoxemia was the indication for
At the clinical examination, the physiotherapist’s findings were:
decreased mobility, dullness and abolished vesicular sound at the
base of right hemithorax.
This clinical examination and chest x-rays analysis allowed the
physiotherapist to propose several clinical hypotheses: pleural effusion,
obstructive atelectasis or pneumonia.
The chest physiotherapy treatment differs according to the type of
lung deficiencies. For example, the physiotherapist must to refer
the patient to the medical staff in case of pleural effusion or may
implement hyperinflation technique in case of obstructive atelectasis.
Determining the nature of lung deficiencies is essential to provide the
more suitable therapeutic strategy. So, the physiotherapist decided
to perform a lung ultrasound examination to retain the more likely
Results Ultrasound examination performed by the physiotherapist
highlighted the presence of a lung consolidation at the infero-lateral
and posterior parts of the right lung with a pneumonia pattern:
presence of tissue-like sign, shred sign, dynamic air bronchogram and
The medical staff implemented antibiotic treatment. The ultrasound
findings guided the physiotherapist to choose chest physiotherapy
technique improving the alveolar recruitment: nearly prone position
(left side down) and continuous positive airway pressure during 45 min.
The patient response to the treatment was monitored by ultrasound
and showed a decrease of the lung consolidation size and apparition
of B lines, meaning a gain of lung aeration. These findings were
associated with SpO2 improvement but without decrease of dyspnoea.
Discussion Lung ultrasound allowed the physiotherapist to precise
the nature of the radiological lung opacity. As it is more accurate
than clinical examination or chest x-ray, this suggests a more suitable
choice of chest physiotherapy techniques than conventional clinical
Ultrasound findings suggested a positive response to the chest
physiotherapy treatment. The apparition of re-aeration signs (B lines,
decreased consolidation size) showed a short-term efficacy of the chest
physiotherapy treatment. This allowed the physiotherapist to continue the
treatment during 1 week and obtain a substantial clinical improvement.
Conclusion The use of lung ultrasound in the clinical decision-making
process may help the physiotherapist to choose with more accuracy
the therapeutic strategy. Moreover, it allows to monitor the treatment
in real-time and assess the patient’s response. The use of this tool
may allow the physiotherapist to determine the optimal indications
for chest physiotherapy and thus avoid unnecessary or inappropriate
Introduction Chronic Critical Illness (CCI) syndrome is a new
condition affecting an increasing number of patients, who survived an acute
critical illness but have persistent severe organ dysfunction, requiring
prolonged specialized care. CCI is a iatrogenic process, reflecting the
efficacy of modern life support technologies(1), and encompasses
multiple organ failure, need for prolonged mechanical ventilation
(MV), organ support, and palsy due to polineuromyopathy. The
transition from acute to CCI is gradual: definitions are based on duration of
MV, with cut-offs of 7, 14 or 21 consecutive days of MV for ≥6 h/day.
CCI patients may come from either medical or surgical ICU; their health
status fluctuates between improvements and deteriorations implying
recurrent transitions between different levels of care (1).The risk of
death is reported to be as high as 50%. Despite a relatively young age
(65 years on average), functional status of CCI patients discharged is
seriously impaired, thus CCI patients require long-term rehabilitation.
AIM: To estimate the frequency of CCI Syndrome in Careggi, a large
academic, tertiary care hospital; to describe the clinical course of CCI
patients through discharge, and their functional status at discharge.
Patients and methods Administrative data on admission, transfer,
death and discharge of all CCI patients, consecutively admitted in one
of the 56 ICU beds at Careggi Hospital from January 1 to December
31, 2014, were collected. CCI was defined with the cut off of ≥21 days
of ICU stay, representing the index event (IE) without contribution of
previous or subsequent hospitalization in other hospitals. Reasons
for admission were grouped into the 4 broad categories of medical
causes, surgery, major trauma and cardio-respiratory arrest. Patients
discharged were evaluated in daily living, cognitive status, and
mobility using Barthel Index.
Results We identified 123 subjects who developed CCI (71 males; age
61.7 ± 1.5 years, mean ± SEM); 36 of them came from an external
ICU, 87 began their CCI course within Careggi hospital (60 from the
Emergency Room, 27 from a regular ward). Average duration of
the IE was 36.1 ± 2.1 days. These sample developed accumulative
length of ICU stay of 4440 days, corresponding to a 22% ICU bed
occupation over the theoretical total of 20,440. When days of
subintensive care and regular ward were separately added, 5500 days of
highly specialized care and 6266 days of total acute hospital stay were
reached. Surgical patients had longer hospitalizations (p = 0.009).CCI
patients confirmed to be highly erratic: a total of 302 transitions across
different services were recorded in the 123 patients, with a maximum
of 9 in 6 of them. Mean age was comparable between the 27
patients who died (22%) and the remaining 95 who were discharged
alive (66.9 ± 2.5 vs. 60.3 ± 1.7 years; p = 0.058).Fourteen subjects
continued their ICU stay out of hospital. Only 6, whose age was lower
(37.7 ± 3.7 years), were discharged home; half of the participants
(n = 68, 55.2%) were admitted to a residential rehabilitation facility.
Younger subjects scored better in the domains of self care (p = 0.018)
and cognitive status (p = 0.008) but not in the domain of mobility,
including walking ability: 45 patients required maximal assistance in
performing activities of daily living and transfers, other 12 required
medium/maximal assistance, with no statistical difference between
Conclusion CCI is a relevant clinical condition that need to be assessed
and possibly prevented, as it causes severe morbidity, long-term
functional impairment and exceeding healthcare costs.
Introduction Critical illness together with immobilization have
deleterious effects on patients outcome, especially in the presence of
sepsis. Increased muscle catabolism and membrane inexcitability reduce
muscular mass and impair function within the first days after sepsis
onset (1). Early mobilization could potentially limit muscle wasting and
functional impairment in this population. The purpose of this study
was to test whether exercise during the early phase of sepsis is safe
and beneficial and to which extent it can limit skeletal muscle protein
catabolism and preserve function.
Patients and methods Adult patients admitted with the diagnosis of
severe sepsis were included and randomly allocated to two groups;
1) Control group (Ctrl-G): manual passive/active manual mobilization
twice a day or 2) Experimental group (Exp-G): additional two times
30 min of passive/active cycling exercise. Both groups benefited
from a reduced sedation, adjusted nutritional intake and bed to chair
transfer as soon as possible.
Skeletal muscle biopsy and electrophysiological testing were realized
at day-1 and day-7. Muscle histology, biochemical and molecular
analyses of anabolic/catabolic and inflammatory signalling pathways were
performed. A group of four healthy subjects was used to obtain non
Hemodynamic parameters and patients perception were collected
during each session.
Results Twenty-one patients were included, however 3 died before
the second muscle biopsy. Ten patients in Ctrl-G and nine in Exp-G
were finally analysed. Muscle fibre cross sectional area (µm2) was
significantly preserved by exercise (relative changes were Ctrl-G:
−45 ± 41% vs Exp-G:12 ± 19%, p = 0.001). Markers of catabolic
systems were highly increased during sepsis compared to healthy
subjects and reduced in both groups 7 days after admission. However the
reduction in mRNA (relative change) tended to be more important in
Exp-G: MURF-1 (Ctrl-G: −31 ± 67% vs Exp-G: −63 ± 45%, p = 0.15),
MAFbx (Ctrl-G: −7 ± 138% vs Exp-G: −56 ± 37%, p = 0.23), LC3b
(Ctrl-G: 5 ± 47% vs Exp-G: −21 ± 18%, p = 0.18) and Bnip3 (Ctrl-G:
27 ± 198% vs Exp-G: −59 ± 23%, p = 0.02). Anabolic and
inflammatory markers were not affected by exercise.
Electrophysiological testing, including direct muscular stimulation,
was abnormal on Day-1 in 10 of 13 evaluated patients. Since only a
limited number of patients could be reassessed a second time,
comparison between groups was not possible.
In general, all activities were well tolerated by patients with no adverse
Where should we place the stethoscope’s chestpiece to hear the
noise of the primary bronchi?
Frédéric Duprez1, Bastien Dupuis2, Grégory Cuvelier2, Thierry Bonus1,
Sandra Ollieuz1, Sharam Machayeckhi1, Gregory Reychler3
1Icu, C.H. Epicura, Hornu, Belgium; 2Laboratoire de l’effort et du mouve‑
ment, Condorcet, Tournai, Belgium; 3Service de pneumologie, Cliniques
Universitaires Saint Luc, Bruxelles, Belgium
Correspondence: Frédéric Duprez ‑
Annals of Intensive Care 2017, 7(Suppl 1):O82
Introduction The pulmonary auscultation is used by respiratory
therapist (RT) to evaluate the efficiency of a treatment. Listen to the noises
coming from the primary bronchi (PB) is important because it is the
place where secretions can be accumulated. Therefore, it is crucial
to know exactly where to place the stethoscope’s chestpiece on the
chest. Few studies have analyzed the chest area where the PB were
located. Our hypothesis is that PB are localized on a line that joins
axillary fossa (Bi-Axillary line: BAL). The aim of our study is to
evaluate the probability to find the primary bronchi by analysis of chest
Patients and methods A retrospective study was performed by
analysis of chest X-Ray using the software: TM reception®, which
allows precise measures to the tenth of millimeter. All the X-Rays were
made on confined to bed patients hospitalized within intensive care
unit, internal medicine and abdominal surgery rooms.
The following measures (in mm) were made between:
a) Lowered perpendicular (LP) of:
• Bi‑Axillary Line (BAL) and the sternal carina (SC)
• BAL’s and the position of right and left PB
• Middle of the body‑sternum (BS) and the perpendicular middle of
right and left PB.
b) Hyoid bone and the SC
The exclusion criteria were: BMI < 18.5 kg/m2 and BMI > 30 kg/m2,
scoliosis, minor patient, lack of visibility of one of the axillary fossa, lack of
visibility of PB, clavicular asymmetry, kyphosis, lack of symmetry in the
shot, atelectasis and pneumothorax.
Statistics: Normality test: KS. Mean values are expressed with their SD
and 95% CI.
Discussion In this study, we performed analysis of chest x-Rays of
bedridden patients and we demonstrated that it is possible to localize
easily, on either side of the BS, the right and left PB at ± 25 mm
distance (LP) above a line joining axillary fossa. This study constitutes
a new tool for the RT who, by using stethoscope with a chestpiece of
10 cm2 surface area, will be able to listen to noise coming from PB.
Conclusion The data presented herein (Fig. 31) show that right and
left PB are located at a mean distance of 25 (±5) mm and 27 (±6)
mm above the BAL, on both sides of the BS. The BAL represents thus
an easy and precise mode to detect right and left PB by bedridden.
Finally, the distance between the hyoid bone and the SC is about
12 cm. As the PB are located after the bifurcation, this information
constitutes another useful way for the localization the right and left PB by
Study of efficacy on ICU acquired weakness of early standing
with the assistance of a tilt table in critically ill patients
Celine Sarfati1, Alex Moore1, Paula Mendialdua1, Emilie Rodet1, Catherine
Pilorge2, Francois Stephan2, Saida Rezaiguia‑Delclaux 2
1Physiotherapy department, Surgical Center Marie Lannelongue, Le
Plessis‑Robinson, France; 2Réanimation adulte, Surgical Center Marie Lan‑
nelongue, Le Plessis‑Robinson, France
Correspondence: Celine Sarfati ‑
Annals of Intensive Care 2017, 7(Suppl 1):O83
Introduction Critically ill patients frequently develop muscle
weakness, which is associated with prolonged intensive care unit and
hospital stay (1). This randomized controlled trial (Clinical Trials
NCT02047617) was designed to investigate whether a daily training
session using a tilt table, started early in stable critically ill patients
with an expected prolonged ICU stay, could improve strength at
ICU and hospital discharge compared to a standard physiotherapy
Patients and methods The study protocol was approved by an
ethics committee and informed consent was obtained from all patients.
Patients admitted in adult ICU of Marie Lannelongue hospital, France,
who were mechanically ventilated for at least 3 days were included.
Exclusion criteria were cerebral or spinal injury, pelvic or lower limb
fracture. Patients were assessed each day for temporary
contraindications for mobilization out of bed (RASS score <−2 or >1;
hemodynamic instability; a continuous intravenous dose of epinephrine/
Fig. 31 50 X‑Rays (Men = 26, women = 24) have been analyzed.
Normality test passed. LP lower perpendicular, BAL bi‑axillary line
Fig. 32 See text for description
norepinephrine >2 mg/h; continuous renal replacement; ECMO).
Interventions for patients assigned to the standard physiotherapy group
(Std) included sitting in armchair for at least 2 h per day. In addition to
the standard physiotherapy mobilization protocol, patients assigned
to the Tilt table physiotherapy group (Tilt) were positioned on a tilt
table for 1 h per day. The primary outcome was the muscles strength
evaluated using the Medical Research Council (MRC) score (range
0 = no muscle contraction, to 5 = normal strength), scoring 3 muscle
groups in each limb, at ICU and hospital discharge, compared to MRC
score evaluated in ICU before the implementation of the
physiotherapy program. Secondary outcome variables included ICU and hospital
length of stay.
Results The flow chart of the study, conducted between October 2013
and October 2014, is presented in the Fig. 32.
Both groups (Std vs Tilt) are comparable for age (63 ± 16 vs 60 ± 15,
p = 0.37), gender (21 Females vs 26 F and 52 Males vs 46 M, p = 0.34)
and the SAPSII (43 ± 13 vs 42 ± 12, p = 0.65). No significant
difference was observed in terms of MRC score or in terms of pts with or
without weakness (MRC > 48) at ICU or hospital discharge. However,
the number of pts with weakness was significantly higher in the group
before Tilt mobilization, suggesting a more rapid improvement in
the tilt group. The ICU and hospital lengths of stay were not different
Discussion The prevalence of muscle weakness in our population is
high before mobilization (90.6%, 95% CI 85.2–95.6), is still 48.6% at ICU
discharge but represents only ~ 1% at hospital discharge. This low
hospital discharge prevalence is probably related to the early and intense
physiotherapy in both groups, which may explain our inability to
demonstrate superiority of the addition of tilt table positioning, although a
faster recovery is suggested.
Conclusion Training sessions using a tilt table, in addition to early and
intense physiotherapy did not improve muscle strength evaluated
using MRC score in surgical ICU patients with muscle weakness.
Aerosol delivery using two nebulizers through high flow nasal
cannula: a randomized cross‑over SPECT‑CT study
Jonathan Dugernier1, Michel Hesse2, Thibaud Jumetz1, Emilie Bialais1,
Jean Roeseler1, Virginie Depoortere2, Jean Bernard Michotte3, Xavier Wit‑
tebole1, Pierre‑François Laterre 1, François Jamar4, Gregory Reychler5
1Sevice des soins intensifs, Cliniques Universitaires Saint‑Luc, Bruxelles,
Belgium; 2 Médecine nucléaire, Cliniques Universitaires Saint‑Luc,
Bruxelles, Belgium; 3Respiratory, Haute École de Santé Vaud, Lausanne,
Switzerland; 4Service de médecine nucléaire, Cliniques Universitaires
Saint‑Luc, Woluwe‑Saint‑Lambert, Belgium; 5Service de pneumologie,
Cliniques Universitaires Saint Luc, Bruxelles, Belgium
Correspondence: Jonathan Dugernier ‑
Annals of Intensive Care 2017, 7(Suppl 1):O84
Introduction Patients with high flow nasal cannula may benefit from
combined aerosol therapy. Clinical efficacy depends on pulmonary
deposition which is related to the type of nebulizer. All new nebulizers
or delivery methods require rigorous evaluation. The aim of this study
was to compare lung deposition between two nebulizers (jet
nebulizer vs vibrating-mesh nebulizer) through high flow nasal cannula in
Patients and methods Aerosol delivery of
diethylenetriaminepentaacetic acid labelled with technetium-99m (99mTc-DTPA,
4 mCi/4 mL) to the lungs using a vibrating-mesh nebulizer (Aerogen
Solo®, Aerogen Ltd., Galway, Ireland) and a constant-output jet
nebulizer (Opti-Mist Plus Nebulizer®, ConvaTec, Bridgewater, NJ) through
high flow nasal cannula (Optiflow®, Fisher & Paykel, New Zealand) was
compared in 6 healthy subjects. Flow rate was set at 30 L/min through
the heated humidified circuit. Pulmonary and extrapulmonary
deposition were measured by single photon emission computed
tomography combined with a low dose CT-scan (SPECT-CT) and by planar
Results Lung deposition was only 3.3 ± 1.3 and 1.2 ± 0.8% of the
nominal dose with the vibrating-mesh nebulizer and the jet nebulizer,
respectively (p < 0.05). Dose lost in the high flow circuit,
humidification chamber and nasal cannula was higher with the vibrating-mesh
nebulizer as compared to the jet nebulizer (75.2 ± 8.2 vs 45.0 ± 6.2%
of the nominal dose, p = 0.001). Expressed as percentage of emitted
dose, lung deposition was similar with both nebulizers.
Conclusion This study demonstrated that aerosol delivery through
HFNC is poor in the specific conditions of the study despite the
higher efficiency of the vibrating-mesh nebulizer as compared to the
jet nebulizer. Placing the nebulizer on the HFNC circuit at 30 L/min
induces high aerosol loss on the circuit and the oropharynx.
J. Dugernier: unrestricted grant by Aerogen Ltd. (Galway, Ireland).
1. Am J Respir Crit Care Med . 2007 ; 175 : 480 - 9 .