40th International Symposium on Intensive Care & Emergency Medicine

P001 Physiological emergence of amyloid-β1-40 with mechanical ventilation-induced cerebral immunochallenge

S Lahiri¹, N Sparrow², L Mangiacotti², PS Rajput², M Koronyo²

¹Cedars-Sinai Medical Center, Neurocritical Care, Los Angeles, United States; ²Cedars-Sinai Medical Center, Departments of Neurology, Neurosurgery, and Biomedical Sciences, Los Angeles, United States

Introduction:

A long-term cognitive impairment that resembles Alzheimer’s disease (AD) is a known complication of acute critical illnesses that affects up to 2 million individuals annually in the US. Mechanical ventilation (MV) is a hallmark critical care intervention that is strongly associated with cognitive decline.

Methods:

We subjected double transgenic Alzheimer’s disease (Adtg) (APP/PSEN1) and wild-type (WT) mice to MV for 4 hours and compared to spontaneously breathing (SB) controls. Cerebral soluble/insoluble amyloid-β (Aβ) and neurological and systemic markers of inflammation were quantified. Hippocampal blood-brain barrier permeability was quantified using a novel methodology that enabled assessment of small and large molecule permeability across the blood-brain barrier. Immunohistochemistry was used to assess the regional relationship between amyloid-β1–40 and acute vascular disruption and neuronal injury.

Results:

See image

Conclusions:

Short-term MV resulted in increased cerebral soluble Aβ1-40 and increased cerebral TNF-α and IL-6 concentrations. BBB permeability and neuronal injury were decreased in mechanically ventilated ADtg mice, whereas BBB permeability and neuronal injury were increased in mechanically ventilated WT mice compared to their respective SB controls. There was increased distribution of Aβ1-40 in regions of acute vascular disruption, resulting in lower BBB permeability. Overall, these results support a possible physiological role for Aβ1-40 to decrease BBB permeability and neuronal injury during the acute stress of MV, however it is expected that long-term sustained of this putative protective pathway will contribute to neurodegeneration and cognitive impairment.

Fig. 1 (abstract P001).

(1) Representative images from ADtg mouse showing markedly increased distribution of Aβ1-40 in a “banding” pattern within a region of acute vascular disruption. Graph showing significant increase in Aβ1-40 bands/% area of FITC in ADtg mice subjected to MV compared to SB ADtg mice. (2) Increased cleaved caspase-3 in the entorhinal cortices of WT mice subjected to MV compared to SB controls. (3) Significantly decreased activation of cleaved caspase-3 in the entorhinal cortices of ADtg mice subjected to MV compared to SB ADtg controls

P002

Withdrawn

P003 Molecular mechanisms of xenon neuroprotection (experimental data)

A Kuzovlev¹, O Grebenchikov¹, A Shabanov², I Kasatkina¹, L Nikolaev³, I Molchanov⁴

¹Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; ²Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology; N.V. Sklifosofsky Research Institute of Emergency Medicine, Moscow, Russia; ³Russian Academy of Postgraduate Education, Moscow, Russia; ⁴Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology; Russian Academy of Postgraduate Education, Moscow, Russia

Introduction:

The aim of the study was to investigate into the molecular mechanisms of neuroprotection with 50 vol% xenon in an in vivo model experiments.

Methods:

Eight rats were anesthestized (Combi-Vet machine; induction chloralhydrate 300 mg/kg intraabdominally; then 30 mins of 50 vol% xenon inhalation (95% O2 0.5 l/min, 100% xenon 0.5 l/min; O2 50%, Xe 50%); 8 rats were in the control group (Combi-Vet anesthesia machine; induction chloralhydrate 300 mg/kg intraabdominally; then 30 mins of 95% O2 0.5 l/min). Rats were euthanized and brain homogenates were made. Content of the phosphorylated (inactivated form) of the GSK-3 beta enzyme and key antioxidant enzymes (hemoxygenase, superoxide dismutase, catalase) in rat brain homogenates was assessed by western - immunoblotting. Statistica 6.0, parametric methods were used for data analysis.

Results:

The research results showed that xenon inhalation anesthesia resulted in a 2-fold increase of the phosphorylated (inactivated form) of the GSK-3 beta enzyme (р<0.05); increased the content of the key antioxidant enzymes (hemoxygenase (by 50%, р<0.05), superoxide dismutase (by 60%, р<0.05), catalase (by 20%, р>0.05) in rat brain homogenates compared to the controls.

Conclusions:

An increase of the phosphorylated GSK-3 beta enzyme and pool of antioxidant enzymes (hemoxigenase, superoxide dismutase, catalase) in the brain under the xenon anesthesia was proved which suggests a new molecular mechanism for the realization of its neuroprotective properties and has a great clinical outlook.

P004 Procalcitonin and C-reactive protein are not increased in ventriculostomy-related infections in patients with hemorrhagic stroke

S Wang, E Pietrzko, E Keller, G Brandi

University Hospital Zurich, Neurocritical Care Unit, Dept. of Neurosurgery and Institute of Intensive Care Medicine, Zurich, Switzerland

Introduction:

Ventriculostomy-related infection (VRI) is a serious complication in patients with hemorrhagic stroke. In such patients, diagnosis of VRIs is complicated by blood contamination of CSF following ventricular hemorrhage. We aimed to evaluate the diagnostic potential of white blood cells count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) to identify VRIs in patients with hemorrhagic stroke during the time of external ventricular drain (EDV) in situ.

Methods:

This retrospective study was conducted at the Neurosurgical-ICU, University Hospital of Zurich. A total of 347 patients with hemorrhagic stroke and an external ventricular drain (EVD) were admitted over a 6 years period at the ICU. Of those, 14 patients with VRIs (“VRI”), defined by positive CSF bacterial culture and increased WBC in CSF (>250/ul), and 115 patients without VRIs and with serial CSF sampling (“no-VRI”) were analyzed. Patients with CSF-contamination or suspected VRI (negative CSF cultures but antibiotic treatments) were excluded. WBC, CRP, and PCT were measured daily. CSF was sampled routinely twice a week or by T>38°C. For the analysis, mean peak values of WBC, CRP, PCT during the time of EVD in situ were compared between groups (t test). Data are expressed as mean with CI 95%.

Results:

Between groups, WBC and CRP were similar (WBC: 15.13 G/L and 14.55 G/L, p=0.68 and CRP: 115.93 mg/l and 129.44 mg/l, p=0.56 in the group VRI and no-VRI, respectively) (Figure 1, panel A and B). In the group VRI, PCT was low and significantly lower than in the group no-VRI (0.16 ug/l and 2.61ug/l, p=0.03 in the group VRI and no-VRI, respectively) (panel C). WBC in CSF were similar between groups (710.14/ul and 675.16/ul p=0.93 in the group VRI and no-VRI, respectively).

Conclusions:

In this study, serum-inflammatory markers were not able to screen patients with VRIs. Their routine measurement should be carefully evaluated.

Fig. 1 (abstract P004).

Box-plots of WBC (panel A), CRP (panel B), and PCT (panel C) in the groups

P005 Central nervous system infections in an intensive care unit: a retrospective study

A Martinho, E Trigo, M Miranda, P Martins

Centro Hospitalar e Universitário de Coimbra - CHUC, Medicina Intensiva, Coimbra, Portugal

Introduction:

Central nervous system (CNS) infections constitute a potentially life-threatening neurological emergency. Patients admitted to the intensive care unit (ICU) usually present with a severe disease and organ failure, leading to high mortality and morbidity.

Methods:

We have performed a retrospective analysis during a 5-year period of patients admitted to a polyvalent ICU. Clinical, demographic and outcome data were collected to evaluate its clinical impact on the outcome of patients with CNS infections.

Results:

We identified 30 patients with the diagnosis of meningitis, meningoencephalitis and ventriculitis, where the median age was 57,6 years (range 24-80). Upon clinical presentation, their most frequent signs were fever (70%), meningeal signs (40%), seizures (30%), and a Glasgow Coma Scale score <8 (66%). All needed ventilation support and 66% needed cardiovascular support. A definitive microbiological diagnosis was achieved on 22 patients and antibiotic therapy was adjusted on 18 of them. Most common microorganisms were Streptococcus pneumoniae (n=7), Listeria (n=5) and Pseudomonas aeruginosa (n=4) (Figure 1). Other gram negative microorganisms were detected and lead to more adverse outcomes. Meningitis was the cause of admission on 26 patients and on a minority (n=4) meningitis was considered to be a secondary diagnosis on patients admitted for other causes (traumatic brain injury, subarachnoid or intraparenchymal hemorrhage, postoperatively of neurosurgical tumor). Patients that eventually died had at least one risk factor (age>65, immunocompromised due to diabetes, corticotherapy, HIV or heart transplantation).

Conclusions:

Patients admitted to the ICU were not so aged, but had some comorbidities and risk factors leading to more uncommon microorganisms, increasing the risk of adverse outcomes. This lead to an increase of mortality: 23% in the ICU and an overall of 43%.

Fig. 1 (abstract P005).

Isolated microorganisms

P006 Study of selenium levels in unresponsive wakefullness (UWS) patients with systemic inflammatory response syndrome (SIRS)

E Kondratyeva¹, S Kondratyev², N Dryagina²

¹Almazov National Medical Reseach Centre, Minimally Conscious Research Group, St Petersburg, Russia; ²Almazov National Medical Reseach Centre, Minimally Conscious Science Group, St Petersburg, Russia

Introduction:

Patients in UWS  are characterized by a persistent systemic inflammatory response syndrome that can lead to selenium deficiency

Methods:

Ànalysis of selenium level was investigated in  54 UWS patients with signs of SIRS:  31patients with TBI and 23 patients with hypoxia. Duration of UWS was 2-4 month.  Selenium blood level was performed once every 10 days for 30 days (three times on the whole). After first blood level measurement, 46 patients (27 TBI and 19 hypoxia) received sodium selenite pentahydrate (Selenase) at a dose of 6 mkg / kg / day for 7 days; In 8 patients (4 TBI and% hypoxia, selenase was not administrated (control group).

Results:

In patients who were treated with selenase, maximum concentration of selenium was observed on the 20th day and was on 34.74% higher on average than in the initial study. In the initial study, the average value in patients with  hypoxia was 24.24 ± 10.90 mkg/l, the maximum value was 61.30 mkg/l, between 2-9 days 28.83 ± 15.46 mkg/l (max 70.00 mkg/l), from 10-19 day - 30.22 ± 8.54 mkg/l (max 50.70 mkg/l), from 20-30 days 34.76 ± 16.75 mkg/ l (57.10 mkg/l). At the first measurement the average value in patients with a consequence of TBI was 24.81 ± 8.83 mkg/l, maximum value was 53.00 mkg/l, between 2-9 days 39.26 ± 12.39 mkg/l (max 64.50 mkg/l), from 10-19 day - 37.41 ± 12.88 mkg/l (max 59.50 mcg/l), from 20-30 days 37.35 ± 12.75 mcg/l (max 64.30 mcg/l). Original selenium blood level are 23-190 mkg/l. The average value of the initial values in the control group was 21.4 ± 1.6, mkg/l on day 30 in the control group 17.8 ± 3.8 mkg/l.

Conclusions:

Therapy with selenase showed a statistically significant increase of selenium blood concentration (p = 0.00) compared with the control group. Selenase administration did not show a statistically significant value on severity of SIRS process. Average values of selenium levels did not depend on the etiology of brain damage in UWS patients.

Funding :

The study was funded by RFBR project number 19-29-01066/2019

P007 Pharmacokinetics of levetiracetam in critically ill patients with normal and augmented renal clearance

H Barrasa¹, I Bilbao-Meseguer², M Solinís³, A Rodríguez-Gascón³, J Maynar⁴, E Uson⁵, G Balziskueta⁴, F Fonseca⁴, A Martín⁴, A Isla⁶

¹University Hospital of Alava, Intensive Care, Vitoria, Spain; ²Cruces University Hospital, Department of Pharmacy, Cruces University Hospital, Barakaldo, Spain; ³Faculty of Pharmacy, PharmaNanoGene Group, Vitoria, Spain; ⁴University Hospital of Alava, intensive Care, Vitoria, Spain; ⁵Can Misses Hospital, intensive Care, Ibiza, Spain; ⁶Faculty of Pharmacy, pharmaNanoGene Group, Vitoria, Spain

Introduction:

The objective of this study was to evaluate the pharmacokinetics (PK) of levetiracetam (LEV) in critically ill patients with normal and augmented renal clearance (ARC), and determine if the recommended dosage regimen provides concentrations in the therapeutic range (12-46 mg/L) [1].

Methods:

A prospective observational study was conducted in a tertiary hospital. Six blood samples were taken during a dose interval at steady state and LEV was quantified by HPLC. A population PK study was carried out. Statistical analysis was conducted to evaluate the differences in PK between patients with and without ARC. The suitability of drug concentrations was also assessed.

Results:

Seventeen patients were included, 13 with normal creatinine clearance (CrCL) (80-129 mL/min) and 4 with CrCl≥130 mL/min (ARC). Ten patients received 500mg q12h, one 1000mg q12h and two 1500mg q12h. The data were best fitted to a two-compartment model. Figure 1 shows LEV concentrations during the dosing interval. Mean clearance (CL) was 4 L/h and mean volume of distribution of central compartment (V) was 44 L. Interindividual variability was 38 and 61% for CL and V, respectively. No differences were identified between both groups (p>0.05) in PK parameters. No correlation was found between LEV CL and CrCL. Trough levels were below the minimum concentration (C_min) 12 mg/L of the therapeutic range in all patients except 1. Furthermore, between 3-5 h 50% of samples were below the C_min.

Conclusions:

Administered doses were not able to maintain LEV concentrations in the recommended therapeutic range. Other dosage strategies, such the extension of infusion time with higher doses, could be evaluated in order to obtain a more favourable profile. No correlation between LEV CL and CrCL was found.

Acknowledgements

We thank the Department of Education of the Basque Government (PIBA 2019-57) and the University of the Basque Country UPV/EHU (PPG17/65, GIU 17/32) for their financial support.

References:

1. Reimers A et al. Drug Des Devel Ther. 12: 271–280, 2018.

Fig. 1 (abstract P007).

LEV concentrations during the dosing interval

P008 Feasibility of quantitative assessment of mechanical properties of muscles in chronic critically ill patients

N Beloborodova, M Petrova, I Buyakova, E Chernevskaya

Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia

Introduction:

The mechanical properties of muscles such as tone, elasticity, and stiffness are often affected in chronic critical ill (CCI) patients. A hand-held device known as the MyotonPRO demonstrated acceptable relative and absolute reliability in a ward setting for patients with acute stroke [1]. The technology works on the principle of applying multiple short impulses over the muscle bulk via the testing probe. The aim of our study is to assess the feasibility of objective measurement of muscle tone in CCI patients with neurological dynamics and serum biomarkers.

Methods:

The study included 23 CCI patients with neurological disorders (stroke, traumatic brain injury, neurosurgical intervention for brain tumors) with more than a 3-weeks stay in ICU. Dynamic measurements of the muscle properties were taken on the deltoideus, brachioradialis, quadriceps femoris, gastrocnemius using the MyotonPRO. To identify the leading factor in impaired muscle tone also were measured neurological (S100, NSE), inflammatory (IL-6), bacterial load (PCT) biomarkers using Elecsys immunoassay and the serum level of microbial metabolites using GC-MS (Thermo Scientific).

Results:

All patients were divided into groups depending on positive and negative clinical dynamics. Significant differences were obtained in parameters characterizing changes in muscle tone of lower limbs - F_{gastrocnemius}(tone) -15.5 vs 18.5 Hz, R_{quadriceps femoris}(the mechanical stress relaxation time) - 16.5 vs 13.6 ms (p < 0.01, respectively). Some significant correlations between five parameters of muscle tone biomarkers and microbial metabolites were revealed.

Conclusions:

The results of a quantitative measurement of muscle tone objectively reflect the dynamics of neurological status, which in the future may be promising technique for the personalized approach CCI in patients.

References:

1. Lo WLA et al Biomed Res Int. 2017: 4294028, 2017

P009 Prognosis of unresponsive wakefulness syndrome outcome based on the determination of certain hormones and natriuretic peptide

E Kondratyeva, N Dryagina, S Kondratyev

Almazov National Medical Reseach Centre, Minimally Conscious Research Group, St Petersburg, Russia

Introduction:

Changes in hormonal status in patients with unresponsive wakefulness syndrome (UWS) remains poorly understood.

Methods:

275 patients in UWS were examined at the period from 2007 to 2017. 152 patients (115 men) with TBI and 123 patients (63 men) after hypoxia. ACTH, cortisol, TSH, free T3 and T4, STH, prolactin and natriuretic peptide were studied in the period from 2 to 4 months UWS. In men, the level of total testosterone, LH and FSH was additionally studied. The obtained data was compared with the UWS outcome in 6-12 months (CRS-R scale assessment).

Results:

None of the studied hormones of the hypothalamic-pituitary-adrenal axis were a reliable criterion for predicting the outcome of UWS. Most often and consistently was revealed a tendency of disrupt the rhythm of cortisol secretion, with higher rates in the evening hours. The average value of STH was higher in men with the consequences of head injury who had recovered consciousness than in those who remained in UWS. Significant decrease in testosterone levels, regardless of age, was found in patients with a consequence of TBI. Mean levels of LH were higher in patients with TBI and hypoxia who remained unconscious than in patients who later restored consciousness. The average level of FSH was higher in patients who had recovered consciousness . The increase of natriuretic peptide level was observed both in patients who remained in chronic UWS and in those who restored consciousness.

Conclusions:

No certain endocrine background, characterising this category of patients was found.  Violations of some hormones secretion rhythms, in particular, cortisol can be considered usual for UWS patients, especially in patients with TBI.

Acknowledgement: The study was funded by the Russian Foundation For Basic Research (RFBR) project number 19-29-01066/2019

P010 Craniocerebral hypothermia as a neuromodulation method in chronically critically ill patients

M Petrova

Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia

Introduction:

Therapeutic hypothermia has not been used before our research in chronically critically ill (CCI) patients. Temperature decrease in neuronal cells is a strong signal that triggers endogenic cytoprotection programs using early response genes expression. Our goal is to determine influences of craniocerebral hypothermia (CCH) on level of consciousness in CCI patients.

Methods:

We examined 98 patients with different types of brain injuries. 54 males and 44 females, mean age 45.56 ±16.03. Patients were divided into 2 groups: main group - 47 patients (Vegetative State (VS) – 28, minimally conscious state (MCS) – 19), comparison group – 51 patient (VS – 32, MCS –19), groups were equal on main parameters (severity, functional state, comorbidity). Patients from main group received courses of CCH, duration -180 minutes, scalp temperature 5-8 °С, cerebral cortex cooling up to 32-34 ^oC, session end was without slow reheating period, and session’s amount was set - until signs of consciousness recovery. Cortex temperature check done noninvasively by using detection of brain tissue EMI in SHF- range. Consciousness recovery in VS and MCS patients controlled using CRS-R scale.

Results:

CCH sessions significantly increased level of consciousness in VS and MCS patient groups. In VS patients vegetative state increased until minimally conscious state and MCS +, and in MCS group until lucid consciousness (p <0.05) (Figure 1).

Conclusions:

Craniocerebral Hypothermia is used in chronically critically ill patients for the first time. Our research results demonstrated effectiveness of CCH as an additive treatment tool in such patients. This let us optimistically determine the perspective of inclusion of CCH method in chronically critically ill patient’s rehabilitation to increase level of consciousness.

Fig. 1 (abstract P010).

Consciousness change after CCH sessions using CRS-R scale

P011 Transcranial Doppler assessment of cerebral perfusion in pediatric severe sepsis and septic shock

A Mostafa¹, A Elbeleidy², S Awad², R Hamdi², H Elgebaly²

¹Children Cancer Hospital, Pediatric ICU, Giza, Egypt; ²Cairo University Hospital, Cairo, Egypt

Introduction:

Sepsis associated encephalopathy (SAE) may manifest in up to 70% of adult septic patients. ^[1]  Transcranial Doppler (TCD) may provide important information about cerebral hemodynamics in various disorders. ^[2] Two indices reflecting cerebro-vascular resistance (CVR) can be calculated; the pulsatility index (PI), and the resistive index (RI). ^[3] In this study, we aimed to assess the cerebrovascular resistance in septic shock paediatric cases with encephalopathy admitted to the PICU and compare them to a group of critically ill conscious non septic patients.

Methods:

This case-control study included 45 critically ill children with sepsis associated encephalopathy and 30 critically ill non-septic and non-encephalopathic children admitted to a tertiary care paediatric hospital. PRISM III score and neurological assessment, including level of consciousness assessed using the Full Outline of Unresponsiveness (FOUR) score were determined. PI and RI of the middle meningeal artery were done on both sides using TCD to all included patients.

Results:

The study showed that mean PI and RI values of the septic critical cases were significantly higher than those of the control group, CVR increases with the more deepening of coma (the decline in FOUR score). Cerebral CO2 reactivity in septic patients were found disturbed. There were positive correlations between both PI and RI and PaCO2 with high significance.

Conclusions:

Cerebrovascular resistance is increased in cases of sepsis - associated encephalopathy. Carbon Dioxide vasoreactivity is impaired in cases of septic shock.

References:

1. Pytel P et al. Curr Opin Neurol 22: 283-287, 2009.

2. Purkayastha S et al. Semin Neurol 32:411-20, 2013

3. Iyer VN et al. Mayo Clin Proc 84:694-701, 2009.

P012 Pupillometry in the follow up of patients undergoing EVT. Could it replace repetitive CT-control

J Koehn, A Giede-Jeppe, M Hagen, JB Kuramatsu, S Schwab, HB Huttner

University of Erlangen-Nuremberg, Department of Neurology, Erlangen, Germany

Introduction:

Despite the clinical benefit of endovascular treatment (EVT) for large vessel occlusion (LVO) in ischemic stroke, space-occupying brain edema (BE) represents a common complication during the course of disease. Routinely, CT imaging is used for monitoring of these patients, notably in the critical care setting, yet novel and easy bed-side techniques with the potential to reliably predict BE without repetitive imaging would be valuable for a time and cost effective patient care. We assessed the significance of automated pupillometry for the identification of BE patients after LVO-EVT.

Methods:

We enrolled 40 patients admitted to our neurocritical-care unit who received EVT after anterior circulation large vessel occlusion. We monitored parameters of pupillary reactivity [light-reflex latency (Lat; s), constriction and re-dilation velocities (CV, DV; mm/s), and percentage change of apertures (per-change; %)] using a portable pupilometer (NeurOptics®) up to every 60 minutes during the first 72 hours of ICU stay. BE was defined as midline-shift ≥5mm on follow-up imaging within 3-5 days after EVT. We assessed differences in pupillary reactivity between patients with and without BE (U-test) and evaluated prognostic performance of pupillometry for development of BE (ROC analysis).

Results:

In 32 patients (19 women, 74.3±12.0 years) without BE, 1,224 assessments were compared to 207 assessments in 6 patients (3 women, 71.7±11.8 years) with BE. On day 1, day 2, and day 3 after EVT, patients with BE had significantly lower CVs and DVs, and smaller per-changes than patients without BE, whereas Lat did not differ between both groups. ROC-analyses revealed a significant negative association of CV, DV, and per-change with development of BE.

Conclusions:

Automated pupillometry seems to identify patients at risk for BE after EVT. A prospective study should validate whether automated pupillometry harbors the potential to reduce unnecessary follow-up CT imaging.

P013 Automated infrared pupillometry: possible hypotheses of extended application in intensive care unit

F Marturano, F Socci, F Marchi, F Disalvo, G Branchetti, M Bonizzoli, M Ciapetti, A Peris

Careggi Teaching Hospital, Intensive Care Unit and ECMO Referral Center, Florence, Italy

Introduction:

The aim of this preliminary analysis is to detect differences between the qualitative and quantitative evaluation of the pupillary function carried out by doctors and nurses of an intensive care unit (ICU) of a tertiary level hospital. Secondary purpose is to investigate new indications for the use of pupillometry in a population admitted in ICU

Methods:

The study has been conducted (currently in progress) at the intensive care unit and ECMO Referral Center at Careggi Teaching Hospital (Florence; Italy). The enrolled patients are adult subjects (> 18 years) with alteration of consciousness defined by a Glasgow Coma Scale (GCS) < 9, following a primary brain injury and/or the use of sedative drugs. The studied parameters, obtained with NeuroLight pupillometer ® (ID-Med, Marseille, France) are analyzed, integrated and matched with clinical evaluations, biochemical laboratory test and neurophysiological investigations according to internal protocols.

Results:

Visual/qualitative evaluation of the pupil function shows a lower reliability if compared to automated pupillometry. The estimated error in the proper determination of photomotor reflex is 34.9% (p< 0.01). No significant difference is reported between quantitative and qualitative pupillometry in the detection of anisocoria.

Conclusions:

Our preliminary results are compatible with previously reported data [1-3], even if there was no difference in anisocoria determination. Interestingly, a longer latency period among patients treated with opioids has been observed. Other results are still in progress.

References:

1. Morelli P et al. Minerva Anestesiol 85:995-1002, 2019

2. Oddo M et al. Intensive Care Med 44:2102-2111, 2018

3. Couret D et al. Crit Care 13;20:99, 2016

P014 Use of color-coded duplex sonography in neuromonitoring of critical care patients. Experience at Pirovano Hospital in Buenos Aires

DN Gauna, L Macchiavello

Hospital Pirovano, Critical Care, City of Buenos Aires, Argentina

Introduction:

Due to the dynamic of critical care disease, a rapid bedside, non-invasive and highly sensitive and specific method is required for diagnosis. In this study we set out our experience with trancranial color-coded duplex ultrasound (DXT) [1]. The DXT study identifies cerebral arteries as well as hemorrhagic phenomenon, hydrocephalus, mass-occupying lesions and midline shift. This is the main difference between DXT and conventional Transcranial Doppler (DTC) which is a blind study and do not provide any image.

Methods:

Descriptive, cross-sectional and observational study from December 2018 to June 2019. 21 patients were included. Inclusion criteria: Neurocritical patients. Exclusion criteria: No acoustic window, presence of ultrasound artifacts. Data collection was performed. It was used a low-frequency transducer from 1.5-3.5 MHz with trancranial duplex preset (Figure). The patterns were defined as normal, vasospasm, high resistance, hypermedia and cerebral circulatory arrest, depending on the cerebral flow velocity, Lindegaard Ratio (LR) and Pulsatility Index (IP).

Results:

12 men (57.1%) and 9 women (42.9%). Average age 55.6(20-79). Patients diseases: Subarachnoid hemorrhage 6, traumatic brain injury 5, AV malformation 4, stroke 2, hemorrhagic cerebrovascular accident 2 and mass occupying lesions 2. Normal Pattern: 10 patients (rel. freq 0.47). Vasospasm: 5 patients (rel. freq 0.23). High resistance: 4 patients (rel. freq 0.19). Hyperemia: 1 patient (real. freq 0.04). Cerebral circulatory arrest: 1 patient (rel. freq 0.04)

Conclusions:

DXT should be part of the routine of neuromonitoring, it allows real time images especially useful in unstable conditions. Although it will be needed a large amount of patients to be statistical significant, DXT is useful considering a non invasive study, bedside and it allows early identification of different clinic conditions.

References:

1. Lau VI. Crit Ultrasound J 9:21, 2017

Fig. 1 (abstract P014).

Circle of Willis and Pulsed-wave Doppler mode of middle cerebral artery

P015

Withdrawn

P016

Withdrawn

P017 Use of adenosine-induced cardioplegia in anesthesia during endovascular treatment of arteriovenous malformation of the brain

N Lesteva, A. Kondratyev, M Aibazova, D Vasilyev, G Ryibakov, S Lesina

Polenov Neurosurgical Institute - Almazov National Medical Research Centre, Anesthesiology and Intensive Care, Saint-Petersburg, Russia

Introduction:

Embolization of the draining vein during endovascular treatment of arteriovenous malformation (AVM) may result in venous outflow obstruction and hemorrhage. Anaesthesiologist can use deliberate hypotension to reduce blood flow through AVM which may be somehow helpful to prevent this scenario. Adenosine-induced cardiac arrest may facilitate the embolization too. The goal of our study was to improve the results of endovascular treatment of AVM using adenosine-induced cardiac arrest.

Methods:

After obtaining informed consent 13 patients (8 male, 5 female) were selected for adenosine-induced cardiac arrest during endovascular AVM embolization. Main age was 40,8±6 years old. 9 of them were evaluated as III class ASA, 4 as IV. Endovascular treatment in all cases was performed under general anaesthesia. Propofol, fentanyl, rocuronium were used to induce anaesthesia, then all the patients were intubated and ventilated with parameters to keep EtCO2 32-35 mm Hg. Sevoflurane 2,1-2,6 vol% (12 cases) or desflurane 6 vol% (1 case) were used to maintain anaesthesia. Hemodynamic monitoring consisted of ECG, pulsoximetry, non-invasive blood pressure measurement. Onyx or/and Squid were used as embolic agents. CT was performed to every patient just after procedure as well as neurological examination.

Results:

Adenosine dosage was 0.875-1.26 mg/kg. Time of consequent cardiac arrest was 10-40 sec. There were 10 cases we administered adenosine for 1 time, in one case we had to administer it twice, in one - 3 times and 4 times in one more case as well. Hemodynamic parameters recovered without any particular treatment in all the patients. Embolization has been performed in all the cases uneventfully. Postoperative CT showed no hemorrhage. Nobody from investigated group had neurological deterioration in postoperative period.

Conclusions:

Our study shows that adenosine-indused cardiac arrest is not very difficult to perform method and it can be useful during AVM embolization.

P018 Incidence of postoperative major adverse cardiac events in patients undergoing carotid endarterectomy: a single-center retrospective study

A Suphathamwit, C Leewatchararoongjaroen

Faculty of Medicine Siriraj Hospital, Mahidol University, Department of Anesthesiology, Bangkok, Thailand

Introduction:

Major adverse cardiac events (MACE) is an important causes of morbidity and mortality after carotid endarterctomy (CEA)[1,2,3]. The investigators aim to determine the incidence of MACE in patients undergoing CEA in the tertiary university hospital.

Methods:

This retrospective study recruited 175 patients between January 1999 – June 2018. The patients received CEA with coronary artery bypass graft surgery were excluded. Primary outcome was the incidence of MACE at 7 days, 30 days and 1 year postoperatively. MACE was defined as myocardial infarction, congestive heart failure, significant arrythmia and cardiac arrest. Secondary outcome was the incidence of postoperative stroke. The patients’ chart was reviewed and direct contact was performed for patient’s information.

Results:

The incidences of MACE were 7.5%, 1.1% and 1.1% at 7 days, 30 days and 1 year, respectively. MACE at 7 days were 1.1% of myocardial infarction, 2.9% arrhythmia, 1.1% congestive heart failure and 2.3% cardiac arrest. There were no significant differences in age, BMI, baseline hemoglobin level, creatinine level and severity of carotid artery stenosis between those with and without MACE. The incidence of stroke at 7 days postoperatively was 4.6%. There was no new stroke occurred at 30 days and 1 year after surgery.

Conclusions:

The patients with carotid artery stenosis were at high risk from major cardiac disease. The overall incidence was 7.5% within 7 days after surgery. Significant arrythmia was the most common adverse cardiac event.

References:

1. Mutirangura P et al. J Med Assoc Thai 99:785-93, 2016.

2. Go C et al. Ann Vasc Surg 29:1265-71, 2015.

3. Boulanger M et al. Stroke 46:2843-8, 2015

P019 The antithrombotic effects of different oral anticoagulants in the monitoring of acute stroke

M Lawrence¹, V Evans², J Whitley², S Pillai², P Slade³, M Krishnan³, K Power⁴, PA Evans²

¹Welsh Center of Emergency Medicine, HBRU, Swansea, United Kingdom; ²Welsh Center of Emergency Medicine, Swansea, United Kingdom; ³Swansea Bay UHB, Stroke Department, Swansea, United Kingdom; ⁴Swansea Bay UHB, Pharmarcy, Swansea, United Kingdom

Introduction:

A major risk factor for stroke is atrial fibrillation (AF). To treat AF anticoagulation is needed. There are now several anticoagulants available. However, a lack of head to head data as well as the absence of accurate techniques makes it difficult to compare them and measure determine there efficacy. Stroke is known to produce an abnormal clot microstructure which is a common factor in many thrombotic diseases. This pilot study aims to use a functional biomarker of clot microstructure (d_f) and clotting time (TGP) to investigate the therapeutic effects of different anticoagulants in stroke and AF.

Methods:

We recruited 114 patients (59 AF and 55 stroke & AF). Two samples of blood were taken: before anticoagulation (baseline) and post anticoagulation (6-10weeks). Patients were either given warfarin (31%) or axipaban (69%). d_f and TGP were measured and compared before and after anticoagulation.

Results:

Warfarin increased T_GP (267±56 secs to 332±78 secs (p<0.05)), and decreased d_f (1.71±0.05 to 1.65±0.06 (p<0.05)). Apixaban increased TGP (235±66 sec to 410±105 sec (p<0.05)) but did not change df (1.72±0.04 & 1.72±0.05). Interestingly we found that in the apixaban group TGP significantly correlated (p=0.05) with blood drug concentration levels.

Conclusions:

In this study we show that d_f and TGP can quantify and differentiate between the therapeutic effects of two different oral anticoagulants. Showing that warfarin prolongs clotting and weakens the ability of the blood to form stable clots. Conversely apixaban prolongs clotting time but does not affect the bloods ability to form stable clots. This shows the utility of the d_f and TGP biomarkers in comparing two different treatment options, something no other current marker has proven able to do. Where d_f and TGP may prove useful tools in a personalized approach to anticoagulation treatment and monitoring in an acute setting.

P020 HAIR-score optimalisation in subarachnoidal bleeding

L Capiau¹, H Vanoverschelde¹, A Decruyenaere², J Decruyenaere¹, K Colpaert¹

¹Ghent University Hospital, Intensive Care Unit, Ghent, Belgium; ²Ghent University Hospital, Internal Medicine, Ghent, Belgium

Introduction:

The HAIR-score stratifies the risk for in-hospital mortality after spontaneous subarachnoid hemorrhage (SAH) [1]. Maximal early lactate is associated with increased risk for poor outcome [2]. We investigated whether the combination of both HAIR-score and early abnormal lactate (<24h), gives a better association with mortality after spontaneous SAH.

Methods:

In this retrospective cohort study at a tertiary university hospital, data was collected for all patients with spontaneous SAH during a period of eleven years (2007-2017). Multiple binary logistic regression models were fitted for each outcome (ICU mortality and hospital mortality). The first one included the individual components of the HAIR-score, the second model also included an indicator for abnormal (>18 mg/dl) lactate within the first 24h (La-HAIR-score). In addition, two simple binary logistic regression models were fitted as continuous covariates: The HAIR-score (theoretical range 0-8) and the La-HAIR-score, with one extra point to patients with abnormal lactate concentration (theoretical range 0-9). These models were compared with a likelihood ratio test and Nagelkerke’s R² test.

Results:

A total of 470 patients were included. In our sample, not all original HAIR components were associated with ICU or hospital mortality. The multiple logistic regression model of the La-HAIR-score had a significantly better fit to the data, compared to the original HAIR-score. The p-value of the likelihood ratio test was 0.01 for ICU mortality and 0.025 for hospital mortality. A score of 8 on the La-HAIR-score had a 100% specificity for both ICU and in-hospital mortality.

Conclusions:

Combination of HAIR-score and abnormal lactate within the first 24h, the La-HAIR-score, significantly improved the model fit for ICU and hospital mortality compared to the model with the original HAIR-score.

References:

1. Lee VH et al. Neurocrit Care 21:14, 2014

2. Imo P et al. Am J Emerg Med 34:708-712, 2016

P021 South American experience with urapidil in neurocritical care patients

M Canitrot¹, J Ramirez², J Serra³, L Brunetto³, Y Santos³, R Villa⁴, I Previgliano⁴, S Ugarte³

¹INDISA Clinic, Critical Care, Santiago, Chile; ²Andres Bello University, NeuroICU, Santiago, Chile; ³INDISA Clinic, NeuroICU, Santiago, Chile; ⁴Hospital General J. A. Fernandez, NeuroICU, Buenos Aires, Argentina

Introduction:

Urapidil is an antihypertensive, vasodilatory drug with no tachycardia or increased ICP effect.  Recommended for neurocritical patients in European and Asian guidelines. OBJECTIVE: To evaluate the efficacy and tolerance of injectable urapidil for the treatment of hypertensive emergencies in neurocritical patients.

Methods:

We carried out a prospective study of 175 cases in 2 South American Neuro ICU (Chile and Argentina), with clinical and biological monitoring. Treatment was initiated if the blood pressure was higher than 180/110mmHg with organ disfunction. Efficacy was defined as a lowering of blood pressure to 150/100 mmHg or below. The drug was administered according to protocol by IV bolus (by PVC) followed by continuous infusion. Sex, age, SAP, MAP, DAP and CR were evaluated at the beginning and end of bolus therapy, as well as  response to the drug at 5, 10, 15 minutes, and maintenance dose.  Statistical analysis: Wilcoxon test for paired samples.

Results:

175 patients (average age : 63). Ischemic stroke (86), ICH (59), SAH (16), HELLP / PEE (5), ACS (3), HE (2). Changes in SAP (198 to 130), DAP (116 to 78) and MAP (155 to 94) (p two tails <0.001) (Figure 1). No significant changes in CR (median 76 to 72). 9 deaths, none attributable to administration of urapidil. 124 (71%) responded to 1st dose at 5 min, 50 (28%) to 2nd dose at 10 min and 1 (1%) required a 3rd dose at 15 min. All responded favourably. Urapidil was effective in all cases, with a significant decrease in BP. 99% within 10 minutes. There was no lack of response or complications.

Conclusions:

Injectable urapidil seems to be an antihypertensive agent that is easy to use and effective in all the cases of this first South-American experience. Further comparative studies are required.

Fig. 1 (abstract P021).

Hemodynamic effects of urapidil

P022 Poor-grade aneurysm subarachnoid hemorrhage in neuro ICU: how poor is their prognosis?

M Canitrot¹, J Ramirez², J Serra³, Y Santos³, V Munoz³, JL Sufan³, J Contreras³, F Paravic⁴, C Droguett⁴, S Ugarte²

¹INDISA Clinic, Critical Care, Santiago, Chile; ²Andres Bello University, NeuroICU, Santiago, Chile; ³INDISA Clinic, NeuroICU, Santiago, Chile; ⁴INDISA Clinic, Neurorehabilitation, Santiago, Chile

Introduction:

Patients with poor-grade aneurysm subarachnoid hemorrhage (aSAH) World Federation of Neurological Surgeons (WFNS) Grades IV and V, have commonly been considered to have a poor prognosis (70-100% mortality). Though early intervention and aggressive treatment in NeuroICU has improved outcome in the past years, it is controversial because most of the patients left hospital severely disabled. The objective of this study was to investigate the clinical and social outcomes in intracranial aneurysm patients with poor-grade aSAH underwent different intervention therapies.

Methods:

A single center observational registry of 25 poor-grade aSAH consecutive patients, defined as WFNS Grades IV and V, treated at tertiary chilean referral center from December 2013 to March 2019 were enrolled in this study. The clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. Clinical outcomes were assessed via GOSE and and socio-occupational outcome, both at discharge and at 6 months.

Results:

883 admissions, 190 were SAH. 84 patients Fisher III and IV. 25 patients WFNS 4 or 5: 20% mortality (5/25). Every death was declared out of therapeutic reach during admission by neurosurgeons. Mortality per year (3/3 2014, 0/4 2015, 1/3 2016, 0/4 2017, 0/6 2018, 1/5 2019), suggesting reduction of mortality rates while expertise increased. Of the 20 survivors, 3 were released in poor neurological conditions (GOSE ≥4) at the neuro ICU discharge. After 6 months, all patients (20/20) achieved GOSE ≤ 3, with adequate family, social and labor reintegration (Figure 1). 20% mortality is less than previously reported, and survivors had a favorable recovery, confirmed with neuro psychological test.

Conclusions:

Poor-grade aSAH patients in our study shows a more positive outcome than previously considered.

Fig. 1 (abstract P022).

GOSE WFNS 4 - 5 SAH patients

P023 Success in intravenous thrombolysis with alteplase for acute ischemic stroke: a matter of distance?

P Papamichalis¹, AL Skoura¹, P Katsiafylloudis¹, E Neou¹, S Karagiannis¹, E Dardiotis², M Karvouniaris¹, D Papadopoulos¹, T Zafeiridis¹, A Komnos¹

¹General Hospital of Larissa, Department of Intensive Care, Larissa, Greece; ²University Hospital of Larissa, Department of Neurology, Larissa, Greece

Introduction:

Pre-hospital management of acute ischemic strokes focuses on factors associated with success in intravenous thorombolysis (IVT)with alteplase [1]. Distance of patient’s residence from stroke ready hospitals could be one such factor.

Methods:

Retrospective study from our department’s thrombolysis database with 157 patients (mean age 66 years). Demographic data, thrombolysis time (from symptoms onset to drug administration, thombolysis within 3 hours or between 3-4.5 hours), complications during hospital stay (symptomatic intracranial hemorrhage or death or new embolic episode or other major hemorrhage), functional outcome at 3 months (modified Rankin Scale-mRS), mortality at 3 months were retrieved and analyzed in association with distance of patient’s home from our hospital. Distance was calculated with the use of an international web mapping service. Those factors were also compared at patients according to residence in a rural, medium urban or large urban area.

Results:

Shorter distance was associated with less time spent for thrombolysis, fewer in-hospital complications and better functional outcome (mRS ≤ 2) at 3 months time (Table 1). Living in a rural area was associated with worse functional and neurologic outcome (p< 0.05, Mann-Whitney U test for both comparisons).

Conclusions:

Unlike previous studies [2] our study showed association of thrombolysis time with distance from stoke centre and furthermore better results with less complications when distance is short. Long distance from stroke centres and residence in rural areas probably play a negative role in thrombolysis outcome and should be taken into consideration when national health systems organize pre-hospital and hospital network for strokes.

References:

1) Kobayashi A et al. Eur J Neurol 25:425-433, 2018

2) Acharya AB et al. J Stroke Cerebrovasc Dis 20:295-301, 2011

Table 1 (abstract P023). Correlation of safety and efficacy markers of thrombolysis and thrombolysis time with distance from stroke centre

P024 Influence of pneumonia on delayed cerebral infarction after subarachnoid hemorrhage: a retrospective study

T Gargadennec¹, V Vermeersch¹, J Ognard², M Geslain¹, P Ariès¹, J Le Roy¹, H Floch¹, A De Tinténiac³, X Chapalain¹, O Huet¹

¹Brest University Hospital, Département d´Anesthésie et Réanimation Chirurgicale, Brest, France; ²Brest University Hospital, Service de Radiologie et Imagerie Médicale, Brest, France; ³Brest University Hospital, Brest, France

Introduction:

Prognosis of subarachnoid hemorrhage (SAH) is scarce, indeed almost half patients die or become severely disable after SAH. Outcome is related to the severity of the initial bleeding and delayed cerebral infarction (DCI). Infection and more precisely pneumonia have been associated with poor outcome in SAH. However, the interaction between the two pathologic events remains unclear. Therefore, we hypothesized that DCI may be associated to pneumonia in SAH patients. Thus the aim of our study was to analyze the association between delayed cerebral infarction and pneumonia in patients with SAH.

Methods:

In this retrospective, observational, monocentric cohort study, patients included in the analysis were admitted in Neurosurgical Intensive Care Unit or Surgical Intensive Care Unit in the University Hospital of Brest (France) for non-traumatic SAH. Primary outcome was diagnosis of DCI on CT scan or MRI 3 months after SAH. Multivariate analysis was used to identify factors independently associated with DCI.

Results:

A total of 224 patients were included in the analysis (female male ratio 141/83, median age 57 [47-65] years). Multivariate analysis was adjusted on sedation, intracranial surgery, Fisher classification of SAH severity, pneumonia occurrence and non-pneumonia infectious event occurrence (Figure 1). Pneumonia occurred in 66 patients (29.5%) and other causes of infections in 45 patients (20.1%). DCI was found in 108 patients (48.2%). Factors independently associated with DCI were pneumonia (OR 3.10 [1.41-7.06]; p=0.006) and non-pneumonia infectious events (OR 2.50 [1.20-5.39]; p=0.016). Interestingly severity of initial bleeding evaluated by Fisher scale was not independently associated with DCI.

Conclusions:

DCI is independently associated with the occurrence of pneumonia or other cause of sepsis. Those results may highlight the need for rigorous approach for prevention protocol, early diagnosis and treatment of hospital acquired infectious diseases in SAH patients.

Fig. 1 (abstract P024).

Forest plot representation of results of multivariate analysis for occurrence of delayed cerebral infarction. Results expressed as odds ratio with 95% confidence interval

P025 Association of prehospital hypocarbia and hypercarbia with outcomes with severe traumatic brain injury patients

Z Weisner¹, D Salcido¹, F Guyette¹, H Siddiqui¹, J Salerno¹, J Elmer²

¹UPMC Presbyterian, Emergency Medicine, Pittsburgh, United States; ²UPMC Presbyterian, Emergency Medicine and Critical Care, Pittsburgh, United States

Introduction:

Hypocarbia and hypercarbia alter cerebral blood flow and intracranial pressure. Both might cause secondary brain injury after traumatic brain injury (TBI).

Methods:

We performed a retrospective observational study from Jan 2012 to Dec 2017 including adult blunt trauma patients with initial Glasgow Coma Scale (GCS) ≤ 14, clinical suspicion for TBI, endotracheal intubation and continuous capnography. We excluded interfacility transfers, penetrating TBI and cases treated for herniation (management includes hyperventilation). All patients were treated by a single air medical transport service in southwest Pennsylvania. Our primary exposure was depth-duration of EtCO2 <35mmHg (hypocarbia). Secondary outcomes were depth-duration of hypercarbia >45mmHg, and maximum depths of hypocarbia and hypercarbia. Our primary outcome was survival to discharge. Covariates were age, sex, initial GCS, shock index and first prehospital serum lactate. We performed unadjusted and adjusted logistic regression testing relationships between EtCO2 and outcome.

Results:

Overall, 148 patients were included and 113 (76%) survived. Overall, 104 (70%) were hypocarbic at least once. Median hypocarbia depth was 26 [IQR 18-30] mmHg, median hypocarbia duration was 15 [4 – 28] min, and median depth-duration was 60 [14 – 141] mmHg*min. Hypercarbia occurred in 56 (38%) patients. Median duration of hypercarbia short (0.5 [0 – 5] min) and median depth duration was only 2 [IQR 0 – 18] mmHg*min. Neither hypocarbia nor hypercarbia (maximum, duration or depth-duration) were associated with outcome in unadjusted or adjusted models. Age [OR; 0.96, 95% CI 0.94-0.98], initial GCS scores [OR; 1.12, 95% CI 1.01 to 1.25] and shock index [OR; 0.41 95% CI 0.19 to 0.88] were independent predictors of mortality.

Conclusions:

Among intubated blunt TBI patients, prehospital hyper- and hypoventilation do not appear to worsen outcomes.

P026 Psychiatric drug burden after intensive care unit treated pediatric traumatic brain injury

E Mikkonen¹, M Skrifvars², R Raj ²

¹Helsinki University Hospital & University of Helsinki, Department of Anesthesiology, Intensive Care and Pain Medicine and Department of Emergency Care and Services, Helsinki, Finland; ²Helsinki University Hospital & University of Helsinki, Helsinki, Finland

Introduction:

Traumatic brain injury (TBI) can have devastating neurological, psychological and social sequelae. Increased psychiatric morbidity after TBI has been shown in both adult and the pediatric population. Also, critical illness as such is a risk factor for psychiatric problems in youth. Our aim was to assess risk factors for later being prescribed psychiatric medication in survivors of intensive care unit (ICU)-treated pediatric TBI.

Methods:

We used the Finnish Intensive Care Consortium (FICC) database to identify patients 5-17 years of age, treated for TBI in four ICU in Finland during the years 2003-2013. We examined electronic health records and CT scans and collected data on drug prescription after discharge. We used multivariable logistic regression models to find statistically significant risk factors for psychiatric drug reimbursement.

Results:

We identified 248 patients of which 46 patients received psychiatric drug prescription (19%) during follow up. The median time to prescription was 14 months after TBI (interquartile range [IQR] 5-31 months). 33 patients received antidepressants, 9 received stimulants and 18 received antipsychotics. Increasing age showed a positive association with all drug prescriptions except for stimulants, where an inverse relationship was observed (Table 1). Using multivariable analyses, we could not find any admission or treatment related factors that significantly associated with being prescribed psychiatric medications. Teenage survivors with moderate disability (Glasgow outcome scale [GOS] 4) showed high numbers of psychotropic drug utilization (45% received any medication, 36% received antidepressants, 24% received antipsychotics).

Conclusions:

Our data suggests, that the risk of psychotropic drug prescription after TBI depends on factors other than those related to injury severity or treatment measures. The incidence of drug prescription is especially high in patients with moderate disability.

Table 1 (abstract P026). Prescription frequencies in patients categorized by GOS score and age group

P027 The effects of 1-adamantylethyloxy-3-morpholino-2-propanol hydrochloride on the formation of steroid neurotoxicity in rats with brain injury

A. Semenenko¹, S. Semenenko², A. Solomonchuk³, N. Semenenko³

¹National Pirogov Memorial Medical University, Department of Anesthesiology, Intensive Care and Emergency Medicine, Vinnytsya, Ukraine; ²National Pirogov Memorial Medical University, Departament of Clinical Pharmacy and Clinical Pharmacology, Vinnytsya, Ukraine; ³National Pirogov Memorial Medical University, Vinnytsya, Ukraine

Introduction:

Depending on the nature of the brain injury and the severity of the victims, mortality in traumatic brain injury (TBI) ranges from 5 to 65% [1]. One of the targets for pathogenetic influence on the course of TBI is the use of pharmacological agents that are able to counteract the negative effects of excess concentrations of glucocorticoids on brain.

Methods:

The therapeutic effect of new pharmacological derivative 1-adamantylethyloxy-3-morpholino-2-propanol hydrochloride (ademol) in rats with TBI was evaluated for 8 days. The pseudoperated animals and control group received 0.9% NaCl solution and the comparison group received amantadine sulfate. Cortisol levels were used to determine the efficacy of the test drugs in TBI.

Results:

In rats treated with ademol, the level of cortisol in the blood ranged from 179 to 188 ng/ml (P5-P95) and was 2.58-fold lower (p<0.05) compared to control pathology group on the 8 day of therapy. Instead, the effect of amantadine sulfate on the level of cortisol in the blood was significantly less than that of ademol. The concentration of cortisol in rats with amantadine sulfate in the blood ranged from 271-280 ng/ml (P5-P95), was 1.73 times lower (p<0.05), compared with the control pathology group, and by 49.2% (p<0.05) exceeded the corresponding value in animals treated with ademol.

Conclusions:

Therapeutic treatment of rats with severe TBI with a solution of ademol, preferably better than rats in the group with 0.9% NaCl and amantadine sulfate protect the brain from the formation of steroid neurotoxicity by cortisol (p<0.05).

References:

1. Rickels E. Eur J Trauma Emerg Surg 43:729–730, 2017.

P028 YKL-40 and neuron-specific enolase as prognostic biomarkers in traumatic brain injury

G Pavlov¹, M Kazakova², V Dichev², D Vasilev³, K Simitchiev⁴, C Stefanov³, V Sarafian²

¹Medical University of Plovdiv, Department of Anesthesiology, Emergency and Intensive Care Medicine *University Hospital “St. George” Plovdiv, Bulgaria, Plovdiv, Bulgaria; ²Medical University of Plovdiv, Department of Medical Biology, Medical Faculty, Medical University- Plovdiv, Bulgaria, Plovdiv, Bulgaria; ³Medical University of Plovdiv, Department of Anesthesiology, Emergency and Intensive Care Medicine, Medical Faculty, Medical University- Plovdiv, Bulgaria, Plovdiv, Bulgaria; ⁴University of Plovdiv, Department of Analytical Chemistry and Computer Chemistry, Faculty of Chemistry, University of Plovdiv, Bulgaria, Plovdiv, Bulgaria

Introduction:

Severe traumatic brain injury (TBI) is the leading cause of morbidity and mortality among young people [1]. The aim of the study is to assess how plasma and cerebrospinal levels of YKL-40 [2], independently or in combination with NSE, IL-6, TNF-α and CRP affect the clinical models and the outcome in TBI.

Methods:

30 patients with isolated severe TBI admitted to the Intensive Care Unit at the University Hospital “St. George”- Plovdiv from 2017 to 2018 were included. Cerebrospinal fluid (CSF) and plasma were collected on the 24^th and 96^th hour after the injury. CSF samples were also collected from 15 adult cadavers and served as an age-matched and gender-matched control group. Levels of YKL-40, NSE, IL-6 and TNF-α were analyzed with ELISA. GCS, APACHE III and Marshall Classification were determined prior to randomization and at the 96^th hour after admission. Outcome was assessed as in-hospital mortality and at six months mortality.

Results:

The CSF level of YKL-40 in the TBI group was significantly higher compared to the control group (p=0.005). CSF levels of NSE are significantly higher compared to plasma concentrations on 24^-th hour in TBI patients. Mean plasma levels of YKL-40 and TNF-α were higher compared to CSF, but the difference was feeble. We found statistically significant difference in plasma levels of YKL-40 (p<0.001) and NSE (p<0.001) in patients with short survival. A significant correlation between plasma concentrations of YKL-40, TNF-α and NSE was determined.

Conclusions:

Plasma NSE concentration is the major independent variable which influenced the survival of TBI patients. Plasma and CSF YKL-40 levels along with NSE, reflect the inflammatory process and would provide new information about its dynamics in TBI patients.

Acknowledgements: The financial support by the National Science Fund of Bulgaria (Contract DM 03/2 12.12.2016) is gratefully acknowledged.

References:

1. Peeters W, et al. Acta Neurochir 157: 1683–1696, 2015.

2. Bonneh-Barkay D, et al. J Neurotrauma 27:1215–1223, 2010.

P029 Cerebro-vascular perfusion correlation index (CPC) predicts outcomes in severe traumatic brain injury

D Colombo¹, G Berdin², A Scerrati³, G Golino⁴, E Bonaldi², E Roman-Pognuz⁵, P Persona⁶, MA Martin², S De Rosa⁷

¹SS. Trinità Hospital,Borgomanero, Borgomanero, Novara, Italy; ²San Bortolo Hospital, Department of Anesthesia and Intensive Care Medicine, Vicenza, Italy; ³San Bortolo Hospital, Department of Neurosurgery, Vicenza, Italy; ⁴San Bortolo Hospital, Department of Medicine – DIMED, Section of Anesthesiology and Intensive Care Medicine, Vicenza, Italy; ⁵Azienda Sanitaria Universitaria Integrata di Trieste, Hospital of Trieste, Department of Anesthesia and Intensive Care Medicine, Trieste, Italy; ⁶University of Padova, Department of Medicine – DIMED, Section of Anesthesiology and Intensive Care Medicine, Padova, Italy; ⁷San Bortolo Hospital, Department of Intensive Care, Vicenza, Italy

Introduction:

Although cerebrovascular pressure reactivity (PRx) well correlate to patient’s outcome [1], it requires continuous monitoring and mobile average calculation for its determination. We therefore hypothesized that a simplified model of variation between mean arterial pressure (MAP) and intracranial pressure ICP over the first three days of admission would have been able to predict patient outcome: we call this new parameter Cerebrovascular Pressure Correlation index (CPC).

Methods:

We performed a retrospective observational study of all adult patients with severe TBI admitted to ICU from January 2017 to April 2018 inclusive. All consecutive patients with a clinical need for ICP monitoring were included for analysis. Both for ICP and MAP data were mean value over 2-hours registration, for a total of 12 observations/day, CPC was therefore calculated as the Pearson Correlation Coefficient between ICP values (x axis) and MAP values (y axis), obtaining one single value every 24 hours. Variables included in the model (i.e. CPC, CPP, ICP, systemic glucose, arterial lactate, PaCO₂, ICP, and internal body temperature) were collected for the first 3 days since trauma.

Results:

For the main outcome only the minimum value of CPC fit the regression analysis (P = 0.004). The correspondent ROC curve showed an AUC of 0.80. The associated Youden criterion was ≤0.26 (Sensitivity = 0.90; Specificity = 0.68). Of all the variables considered for the secondary outcome only CPCmin fit the regression model (P =0.03). Table 1 reports the median and IQR range for SG and NSG of all the variables considered in the model.

Conclusions:

This observational study suggests that CPC could be a simplified model of variation between MAP and intracranial pressure ICP over the first three days of admission predicting patient outcome.

References:

1. Donnelly J, et al. Neurocrit Care 22: 20–25, 2015

Table 1 (abstract P029). Odds ratio and significance level for each variable

P030 The brain heart interaction - dynamic relationship between variability of heart rate, interventions and outcome in traumatic brain injury

BA Ianosi¹, V Rass¹, A Lindner¹, P Smielewski², A Ercole³, R Beer¹, A Schiefecker¹, B Pfausler¹, N Stocchetti⁴, R Helbok¹

¹Medical University of Innsbruck, Neurological Intensive Care Unit, Department of Neurology, Innsbruck, Austria; ²Cambridge University, Division of Neurosurgery, Cambridge, United Kingdom; ³Cambridge University, Division of Anaesthesia, Cambridge, United Kingdom; ⁴Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Milano, Italy

Introduction:

In severe traumatic brain injury (TBI) the heart rate variability (HRV) could inform about severity and predict outcome. In this study we depicted the dynamic response of HRV to iatrogenic interventions.

Methods:

Prospectively collected high resolution data of patients from multiple centers with severe TBI from the Intensive Care Unit (ICU) cohort of the CENTER-TBI study were analyzed. Bad outcome was defined as having a Glasgow-Outcome-Scale GOSE between 1-3 at 6 months. HRV parameters were calculated according to international guidelines using a 5-minute sliding window, updated every 10s. Hourly and daily medians were further analyzed

Results:

We included 273 patients (11403 h analyzed).80% were male, 46±19 years old and had an initial GCS of 6 (IQR 3-10). 72 had at least one unresponsive pupil. Outcome data was available for 90.1% of patients with 50.8% (N=125/246) having a bad outcome. The ratio of LF (low frequency) to HF (high frequency) power (LF/HF ratio) was lower in patients with at least one unreactive pupil (1.2±1.1 vs.1.5±1.3, p=0.03) and who had a bad outcome (1.1±0.9)vs. good outcome (1.8±1.4) (mean difference 0.69; 95%CI 0.38-0.99, p<0.001) suggesting parasympathetic dominance. During deep sedation we found a lower LF/HF Ratio (0.9±1.1 vs.1.6±1.7, p<0.001), a lower heart rate standard deviation(HR-SD)(p<0.001) and root mean square of successive differences heartbeats(RMSSD) (p=0.006), compared to patients that were not suppressed. During 151 sedation boli the HR-SD increased (mean diff.0.71 95%CI 0.9-0.4, p<0.002) compared to baseline (30min before bolus). During days with induced hypothermia (63d-mild hypothermia; 23d≤35°C, N=42) the LF/HF Ratio was lower (1.6±1.7 vs 1.1±1.1, p=0.02), as were the HR-SD(p=0.01)&RMSSD (p=0.01).Patients with a good outcome but not those with poor outcome showed increased RMSSD during suctioning(reflecting better vagal response) (Figure 1).

Conclusions:

HRV reflects severity and ICU interventions. A dynamic analysis during interventions may offer prognostic information.

Fig. 1 (abstract P030).

The patients with a good 6-month outcome (GOSE>3) after severe traumatic brain injury showed an increase in root mean square of successive differences between normal heartbeats (RMSSD) (compared to baseline 30 -minutes before tracheal succtioning)

P031 Temperature and cerebral autoregulation in severe TBI patients

BA Ianosi¹, V Rass¹, A Lindner¹, M Kofler¹, A Schiefecker¹, R Beer¹, B Pfausler¹, N Stocchetti², A Ercole³, R Helbok¹

¹Medical University of Innsbruck, Neurological Intensive Care Unit, Department of Neurology, Innsbruck, Austria; ²Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Milano, Italy; ³Cambridge University, Division of Anaesthesia, Cambridge, United Kingdom

Introduction:

Impaired cerebrovascular reactivity (CAR) after traumatic brain injury (TBI) is a marker for disease severity and poor outcome. It is unclear how dynamic changes in body temperature and fever impact CAR and outcome.

Methods:

We calculated the pressure reactivity index (PRx) using the CENTER-TBI high-resolution intensive care unit cohort, as a moving correlation coefficient between intracranial pressure (ICP) and mean arterial pressure (MAP). Minute and hourly values of PRx and temperature were averaged in patients with simultaneous recording of ICP and ABP. Demographic data was based the Core Registry (V2.0). Linear mixed models were calculated based on minute-by-minute data using R with lme4 V1.1-21 and ggeffects V0.9.0. Generalized estimating equation models were used to analyze changes during effervescence (increase of temperature of >1°C within 3 hours).

Results:

We assessed high frequency physiological data during 567 days of 102 patients admitted to the ICU with predominantly a closed injury type (N=94/102). Median age was 46 years (IQR 29-62), baseline GCS was 6 (IQR 3-9), and 27% had at least one unreactive pupil. The main measurement site for temperature was the urinary bladder 55/102(54%). Half of the patients (49/102) developed fever(>1h with mean T ≥ 38.3°C) with a total of 834h fever and a median of 9h fever(IQR 4-24) per patient. Of 110 effervescence episodes 30(27%) reached the febrile threshold of 38.3°C which was associated with an increase in PRx from 0.09 (±SD 0.25) at baseline (2h before) to 0.26 (±SD 0.3) during the febrile peak (p=0.014) (Figure 1-A). Linear mixed models showed a quadratic relationship between PRx and temperature (p<0.001) with an increase in predicted PRx with febrile and hypothermic temperatures (Figure 1B).

Conclusions:

The association of increasing body temperature with worsening of CAR supports prevention of fever in severe TBI. Prospective studies are needed to further differentiate between mechanisms involved (i.e. inflammation) and central autonomic dysregulation.

Fig. 1 (abstract P031).

A) Changes in mean PRx during episodes of effervescence (1°C within 3 hours); B) Predicted relationship between PRx and temperature based on mixed linear models

P032 Brain temperature after traumatic injury: a center-TBI study

T Birg¹, F Ortolano¹, M Carbonara¹, T Zoerle¹, R Helbok², Y Savchenko³, BA Ianosi², N Stocchetti¹

¹Fondazione IRCCSC a’Granda Ospedale Maggiore Policlinico, Neurointensive care unit, Milan, Italy; ²University of Innsbruck, Department of Neurology, Innsbruck, Austria; ³Burdenko Neurosurgical Center, Neurointensive care unit, Moscow, Russia

Introduction:

After traumatic brain injury (TBI) fever is common and may cause secondary brain damage. In this study we investigated the association between changes in brain temperature (BT), intracranial pressure (ICP), and cerebral perfusion pressure (CPP).

Methods:

CENTER-TBI is a co-operative effort of several neurotrauma centers in Europe and includes a repository of monitored data sampled at high-frequency (from 200 Hz to 500 Hz). Simultaneous BT, ICP and CPP recordings were studied, focusing on episodes of BT changes (delta BT ≥0.5 °C, lasting 15 minutes - 3 hours) up or down-ward. Using the linear correlation coefficient episodes were coded as responding (R), when there was a clear association between ICP and BT (Pearson’s R value ≥0.5) or non-responding (NR) when the correlation coefficient was <0.5.

Results:

Twenty-one patients were selected for the study for a total of 2435 monitoring hours. The mean duration of monitoring was 86 hours. All patients reached a BT above 38° and experienced at least one episode of ICP above 20 mmHg. A CPP lower than 60 mmHg (often of very short duration) has been recorded in all patients. 149 episodes (79 for BT elevation and 70 for BT reduction) were identified. During BT elevations, the increase in temperature was accompanied by ICP increases in slightly more than half episodes (43 R (54%) vs 37 NR (46%)). During BT reduction there were 32 R (46%) and 38 NR (54%) episodes.

Conclusions:

Patients after TBI usually develop BT> 38° soon after the injury. The BT may influence brain physiology, as reflected by ICP, through vascular responses (respectively vasodilation/vasoconstriction). Our analysis identified potential ICP and CPP variations connected to BT changes in approximately half of episodes. However, it has to be noted that both ICP and CPP have been actively manipulated in the ICU, potentially blunting the biological responses due to BT.

P033 Subclinical AKI in severe traumatic brain injury

S De Rosa¹, G Golino², G Villa³, S Samoni⁴, M De Cal⁴, MA Martin⁵, G Berdin⁵, P Persona², P Navalesi², C Ronco⁶

¹San Bortolo Hospital, Department of Intensive Care, Vicenza, Italy; ²University of Padova, Department of Medicine – DIMED, Section of Anesthesiology and Intensive Care Medicine, Padova, Italy; ³University of Florence, Department of Anesthesia and Intensive Care Medicine, Florence, Italy; ⁴San Bortolo Hospital, Department of Nephrology, Vicenza, Italy; ⁵San Bortolo Hospital, Department of Anesthesia and Intensive Care Medicine, Vicenza, Italy; ⁶San Bortolo Hospital, Department of Medicine, University of Padova, Padova-Italy, Vicenza, Italy

Introduction:

Acute kidney injury (AKI) is relatively common in patients with severe traumatic brain injury (sTBI) and it can contribute to morbidity and mortality [1]. NephroCheck is a point-of-care urine test that flags two biomarkers that indicate if a critically ill patient is at risk for AKI. We investigated the incidence of subclinical AKI in patients with sTBI.

Methods:

We performed a prospective observational study of all adult patients with severe TBI admitted to ICU from January 2017 to April 2018 inclusive. All consecutive patients with a clinical need for ICP monitoring were included for analysis. Urine samples of severe TBI patients was collected at ICU admission from 33 patients to measure NephroCheck (NC) test [IGFBP7]x[TIMP-2] was performed using the NephroCheck® Astute1 40 ™ meter. Serum creatinine was collected at admission, during the first three days, at ICU dismission and 60-days follow up to assess renal recovery. The diagnosis of AKI was based on KDIGO criteria. Hemodynamics, electrolytes, PEEP, P/F, kind of fluid administered, Fluid Balance, % Fluid overload, length of stay, The Sequential Organ Failure Assessment score, injury severity scores and mortality were collected.

Results:

A total of 15 patients (45%) presented a median NC higher values at ICU admission. One patient with positive NC value experienced AKI at 24 hrs. The positive NC group had more plasma transfusion (p-value 0.03) and a lower median hematocrit at 24 hrs (p-value 0.013), but similar hospital length of stay (p=0.17) and mortality rate (p=0.80)

Conclusions:

NC at ICU admission identifies subclinical AKI in TBI patients and it maight be used to predictclinical AKI. Hemodilution (but not fluid overload) seems to be associated with development of subclinical AKI. Higher NC at ICU admission is not associated with worst long-term outcome in TBI patients.

References:

1. Moore EM et al. Ren Fail 32:1060-5, 2010

P034 Benchmarking outcomes after severe traumatic brain injury with the CRASH and IMPACT prediction models: a single center analysis in the Netherlands

WR Van de Peppel¹, HF Lingsma², I Haitsma³, M Van der Jagt⁴

¹Erasmus MC - University Medical Center, Departments of Intensive Care Adults, Rotterdam, Netherlands; ²Erasmus MC - University Medical Center, Department of Public Health, Rotterdam, Netherlands; ³Erasmus MC - University Medical Center, Department of neurosurgery, Rotterdam, Netherlands; ⁴Erasmus MC - University Medical Center, Department of Intensive Care Adults, Rotterdam, Netherlands

Introduction:

Severe traumatic brain injury (TBI) is considered a serious public health problem in Europe. Partly because of the heterogeneity of TBI, considerable uncertainty may exist in the expected outcome of patients. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) and the Corticosteroid Randomization After Significant Head Injury (CRASH) prediction models are considered the most widely validated prognostic models [1,2]. However, studies using these prediction models for benchmarking of outcomes have been scarce. We aimed to compare actual outcomes in a TBI cohort of critically ill TBI patients with predicted outcomes in a quality of care initiative in an Academic Hospital.

Methods:

In this retrospective cohort study, we included consecutively admitted TBI patients to the ICU Adults of Erasmus MC, University Medical Center, Rotterdam, The Netherlands between January 2018 and February 2019.

Results:

We included 87 patients with TBI. 14-day mortality was 25%, six-month mortality was 36% and six-month unfavourable outcome was 50%. The IMPACT core+CT+lab model predicted 34% 6-month mortality (vs 35% actual, p=0.89) and 51% unfavourable outcome (vs 50% actual, p=0.9). The 14-day mortality prediction by CRASH prognosis calculator was 43% versus actual 14-day mortality of only 25% (p=0.01), whereas 6-month unfavourable outcome prediction by CRASH was 67% (vs. 50% actual, p=0.02) (Figure 1).

Conclusions:

The IMPACT model, although developed more than a decade ago, seemed appropriate for benchmarking purposes in this single center cohort in the Netherlands, while CRASH predictions were less applicable to our setting.

References:

1. Perel P et al. BMJ 23 :425-429, 2003

2. Steyerberg EW et al. PLoS Med 5:e165, 2008

Fig. 1 (abstract P034).

Actual and predicted outcome according to CRASH and IMPACT

P035 Neuroprognostication following out of hospital cardiac arrest

R Davidson¹, T Bagnall², M Ahmed³

¹St George´s Hospital Cardiothoracic Intensive Care, Atkinson Morley Wing, London, United Kingdom; ²Kingston Hospital, Cardiology, London, United Kingdom; ³St George´s Hospital Cardiothoracic Intensive Care, London, United Kingdom

Introduction:

Out of hospital cardiac arrest (OHCA) continues to be associated with significant mortality and morbidity. Centralisation of care has considerably improved patient survival but has resulted in increased morbidity in the form of neurological deficit. Accurate neurological prognostication remains challenging incorporating repeated clinical examination and ancillary investigations [1, 2].

Methods:

Data was collected retrospectively and analysed for 96 patients admitted post OHCA from October 2018 to October 2019. Patient arrest demographics were collected in conjunction with extensive inpatient investigation findings including CT, traditional pupil assessment, pupillometry and EEG.

Results:

50% of patients survived to hospital discharge. Patients presenting in a shockable rhythm continue to have higher survival rates (Table 1). 53% of patients who received immediate CPR survived to hospital discharge in comparison to 41% of patients who did not receive immediate CPR. 73% of patients underwent non-contrast CT head. 74% of patients had traditional pupillary examination performed on arrival. Pupillometry was introduced in December 2018; 31 out of a possible 85 patients had pupillometry during their inpatient stay. EEG was undertaken in 11% of cases.

Conclusions:

Our data shows receiving immediate CPR and presenting with a shockable rhythm remain positive prognostic factors. CT head as a stand-alone prognostic modality is unreliable with 14% of patients who survived to discharge, with intact neurology, had an admission CT head reported as hypoxic brain injury. A new neuroprognostic strategy is required in our unit that adds further certainty to likely clinical outcome. This includes increased use of tests such as EEG and pupillometry and the introduction of biomarkers such as neuron specific enolase, somatosensory evoked potential testing and magnetic resonance imaging.

References:

1. Sandroni et al. Crit Care 22:150, 2018

2. Eertmans et al. Scand J Trauma Resusc Emerg Med 26:93, 2018

Table 1 (abstract P035). Survival to discharge based on presenting rhythm

P036

Withdrawn

P037 Audit of end of life care and neuroprognostication in the intensive care department at Bristol Royal Infirmary

KJ Richardson, M Thomas

Bristol Royal Infirmary, Intensive Care Unit, Bristol, United Kingdom

Introduction:

Post-resuscitation care of patients following an out-of-hospital cardiac arrest (OOHCA) is set out by the UK Resuscitation Council [1]. This is in line with the European Resuscitation Council guideline [2]. The aim of this audit was to review compliancy to this guideline at the Intensive care unit at the Bristol Royal Infirmary .

Methods:

A retrospective audit was performed over a six-month period in adults who were admitted to the intensive care unit at the BRI following an OOHCA whom later died during that admission (41 patients). The focus was on whether the Neuroprognostication and End-of-life (EOL) care received was as per the standards set by the UK Resuscitation Council.

Results:

The main neuroloical examinations documented were pupillary reflex (100%), corneal reflex (75%) and motor response to pain (100%). 61.5% of patients received an SSEP analysis >72 hours post-ROSC, 81.5% underwent an EEG and 66.7% had >2 serum neuron-specific enolase measurements recorded. All patients (100%) underwent a CT Head during their admission. 5.6% of patients were referred to Palliative Care during their admission. 22% of patients were prescribed all EOL medications. Most common prescriptions included Alfentanil (90.2%) and Midazolam (58.5%). Finally, 100% of appropriate patients were referred to be potential organ donors.

Conclusions:

The audit reflected our local practice and that some parameters were not being maintained as set by UK Resuscitation guideline. Multiple modalities of documentation posed a problem in analysing the care that these patients received.

References:

1. Resuscitation council UK BHF, NHS England. Consensus Paper on out-of-hospital cardiac arrest in England. 2015.

2. Nolan JP et al. Resuscitation 95:202-22, 2015

P038 Target temperature management after out of hospital cardiac arrest

P Liddicoat, M Ahmed, A Obhrai

St George's Hospital, Intensive Care, Tooting, United Kingdom

Introduction:

Targeted temperature management (TTM) and fever avoidance improves mortality and neurological outcome post out of hospital cardiac arrest (OHCA) [1]. Patients follow a protocol from admission: TTM for 72 hours (36°C for 24h and then normothermia for 48h). We looked at the rationale for commencing TTM, temperature control devices, if we met temperature guidelines and the reasons for TTM failure.

Methods:

We retrospectively analysed patients who had been coded OHCA on iCLIP (our electronic patient record) between 30/06/2018 to 30/06/19. We analysed ICU charts for recorded temperatures (< 72hrs) for TTM patients. We then accessed notes through iCLIP and assessed rationale for TTM commencement and reasons for failure. We compared our results to our ICU standards, based on current consensus and the TTM1 results [1]. We also looked at the effectiveness of a clerking proforma (Feb 2019) on documentation.

Results:

95 patients were admitted post OHCA. 76 were initiated on TTM; of the 19 not: 10 patients were critically unstable, while 9 patients had good GCS on ROSC. Of recorded arrest rhythms 57/71 (80%) of TTM patients were shockable while 9/15 (60%) of non TTM patients were shockable. Of the TTM patients: 6 had surface cooling devices and 70 had intravascular cooling devices. 21/73 (29%) of TTM patients failed TTM adherence by either having a mean of >0.5°C OR a spike of >1°C above target temperature. 13/ 21 (62%) had predictable medical causes of TTM failure: Aspiration pneumonia or myoclonic jerks. The other 8 patients had process-based failures: going for PCI or being warmed early. The proforma has had a marked improvement on documentation.

Conclusions:

These results highlight that raised temperatures in TTM are predictable. To improve this we will focus on recognition of these risk factors and establish means to minimise their impact. We have also shown the benefit of an established clerking proforma.

References:

1. Nielsen N et al. N Engl J Med 369:2197-2206, 2013.

P039 Serum GFAP and UCH-L1 for the prediction of long term neurological outcome in comatose out-of-hospital cardiac arrest patients

F Ebner¹, M Moseby-Knappe², N Mattsson², J Undén³, S Ullén⁴, T Cronberg², N Nielsen⁵

¹Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Helsingborg, Sweden; ²Skane University Hospital, Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden; ³Halland Hospital, Lund University, Halland Hospital, Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Halmstad, Sweden; ⁴Skane University Hospital, Clinical Studies Sweden, Skane University Hospital, Lund, Sweden; ⁵Helsingborg Hospital, Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Helsingborg, Sweden

Introduction:

The prognostication of neurological outcome in comatose out-of-hospital cardiac arrest (OHCA) patients is an integral part of post cardiac arrest care. Biochemical biomarkers released from cerebral cells after hypoxic-ischemic injury represent potential tools to increase accuracy in predicting outcome after OHCA. Currently, only neuron-specific enolase (NSE) is recommended in European prognostication guidelines. In this study, we present the release dynamics of GFAP and UCH-L1 after OHCA and evaluate their prognostic performance for long-term neurological outcome in OHCA patients.

Methods:

Serum GFAP and UCH-L1 were collected at 24, 48 and 72 h after OHCA. The primary outcome was neurological function at 6-month follow-up assessed by cerebral performance category scale (CPC), dichotomized into good (CPC 1-2) and poor (CPC 3-5). Outcome prognostic performance was investigated with receiver operating characteristics (ROC) by calculating the area under the receiver operating curve (AUROC) and compared to NSE.

Results:

717 of 819 included patients had at least one serum GFAP or UCH-L1 value at 24, 48 or 72 h after OHCA. GFAP and UCH-L1 levels were significantly elevated in patients with poor outcome. GFAP and UCH-L1 discriminated excellently between good and poor neurological outcome at all time-points (AUROC GFAP 0.88-0.89; UCH-L1 0.86-0.87) and overall predictive performance measured by AUROC of GFAP and UCH-L1 was superior to NSE (AUROC 0.76-0.85) (Figure 1). However, the ROC at the highest specificities of UCH-L1 and GFAP overlap those of NSE and comparing the sensitivities for UCH-L1 and GFAP with those of NSE for the highest specificities (>95%) revealed higher sensitivities for NSE than for UCH-L1 and GFAP at 48 and 72 h.

Conclusions:

GFAP and UCH-L1 predict poor neurological outcome in patients after OHCA excellently and with a higher overall accuracy than NSE, but both biomarkers perform inferior to NSE at specificities over 95% at 48 and 72 h limiting their clinical use to guide decisions on prognosis.

Fig. 1 (abstract P039).

A-C, Receiver-operating characteristic analyses for prediction of Cerebral Performance Category (CPC) Scale 1-2 vs CPC 3-5 at 6-months follow-up for serum samples collected at 24, 48 and 72 hours. The enlarged sections in B and C show the overlap of GFAP, UCH-L1 and NSE at high specificities at 48 and 72 hours

P040 Blood pressure after cardiac arrest and severity of hypoxic-ischemic encephalopathy

C Endisch¹, S Preuß², C Storm³, CJ Ploner¹, C Leithner¹

¹Charité Universitätsmedizin Berlin, Department of Neurology, AG Emergency and Critical Care Neurology, Berlin, Germany; ²Charité Universitätsmedizin Berlin, Departement of Cardiology, Berlin, Germany; ³Charité Universitätsmedizin Berlin, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany

Introduction:

Blood pressure management in post cardiac arrest (CA) patients ensures sufficient cerebral perfusion to avoid secondary brain injury. In previous studies, lower mean arterial pressure (MAP) was associated with poor clinical outcome. However, the relationship between hypotension and severity of hypoxic-ischemic encephalopathy (HIE) remains uncertain.

Methods:

We retrospectively analyzed MAP during the first week in three CA patient groups: (1) Patients surviving with no/mild HIE – cerebral performance category (CPC) 1. (2) Patients surviving with severe HIE – unresponsive wakefulness syndrome (CPC 4). (3) Deceased patients with post-mortem brain autopsy. In these autopsy patients, we used the Selective Eosinophilic Neuronal Death (SEND) classification to quantify the histopathological severity of HIE.

Results:

We included 354 autopsy patients, 118 had histopathological severe and 236 patients no/mild HIE. Between autopsy patients with no/mild HIE and severe HIE, there was no difference in mean MAP during the first week. However, no/mild HIE autopsy patients with post-CA regain of consciousness had a mean MAP of 75 mmHg compared to 65 mmHg in those never conscious before death. We found no difference in MAP between 216 patients with full neurological recovery (CPC 1) and 57 surviving with unresponsive wakefulness syndrome (CPC 4). Hypothermia induced small reversible hypotension in all groups.

Conclusions:

Contradicting previous studies, we found no difference in post-CA MAP of patients with histopathological and clinical evidence of presence and absence of HIE. No/mild HIE patients with post-CA regain of consciousness before death showed high-normal blood pressure stability. This may indicate a blood pressure effect on neuronal function rather than structural integrity. Importantly, extracerebral causes for loss of consciousness and mortality need to be considered.

P041

Withdrawn

P042

Withdrawn

P043 P25/30 somatosensory evoked potentials and neurological outcome in comatose survivors of out of hospital cardiac arrest

N Nikitas¹, L Nye², C Bigham¹, N Broomfield², A MacCormick¹, L Lankester¹, N Gourd¹, R Squire³, E Dunn², N Hudson²

¹University Hospitals Plymouth NHS Trust, Department of Intensive Care Medicine, Plymouth, United Kingdom, ²University Hospitals Plymouth NHS Trust, Department of Neurophysiology, Plymouth, United Kingdom, ³University Hospitals Plymouth NHS Trust, Department of Emergency Medicine, Plymouth, United Kingdom

Introduction:

The objective of the study is to analyse the 20-30msec complex of the somatosensory evoked potentials [SSEP] in comatose survivors of out of hospital cardiac arrest [OHCA], to identify the patterns of this complex and to test whether the addition of P25/30 in analysis could improve N20’s positive predictive value for favourable outcome. Previously it was suggested that P25/30 have a role in the prognosis of neurological outcome after OHCA [1].

Methods:

Single-centre, prospective, observational study. Patients: Adult comatose survivors of OHCA treated with organ support, neuroprotection and targeted temperature [T] management for normothermia. SSEP recorded at 24-36h post ROSC and interpreted by two interpreters for P25/30 and N20 in different amplitude thresholds. Neurological outcome at hospital discharge was assessed by the cerebral performance category [CPC] score.

Results:

First 30 patients: 18 male, 12 female, mean age 62.3 years. OHCA rhythm VF in 17, asystole in 13. Cause of OHCA: cardiac in 20 and non-cardiac in 10. Mean anoxic time 30min. Mean T in the first 24-36 hours 35.9. Among survivors with unfavourable outcome [CPC 3-5] 14 had bilaterally absent P25/30 and N20, 2 bilaterally present P25/30 and bilaterally absent N20, 1 bilaterally present P25/30 and N20, 1 bilaterally present 25/30 and unilaterally present N20 and 1 unilaterally present P25/30 and N20. All 11 survivors with favourable outcome [CPC 1-2] had bilaterally present P25/30 and N20.

Conclusions:

Early results suggest the presence of variable patterns of 20-30msec SSEP complex in comatose survivors of OHCA. As the number of enrolled participants increase, it is yet to be determined whether the presence of P25/30 could potentially increase the positive predictive value of N20 for the favourable neurological outcome.

References:

1. Kim SW et al. Crit Care Med 46:545-551, 2018

P044 Relationship between shockable rhythm and long-term outcome in pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: a 16 year observational study.

M Albrecht¹, RCJ De Jonge¹, M Hunfeld¹, JAE Kammeraad¹, XRJ Moors¹, VM Nadkarni², L van Zellem¹, CMP Buysse¹

¹Erasmus MC – Sophia Children's Hospital, Intensive Care and Department of Pediatric Surgery, Rotterdam, the Netherlands; ²Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA., USA

Introduction:

Local chain-of-survival improvements affect P-OHCA survival [1-5]. Also initial rhythm in P-OHCA is an important predictor of survival [1,4]. Little is known about the relationship between initial rhythm in P-OHCA and long-term outcome [6-8]. Our aim was to establish the relation between shockable rhythm and favorable long-term outcome in POHCA.

Methods:

All children aged 1 day-18 years who experienced non-traumatic OHCA between 2002-2017 and were admitted to the Sophia Children’s Hospital in Rotterdam were included. Long-term outcome was determined using a Pediatric Cerebral Performance Category score at the longest available follow-up interval. The primary outcome measure was survival with favorable neurologic outcome, defined as PCPC 1-2 or no difference between pre- and postarrest PCPC. The association between shockable rhythm and the primary outcome measure was calculated in a multivariable regression model, adjusted for the pre-defined variables.

Results:

From the 329 patients included in the 16 year study period 126 (38%) patients survived to hospital discharge of which 99 patients (30%) had favorable neurologic outcome (median follow-up duration of 24 months). The rate of favorable neurologic outcome rose from 17% in 2002 to 52% in 2017 (p < 0.001 for trend) (Fig. 1). In adjusted analysis initial shockable rhythm (OR 7.2 [95%CI 2.2-23.7]), initial unknown rhythm (OR 10.2 [95%CI 3.5-29.2]) and the year of event (OR 1.2 [95%CI 1.2-1.4]) were associated with favorable long-term neurologic outcome.

Conclusions:

The odds of favorable neurologic outcome at the longest follow-up duration were significantly higher after a shockable initial and unknown rhythm. Secondly, trend analysis showed an increase in AED defibrillation and shorter CPR duration. This was followed, finally, by a rise in ROSC, survival to hospital discharge and favorable neurologic outcome rate.

References:

1. Atkins DL et al. Circulation 2009;119:1484-91.

2. Kitamura T et al. Lancet 2010;375:1347-54.

3. Tijssen JA et al. Resuscitation 2015;94:1-7.

4. Fukuda T et al. Resuscitation 2017;111:1-7.

5. Naim MY et al. JAMA Pediatr 2017;171:133-41.

7. Michiels E et al. Resuscitation 2016;102:122-6.

8. Meert KL et al. Pediatr Crit Care Med 2016;17:e543-e50.

Fig. 1 (abstract P044).

Patient and arrest characteristics over time. A. The total amount of mortality as a stacked bar: in light-red the number of patients who deceased at scene, in green the number of patients deceased during admission, in red patients who died after discharge. The grey line is the total number of inclusions. B. The rate of bystander AED use, rate of initial shockable rhythm, rate of less than 15 minutes of CPR and rate of favorable neurologic outcome over time. P for trend significant for bystander AED use, less than 15 minutes of CPR and favorable neurologic outcome. Trend analysis performed using binary logistic regression for dichotomous data (and a Kruskal-Wallis test for non-normally distributed continuous data)

P045 Acute kidney injury in cardiac arrest patients

S Bazzano¹, G Villa², G Golino³, S Samoni⁴, M De Cal⁴, S Marcante⁵, M Martin⁵, R Vaschetto¹, C Ronco⁴, S De Rosa⁶

¹Università degli studi del PIemonte Orientale, Department of Anesthesia and Intensive Care Medicine, Novara, Italy; ²University of Florence, Department of Anesthesia and Intensive Care Medicine, Florence, Italy; ³University of Padova, Department of Medicine – DIMED, Section of Anesthesiology and Intensive Care Medicine, Padova, Italy; ⁴San Bortolo Hospital, Department of Nephrology, Vicenza, Italy; ⁵San Bortolo Hospital, Department of Anesthesia and Intensive Care Medicine, Vicenza, Italy; ⁶San Bortolo Hospital, Department of Intensive Care, Vicenza, Italy

Introduction:

Cardiac arrest (CA) is a global ischemia-reperfusion injury syndrome [1]. The aim of the study is to evaluate the incidence of AKI in comatose patients resuscitated from CA.

Methods:

We performed retrospective study of consecutive comatose patients resuscitated from CA and admitted to our ICU from January 2013 to May 2019 inclusive. Data obtained at baseline, 24 hrs, 48 hrs, and 72 hrs included: temperature trend and rate, serum creatinine,MAP, VIS, PEEP, diuretic use, urine output, fluid balance (FB). AKI was defined according to KDIGO criteria.

Results:

Thirty-six patients were treated with TH 33°C out of 46 ICU admissions (78%). Fifty-four patients were treated with TTM 35°C out of 106 ICU admission (51%) while fifty-two were not treated with temperature management (49%). The incidence of AKI was 17.35 at 24h for NO TTM group, 13.9% for TH group and 14.9% for TTM group. At 48h the incidence of AKI increased at 41.7% for TH, 37.1% for TTM while in NO TTM group increased less (18.8%). At 72h the incidence of AKI was 33.3% for TH group, 27.8% for TTM group and 32.7% for NO TTM group.SCr at baseline, at admission at 24 and 48h was not significant different in the three groups. Median cumulative FB was significant different in the TH group at 48h 1522 (488 – 2236) compared to 382 (- 397 – 1553) in TTM group and 228 ( -393 – 1530) in NO TTM group (p< 0.003). Twenty-four patients (16.9%) required RRT in the overall population. Urinary TIMP-2 e IGFBP7 was 1.54 (0.8 – 3.46) in TTM group and 1 (0.19 – 2.18) in TH group (p = 0.105).

Conclusions:

AKI occurred in more then 30% of patient after CA even if there are no clear impairment of serum creatinine, AKI can show in a subclinical way and determine an alteration of FB, hemodynamic function, and chronic renal loss of function

References:

1. De Rosa S et al. BMC Nephrol 18:376, 2017.

P046 Socioeconomic status is associated with early coronary angiography after out-of-hospital cardiac arrest

R Lagedal¹, M Jonsson², L Elfwén³, D Smekal⁴, P Nordberg², S James⁵, S Rubertsson⁴

¹Department of Surgical Sciences, Anaesthesia and Intensive Care, Uppsala University, Uppsala, Sweden; ²Department of Surgical Sciences, Anaesthesia and Intensive Care, Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden; ³Department of Surgical Sciences, Anaesthesia and Intensive Care, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Sweden, Uppsala, Sweden; ⁴Department of Surgical Sciences, Anaesthesia and Intensive Care, Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden; ⁵Department of Surgical Sciences, Anaesthesia and Intensive Care, Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center Uppsala University, Uppsala, Sweden

Introduction:

Low socioeconomic status is associated with worse outcome after cardiac arrest. This study aims to investigate if patients´ socioeconomic status impacts the chance to receive early coronary angiography after cardiac arrest.

Methods:

In this nationwide retrospective cohort study, 4011 patients admitted alive after out-of-hospital cardiac arrest (OHCA) and registered in the Swedish Registry for Cardiopulmonary Resuscitation were included. Individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from other national registers.

Results:

In the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where 35% of patients in the highest income quartile received early angiography compared to 15% in the lowest income quartile. When adjusting for confounders (educational level, sex, age, comorbidity and hospital type) there were still higher chance of receiving early coronary angiography with increasing income, OR 1.31 (CI 1.01-1.68) and 1.67 (CI 1.29-2.16) for the two highest income quartiles respectively compared to the lowest income quartile. When adding potential mediators to the model (initial rhythm, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. The main mediator was initial rhythm (Figure 1).

Conclusions:

Higher income is strongly related to the rate of early coronary angiography after OHCA. This finding is consistent when adjusting for known confounders. However, the association between income and early angiography seems to be mediated by initial rhythm. Patients with low income more often presents with non-shockable rhythms which lowers the likelihood to undergo early coronary angiography.

Fig. 1 (abstract P046).

Correlation between disposable income and rate of early coronary angiography. Confidence interval in gray. Values above 0 on y-axis indicate increased rate of early coronary angiography. Second figure adjusted for confounders. Third and fourth figure adjusted for increasing numbers of potential mediators as stated in Figure

P047 Effect of simulation teaching of cardiopulmonary resuscitation for nursing

V Spatenkova¹, I Danilova², Z Jindrisek², M Fronkova², I Veverkova²

¹Faculty of Health Studies, Technical Faculty of Liberec, Neurocenter, NICU, Liberec, Czech Republic; ²Faculty of Health Studies, Technical Faculty of Liberec, Liberec, Czech Republic

Introduction:

Simulation teaching is a modern type of critical care (CC) education. The aim of this study was to assess the effect of simulation teaching of CC on a comparison of final examination in different model levels of cardiopulmonary resuscitation (CPR) after the first (CC1) and third, final CC3.

Methods:

The success rate of CPR was tested in prospective study (2017-2018) on two groups with a total of 66 students in CC1 and CC3 at the Faculty of Health Studies. Three semester of undergraduate nursing simulation education (lectures and training) used the Laerdal SimMan 3G. Quality of CPR was evaluated according to 4 parameters: compression depth, compression rate, chest release and time of correct frequency. We tested if CPR quality differed between the two groups. For the compression depth and compression rate parameters, first the conformity of variance was verified and then two-sample t-test. As the chest release and time of correct frequency are recorded as percentages, the Wilcoxon rank-sum test was conducted for these parameters. To ensure good resuscitation, all recorded parameters must be properly performed during resuscitation. Thus, pivot tables were used to generate statistics and test if the number of correctly performed resuscitation parameters for CC1 and CC3 differ.

Results:

The compression depth parameter was statistically significantly higher for the CC3 than for the CC1 (p=0.016). There were no differences in compression rate (p=0.210), chest release (p=0.514) and time of correct frequency (p=0.586). It was also tested how many of the parameters were performed correctly by students at CPR. The chi-square test shows the relative frequency of CPR success is higher for the CC3 group than for the CC1 group. At least 3 out of 4 parameters were correctly performed by 13% of CC1 students compared to 28% of CC3 students.

Conclusions:

The study showed a significant improvement of CPR in the final CC3 and supported the three semester simulation education.

P048

Withdrawn

P049 Changes in blood gases during intraoperative cardiac arrest

JJ Wang, R Borgstedt, S Rehberg, G Jansen

Protestant Hospital of the Bethel Foundation, Anaesthesiology, Intensive Care and Emergency medicine, Transfusion medicine and Pain therapy, Bielefeld, Germany

Introduction:

Blood gas analysis (BGA) is a common approach for monitoring the homeostasis during surgery. While it is well known that cardiac arrest (CA) leads to circulatory collapse and disturbances in homeostasis, little is known about changes of blood gas during peri-operative CA.

Methods:

We retrospectively analysed patients ≥18 years who suffered from peri-operative CA during non-cardiac surgery from 01/2014 to 12/2018. Peri-operative CA was defined as need for cardiac compression during anaesthesia care. Collected data included pH, PaCO2, PaO2, return of spontaneous circulation (ROSC) and 30-day mortality after CA.

Results:

Within the study period, we observed 56 peri-operative CA (m=35, f=21; age 69±16) during 62742 anaesthesia procedures (ROSC occurred in 38 patients (68%). 30 days after CA, the mortality was 45% (n=17), 23% (n=13) were discharged, and 14% (n=8) still in hospital. 87% (n=49) of CA patients had an invasive blood pressure monitoring, 52% (n=29) had BGA before and 66% (n=37) during peri-operative CA. Prior to CA, the average values were: pH 7.3±0.1, PaCO2 39±8 and PaO2 225±107. During CA, the average values were pH 7.2±0.2, PaCO2 50±17 and PaO2 215±138. Table 1 shows the distributions of blood gas before and during CA. There were no statistical differences between the groups (pH: p=0.4; PaCO2: p=0.19; PaO2: p=0.21).

Conclusions:

Hypercapnia and respiratory acidosis is common in peri-operative CA. These data suggests inadequate ventilation during peri-operative resuscitation. Further studies should focus on its impact on the outcome.

Table 1 (abstract P049). Changes in blood gases during intraoperative cardiac arrest

P050 Diagnostic strategies in intensive care unit cardiac arrest

FO Holland¹, S Entz², S Lamprinaki², M Abu-Tair¹, R Borgstedt³, S Rehberg³, G Jansen³

¹Protestant Hospital of the Bethel Foundation, Department of Internal Medicine, Cardiology, Nephrology and Diabetology, Bielefeld, Germany; ²Protestant Hospital of the Bethel Foundation, Department of Internal Medicine and Gastroenterology, Bielefeld, Germany; ³Protestant Hospital of the Bethel Foundation, Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Bielefeld, Germany

Introduction:

Cardiac arrest on ICU (ICU-CA) is usually monitored. Beside-diagnostics and trained healthcare professionals are immediately available. This offers exceptional opportunities and poses the question which diagnostic strategies are carried out in ICU-CA.

Methods:

Retrospective analysis of adult ICU-CA from 2016-2018 at a maximum care hospital in Germany with five ICU (two perioperative, two medical, one interdisciplinary) summarizing 71 ICU beds. ICU-CA was defined as requirement for chest compressions and/or defibrillation according to Utstein criteria. Diagnostics during ICU-CA were collected and analysed. Subgroup analyses included patients with and without ROSC. Primary endpoint was the performance rate of additional diagnostics during ICU-CA. Secondary endpoints were the type of diagnostics (i.e. blood gas analysis [BGA], echocardiography [EC] or chest-x-ray [XR]) and its therapeutic consequences.

Results:

There were 114 ICU-CA out of 14.264 ICU patients in total (incidence 79.9 per 10.000 ICU patients [CI95 65.3-94.5). All patients were monitored (electrocardiogram, pulsoxymetry, invasive blood pressure). During ICU-CA 50 (44%) patients received at least one additional diagnostic [i.e. BGA 41 (36%), EC 22 (19%) or XR 7 (6%)]. In 27 (54%) of these cases a therapeutic consequence was documented. These were application of HCO3- [n=12 (11%)], thoracic drainage [n=5 (4%)], transfusion or pericardiocentesis [each n=3 (3%)], lysis and bronchoscopy [each n=2 (2%)]. Comparing cases with and without ROSC, there were significant more diagnostics done in the group without ROSC but more therapeutic consequences seen in the ROSC-group (Table 1).

Conclusions:

ICU-CA is frequent. Diagnostics to detect reversible causes of CA were used rarely in ICU-CA (44%), even in patients without ROSC. Notably, diagnostics often had therapeutic consequences particularly in ROSC. Further studies are required to define standardized diagnostic algorithms during ICU-CA.

Table 1 (abstract P050). ICU-CA characteristics

P051 Continuous monitoring of cardiac patients on general ward were improved short term survival of in-hospital cardiac arrest

UJ Go¹, YJ Shin¹, JM Lee¹, HY Oh¹, SB Hong²

¹Medical Alert Team, Asan Medical Center, Seoul, South Korea; ²Asan Medical Center, Department of Pulmonary and Critical care medicine, Seoul, South Korea

Introduction:

The importance of early detection in the in-hospital cardiac arrest (IHCA) is emphasized. Previous studies have reported that clinical outcomes are improved if IHCA is witnessed, or if a patient admitted to a monitored location [1, 2]. This study aimed to evaluate the association between continuous monitoring and survival of IHCA on general ward.

Methods:

A retrospective cohort study of IHCA in patients admitted to ward at an academic tertiary care hospital between January 2009 and December 2018 was performed. The primary outcome was return of spontaneous circulation (ROSC). The secondary outcomes were 72-hour survival and survival to hospital discharge.

Results:

Of the 996 enrolled patients, 54.7% patients had monitored. Among monitored group, 63.5% patients were pulse oximetry and electrocardiogram monitored. There were many witnessed events in the monitored group (93.8% vs. 57.4%, p<0.0001). By univariate analysis, there was difference of ROSC in the monitored group (73.8% vs. 66.7%, odds ratio [95% confidence interval] = 1.40 [1.07-1.84]; p=0.016). There were no significant difference 72-hour survival (1.00 [0.68-1.47]; p=0.993) and survival to hospital discharge (1.03 [0.77-1.36]; p=0.864). In subgroup multivariate analyses, the groups were divided according to illness category. In patients with cardiac illness, ROSC (83.0% vs, 63.5%, 2.86 [1.02-8.09]; p=0.047) and 72-hour survival (67.0% vs. 49.4%, 2.40 [1.04-5.51]; p =0.039) were higher in the monitored group (Table 1).

Conclusions:

Cardiac patients with continuous monitoring on general ward showed improving ROSC and 72-hour survival but not survival to hospital discharge in IHCA.

References:

1. Brady WJ et al. Resuscitation 82:845-852, 2011

2. Perman SM et al. J Am Heart Assoc 5:e003638, 2016

Grant Acknowledgment: This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (HI18C0599).

Table 1 (abstract P051). Association between monitored cardiac arrest and patient survival

P052 Physiologic effects of steroids in in-hospital cardiac arrest (CORTICA study group1,2)

E Pappa¹, E Ischaki¹, S Malachias¹, A Giannopoulos¹, K Vrettou¹, G Karlis¹, I Pantazopoulos¹, D Makris², S Zakynthinos¹, S Mentzelopoulos¹

¹Evaggelismos General Hospital, First Department of Intensive Care Medicine University of Athens Medical School, Athens, Greece; ²Larisa University Hospital, Department of Intensive Care Medicine, University of Thessaly Medical School, Larissa, Greece

Introduction:

In-hospital cardiac arrest is associated with poor outcomes. Although steroids are frequently used in patients with septic shock, it is unclear whether they are beneficial during cardiac arrest and after return of spontaneous circulation (ROSC).

Methods:

Of 369 cardiac arrest patients evaluated, 100 were enrolled. Advanced life support was conducted according to the2015 resuscitation guidelines. Forty-six patients were randomly assigned to receive methylprednisolone 40 mg during resuscitation, and 54 to receive saline (placebo). After resuscitation, steroid-treated patients received hydrocortisone 240 mg daily for up to 7 days, followed by tapering over the next 2 days. Primary outcomes were mean arterial blood pressure and central venous oxygen saturation (ScvO₂) at 20 minutes, 4, 24, 48 and 72 hours after ROSC. Secondary end-points included left ventricular ejection fraction and eccentricity index at 12 and 72 hours, cardiac output and serum cytokine levels at 4, 24, 48 and 72 hours, cerebral blood flow index at 4 and 72 hours after ROSC, organ failure–free days from follow-up day 1 through 60,neurological status at dischargeand steroid-associated complications.

Results:

Post-resuscitation MAP did not differ significantly between steroid- and placebo-group at any time point (20 min: 85.2±21.3 vs. 84.7±21.4; 4h: 83.9±18.1 vs. 78.9±15.9; 24h: 79.9±16.0 vs. 81.9±15.2; 48h: 80.2±10.0 vs. 84.2±13.6; 72h: 85.2±11.6 vs. 84.7±14.5 (p>0.05 for all comparisons). There was no significant difference between the two groups in ScvO₂ andall the secondary outcomes (p>0.05 for all comparisons).

Conclusions:

The present study found no significant physiologic benefit of corticosteroid administration during and after resuscitation in hospitalized patients with cardiac arrest.

P053 The experiences of EMS providers taking part in a large randomized trial of airway management during out of hospital cardiac arrest, and the impact on their views and practice. Results of a survey and telephone interviews

M Thomas¹, M Robinson², K Kirby³, J Brandling³, S Voss³, J Benger³

¹Bristol Royal Infirmary, Intensive Care Unit, Bristol, United Kingdom; ²South West Ambulance Service, Exeter, United Kingdom; ³University of West of England, Bristol, United Kingdom

Introduction:

The aim is to explore EMS experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (AIRWAYS-2), specifically to explore:

• 1. Any changes in views and practice as a result of trial participation.

• 2. Experiences of trial training.

• 3. Experiences of enrolling critically unwell patients without consent.

• 4. Barriers and facilitators for out-of-hospital trial participation.

Methods:

An online questionnaire was distributed to 1523 EMS providers who participated in the trial. In-depth telephone interviews explored the responses to the online questionnaire. Quantitative data were collated and presented using simple descriptive statistics. Qualitative data collected during the online survey were analysed using content analysis. An Interpretive Phenomenological Analysis approach was used for analysis of qualitative interview data

Results:

Responses to the online questionnaire were received from 33% of AIRWAYS-2 study paramedics and 19 study paramedics were interviewed. Paramedics described barriers and facilitators to trial participation and changes in their views and practice. The results are presented in five distinct themes: research process; changes in views and practice regardingairway management; engagement with research; professional identity; professional competence.

Conclusions:

Participation in the AIRWAYS-2 trial was enjoyable and EMS providers valued the training and study support. There was enhanced confidence in airway management as a result of taking part in the trial. Study paramedics expressed preference for the method of airway management to which they had been randomized. There was support for the stepwise approach to airway management, but also concern regarding the potential to lose tracheal intubation from ‘standard’ paramedic practice.

P054 Causes of medical care-associated cardiac arrest on the intensive care unit

S Entz¹, FO Holland², S Lamprinaki¹, M Abu Tair², M Krüger¹, R Borgstedt³, S Rehberg³, G Jansen³

¹Protestant Hospital of the Bethel Foundation (EvKB), Department of Internal Medicine and Gastroenterology, Bielefeld, Germany; ²Protestant Hospital of the Bethel Foundation (EvKB), Department of Internal Medicine, Cardiology and Nephrology, Bielefeld, Germany; ³Protestant Hospital of the Bethel Foundation (EvKB), Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and PainTherapy, Bielefeld, Germany

Introduction:

Cardiac arrest on intensive care unit (ICUCA) following therapeutic interventions is of imminent importance, because the interventions are comparatively predictable and precautions can potentially be taken. This study investigates medical care associated complications that led to ICUCA.

Methods:

Intensive care database was screened for patients ≥18 years who experienced ICUCA in a tertiary hospital with five ICU (two medical, two surgical, one interdisciplinary, with a sum of 71 ICU beds) in Germany from 2016-2018. ICUCA was defined as receiving chest compression and/or defibrillation after admission on ICU and classified as “medical care associated” if it was preceded by a therapeutic intervention (i.e. induced by medication, bedding procedures, iatrogenic injuries, procedure associated). Subgroups included patients with recurrence of spontaneous circulation (ROSC) vs. no-ROSC and patients with vs. without vasopressor therapy before intervention.

Results:

There were 125 ICUCA in 114 patients of totally 14,264 ICU patients. Medical care associated complications leading to ICUCA were detected in 28 cases (22%) [Incidence 19.6/10,000(CI95 12.3 -26.9)]. ICUCA following therapeutic interventions occurred because of circulatory insufficiency [n=20(70%)], respiratory failure [n=5(17%)] and airway associated problems [n=3(10%)]. Nine of the 28 patients (32%) with care-associated ICUCA died. Table 1 demonstrates therapeutic interventions followed by ICUCA.

Conclusions:

Care-associated complications were common reasons for ICUCA. Most of events were induced by circulatory insufficiency due to induction of anaesthesia and bedding procedures. Further investigations should focus on preventive strategies, such as vasopressor infusion before therapeutic interventions.

Table 1 (abstract P054). Medical care associated causes of ICUCA

P055

Withdrawn

P056 Favorable effects of reducing low-flow duration in ECPR patients

A Higashi¹, TA Nakada¹, T Imaeda¹, R Abe¹, K Shinozaki², S Oda¹

¹Chiba University Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Chuo, Chiba, Japan; ²The Feinstein Institute for Medical Research, The Feinstein Institute for Medical Research, Manhasset, United States

Introduction:

The low-flow duration (LFD) in extracorporeal cardiopulmonary resuscitation (ECPR) is considered to be related to the neurological outcome. Nevertheless, there are a few reports on how the LFD and the prognosis had changed over time with continuous efforts. In this investigation, we aimed to clarify the temporal change in the LFD and outcomes of patients with ECPR at a single center between January 2003 and December 2017.

Methods:

This retrospective observational study was performed at Chiba University Hospital, a tertiary-care hospital in Japan. We reviewed medical records of all patients who received ECPR from January 2003 to December 2017. Over time changes in LFD were investigated, and then, the association of LFD with a 90-day outcome was analyzed.

Results:

Records from 175 patients were utilized in this study. Of them, 117 patients were in-hospital cardiac arrest (IHCA), and 58 patients were out-of-hospital cardiac arrest (OHCA). We found the significant shortening of LFD during the study period (IHCA, slope -5.39 [min/3-year], P<0.0001; OHCA, slope -5.49 [min/3-year], P=0.0084). In the multivariable regression, the shorter LFD was significantly associated with better 90-day survival and a favorable neurological outcome only in the IHCA group (LFD per minute, 90-day favorable neurological outcome: odds ratio=1.03, 95% confidence interval=1.00-1.06, P=0.046).

Conclusions:

The LFD was significantly shortened over time in both groups of IHCA and OHCA. The shorter LFD was associated with a better 90-day outcome.

P057 Clinical features and outcomes of in-hospital cardiac arrest in Code Blue events: a retrospective observational study

M Akatsuka, H Tatsumi, H Kuroda, S Kazuma, W Aisaka, S Suzuki, K Kikuchi, Y Goto, M Kodama, Y Masuda

Sapporo Medical University School of Medicine, Department of Intensive Care Medicine, Sapporo, Japan

Introduction:

In-hospital cardiac arrest (IHCA) is a lethal event. However, IHCA has received less attention than out-of-hospital cardiac arrest (OHCA). There have been some studies on IHCA; however, there is a lack of information on the evidence and clinical features of IHCA compared with information for OHCA. We therefore conducted this study to clarify important aspects of the epidemiology and prognosis of IHCA in patients with code blue activation.

Methods:

We carried out a retrospective observational study of patients with code blue events in our hospital during the period from January 2010 to October 2019. We obtained information on the characteristics of patients including age and gender, IHCA characteristics including the time of cardiac arrest, event being witnessed, presence of bystander cardiopulmonary resuscitation (CPR), initial shockable rhythm, vital signs 1 h or 6 h before cardiac arrest, survival to hospital discharge (SHD), and the cardiac arrest survival postresuscitation in-hospital (CASPRI) score. The primary endpoint was SHD. We performed univariate and multivariate logistic regression analyses.

Results:

A total of 293 code blue events were activated during the study period. Finally, 81 patients were included in this study. Overall, the SHD rate was 28.4%. The median time of CPR was 14 min (interquartile range, 6-28 min). The rate of initial shockable rhythm was 19.8%. There were significant differences in CPR duration, shockable rhythm, and CASPRI score between the SHD group and non-SHD group by univariate-logistic regression analysis. CASPRI score was found to be the most effective predictive factor for SHD (OR=0.98, p=0.006) by multivariate-logistic regression analysis.

Conclusions:

Our results demonstrated that CASPRI score is associated with SHD in CPA patients with in-hospital code blue events. CASPRI score in IHCA patients would be a simple and useful adjunctive tool for management of post-cardiac arrest syndrome (PCAS).

P058 Peri-operative cardiac arrest in prematurity – incidence and causes at a tertiary care hospital between 2008-2018

G Jansen, J Popp, E Lang, R Borgstedt, B Schmidt, S Rehberg

Protestand Hospital of the Bethel Foundation, Anaesthesiology, Intensive Care and Emergency Medicine, Bielefeld, Germany

Introduction:

The peri-operative care of premature pediatric patients requires special expertise and is therefore reserved for specialized centers. Although premature birth is described as a risk factor for peri-operative complications and cardiac arrest (POCA) there are no data on its incidence and causality in this particular population [1]. The present study investigates the incidence and causality of pediatric POCA at a tertiary care hospital and level I perinatal center in Germany.

Methods:

In the anesthesia database of the study center, all anaesthesiological procedures in patients <16 years of age were examined for POCA in preterm infants (gestational age <40th week of gestational age) between 2008 and 2018. The peri-operative period was defined between the beginning of anesthesiological care up to 60 minutes after anesthesia and/or sedation. We defined cardiac arrest as the necessity of chest compressions. The perioperative phase and the cause of the POCA, gestational age and birth weight were recorded.

Results:

Between 2008 and 2018, 308 (1.3%) of the 22,650 pediatric anesthesiological procedures were performed on 301 premature infants. In total, 10 POCA occurred in 9 of these patients (f=6, M=3; average gestional age 208±27 days; average birth weight 1510±747g (incidence 3.2%, CI 96 1.3-5.2%). The time of occurrence and the causes of POCA are shown in Table 1.

Conclusions:

POCA in premature babies is rare and has an incidence of 1.3%, which is significantly higher than the non-premature babies. The main causes are problems or complications associated with the respiratory tract and its management, as well as massive hemorrhage.

References:

1. Habre W et al. Lancet Respir Med 5:412-25, 2017

Table 1 (abstract P058). Perioperative phase and causes of peri-operative cardiac arrest

P059 Peri-operative pediatric cardiac arrest – incidence and mortality in 22,650 pediatric anesthetics at a tertiary care hospital between 2008-2018

G Jansen¹, J Popp², E Lang¹, R Borgstedt¹, B Schmidt¹, S Rehberg¹

¹Protestand Hospital of the Bethel Foundation, Anaesthesiology, Intensive Care and Emergency Medicine, Bielefeld, Germany; ²Protestand Hospital of the Bethel Foundation, Bielefeld, Germany

Introduction:

Peri-operative cardiac arrest (POCA) in children's anesthesia care is a dreaded event. Depending on the country and population, studies describe incidences between 2.9-20.6 per 10,000 children's anesthetics. There are no data on the current incidence of pediatric POCA in Germany. The present study investigates the incidence of POCA at a tertiary hospital and level I perinatal center in Germany.

Methods:

In the anesthesia database of the study center, all anaesthesiological procedures in patients <16 years were examined for POCA. The peri-operative period was defined between the beginning of anesthesia care up to 60 minutes after anesthesia or sedation. Cardiac arrest was defined as the necessity of chest compressions. Age, weight, ASA status, cause of death and survival after 30 days were recorded.

Results:

18 POCA (median weight was 2525g [Q1 7151;Q75(14748)]) were observed in 22,650 anaesthesiological procedures (incidence 7.9±4.2 per 10,000 [CI95 4.3-11.6]). Table 1 shows the distribution of the individual age groups, incidences and mortalities of POCA. Peri-operative 30-day mortality was 3 per 10,000 [CI 95 1-5]. Three children died intraoperatively as a result of hemorrhagic shock, one on the PICU as a result of malignant hyperthermia. 30 days after POCA, 4 more children had died on the ICU due to their underlying disease.

Conclusions:

POCA is a rare event. Risk factors are an age <28 days and an ASA status ≥ III. The main cause of peri-operative death in patients <16 years of age is massive hemorrhage, the 30-day mortality is determined by the underlying disease.

Table 1 (abstract P059). Distribution of age groups

P060 In-hospital cardiac arrest - predicting adverse outcomes

T Partington, J Borkowski, J Gross

Northwick Park Hospital, Anaesthesia/Critical Care, London, United Kingdom

Introduction:

Cardiac arrest occurs in 1.2 per 1000 hospital admissions in the UK. Return of spontaneous circulation (ROSC) is achieved in approximately half of resuscitation attempts, but rate of survival to hospital discharge is substantially lower [1]. In our centre, post-arrest care accounts for 6.4% of ICU admissions. Premorbid social function is purported to affect outcomes, but comorbidity scores are more often used for risk stratification. Using a novel Social Function Score alongside an existing comorbidity scale, we aimed to identify trends to inform management of patients at risk of deterioration.

Methods:

A six-month prospective observational study was conducted in a major UK hospital from October 2017 to April 2018. For all adult inpatient cardiac arrests, medical notes were reviewed and data collected on the following domains:

Patient demographics

• Comorbidities and functional status

• Admission details

• Post-arrest events

Statistical analysis was performed using Student’s unpaired t-test.

Results:

54 cardiac arrests occurred. 85% were in medical patients, with the majority male (63%) and aged over 75 (63%). 89% were emergency admissions, with mean duration of hospital stay pre-arrest 9 days. In 17 cases (31%) sustained ROSC was achieved. However, seven of these (41%) were not subsequently admitted to the ICU. Only six patients (11%) survived to hospital discharge. Pre-admission function and comorbidity were worse in patients who did not survive to discharge (Fig. 1), but these were not statistically significant in view of small survivor group size.

Conclusions:

In an increasingly frail inpatient population, a substantial proportion of patients in whom circulation is restored after cardiac arrest are subsequently considered unsuitable for ICU admission. Given our understanding of inferior outcomes in patients with poor physiological reserve, we encourage early discussion regarding the appropriateness of CPR in selected patients, guided by social function and comorbidity.

References:

1. National Cardiac Arrest Audit 2017/18

Fig. 1 (abstract P060).

Box and whisker plots displaying a) Modified Charlson Comorbidity Index and b) Social Function Score at time of admission, in patients alive at hospital discharge (blue) vs. dead (orange)

P061 Investigation of factors determining mortality in out-of-hospital cardiac arrest (OCHA)

C Balci¹, O Kucuk², E Haftaci³, E Karaca⁴, S Ozbay⁴, H Karaca⁴

¹Kutahya Healty Science Un, Anaesthesiology and Reanimation, Kutahya, Turkey; ²Balıkesir City Hospital, ICU, Balıkesir, Turkey; ³Karaman Goverment Hospital, Karaman, Turkey; ⁴Derince Traning Hospital, Anaesthesiology and Reanimation, Kocaeli, Turkey

Introduction:

There are studies that determine events related to poor outcome in cardiac arrest [1].  In our study, following parametres were determined OHCA patients; age median years, Asian/Europe/Syrian, Bystander CPR, Bystander AED, EMS defibrillation, initial cardiac rhythm, prehospital ROSC, corneal and pupillary light reflex and day survival. We determineted poor prognostic sign with post-cardiac arrest patients. In this study, we identified the causes of poor outcome in patients with OHCA.

Methods:

This was a single-centre, retrospective study.  We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm. Our study population were non-traumatic OHCA. Our ICU, All OHCA patient were evaluated wtih ECHO, and fluid, inotrope and vazopressor were added according to cardiac performance.

Results:

During our study, 5970 patients who were admitted to intensive care unit between 2012-2019 were screened. 133 of these patients were out-of-hospital arrest and 41 of them were in-hospital arrest. Development of cerebral oedema during treatment in hospital remains a poor prognostic sign. The evaluation of initial cardiac ritm is useful to predict neurological outcome in post-cardiac arrest patients.

Conclusions:

Survival after OHCA remains low. The evaluation of initial cardiac ritm is useful to predict mortality and neurological outcome in post-cardiac arrest patients.

References:

1. Ørbo M et al. Resuscitation 85 :1462-1468, 2014

P062 Time factors, basic life support performance and outcomes of out-of-hospital cardiac arrests detected by schoolchildren

H Inaba¹, K Takada², H Kurosaki², Y Wato³, A Yamashita²

¹ Kanazawa University Graduate School of Medicine, Department of Circulatory Emergency and Emergency Medical Science, Kanazawa, Japan; ²Kanazawa University Graduate School of Medicine, Kanazawa, Japan; ³Kanazawa Medical University, Uchinada, Japan

Introduction:

Basic life support (BLS) education and training for school children is active in Japan. However, the BLS action by schoolchildren may be limited by school rules. This study aimed to analyse the time factors for basic life support performance and outcome in classmate-witnessed out-of-hospital cardiac arrest (OHCA) and to investigate how schoolchildren act when they detect OHCA.

Methods:

Nation-wide database for 1,068 school children cases with OHCA and local extended database for 5,478 EMS-unwitnessed OHCA, both of which were prospectively collected during the period of 2011–2016, were retrospectively analysed.

Results:

Proportion of schoolchildren-detected OHCA was low in classmate cases (16.8%, 179/889) in nationwide database and extremely low in all EMS-unwitnessed OHCAs (1.6%, 88/5,478) in local database. Nationwide database analyses revealed that both emergency call and bystander CPR were delayed when a classmate witnessed the OHCA case: median, 1 vs. 0 min and 3 vs. 2 min, respectively. Classmate-witnessed cases were associated with higher incidences of shockable initial rhythm, AED use and traumatic causes. The rate of neurologically favourable outcome was 19.6% and 12.3%, respectively in classmate-witnessed and other cases: adjusted OR; 99% CI, 1.24; 0.63–2.47. Of 88 cases detected by schoolchildren in our prefecture, 8 (34%) cases had presumed cardiac aertiology and 12(13.8%) cases were caused by suicide attempts (hanging and fall). School children placed emergency 119 calls as the first action only in 32 (36.4%) cases. Emergency calls were largely delayed when school children dialled other numbers or left the scene to seek adult help. School children were rarely involved in bystander CPR (21%) and AED placement (1%).

Conclusions:

School children are rarely involved in entire BLS. Emergency calls and bystander CPR are delayed when schoolchildren act to seek help. Because schoolchildren detect suicide-related OHCAs, psychological care to schoolchildren involved in BLS may be necessary.

P063 Prognostic value of neutrophil/lymphocyte and platelet/lymphocyte predicting cardiopulmonary resuscitation with spontaneous circulation recovery

C Li

the Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China

Introduction:

To investigate the predictive value of peripheral blood neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) on in-hospital mortality in patients with spontaneous circulation recovery after cardiac arrest.

Methods:

A retrospective analysis was made of 30 patients who recovered from cardiac arrest in our hospital from April 2012 to November 2018 and were admitted to the intensive care unit for more than 24 hours. They were divided into survival group and death group according to the outcome of discharge.The dynamic changes and differences of NLR and PLR in 24 hours and 48-72 hours after admission to ICU between the two groups were analyzed and compared. Multivariate analysis and ROC curve were used to explore the predictive value of NLR and PLR for in-patient mortality.

Results:

Compared with the survival group, PLR in the dead group was significantly lower within 24 hours of admission to the intensive care department (P < 0.05), while NLR in 48-72 hours was significantly higher (P < 0.05). The NLR of surviving group was significantly lower than that of 24 hours (P < 0.05), while the NLR and PLR of death group were not significantly different (P < 0.05) from that of 24 hours (P < 0.05). Multivariate logistic regression analysis and ROC curve showed that NLR of 48-72 h in ICU was an independent risk factor for predicting in-patient mortality, and had high sensitivity and specificity in predicting death outcomes.

Conclusions:

Neutrophil to lymphocyte ratio, platelet to lymphocyte ratio can help to judge the outcome of patients with cardiac arrest and recovery of autonomic circulation after cardiopulmonary resuscitation.

P064 Neurofilament light chain as an outcome predictor after cardiac arrest

L Wihersaari¹, N Ashton², M Reinikainen¹, P Jakkula³, V Pettilä³, J Hästbacka³, M Tiainen³, K Blennow², H Zetterberg², MB Skrifvars³

¹University of Eastern Finland and Kuopio University Hospital, Department of Anaesthesiology and Intensive Care, Kuopio, Finland; ²University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden; ³University of Helsinki and Helsinki University Hospital, Helsinki, Finland

Introduction:

High concentrations of neurofilament light chain (NFL) in serum predicted poor outcome in patients resuscitated from cardiac arrest [1]. We aimed to evaluate the prognostic value of NFL in COMACARE trial [2,3] patients who were resuscitated from cardiogenic out-of-hospital cardiac arrest (OHCA) with a shockable initial rhythm.

Methods:

Using the commercially available Single Molecule Array (Simoa) NF-light immunoassay (Quanterix, Lexington, MA), we measured NFL levels from plasma taken 48 h after OHCA. We assessed neurological outcome six months after OHCA and defined good outcome as Cerebral Performance Category (CPC) 1-2 and poor outcome as CPC 3-5.

Results:

Overall, six-month outcome was good for 73 of 112 (65.2%) patients. The median (interquartile range) NFL concentration at 48 h was 19 pg/ml (11-31) in the patients with good outcome and 2343 pg/ml (587-5829) in those with poor outcome, p<0.001. NFL at 48 h predicted poor outcome with an area under the receiver operating characteristic curve (ROC) of 0.98 (95% CI, 0.97-1.00). With the cutoff 263 pg/ml, the sensitivity was 0.83 (95% CI, 0.71-0.96), specificity was 0.99 (95% CI, 0.96-1.00), and the positive likelihood ratio was 60.8 (95% CI, 8.6-428.4)

Conclusions:

In patients resuscitated from OHCA with a shockable rhythm, the plasma NFL concentration at 48 h after cardiac arrest had an excellent ability to predict 6-month outcome.

References:

1. Moseby-Knappe M et al. JAMA Neurol 76:64-71, 2019.

2. Jakkula P et al. Intensive Care Med 44:2091-2101, 2018.

3. Jakkula P et al. Intensive Care Med 44:2112-2121, 2018.

P065 Changes in iron metabolism and prognosis of patients with out-of-hospital cardiac arrest

P Aries¹, O Huet¹, O Tocquer¹, M Consigny², T Lefebvre³, M Padelli⁴, E Lher⁵, JM Tonnelier⁵, C Aubron⁵

¹Brest Teaching Hospital, Departement of Anaesthesia and Surgical Intensive Care, Brest, France; ²Brest Teaching Hospital, Centre d’Investigation Clinique CIC INSERM 1412, CHRU Brest, Brest, France; ³Hôpital Louis Mourier HUPNVS, Biochimie/Centre Français des Porphyries, Colombes, France; ⁴Brest Teaching Hospital, Département de Biochimie et Pharmaco-toxicologie, Brest, France, ⁵Brest Teaching Hospital, Department of Medical Intensive Care Unit, Brest, France

Introduction:

Out-of-hospital cardiac arrest (OHCA) remains associated with a very high mortality and poor long-term prognosis.  Ischemia reperfusion through lesions due to oxidative stress is responsible for cell damages and free iron may play a key role in these phenomenons. Little is known about magnitude of changes in iron metabolism parameters after cardiac arrest and its association to patient’s prognosis.

Methods:

This is a single centre cohort study.  Adults admitted for OHCA and receiving targeted temperature management were eligible. Free iron, transferrin saturation coefficient, ferritin, hepcidin and soluble transferrin receptor were measured in plasma at ICU admission (H0), at 24 hours (H24) and 48 hours (H48). SOFA score changes were calculated between H0, H24 and H48. Demographic data and neurological status at 6 months with Cerebral Performance Category score (CPC score) were also assessed. (NCT number:NCT03491670)

Results:

Between May 2018 and March 2019,31 patients were hospitalized for OHCA and 25 patients have been included. The reasons for cardiac arrest were asystole in 13 patients (52%) and shockable rhythm in 10 patients (40%). Hospital mortality was 68% (17 patients) and 19 patients had a poor neurological outcome (CPC score 3-5 or death) at 6 months. Mean SOFA score at H0 was 11.40 ± 3.14. Mean free iron level at ICU admission was 22.46± 12.41 μmol/l and significantly decreased between H0 and H48 (mean: 22.46 ± 12.41 μmol/l vs 5.27±6.10μmol/l; p = 0.0003). At H48, patients with SOFA score > 12 (vs SOFA score ≤ 12) had a higher free iron level (35.5 μmol/l vs 16 μmol/l, p = 0.0333) (Figure 1). We found a positive correlation between free iron level at H0 and changes of SOFA score between H0 and H48 (r= 0.56 IC95[0.08;0.76]).

Conclusions:

Out-of-hospital cardiac arrest is associated with a significant change of plasma free iron level. Free iron level at admission is associated with short term outcome. Further research is warranted to better determine the significance of such changes.

Fig. 1 (abstract P065).

Comparison of serum free iron level at admission, 24 hours and 48 hours according to SOFA score at 48 hours

P066 Association between early hyperoxia after out of hospital cardiac arrest with return of spontaneous circulation and 30-day survival

A Awad¹, J Olsson², P Nordberg¹, M Jonsson³, M Ringh¹, J Hollenberg³, E Joelsson-Alm²

¹Karolinska Institute, Solna, Sweden, Department of Medicine, Center for Resuscitation Science, Solna, Stockholm, Sweden; ²Karolinska Institute, Solna, Sweden, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden, Solna, Stockholm, Sweden; ³Karolinska Institute, Solna, Sweden, Solna, Stockholm, Sweden

Introduction:

The optimal level of arterial oxygen in the post-resuscitation period is unknown. Recent studies show conflicting results in regard to hyperoxia and its association with survival after out-of-hospital cardiac arrest (OHCA) [1]. The aim of this trial is to study the association between early hyperoxia after OHCA with return of spontaneous circulation (ROSC) and 30-day survival.

Methods:

Observational study using data from three Swedish national registers (i.e. intensive care, cardiac arrest and national patient registries). Resuscitated OHCA patients, who are unconscious (Glascow Coma Scale ≤8) and admitted to an ICU between January 2010-March 2016 were included. Patients were divided into 4 groups based on lowest PaO₂ within 1 hour from ICU arrival. Hypoxia was defined as PaO₂<60 mmHg, normoxia as PaO₂ 60-100 mmHg, hyperoxia as PaO₂ 100-400 mmHg and severe hyperoxia as PaO₂ > 400 mmHg. Multivariate logistic regression was performed. The primary endpoint was 30-day survival.

Results:

In total, 3496 patients were included in the analysis of which 284 patients had hypoxia, 1490 had normoxia, 1448 had hyperoxia and 274 had hyperoxia. The crude 30-day survival rates were 27.1% in the hypoxia group, 38.1% in the normoxia group, 34.9% in the hyperoxia group and 25.9% in the severe hyperoxia group (Figure 1). The hyperoxia group had significantly lower 30-day survival compared to the normoxia group, adjusted odds ratio 0.62 (95% confidence interval 0.44-0.89, p=0.01). The difference in survival between the other groups compared to the normoxia group did not meet statistical significance.

Conclusions:

In this Swedish observational cohort study of resuscitated OHCA patients, early severe hyperoxia, compared to normoxia, was associated with significantly lower 30-day survival. This is in accordance with several previous reports and warrant further studies.

References:

1. Wang CH et al. Resuscitation 85:1142-1148, 2014

Fig. 1 (abstract P066).

Comparison in 30-day survival between different groups according to lowest PaO2 (mmHg) within 1 hour from ICU arrival. Adjusted odds ratios (OR) are used and the normoxia group is used as a reference group

P067 Correlation between increased inflammation and early-onset pneumonia in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation

D Shiba¹, T Hifumi², N Otani², S Ishimatsu²

¹St. Luke´s International Hospital, Emergency Department, Tokyo, Japan; ²St. Luke´s International Hospital, Tokyo, Japan

Introduction:

After a successful resuscitation, a systemic inflammatory response occurs, and the C-reactive protein (CRP) level represents the degree of inflammation [1-3]. This study examined the association between increased inflammation and early-onset pneumonia (EOP) in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) after out-of-hospital cardiac arrest (OHCA).

Methods:

This retrospective study included data of patients with OHCA treated with ECPR admitted to St. Luke’s International Hospital between April 2006 and April 2019. The exclusion criteria were as follows: age < 18 years, therapeutic hypothermia withdrawal due to death or circulatory failure, or sepsis as a suspected cause of cardiac arrest. Patients were diagnosed with EOP according to clinical signs and symptoms acquired after a hospitalization period of >48 h and within 7 days of admission. The CRP levels were measured daily from admission to day 3.

Results:

We studied 55 patients with a median age of 55 years (interquartile range: 42-65 years). Furthermore, 52 (95%) patients were males, and the median time interval from collapse to adequate flow was 51 (42-63) min. All patients received prophylactic antibiotics, and 18 (33%) of them had favorable neurological outcomes (CPC, 1-2). EOP occurred in 32 (58%) patients, with a significantly higher CRP level on day 3 than that in those without EOP (13.9 [11.2-19.0] mg/dL vs. 10.9 [7.3-13.6] mg/dL, p = 0.006). Multivariable analysis revealed that the CRP level on day 3 (odds ratio, 1.28; 95% confidence interval, 1.06-1.56; p = 0.002) was significantly associated with EOP development.

Conclusions:

Increased inflammation correlated with EOP development in patients with OHCA treated with ECPR.

References:

1. Francois B et al. N Engl J Med 381:1831-1842, 2019

2. Dell'anna AM et al. Resuscitation 85:932-938, 2014

3. Shiba D et al. Circ Rep 1: 575–581, 2019

P068 Mode of death after cannulation for venoarterial extracorporeal membrane oxygenation, insights from a single center registry

V Zotzmann¹, J Rilinger², CN Lang², M Jäckel², T Wengenmayer², C Bode ², D Staudacher³

¹University of Freiburg, Heart Center, Freiburg, Germany; ²University of Freiburg, Freiburg, Germany; ³University of Freiburg, University of Freiburg, Freiburg, Germany

Introduction:

Categorizing reasons for death after eCPR is important for comparing outcomes to other studies, assessing benefits of interventions, and better define this heterogeneous patient collective. A categorizing for death after cardiac arrest in both in-hospital (IHCA) and out-of-hospital (OHCA) arrests has been proposed in non-eCPR patients by Witten et al. Here, we adopt this categorization to eCPR patients.

Methods:

Single-center, retrospective, cohort study of patients without ROSC after IHCA or OHCA and eCPR between 2010 and 2017. Patients with survival below 24 hours were excluded. Patients were allocated to one of five predefined reasons for death.

Results:

231 va-ECMO patients were included (age 58.6±14.3, 29.9% female, 58% eCPR, 30 day survival 42.9%). Reasons for death for patients with va-ECMO for shock (survival 53%) and eCPR (36%) were: neurological withdrawal of care (10% vs 25%), comorbid withdrawal of care (18% vs 4%), refractory hemodynamic shock (16% vs 33%), respiratory failure (3% vs 2%), and withdrawal due to presumed patient will (0% vs 1%) (Figure 1). The differences in reasons for death among the two groups were significant (p <0.001), driven by withdrawal due to neuroprognostication, comorbidity and hemodynamic instability.

Conclusions:

Categorizing death after va-ECMO into five categories is feasible. There are significant difference between patients with va-ECMO for shock and eCPR. Interestingly, only a quarter of patients after eCPR died due to brain damage.

Fig. 1

(abstract P068). Mode of death in VA-ECMO patients and patients after ECPR

P069 ECMO mobile team for donor cardiac death. a pilot ECMO-TT study

R Badenes¹, C Álvarez², F Hornero³, J Guijarro³, JM Segura³, R Zaragoza²

¹Hospital Clinic Universitari de Valencia, Department of Anesthesiology and Surgical-Trauma Intensive Care, Valencia, Spain; ²Hospital Dr. Peset, Valencia, Spain; ³Hospital Clinic Universitari de Valencia, Valencia, Spain

Introduction:

Scarcity of potential dead brain donors and the persistent mismatch between supply and demand of organs for transplantation has led the transplant community to reconsider donation after circulatory death (DCD) as a strategy to increase the donor pool. Normothermic regional perfusion (nRP) by extracorporeal membrane oxygenation (ECMO) may be the most effective method for preserving abdominal organs in DCD, especially in liver transplantation [1, 2]. A pitfall of this method is its complexity and the unavailability of this resource in some hospitals, especially in regional hospitals, where potential DCD donors may exist. Aim of this study is to report the use of Mobile ECMO team in controlled DCD.

Methods:

From June 2018 to November 2019 our group has worked as a mobile ECMO team for cDCD outside our center. Portable equipment included cannulation material and the ECMO device. The transplant team consisted of 1 transplant coordinator (anesthesiologist-intensivist, ECMO operator and organ extraction supervisor), 1 cardiac surgeon (cannulation), 1 interventional radiologist (cannulation) and one cardiovascular perfusionist (ECMO operator).

Results:

Twenty-five cDCD donations were performed. Characteristics of donors and organs retrieved are summarized in Figure 1. From 25 cDCD, 17 livers, 4 lungs, 45 kidneys were obtained. The evolution of grafts and receptors was favorable at day 30 post-transplant.

Conclusions:

Mobile ECMO teams may enable cDCD in hospitals without these resources, thereby increasing the pool of donors and optimizing graft outcomes.

References:

1. Oniscu GC et al. Am J Transplant 14:2846 2854, 2014.

2. Eren EA et al. Exp Clin Transplant 5:463 470, 2016.

Fig. 1 (abstract P069).

WLST, withdrawal of life sustaining therapy; ICU, intensive care unit; M, male; F, female; TBI, traumatic brain injury; L, liver; RL, right lung; LL, left lung; RK, right kidney; LK, left kidney

P070 Veno-venous extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant

C Palfreeman, P Vila, J Sokhi, A Hurtado-Doce

Harefield Hospital, Critical Care, Harefield, United Kingdom

Introduction:

The demand for donor lungs is still considerably greater than supply. 17% of patients listed for a lung transplant die within one year [1]. Veno-venous (VV) ECMO is an effective bridging strategy for patients listed for transplant, with end stage respiratory failure, who acutely deteriorate.

Methods:

A retrospective observational study of patients supported by VV ECMO whilst awaiting lung transplantation, over a 67-month period (March 2014- October 2019) at Harefield Hospital, in the UK.

Results:

32 patients with an acute deterioration of their end-stage lung disease required VV ECMO support as a bridge to transplantation (BTT). The mean age was 34.8 years (range 19-57), 62% were male patients. Aetiology included; end stage cystic fibrosis (n=24, 75%), pulmonary fibrosis (n=4, 12.5%), previous lung transplant failure (n=2, 6.3%), bronchiectasis (n=1, 3.1%) and pulmonary hypertension (n=1, 3.1%). Average duration of ECMO support pre-lung transplant was 11.1 days (range 1-39 days). Cannulation was femoral-femoral (n= 20), Avalon Elite® (n = 6) and femoral – jugular (n= 6). 19 patients (59.4%) underwent lung transplant on VV ECMO support, the others required conversion to veno-arterial (VA) ECMO or cardiopulmonary bypass, most commonly due to hemodynamic compromise. Average duration of invasive ventilation post-transplant was 19.8 days, with 18 patients (56.3%) requiring a tracheostomy. The mean ICU stay was 25.6 days, with an ICU mortality of 21.9% (n =7); in keeping with the literature [2]. However, patients requiring intubation despite VV ECMO (n=7), pre-transplant had a far higher mortality (n=5, 71.4%).

Conclusions:

VV-ECMO is a recognized support therapy for patients awaiting lung transplant. Our overall survival to discharge of 78.1%, suggests favourable outcomes are achievable.

References:

1. NHS Blood and transplant, 2017. Annual report on cardiothoracic organ transplantation 2016/17.

2. Chiumello D et al. Crit Care 19:19, 2015.

P071 What is the useful coagulation and fibrinolysis marker for predicting extracorporeal membrane oxygenation circuit exchange due to intra-circuit thrombus?

Y Izutani, K Hoshino, S Morimoto, K Muranishi, J Maruyama, Y Irie, Y Kawano, H Ishikura

Fukuoka University Hospital, Emergency and Critical Care Center, Fukuoka-shi, Japan

Introduction:

A thrombus formation is one of the most frequent and adverse complications during extracorporeal membrane oxygenation (ECMO) support. Previous studies have reported that increased D-dimer is a useful predictor of thrombus formation within the ECMO circuit. The purpose of this study was to identify coagulation/fibrinolysis markers for predicting the replacement of ECMO circuit due to intra-circuit thrombus during ECMO support.

Methods:

Fourteen patients who underwent veno-venous ECMO for acute respiratory failure between January 2014 and December 2018 were enrolled. These patients received a total of 125 days of ECMO support. Of these, 9 days (times) on which the ECMO circuits were replaced was regarded as the replacement group, while the remaining 116 days were considered as the non-replacement group. The several coagulation/fibrinolysis markers were routinely measured every day during ECMO support. we compared with the levels of these markers between two group to identify the most relevant marker for ECMO circuit replacement due to thrombus.

Results:

The mean duration of ECMO support was 9±11 days, and the mean number of ECMO circuit replacement was 0.6±1.0 times per patient. D-dimer, Thrombin-antithrombin complex (TAT), Plasmin-α2 plasmin inhibitor complex (PIC), and soluble fibrin (SF) were significantly higher in the replacement group rather than in the non-replacement group (P < 0.01, respectively). According to a multivariate analysis, SF was the only independent predictor of ECMO circuit replacement due to thrombus. The odds ratio (95% confidence intervals) for SF (10 μg/mL) was 1.2 (1.1-1.3). The area under the curve and optimal cut-off value were 0.94 and 85 ng/mL for SF, respectively (sensitivity, 100%; specificity, 85%).

Conclusions:

From these results, we concluded that SF may be the useful marker rather than D-dimer for predicting the replacement of ECMO circuit due to intra-circuit thrombosis.

P072 Inhomogeneity of lung elastance in patients who underwent veno-venous extra corporeal membrane oxygenation (V-V ECMO)- a computed tomography scan study

RD Di Mussi¹, RI Iannuzziello², FM Murgolo², FD De Carlo², E Caricola², NA Barrett³, LC Camporota³, SG Grasso²

¹Università degli studi di Bari "Aldo Moro", Department of emergencies and organ transplant, Bari, Italy; ²Università degli studi di Bari "Aldo Moro", Bari, Italy; ³Department of Adult Critical Care, Guy´s and St Thomas´ NHS Foundation Trust, King´s Health Partners, London, UK

Introduction:

In patients with acute respiratory distress syndrome (ARDS), nonaerated, poorly aerated, and normally aerated regions coexist to variable degrees in lung parenchyma. The recruitment maneuvers aim to re-open collapsed lung tissue. In a theoretical point view, this strategy may also prevent the normal aerated lung tissue hyperinflation [1]. The objective of our study was to evaluate lung characteristics in terms of Hounsfield Units (HU), volume and elastance before and after a recruitment maneuver.

Methods:

In 37 patients with severe ARDS who underwent V-V ECMO, computed tomography scans (CT-scans) at 5 cmH₂O of continuous positive airway pressure (CPAP) and 45 cmH₂O were performed. The same CT image was selected at the two different levels of pressure. The distribution of lung opacities, in terms of HU, was classified using the “UCLA” colour coding table (OsiriX image processing software, Geneva, Switzerland). Correspondent lung regions of about 1020 voxels were selected. The quantitative analysis, in terms of Volume air (Vair) was performed with Maluna software (Version 3.17; Maluna, Goettingen, Germany). Elastance was calculated as the pressure(cmH₂O)/ Vair (ml) ratio.

Results:

See Figure 1.

Conclusions:

Lung inhomogeneity occurs also after recruiting maneuvers. Our data confirm that the elastance of recruited lung regions is higher than the elastance of the normal aerated lung regions at low positive end-expiratory pressure (PEEP) (baby lung). On the contrary the “baby lung” frequently develops hyperinflation. The unpredictable pattern of distribution of volume after recruitment maneuverers may explain the controversial role of PEEP during the ARDS treatment.

References:

1. Camporota L et al. Crit Care Med 47:1177-1183, 2019

Fig. 1 (abstract P072).

Variations in terms of HU, Vair and elastance in the correspondent lung regions at the two different levels of CPAP

P073 Phase 3, pilot, prospective, randomized, single blinded, multicenter, controlled, two-arm trial on antithrombin supplementation during extracorporeal membrane oxygenation. the GATRA (Grifols Antithrombin Research Awards) study

M Panigada¹, A Cucino¹, E Cipriani¹, S De Falco¹, E Spinelli¹, G Occhipinti², G Panarello², A Arcadipane², A Pesenti¹, G Grasselli¹

¹Fondazione IRCCS Ca´ Granda Ospedale Maggiore Policlinico, Intensive Care Unit, Milano, Italy; ²Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), Intensive Care Unit, Palermo, Italy

Introduction:

Supplementation of antithrombin (AT) might decrease heparin requirement to achieve an adequate level of anticoagulation during extracorporeal membrane oxygenation (ECMO). Formal recommendations on target, timing, and rate of AT supplementation are lacking. We conceived this study to evaluate the effect of prolonged AT supplementation in adult patients requiring veno-venous ECMO for respiratory failure on heparin dose, adequacy of anticoagulation and safety

Methods:

Before ECMO start patients were randomized to either receive AT supplementation to maintain a functional AT level between 80 and 120% (AT supplementation group) or not (control group) for the entire ECMO course. Anticoagulation was provided with unfractionated heparin following a standardized protocol [1]. The primary outcome was the dose of heparin required to maintain the ratio of activated partial thromboplastin time between 1.5 and 2. Secondary outcomes were the adequacy of anticoagulation measured with anti-Factor Xa and the incidence of hemorrhagic and thrombotic complications and amount of blood products transfused

Results:

From August 2017 to March 2019, 72 patients were screened and 49 enrolled in the study. Forty-eight patients underwent final analysis (1 patient was excluded for erroneous randomization). Patients did not differ with regards to baseline characteristics. AT (%) was 82.6±23.3 % in the control group and 106.2±22.3 %, p=0.001 in the treatment group. Supplementation of AT did not decrease heparin dose (14.9±6.2 vs 13.8±6.6 IU/Kg/h in the control and treatment group respectively, mean difference: -1.2 (95% CI: -3.7; - 1.2), p=0.33) and anti-Factor Xa levels. Bleeding, blood product transfusions and thrombosis were comparable in the two groups

Conclusions:

AT supplementation did not decrease heparin requirement in patients on veno-venous ECMO for respiratory failure

References:

1. Panigada et al. Ann Intensive Care 8:1–9, 2018

P074 Prone positioning while extracorporeal membrane oxygenation therapy in severe ARDS

J Rilinger, V Zotzmann, X Bemtgen, PM Biever, D Duerschmied, C Bode, DL Staudacher, T Wengenmayer

Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany

Introduction:

Prone positioning (PP) improves survival in patients with severe ARDS. However, there is little evidence if PP is able to improve outcome in veno-venous extracorporeal membrane oxygenation (ECMO) patients. Therefore, we performed a retrospective analysis of patients treated with PP while ECMO support.

Methods:

We report retrospective data of a single-center registry of all patients treated with veno-venous ECMO for severe ARDS between October 2010 and Mai 2018 at the Interdisciplinary Medical Intensive Care Unit at the Medical Center, University of Freiburg, Germany. ECMO weaning success and survival were analysed before and after propensity score matching. Moreover, predictive factors for survival in patients with PP while ECMO were analysed.

Results:

A total of 158 patients with complete medical data could be analysed (age 52.2 years, 67% male). 38 patients (24.1%) received PP while ECMO therapy. There was no difference in ECMO weaning rate (47.4% vs. 46.7%, p=0.940) or ICU and hospital survival (36.8% vs. 36.7%, p=0.984, Fig. 1 A) between patients with and without PP while ECMO therapy. Propensity score matching confirmed this finding (survival: 36.8% vs. 42.1%, p=0.639). However, early initiation of PP while ECMO support (cut off via Youden-Index <0.71 days) was associated with superior survival in univariate and multivariate analysis (Odds ratio 20.6 [95%-CI 1.4-312.9], p=0.029, Fig. 1 B).

Conclusions:

This retrospective analysis was not able to show a survival benefit for additive PP to ECMO support in general. Early initiation of PP could be an important factor for improving survival in this setting and should be considered in a randomized controlled trial for further evaluation.

Fig. 1 (abstract P074).

A) Survival of ECMO patients with vs. without prone positioning while ECMO. Initial survival differences equalized in Kaplan-Meier survival curve after 30 days (Log rank=0.109). B) Survival depending on early prone positioning after initiation of ECMO support. Patients treated with early PP while ECMO showed a superior survival to patients treated with late PP or without PP while ECMO. Optimal cut off value for duration of ECMO initiation to first PP was calculated using ROC-analysis (AUC = 0.789) and the Youden-Index. Highest sensitivity and specificity for beneficial survival were achieved for a beginning of PP in <0.71 days. (Log rank=0.018). PP: Prone positioning

P075 Cause-specific mortality during extracorporeal membrane oxygenation, a single center review of medical records

M Panigada, D Tubiolo, P Properzi, G Grasselli, A Pesenti

Fondazione IRCCS Ca´ Granda Ospedale Maggiore Policlinico, Intensive Care Unit, Milano, Italy

Introduction:

Mortality during Extracorporeal Membrane Oxygenation (ECMO) settles around 35% and the occurrence of bleeding during ECMO is associated with a high mortality rate. However, cause-specific mortality is rarely reported, probably due to the difficulty of its classification. The purpose of the study was to evaluate the agreement between two expert ICU physician in the classification of the cause of death of patients supported with ECMO for either respiratory or cardiac support.

Methods:

Two Intensive Care Unit (ICU) expert staff physicians independently reviewed the entire medical records of all ECMO patients who died before ICU discharge from January 2011 to September 2019 at Fondazione IRCCS Ca’ Granda, Milan. They were asked to choose the cause of patient’s death among six categories. In case of disagreement, a third expert adjudicated the case. The two reviewers were also asked whether, in their opinion, bleeding during the last 24 hours contributed to death. ELSO definition of major bleeding [1] during the last 24 hours was also recorded for each patient.

Results:

Two-hundred and two patients were supported with ECMO of whom 70 (34.6%) died. Most of these patients (N=53, 75.7%) died during ECMO. Interrater agreement for cause-specific mortality between the two expert physicians was substantial (k 0.71, SE 0.07, p<0.01) Of the 14 discordant cases 6 were categorized as refractory respiratory failure and 4 as multiorgan failure and septic shock respectively. The distribution of cause-specific mortality is shown in Figure 1. Major bleeding (ELSO) was present in 27 (38.6%) patients, only in 9 (33.3%) of them bleeding contributed to death according to the reviewers.

Conclusions:

The most common cause of death during ECMO in our cohort was multiorgan failure with substantial agreement between the two reviewers. Apparently, major bleeding contributed to death only in a small proportion of patients.

References:

1. https://www.elso.org/portals/0/files/elsoanticoagulationguideline8-2014-table-contents.pdf

Fig. 1 (abstract P075).

Causes of death during ECMO

P076 Non-invasive mechanical ventilation in veno-venous extracorporeal membrane oxygenation

J Rilinger, V Zotzmann, X Bemtgen, PM Biever, D Duerschmied, C Bode, DL Staudacher, T Wengenmayer

Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany

Introduction:

Veno-venous extracorporeal membrane oxygenation (ECMO) support can be combined with a variety of different non-invasive ways to deliver oxygen to the patient’s lung. Several positive effects might be linked to this so called “awake ECMO”. So far there is little evidence about indications and outcome of this approach.

Methods:

We report retrospective registry data on all ARDS patients treated with ECMO support at a university hospital between 10/2010 and 04/2019. In a systematic review of medical records, we distinguished between patients with invasive mechanical ventilation (IMV) from the initiation of ECMO therapy (IMV group) and patients that received any kind of non-invasive oxygen supply (non-IMV group).

Results:

A total of 276 patients could be analysed. 16 (5.8%) patients received non-IMV ECMO support. Patients receiving non-IMV ECMO therapy showed severe underlying pulmonary disease and immunosuppression (Fig. 1). These patients had higher rates of lung fibrosis, long-term oxygen therapy, pulmonary hypertension, renal insufficiency and immunosuppression (p<0.05). 12 of 16 patients (75%) required IMV during the hospital stay in average 5.3±5.0 [0.8-17.1] days after ECMO initiation. Reasons were hypoxia despite of ECMO, insufficient ECMO-flow, insufficient protective reflexes or patient agitation. Patients with initially non-IMV ECMO support showed a numerical but not significant lower ICU and hospital survival (25.0% vs. 45.4%, p=0.111).

Conclusions:

Non-IMV ECMO support was applied in patients with severe underlying pulmonary disease and/or immunosuppression. In a high proportion of patients the ventilation regime had to be switched from non-invasive to invasive. Survival in this very selected cohort was low. In this retrospective analysis no evident benefit for a non-invasive ventilation strategy could be found. The high proportion of patients who switched from non-IMV to IMV therapy underlines the need for rigorous patient selection.

Fig. 1 (abstract P076).

Underlying pulmonary disease or status of immunosuppression in ECMO patients without invasive mechanical ventilation

P077 Intra-hospital transportation on extracorporeal membrane oxygenation (ECMO) - a single centre experience in Ireland.

Z Siddique, S O´Brien, E Carton, I Conrick-Martin

Mater Misericordiae University Hospital, Department of Critical Care Medicine, Dublin, Ireland

Introduction:

The objective of this study is to evaluate intra-hospital transportation of patients on extracorporeal membrane oxygenation (ECMO). It is a retrospective analysis of prospectively collected database, performed as part of ongoing quality improvement initiatives.

Methods:

The setting of this study is an 18-bed, combined surgical and medical adult Intensive Care Unit (ICU) located in a 570-bed hospital that serves as the national referral centre for Cardiothoracic Surgery, Heart & Lung transplantation and ECMO in Ireland. We reviewed 33 months of data (from 2017 to 2019) regarding patients admitted to our critical care unit who required intra-hospital transfer for diagnostic and/or therapeutic interventions. We also compared the data to available local guidelines.

Results:

23 patients were transported on ECMO on a total of 28 occasions; the most common indication being CT brain (Table 1). ECMO cannulation sites were peripheral in 20 patients, 3 patients were centrally cannulated. Median time from start of the transfer until the patient was returned to ICU was 50 minutes (range: 35-195). The ECMO console was placed on a dedicated ECMO trolley apart from two occasions where it was placed on the patient's bed. Number of staff required for transport was between 4 to 10; with an ICU Consultant as team leader. ECMO specialist nurses were always present on the transport team. 27 transfers were during normal working hours with 1 happening on a weekend. A total of 12 complications occurred during the transports, of which 1 was significant and 11 were not. The significant complication encountered was Ventricular Tachycardia in a V-A ECMO patient which required electrical defibrillation. No adverse events related to transport were seen following return to ICU.

Conclusions:

In this single-centre study, we have demonstrated safe intra-hospital transport of ECMO patients. The use of local guidelines, appropriate personnel and performance during normal working hours is recommended.

Table 1 (abstract P077). Summary of results

P078 A novel approach for flow simulation in ECMO rotary blood pumps

A Supady¹, C Benk², J Cornelis³, C Bode¹, D Duerschmied¹

¹Heart Center Freiburg University, Cardiology and Angiogiology I, Freiburg, Germany; ²Heart Center Freiburg University, Department of Cardiovascular Surgery, Freiburg, Germany; ³FIFTY2 Technology GmbH, 79108 Freiburg, Germany

Introduction:

Extracorporeal membrane oxygenation (ECMO) is used increasingly in critically ill patients suffering from acute respiratory failure, cardiogenic shock or cardiac arrest. However, this therapy can have deleterious side effects such as bleeding or clotting complications and hemolysis. These complications are particularly caused by physical stress acting upon the blood components while passing through the ECMO system, especially within the rotary pump. We here present a novel approach to simulate blood flows through rotary blood pumps used in current ECMO systems in order to better understand the genesis of these complications.

Methods:

Geometries of the Xenios DP3 (Xenios AG, Heilbronn, Germany) rotary pump were reconstructed by CT-scans and manual measurements using computer-aided design (CAD). The Computational Fluid Dynamics (CFD) simulation was performed using the software PreonLab (FIFTY2 Technology GmbH, Freiburg, Germany), which implements a mesh-free Lagrangian method requiring minimal preprocessing of the CAD data. The geometries are introduced to the simulation model as tessellated surfaces. Five operating points have been specified by the rotation of the centrifugal fan and the corresponding inflow and outflow of blood. The blood is approximatively modelled as a Newtonian fluid with a density of 1040 kg/m³.

Results:

PreonLab allows detailed assessment of the blood flow while passing through the rotary pump including analysis of local flow rates, pressure gradients and shear stress acting upon the blood. Dead zones in the fluid flow can be detected which gives reference points for optimizations of the pump design.

Conclusions:

For the first time, we demonstrate a novel approach for flow simulation in an ECMO rotary pump (Figure 1). This approach may help better understand hemodynamics within the extracorporeal system to define optimal operating points or re-design components aiming to limit hemolysis, coagulation disorders and bleeding in seriously ill patients.

Fig. 1 (abstract P078).

Visualization of fluid velocity (in m/s) within the rotary pump (cross-section)

P079 One-year experience of bedside percutaneous VA-ECMO decannulation in a territory ECMO center in Hong Kong

KM Fong, SY Au, PW Leung, KC Shek, HJ Yuen, SK Yung, HL Wu, SO So, WY Ng, KH Leung

Queen Elizabeth Hospital, Intensive Care Unit, Hong Kong

Introduction:

When veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) support can be terminated, arteriotomy wounds of the patients of are traditionally closed by open repair in the operation theaters. Lots of manpower are involved and timeslots in operating theaters are scarce. Transport of the critically-ill is risky. Successful VA-ECMO decannulation using percutaneous device called ProGlide has been reported and our group had adopted and modified this approach [1].

Methods:

This is a retrospective study analyzing the one-year experience of bedside VA-ECMO decannulation. Our institution is a 23-bed tertiary ECMO referral center in Hong Kong. Our first bedside decannulation was performed in November 2018, and since then, this practice had replaced the traditional open repair, unless contraindicated. Data from November 2018 to October 2019 were analyzed.

Results:

In the study period, 39 patients received VA-ECMO. 28 survived to decannulation and 25 received bedside percutaneous decannulation. Their median age was 59 (52-67). The default arterial catheter size was 17Fr, with 15 Fr in 3 cases and 19Fr in one. Five (20%) failed percutaneous closure and they were subsequently surgically repaired without additional complications. Among the 20 successful cases, 2 ProGlides were used in 15 cases and 3 used in 5 cases. The procedure time was 27 minutes (15-45), which was faster than 2.5 hours by open repair. Median blood loss was 300mL (250-400). Post procedural clinical and ultrasound Doppler examination revealed minor complications in 4 patients, including 2 arterial clots and one pseudoaneurysm who were managed conservatively and one wound infection requiring exploration. There were no other major vascular complications.

Conclusions:

Bedside percutaneous VA-ECMO decannulation is safe and effective.

References:

1. Au SY et al. J Emerg Crit Care Med. 4:4, 2020.

P080 CD52 positive NKT cells predict survival during veno-arterial extracorporeal membrane oxygenation

EJ Kort¹, MW Weiland¹, EG Eugster¹, EG Grins², SF Fitch³, GM Marco⁴, T Timek⁴, ML Leacche⁴, TJ Boeve⁴, SJ Jovinge⁵

¹Van Andel Institute/Spectrumhealth, Grand Rapids, United States; ²Scania Univ Hosp Lund/Lund Univ, Dep of Clinical Medicine, Scania Univ Hosp Lund/Lund Univ Lund Sweden, Lund, Sweden; ³DeVos CV Res/Fredrik Meijer Heart and Vascular Inst Spectrumhealth, Spectrumhealth, Grand Rapids, MI United States, Grand Rapids, MI, United States; ⁴DeVos CV Res/Fredrik Meijer Heart and Vascular Inst Spectrumhealth, Grand Rapids, MI, United States; ⁵Van Andel Institute/Spectrumhealth, DeVos Cardiovascular Research Program, Grand Rapids, United States

Introduction:

Extra corporeal life support (ECLS) continues to be associated with high mortality rates. Our ability to predict outcome prior to initiation ECLS remains limited. Here we take a single cell RNASeq approach in an effort to identify novel immune cell types that are associated with—and may contribute to—survival on ECLS.

Methods:

Whole genome transcriptomic profiles were generated from ~40,000 peripheral blood monocytes obtained from 38 patients at the time of cannulation for veno-arterial ECLS (VA-ECLS). Within each subpopulation, differential gene expression analysis was performed to identify new markers associated with survival. Findings were validated in a additional cohorts by flow cytometry.

Results:

Surviving patients had significantly higher proportions of CD8⁺ NKT cells (CD3⁺/CD8⁺/CD19^-/CD56⁺) that were CD52⁺ (p = 0.001, FDR < 0.05) (Figure 1). To validate this observation, we performed FC analysis of a second cohort of 20 patients. For each patient, we quantified the proportion of CD8⁺ NKT cells that were CD52⁺. Using the median proportion as the cutoff, we again found that a high proportion of CD52⁺ cells among CD8⁺ NKT cells was predictive of 48 hour survival (p=0.024). We noted that while high levels of CD52+ cells among the CD8+ NKT cells was protective in this cohort of VA-ECLS patients, this relationship did not hold for patients with sepsis. As only a few the VA-ECLS patients were septic, we analyzed a third cohort of septic ECLS patients. We observed that high levels of CD52+ cells among the CD8+ NKT populations was not protective in this population.

Conclusions:

The proportion of CD8+ NKT cells that are positive for CD52 is predictive of survival among patients undergoing VA-ECLS for non-infection related indications.

Fig. 1 (abstract P080).

72 h survival

P081 Neurologic complications in adult postcardiotomy cardiogenic shock patients receiving venoarterial extracorporeal membrane oxygenation: a cohort study

H Wang, D Hou

Beijing Anzhen Hospital, Capital Medical University, Center for Cardiac Intensive Care, Beijing, China

Introduction:

This study aims to describe the prevalence of neurologic complications and hospital outcome in adult post-cardiotomy cardiogenic shock (PCS) patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support and factors associated with such adverse events.

Methods:

415 adult patients underwent cardiac surgery and received V-A ECMO for more than 24h because of PCS. Patients were divided into two groups: those who developed a neurological complication and those who did not (the control group). Multivariable logistic regression was performed to identify factors independently associated with neurologic complications.

Results:

Neurologic complications occurred in 87 patients (21.0%), including cerebral infarction in 33 patients (8.0%), brain death in 30 patients (7.2%), seizures in 14 patients (3.4%), and intracranial hemorrhage in 11 (2.7%) patients. In-hospital mortality in patients with neurologic complications was 90.8%, compared to 52.1% in control patients (p <0.001). In a multivariable model, the lowest systolic blood pressure (SBP) level pre-ECMO (OR, 1.12; 95% CI: 1.08–1.17) and aortic surgery combined with coronary artery bypass grafting (OR, 9.22; 95% CI: 2.10–40.55) were associated with overall neurologic complications (Figur 1). Lowest SBP (OR, 1.22; 95% CI: 1.15–1.31) was the only risk factor of brain death as well. Coagulation disorders (OR, 9.75; 95% CI: 1.83–51.89) and atrial fibrillation (OR, 12.19; 95% CI: 1.22–121.61) were shown to be associated independently with intracranial hemorrhage, whereas atrial fibrillation (OR, 8.15; 95% CI: 1.31–50.62) was also associated with cerebral infarction.

Conclusions:

Neurologic complications in adult PCS patients undergoing VA ECMO support are frequent and associated with higher in-hospital mortality. Identified risk factors of neurologic complications might help to improve ECMO management and might reduce their occurrence.

Fig. 1 (abstract P081).

Risk factors of neurologic complications during extracorporeal membrane oxygenation. SBP, systolic blood pressure; CABG, coronary artery bypass grafting

P082 Use of levosimendan during weaning of mechanical circulatory support

S Hendrickx, J Verbeke, N De Neve, K De Decker

OLV Aalst, Intensive Care, Aalst, Belgium

Introduction:

The use of calcium sensitizers has grown enormously in the last decade, probably due to their interesting pharmacodynamic properties. Levosimendan (LS) is frequently administered in patients under mechanical circulatory support. We performed a retrospective evaluation of patients treated with LS prior to weaning from mechanical support. This evaluation was combined with a review of the literature.

Methods:

A query of our ICU patient data management system revealed 22 patients receiving LS prior to or during VAD/ECLS support. Outcome data were obtained from the patients medical records.

Results:

Of our 22 patients, 78% was successfully weaned off ECLS. Fourteen patients (63 %) died before being discharged of whom 5 while on ECLS support. Of the weaned patients, 9 died afterwards. 4 of the converted patients needed subsequent veno-venous ECLS support for right ventricular support after the implantation. Survival to discharge ratio for the whole group was 31 %. More detailed demographic results can be found in Table 1.

Literature review

A pubmed search using the terms “(ECMO OR ECLS) AND LS AND weaning” resulted in 7 publications which dealt specifically with weaning of ECLS support. Several weaning approaches are available, however poor outcome has remains a problem. Some recent studies show a possible beneficial effect of LS infusion prior to weaning from ECLS. However most of these studies are retrospective or observational at best. Because LS is primarily reserved for the most severe cases, outcome interpretation is difficult. Overall weaning success ranges from 82%-92% and variation is very dependant of inclusion criteria.

Conclusions:

The calcium sensitizer LS can be used when weaning off patients from ECLS, certainly given its low incidence of complications. Future, large randomized trials are however needed in order to confirm this strategy.

Table 1 (abstract P082). Patient demographics and mortality

P083 A series of two hemorrhage-associated pheochromocytoma crises precipitating cardiogenic shock requiring extracorporeal life support.

P O´Connor, C Costello, S Egan, M Afrasenei, S O´Brien, E Carton, I Conrick-Martin

Mater Misericordiae University Hospital, Critical Care Medicine, Dublin 1, Ireland

Introduction:

Cardiogenic shock induced by catecholamine excess in pheochromocytoma affects 2.9-7.1% of new presentations, in whom 1.5-5.7% require mechanical circulatory support [1, 2]. Of patients in crises requiring veno-arterial extracorporeal membrane oxygenation (V-A ECMO) mortality is 7% [3]. Hemorrhagic pheochromocytoma is a known but rare precipitant of crisis [3].

Methods:

We included patients presenting to MMUH Jan 2016 – Dec 2019 in cardiogenic shock requiring V-A ECMO with new diagnosis of pheochromocytoma.

Results:

Case 1 – 30 year old female presented with abdominal pain & flash pulmonary oedema. Transthoracic echocardiography (TTE) demonstrated inverse Takotsubo’s cardiomyopathy. CT abdomen revealed a hemorrhagic left adrenal mass. Phentolamine precipitated cardiac arrest and following successful resuscitation peripheral V-A ECMO commenced for worsening cardiogenic shock. Decannulated from ECMO after four days, she subsequently underwent uneventful robotic adrenalectomy.

Case 2 – 58 year old female with chest pain and ischemic ECG. TTE revealed Takotsubo’s cardiomyopathy. CT revealed hemorrhage into right adrenal mass. Peripheral V-A ECMO commenced for cardiogenic shock. She awaits surgery following 6 day uncomplicated ECMO course with successful decannulation, extubation, and uptitration of alpha blockade.

Conclusions:

Cardiogenic shock is well described in newly diagnosed pheochromocytoma, and crisis may be precipitated by hemorrhage into tumour. V-A ECMO represents a rescue therapy in a subset of these patients refractory to medical management, facilitating cardiac recovery and subsequent definitive surgery.

Consent to publish: written informed consent for publication was obtained from the 2 patients.

References:

1. Riester A et al Eur J Endocrinol 173:757–764, 2015

2. Giavarini A et al. Heart 99:1438–1444, 2013

3. Hekimian et al. Ann Intensive Care 6:117, 2016

P084 Cardiac tamponade complicating extracorporeal membrane oxygenation: a single center experience

A Fontoura¹, R Roncon-Albuquerque Jr.², JA Paiva², C Basílio²

¹Unidade Local de Saúde da Guarda, Intensive Care Medicine Department, Guarda, Portugal; ²Centro Hospitalar Universitário de São João, Intensive Care Medicine Department, Porto, Portugal

Introduction:

Although cardiac tamponade (CT) complicating extracorporeal membrane oxygenation (ECMO) support is seldom reported, risk factors such as vascular cannulation, systemic anticoagulation and recent heart surgery are frequently present. The goal of this study is to assess the prevalence, diagnostic challenges, therapeutic and outcome implications of CT complicating ECMO.

Methods:

Retrospective analysis of the Centro Hospitalar Universitário São João ECMO Referral Center (Porto, Portugal) database (10 year period). Of the 466 ECMO cases, CT complicating ECMO support occurred in 5 patients (1.07%): 3 veno-venous (VV) and 2 veno-arterial (VA).

Results:

Of the 5 patients, 2 were women and 3 men, with a mean age of 56,4 years. ECMO support was performed during 26,6±22,3 days: 3 for refractory respiratory failure (1 community-acquired pneumonia, 1 pneumocystosis and 1 status asthmaticus), and in 2 for severe cardiogenic shock (1 arrhythmic storm and 1 acute myocardial infarction). CT occurred after 19,6±24,6 days of ECMO support. CT was suspected during VA-ECMO due to sudden hemodynamic deterioration with decreased pulse pressure. In VV-ECMO, CT was suspected due to circulatory collapse, with cardiopulmonary arrest in 2 patients. A large pericardial effusion with collapsed right chambers by transthoracic echocardiography established the diagnosis, in all cases. Patients with VV-ECMO and cardiopulmonary arrest required ECMO-assisted cardiopulmonary resuscitation (E-CPR). Emergent surgical drainage of hemopericardium was required in all cases, with cardiac perforation repair in 2 cases. All patients survived to ICU (42,6±25,6 days) and hospital (55,6±28,9 days) discharge without significant complications.

Conclusions:

CT is a rare but life-threatening complication during both VV- and VA-ECMO. A high index of suspicion is needed and bedside transthoracic echocardiography plays a major role for timely diagnosis and treatment. Excellent prognosis is possible with E-CPR and emergent surgical drainage and repair.

P085 Extracorporeal CO2 removal reduces inspiratory muscle effort during renal replacement therapy in a difficult to wean patient after orthotopic liver transplantation: a case report

I Cavalli

Alma Mater Studiorum - Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche Anesthesia and Intensive Care Medicine, Policlinico di Sant´Orsola, Bologna, Italy, Bologna, Italy

Introduction:

During a spontaneous breathing trial respiratory mechanics can worsen, and respiratory muscle effort can increase, leading to respiratory muscle fatigue, pump failure, hypercapnia and an unsuccessful weaning from mechanical ventilation. This case report discusses the possibility of applying extracorporeal CO₂ removal (ECCO₂R) to reduce respiratory muscle effort in a liver transplant recipient who already failed three weaning attempts from mechanical ventilation.

Methods:

The ECCO₂R membrane lung was integrated into a conventional renal replacement therapy circuit and blood flow was increased from 150 to 300 ml/min. Measurements of respiratory mechanics (including esophageal pressure, as shown in Fig. 1) were used to assess the reduction of respiratory effort before and during the application of ECCO₂R.

Results:

After 5 minutes of spontaneous breathing (SB), respiratory rate increased from 12 to 24 breaths/min, PaCO₂ increased from 39 to 54 mmHg, pressure time product per minute (PTP/b) and pressure time product per liter (PTP/L) increased to 142.9±26.9 cmH₂O^.s/min (from 78.9±15.3 cmH₂O^.s/min in PSV), and 13.4±2.5 cmH₂O^.s/L (from 7.1±1.1 cmH₂O^.s/L in PSV), respectively. ECCO₂R was subsequently started with a sweep gas flow of 10 L/min. After 1 hour of ECCO₂R, respiratory rate decreased to 18 breath/min, PaCO₂ decreased to 44 mmHg; and PTP/b and PTP/L decreased to 83.9±19.3 cmH₂O^.s/min and 9.5±1.8 cmH₂O^.s/L, respectively. The patient was successfully extubated and ECCO₂R was discontinued after 36 hours.

Conclusions:

In a difficult-to-wean patient recovering from orthotopic liver transplantation (OLT), ECCO₂R can be added to a renal replacement circuit and may reduce the ventilatory demand and prevent severe hypercapnia and respiratory distress (Figure 1), thus facilitating the recovery of adequate spontaneous ventilation and allowing effective weaning from mechanical ventilation.

Consent to publish: written informed consent for publication was obtained from the patient.

Fig. 1 (abstract P085).

From the left to the right: esophageal pressure (i) during pressure support ventilation (PSV); (ii) during spontaneous breathing trial (SBT); (iii) during SBT + ECCO2R

P086 AKI during aeCOPD: the potential role of combined renal-respiratory extracorporeal support

L Zamidei¹, R Marco², D Atzeni³, G Boscolo⁴, F Turani⁵, G Consales¹

¹Prato Hospital, emergency and Intensive Care, Prato, Italy; ²IRCCS Policlinico San Donato, Anesthesia and Intensive Care Department, San Donato, Italy; ³Marino Hospital, Intensive Care Department, Cagliari, Italy; ⁴Ospedale dell´Angelo, Anaesthesia and Intensive Care Department, Mestre, Italy, ⁵Aurelia and European Hospital, Anesthesia and Intensive Care Department, Rome, Italy

Introduction:

We describe the use of a low-flow platform (PrismaLung®-Prismaflex®) for combined extracorporeal CO2 removal-renal support (ECCO2R-CRRT) in patients affected by acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) associated to acute renal failure (AKI).

Methods:

We evaluated aeCOPD patients submitted to PrismaLung-Prismaflex due to AKI (AKIN >2) associated to hypercapnic acidosis (pH<7.25, pCO2>60 mmHg) during the period May 2016-July 2019 at Prato Hospital ICU. Physiologic data were collected (T0, 24h, 48h, 72h).  Complications and outcome were recorded. Data were presented as mean±DS; Anova Test was used to compare changes over time (significance P<0.05).

Results:

14 aeCOPD patients with AKI and hypercapnic acidosis were identified (75±9yr SOFA 13±2). Rationale for ECCO2R-CRRT was to treat AKI and to facilitate extubation in invasively ventilated patients (IMV 9patients) or to avoid intubation (4patients at risk of non-invasive ventilation-NIV- failure). Hemo-diafiltration (effluent-flow 35 ml/kg/h) was delivered through a 13fr-double-lumen-cannula; 350 ml/min blood-flow with 10lt oxygen sweep-gas-flow and aPTT 1.5-2 baseline were maintained (iv-heparin). In all cases respiratory and metabolic parameters improved without complications (Figure 1). ECCO2R-CRRT facilitated extubation (4 out 9 IMV pts). In 4 out of 5 pts at risk of NIV failure, it avoided IMV. Treatment mean duration was 73±31 hours, mean lenght of ICU stay was 6±4 days. All patients survived to the treatment, nevertheless 2 patients died due to irreversible multiple MOF.

Conclusions:

In our aeCOPD series PrismaLung®-Prismaflex® facilitated weaning from IMV and avoided intubation in patients at risk of NIV failure without complications. These positive results may be related to minimal invasiveness of the low–flow device used and may constitute the rationale for a larger randomized controlled trial.

Consent: Written informed consent for data publication has been obtained.

Fig. 1 (abstract P086).

Mean CO2 and pH during ECCO2R-CRRT treatment

P087 Extracorporeal carbon dioxide removal rates during the SUPERNOVA trial: estimates from a mathematical model

JK Leypoldt¹, J Kurz², J Goldstein³, D Pouchoulin⁴, JG Laffey⁵, K Harenski²

¹Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Modeling and Supporting of Internal Functions, Warsaw, Poland; ²Baxter Deutschland GmbH, Medical Affairs, Unterscheissheim, Germany; ³Baxter World Trade SPRL, Acute Therapies Global, Braine-l´Alleud, Belgium; ⁴Baxter, Gambro Industries, Research and Development, Meyzieu, France; ⁵School of Medicine, NUI Galway, Anesthesia and Intensive Care Medicine, Galway, Ireland

Introduction:

The primary outcome findings from the SUPERNOVA trial [1] demonstrated that the use of extracorporeal carbon dioxide reamoval (ECCO₂R) allows a reduction in tidal volume (TV) to ultraprotective levels (≈4 mL/kg predicted body weight or PBW) during mechanical ventilation in ARDS patients without significant increases in the arterial partial pressure of carbon dioxide (PaCO₂). Unfortunately, it was not feasible to directly measure ECCO₂R rates during the trial.

Methods:

We used a mathematical model of whole-body oxygen (O₂) and carbon dioxide (CO₂) transport and biochemistry [2] to calculate ECCO₂R rates that permit a fit to the data reported for Hemolung (ALung Technologies) and iLA (Novalung)/Cardiohelp (Getinge) devices in the SUPERNOVA trial [3]. The mathematical model was calibrated under baseline conditions where patients were mechanically ventilated at a TV of 6 mL/kg PBW in the absence of an ECCO₂R device; the O₂ consumption rate, CO₂ production rate and pulmonary shunt fraction were adjusted to match the measured baseline arterial partial pressure of O₂ and PaCO₂. Assuming all baseline parameters were fixed, TV was then reduced to 4.1 mL/kg PBW and the mathematical model predicted the ECCO₂R rate to the change in the PaCO₂ level.

Results:

Model predictions for the devices are shown in Table 1.

Conclusions:

These predictions suggest that ECCO₂R rates for iLA/Cardiohelp devices were approximately twice those for Hemolung devices during the SUPERNOVA trial. These results may be useful to evaluate the expected performance of novel ECCO₂R devices.

References:

1. Combes et al. Intensive Care Med 45:592-600, 2019

2. Leypoldt et al. Artif Organs doi: 10.1111/aor.13601, 2019

3. Combes et al. Thorax 74:1179-1181, 2019

Table 1 (abstract P087). Model predicted extracorporeal carbon dioxide removal rates

P088 Efficiency and safety of a system CRRT plus ECCO2R to allow ultra-protective ventilation protocol in patients with acute renal failure

F Maldarelli¹, FA Alessandri¹, RD D´Albo¹, FP Pugliese¹, MV Ranieri²

¹Sapienza University of Rome, Department of Anesthesia and Critical Care Medicine, Policlinico Umberto I, Rome, Italy; ²Alma Mater Studiorum Università di Bologna, Policlinico Sant´Orsola, Scienze mediche e chirurgiche, Bologna, Italy

Introduction:

Despite renal function replacement techniques (CRRT), a patient who develops acute renal failure(AKI) in intensive care unit (ICU) has a mortality rate of 5-80%. This risk is partly due to the adverse effect of AKI on other organs than the kidney. Respiratory complications are frequently associated with the development of AKI. New machines combining CRRT with a carbon dioxide removal membrane (ECCO2R) allows the setting up of an ultra-protective ventilation (4 ml/kg of predicted boby weight (PBW)) to reduce any lung damage from mechanical ventilation (MV). The reduction in tidal volume (Vt) is associated with a decrease in lung damage partly triggered by AKI. We evaluated the efficacy of a combined system CRRT+ECCO₂R to reduce the Vt to ultraprotective values in patients with acute respiratory failure and AKI.

Methods:

Five patients with acute respiratory failure invasively mechanically ventilated for at least 48 that develop AKI needing CRRT were recruited in our ICU. CRRT + ECCO2R was performed with OMNI system® (B.Braun Avitum, Melsungen, Germany). The Vt was progressively reduced to 4 ml/kg/PBW according to a predefined ventilation protocol and therapy was set as follows: CVVHDF, blood flow up to 400 ml/min, dialysis dose 25-35 ml/kg/h, sweep gas:10 L/min. Hemodynamic, respiratory and biochemical clinical parameters were recorded: before the start of treatment (T0) and at the end of each 12-hour interval. Adverse events during treatment have been reported.

Results:

Within an hour, patients treated with CRRT+ECCO2R have achieved and maintained an ultra-protective ventilation protocol. The pH and PaCO2 values did not show statistically significant differences from T0 throughout the treatment. In treated patients no complications were recorded.

Conclusions:

The combined system CRRT+ECCO2R was safe and effective in allowing a reduction of the Vt up to 4 ml/kg of PBW. Further studies are needed to extend the result of our pilot study.

P089

Withdrawn

P090 Calculating the optimal ventilator strategy to reduce mechanical power in patients with extracorporeal carbon dioxide removal (ECCO2R)

KF Bachmann, M Haenggi, D Berger

Inselspital Bern, University Hospital, Bern, Switzerland, Department of Intensive Care Medicine, Bern, Switzerland

Introduction:

ARDS is a syndrome with high morbidity and mortality. An emerging treatment option is ECCO2R, but the benefit its remains unclear. We assess different degrees of ECCO2R and varying dead space (DS) on ventilator settings in order to minimize mechanical power.

Methods:

We calculated mechanical power as

(1) Power=RR*{∆〖Vt〗^2*[1/2*EL+RR*(1+I:E)/(60*I:E)*R]+ ∆Vt*PEEP}

(EL: system elastance, R: airway resistance, PEEP: positive end expiratory pressure, I:E: Inspiratory to expiratory ratio).

We calculated the combination of respiratory rate (RR) and tidal volume (VT) (“optimal RR” and *optimal VT*) leading to minimal applied power for a stable carbon dioxide elimination of 300 ml/min (VCO2) for two scenarios: 1) variation of physiological DS from 10 to 40 % of VT at a fixed rate of ECCOR2. 2) variation of ECCO2R of either 80, 120, 160 or 200 ml/min at a fixed physiological DS of 20%. The alveolar ventilation (VA) necessary to eliminate the VCO2 was calculated as (2) VA= (-VCO2*σ_CO2*R*T*(1+K_c ))/(VCO2/Q-P_vCO2*σ_CO2*R*T*((1+K_c ))/760)

σCO2: CO2 solubility in blood, R: gas constant, T: temperature. PvCO2: venous partial pressure, Kc: function of pH (12.5 for a pH of 7.2), Q: blood flow [5 l/min]).

Results:

Increasing DS from 10 to 40% increases the minimal mechanical power from 5.9 to 10.8 J/min, primarily caused by an increase of optimal Vt (495 – 672 ml). Optimal RR was only slightly increased (6.4 – 7.5 /min, Figure 1 Panel A). For varying ECCO2R removal, necessary ventilation ranges from 1.6 to 3.6 L/min. This predicts a minimal power between 5.6 and 10.4 J/min with an unchanged optimal Vt (540 - 543 ml) and an increasing optimal RR (5.4 to 12.3 /min (Figure 1 Panel B)).

Conclusions:

In order to minimize mechanical power, increasing shunt or CO2 production should be met with increases in RR while increases in DS should be met with increases in VT. Our results indicate that during ECCO2R, mechanical power and thus risk for lung injury can be minimized with higher VT compared to conservative ventilation strategies.

Fig. 1 (abstract P090).

Mechanical power as a function of RR and VT for varying ECCO2R and deadspace

P091 Validity of empirical estimates of physiological dead space in acute respiratory distress syndrome

JD Dianti, EG Goligher, AS Slutsky

University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Canada

Introduction:

Increased physiological dead space fraction (V_D/V_T) is a hallmark of the acute respiratory distress syndrome (ARDS) and has been shown to predict ARDS mortality. V_D/V_T is also important in estimating the reduction in tidal volume (V_T) and driving pressure (∆P) with extracorporeal CO₂ removal (ECCO₂R). V_D/V_T can be measured with volumetric capnography but empirical formulae using the patient’s age, weight, height, gender and PaCO₂ have been proposed to estimate V_D/V_T based on estimates of CO₂ production (V_CO2). The accuracy of this approach in critically ill patients, however, is not clear.

Methods:

Secondary analysis of a previously published trial [1] in which V_D/V_T and V_CO2 were measured in ARDS patients. Estimated dead space fraction (V_D,est/V_T) was calculated using standard formulae. Agreement between methods was evaluated by Bland-Altman analysis. The predicted change in ∆P with ECCO₂R was evaluated using both measured and estimated alveolar dead space fraction (V_Dalv/V_T).

Results:

VD,est/VT was higher than measured VD/VT, with a low correlation between the 2 (R2= 0.21). VCO2 was underestimated by the predicted approach (Table 1), accounting for 57% of the error in estimating VD/VT. The expected reduction in ∆P with ECCO2R using VDalv/VT was in reasonable agreement with the expected reduction using VDalv,est /VT (Bias= -0.7, Level of agreement (LOA) = -1.87 to 0.47). Measured VD/VT was the only variable associated with increased risk of mortality in univariate and multivariate logistic regressions, after adjusting for, age, SOFA score, respiratory system compliance and PaO2/FiO2 (OR 1.9, [95%CI 1.08-3.3], p= 0.02).

Conclusions:

V_D/V_T and V_D,est/V_T showed low LOA and should not be used interchangeably. The predicted decrease in ∆P from ECCO₂R was similar when using both approaches.

References:

1. Matthay MA et al. Am J Respir Crit Care 184:561–568, 2011

Table 1 (abstract P091). Correlation and agreement between measured and estimated dead space values

P092 Efficacy of PEEP on cyclic recruitment/derecruitment (R/D) in ARDS patients with different percentage of potentially recruitable lung

Y Tang, Q Sun, S Liu, X Liu, J Zhang, S Fan, C Pan, L Liu, H Qiu

Southeast University, School of Medicine, Zhongda hospital, Department of Critical Care Medicine, Nanjing, China

Introduction:

Individualized mechanical ventilation (MV) in patients with ARDS may potentially reduce ventilator induced lung injury (VILI). We explore bedside approach of Electronic Impedance tomography (EIT) to evaluate the percentage of potentially recruitable lung in ARDS patients, and assess the efficacy of PEEPon cyclic R/D in ARDS patients with different recruitability.

Methods:

This is a prospective observational study. Patients with moderate and severe ARDS (PaO₂/FiO₂<200 mmHg) are enrolled. PEEP detrimental titration method (from 24 to 6 cmH2O) is used to estimate percentage of potentially recruitable lung, calculated by electrical impedance algorithm.ARDS patients are divided to non-recruitable and recruitable group with the median. According to ARDS net FiO₂/PEEP table, PEEP is set to routine and high PEEP(PEEP_R/PEEP_H). Electrical impedance is recorded by EIT. Ventilation distribution is evaluated by ΔZ%, GI, alveolar collapse and hyperinflation percentage, RVDI. Respiratory mechanics parameters and gas exchange parameters are recorded.

Results:

20 patients are enrolled and 10 patients are divided to non-recruitable and recruitable group separately. When PEEP is set at PEEP_R or PEEP_H, there is no significant difference in ventilation distribution in dependent lung and independent lung, recruit-able alveolar collapse and hyperinflation percentage between non-recruitable (NR) and recruitable(R) group (P>0.05). Compared with PEEP_R, ventilation distribution (ΔZ%) increase in dependent lung and decrease in independent lung, recruitable alveolar collapse decrease significantly and hyperinflation significantly increase in NR and R group at PEEP_H. At PEEP_H, cyclic R/D in ROI4 is significantly higher in NR group than R group. Compared with PEEP_R, cyclic R/D doesn’t change globally and in ROI1-4 in NR and R group at PEEP_H.

Conclusions:

High PEEP strategy can improve ventilation distribution, but it can only decrease cyclic recruitment/ derecruitment in the dorsal part of ARDS patients in recruitable group.

P093 Early neuromuscular blockers in acute respiratory distress syndrome: a systematic review and meta-analysis

PY Gonzalez noris¹, I Rivera²

¹ISSSTE General Hospital, Intensive Care Unit, La Paz, Mexico; ²ISSSTE General Hospital, Anesthesiology, La Paz, Mexico

Introduction:

Acute Respiratory Distress Syndrome (ARDS) is a common condition in critically ill patient. However neuromuscular blockers (NMB) result controvertial in early treatment of ARDS [1]. We ought to search systematically and realize a meta-analysis on the matter.

Methods:

An electronic search of randomized clinical trials in adult patient treated with early neuromuscular blockers compared without neuromuscular blockers in ARDS. The primary objective of the analysis was the mortality at 21 to 28 days. Secondary endpoints included mechanical ventilation free days, ICU acquired weakness and barotrauma.

Results:

The search obtained 6 studies for the analysis [1-6]. A total of 1557 patients, 785 patients in the NMB group and   772 patients in the control group were included. Comparing those treated with NMB vs. control, the analysis showed relative risk (RR) 0.87 for mortality at 21 to 28 days (95% CI [0.75-0.99], p=0.04), RR. 0.55 for Barotrauma (95% CI[0.35-0.85], p=0.008), RR.1.19 for ICU  acquired weakness (95% CI[0.99-1.42],p=0.07) and mean difference 0.56 for Mechanical ventilation free days (95% CI[-0.46-1.59],p=0.28) (Figure 1).

Conclusions:

The early use of neuromuscular blockers in ARDS showed no increase in mortality, but the results should be taken with caution. There was no differences in mechanical ventilation free days. Barotrauma is less with the use of NMB.

References:

1. PETAL, N Engl J Med 380:1997-2008, 2019.

2. Gainnier et al. Crit Care Med 32:113-9, 2004.

3. Forel JM et al. Crit Care Med 2006 34:2749-57, 2006

4. Papazian L et al N Engl J Med 2010 363:1107-16., 2010

5. Lyu G. Chin Crit Care Med 263:25-9, 2014

6. Gervillu C et al. Intensive Care Med 43:408-418, 2017.

Fig. 1 (abstract P093).

Forest plots

P094

Withdrawn

P095 The role of ultrasound in the detection of pulmonary infiltrates in critically ill patients with hematologic malignancies and acute respiratory failure

MM Grgic Medic, NG Gubarev Vrdoljak^, OZ Zlopasa, RR Radonic

University Hospital Centre Zagreb, Internal Medicine, Zagreb, Croatia

Introduction:

Acute respiratory failure (ARF) is one of the major reason for admission of the patients with hematologic malignancies to the intensice care unit (ICU) and pneumonia is among the leading causes of lung infiltrates in these patients. Lung CT is the golden standard in the detection and characterization of pulmonary infiltrates, but it requires the transportation to the radiology units and radiation exposure. Ultrasound can be performed at the bedside without the need for transportation and without irradiation [1, 2]. The aim of this study was to compare the diagnostic accuracy of ultraound in the detection of lung infiltrates, compared to CT scan.

Methods:

Patients admitted to the ICU for ARF and suspected pulmonary infection, who required CT for detection and characterization of lung infiltrates, were examind by ultrasound. The assessment of six regions per hemithorax was used; each region was classified for the presence of normal aeration, B lines, indicating interstitial fluid and consolidation +/-air bronchogram. Diagnostic variables were assessed for lung ultrasound, using CT as a reference point.

Results:

PUlmonary infiltrates conssitent with pneumonia were confirmed by CT in 24/25 patinets. Ultrasound detected either inhomogenous B lines or onsolidation in 23/24 patients (total sensitivity 96%, specificity 100%, 95% CI 79.65% to 99.90% and 2.50% to 100.00%, PPV. Accuracy of ultrasound was 96.1% (80.36% to 99.90%).

Conclusions:

Ultrasound is fairly sensitive in the detection of lung infiltrates in patients with hematologic malignancies.

References:

1. Lichtenstein D. Minerva Anestesiol 75:313-7, 2009

2. Chiumello D et al. Crit Care Med 47:1599–1606, 2019

P096 Right ventricular dysfunction is associated with mortality in patients with pneumonia admitted to intensive care

M Chotalia¹, M Bangash¹, T Matthews¹, M Kalla², D Parekh¹, J Patel¹

¹University Hospitals Birmingham, NHS Foundation Trust, Critical Care and Anaesthesia, Birmingham, United Kingdom; ²University Hospitals Birmingham, NHS Foundation Trust, Birmingham, United Kingdom

Introduction:

In patients with pneumonia requiring intensive care (ICU) admission, we hypothesise that abnormal right ventricular (RV) function is associated with an increased 90-day mortality. RV dysfunction in critically ill patients has a well-known association with adverse outcomes [1]. However, its impact on mortality in patients with pneumonia has not been directly studied.

Methods:

Patients admitted to the Queen Elizabeth Hospital Birmingham ICU between April 2016 and July 2019 with a diagnosis of pneumonia who had a formal cardiologist TTE were included. Abnormal RV function was defined by either depressed function, dilated size or moderate to severe risk of pulmonary hypertension (pHTN). Abnormal LV function was defined by an LV ejection fraction £ 45% or grade II or more diastolic dysfunction. Patients with a clinical suspicion of pulmonary embolism were excluded. The primary outcome was 90-day mortality. Continuous data is presented as median (IQR). Categorical data is presented as % and analysed using a chi-squared test.

Results:

942 patients were admitted to ICU with pneumonia, of which 347 (37%) had a TTE. Patients were 59% male, had a median age of 67 (46-88) and 90-day mortality of 31%. Abnormal RV function was present in 30% (n=103), with 15% depressed, 15% dilated and 14% with moderate to severe risk of pHTN.  RV dysfunction was associated with an increased 90-day mortality compared to normal RV patients (62% vs. 18%, p<0.0001). LV function was abnormal in 25% (n=88) and was not associated with a higher 90-day mortality compared to normal LV patients (38% vs 29%, p = 0.20). RV dysfunction was associated with a higher 90-day mortality than LV dysfunction (62% vs 38%, p = 0.001).

Conclusions:

This is one of the first studies to demonstrate that abnormal RV function is associated with an increased mortality in ICU patients with pneumonia. Interestingly, abnormal LV function was not associated with an increased mortality.

References:

1. Biteker FS et al. Clin Microbiol Infect 22:1006-e1, 2016.

P097 Validation of a new method for estimation of the change in pleural pressure using the change in central venous pressure in various clinical scenarios: a pig model study

M Kyogoku¹, S Mizuguchi², T Miyasho³, Y Endo⁴, Y Inata¹, K Tachibana⁵, K Yamashita⁶, M Takeuchi¹

¹Osaka Women´s and Children´s Hospital, Intensive Care, Osaka, Japan; ²Kyushu University, Emergency and Critical Care Center, Fukuoka, Japan; ³Rakuno Gakuen University, Laboratory of Animal Biological Responses Department of Veterinary Science School of Veterinary Medicine, Hokkaido, Japan; ⁴Sapporo Night Animal Hospital, Hokkaido, Japan; ⁵Osaka Women´s and Children´s Hospital, Anesthesiology, Osaka, Japan; ⁶Rakuno Gakuen University, Anesthesiology, Hokkaido, Japan

Introduction:

We previously reported a simple correction method of estimating pleural pressure (Ppl) by using central venous pressure (CVP) and that it can be used to estimate Ppl and transpulmonary pressure in pediatric patients with respiratory failure. However, it remains unknown that this method can be applied to patients with various levels of chest wall elastance and/or intravascular volume. The objective of this study is to investigate whether our method is accurate in various conditions of chest wall elastance and intravascular volume.

Methods:

The study was approved by the Animal Care and Use Committee of Rakuno Gakuen University. Ten anesthetized and paralyzed pigs (43.2 ± 1.8kg) were mechanically ventilated and subjected to lung injury by saline lung lavage. Each pig was subjected to 3 different intravascular volume and 2 different intraabdominal pressures; in each condition, the accuracy of our method was tested. Specifically, airway flow, airway pressure (Paw), esophageal pressure (Pes), and CVP were recorded in each condition, then changes in Pes (ΔPes) and ΔPpl calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl) were compared. cΔCVP-derived ΔPpl was calculated as κ × ΔCVP, where κ was the ratio of the ΔPaw to ΔCVP during the occlusion test.

Results:

Means and standard deviations of the two variables that reflect ΔPpl (ΔPes and cΔCVP-derived ΔPpl) in all pigs with all conditions were 6.1 ± 4.1 and 6.4 ± 5.3 cmH₂O. The Bland-Altman analysis for the agreement between ΔPes and ΔCVP showed a bias of -0.3 cmH₂O and a precision of 2.9 cmH₂O in all pigs with all conditions; a bias of 0.1, -0.7, -0.2 cmH₂O and a precision of 2.2, 3.6, 2.8 cmH₂O in low, normal and high intravascular volume, respectively; a bias of -0.3, -0.2 cmH₂O and a precision of 2.8, 3.1 cmH₂O in low and high intraabdominal pressure, respectively.

Conclusions:

Our method can estimate pleural pressure from CVP with a reasonable accuracy regardless of intravascular volume and intraabdominal pressure (Fig. 1).

Fig. 1 (abstract P097).

The Bland–Altman analysis for the agreement between ΔPes and cΔCVP-derived ΔPpl in various conditions. low: low intravascular volume, normal: normal intravascular volume, high: high intravascular volume, abd-: without an abdominal compression band, abd+: with an abdominal compression band

P098 The role of ultrasound in monitoring diaphragm activity in critically ill patients

F Righetti¹, E Colombaroli²

¹Intensive Care Unit, Fracastoro Hospital, Emergency Department, San Bonifacio, Verona, Italy; ²Intensive Care Unit, Fracastoro Hospital, San Bonifacio, Verona, Italy

Introduction:

The activity and functionality of the diaphragm are difficult to measure in patients ventilated in intensive care. Ultrasound can be a useful tool for monitoring diaphragm muscle activity during different ventilation modes. Few data currently exist on diaphragm muscle activity in critically ventilated patients [1]. Our goal is to evaluate the respiratory muscular work of the diaphragm with different settings of the respirator by means of an ultrasound scan.

Methods:

The ultrasound assessments of the diaphragm were performed with a 10MHz linear probe at the apposition zone. We measured the thickening of the diaphragm with the respiratory acts, through the thickening fraction (Thickening Fraction, TF), defined as:TF = (Tdimax - Tdimin / Tdi min)% Tdimax: Diaphragm thickness at the end of inspiration (maximum thickness) Tdimin: Diaphragm thickness at the end of expiration (minimum thickness). Ventilatory support was divided into 4 classes: 1 - spontaneous breathing (SB) or Continous Positive Airway Pressure (CPAP); 2 - Pressure Support Ventilation (PSV) with low pressure support (5-12cmH2O); 3- PSV with high pressure support (> 12 cmH2O); 4 - Controlled Mechanical Ventilation (CMV).

Results:

A total of 223 assessments were performed in 70 patients. The evaluations were all possible at the right hemidiaphragm, while on the left they were not possible in 7% of the cases. The median TF (IQ range) of the 4 ventilation classes was respectively: 42% (25-62%) in SB / CPAP; 26% (17-31%) in low-PSV; 17% (9-22%) in high PSV; and 5% (2-13%) in CMV. The Kruskal-Wallis test confirms a significant difference between the groups (p <0.0001).

Conclusions:

The ultrasound of the diaphragm can be a valid tool for monitoring respiratory muscle activity during mechanical ventilation.

References:

1. Shahshahani A et al. Sensors (Basel). 18 :E2617, 2018

P099 Does high flow nasal oxygen therapy reduce extubation failure in critically ill patients?

A Mcguire, R Sundaram

Intensive Care Unit, Royal Alexandra Hospital, Royal Alexandra Hospital, Paisley, United Kingdom

Introduction:

Extubation failure is defined as reintubation after 48 hours of extubation in mechanically ventilated critically ill patients. It is associated with morbidity and mortality. The aim of our study was to assess reintubation rates in a busy district general hospital and evaluate the impact of high flow nasal oxygen therapy (HFNO) on reintubation rates.

Methods:

We performed a retrospective observational study looking at patients admitted to our 7 bedded Level 3 critical care unit (370 patients a year) for a period of 5 years between 1^stNovember 2014 and 31^stOctober 2019. We included patients over 16 years of age who were mechanically ventilated and length of stay was greater than 48 hours. Exclusions were age < 16 years, tracheostomy and patients requiring ventilation for < 48 hours. Data was collected from Ward Watcher, a SICSAG database and electronic patient records.

Results:

There was 1735 patients and 1413 patients were included (802 male 611 female). 1076 (76.2%) of patients required ventilation for over 48 hours, 66.7% (718/1065) of those were extubated (Table 1). 25.6% (184/718) of patients required reintubation, despite 54.3% (100/184) receiving HFNO.  Of the patients successfully extubated 41.4% (221/534) received HFNO.

Conclusions:

Our study failed to show any impact of HFNO on reducing extubation failure. Further work is needed to develop a standardized approach to weaning and to consider routine application of non-invasive ventilation to reduce reintubation rates [1].

References:

1. Hernández G, et al. JAMA 316:1565-74, 2016.

Table 1 (abstract P099). Extubation/reintubation rates plus use of nasal high flow in patients ventilated for >48 hours

P100 Introduction new practice of endotracheal tube holder to intubated patient to improve oral care in intensive care unit

YT Ho¹, WT Yeung², OK Lee², PO Lei², MT Lai², SC Ho², EH Chan², LY Law², KY Ho², HC Yuen²

¹Ruttonjee & Tang Shiu Kee Hospitals, Cardiac & Intensive Care Unit, Hong Kong; ²Ruttonjee & Tang Shiu Kee Hospitals, Hong Kong

Introduction:

Oral endotracheal intubation is common to critically ill patients in intensive care unit. Oral care for an intubated patient is important to maintain the moisture of oral mucosa. Also, the securement method of oral endotracheal tube developed from cloth tape to commercial tube holder.

Methods:

Training PowerPoint and video for microteaching was prepared to train up 30 ICU nurses to perform the new practice. Demonstration and re-demonstration was arranged to assess skills of every nurse. Afterwards, each nurse answered a quiz to evaluate the understanding of OETTH and its special techniques in application. Questionnaire was designed to collect the feedback from all nurses too.

Results:

The result showed there was 21 nurses (72%) out of 30 nurses achieved full marks in the post-quiz which demonstrated their full understanding of the use of oral ETT holder and its nursing care. About the feedback from nurse, 72% of nurses claimed that they were confident in using the new OETTH in clinical setting after training. 96% of nurses agreed in time-saving of nursing care routine with the use of an OETTH. However, only 56% of nurses agreed that the OETTH is effective in prevention of oral mucosa injuries and another 24% of nursing staff disagreed on its function in improving the patient’s oral care.

Conclusions:

In conclusion, some of the nurses did not agree the prevention of oral mucosa injuries by the new securement method with OETTH while some nurses welcomed the new OETTH as more easy and effective in oral care to intubated patients.

P101 Execution of percutaneous dilatational tracheostomy using the standard laryngeal mask airway for ventilation: a prospective survey study

G Gagliardi¹, V Gagliardi², C Chiani³, G Laccania⁴, F Michielan³

¹AULSS 5 - Veneto, Anesthesia and Intensive Care, Adria, Italy; ²AULSS 5 - Veneto, University of Padua, Adria, Italy; ³AULSS 5 - Veneto, Anaesthesia and Intensive Care, Adria, Italy; ⁴AULSS 6 - Veneto, Anaesthesia and Intensive Care, Padua, Italy

Introduction:

We fulfilled a survey study dealing with bronchoscope-guided percutaneous dilatational tracheostomies (PDT), using the classic laryngeal mask airway (LMA) for the airway management [1]. The aim was to verify the safety and the effectiveness of the aforementioned procedure

Methods:

We performed an observational prospective survey study enrolling 150 patients hospitalized in the Intensive Care Unit. Before performing the tracheostomy, the endotracheal tube has been replaced by the laryngeal mask airway. Arterial blood gases, ventilation pressures and tidal volumes have been monitored, registered and compared.

Results:

The median peak inspiratory pressure has been detected stable in all patients. Furthermore, during the ventilation with the laryngeal mask, the tidal inspiratory and expiratory volume difference observed between before and after the bronchoscope positioning, has shown a statistically significant variation. Finally, in all cases ETCO₂, SpO_2., PaO_2, and blood pH values persisted within the normal range.

Conclusions:

The standard LMA provides for a reliable airway management and allows an effective ventilation while performing the PDT. Once positioned in the supraglottic zone, the LMA does not need to be moved throughout all the PDT performance, avoiding risks of displacement, glottic harm and airway device damage, and permitting an easy handling of the bronchoscope, which gives an appropriated visualization of the trachea and a more efficient aspiration. In consequence to the large internal diameter of the LMA tube, Ppeak has continued to be stable in all patients, providing for minor resistance and inspiratory work. Eventually, no late complications, such as tracheal stenosis and infections, have occurred.

References:

1. Strametz R et al. Cochrane Database of Systematic Reviews 11: CD009901, 2018

P102 Dilatative percutaneous tracheostomy vs surgical tracheostomy: what late complications?

F Righetti¹, E Colombaroli²

¹Intensive Care Unit, Fracastoro Hospital, Emergency Department, San Bonifacio, Verona, Italy; ²Intensive Care Unit, Fracastoro Hospital, San Bonifacio, Verona, Italy

Introduction:

There are many possible post-tracheostomy late complications with both percutaneous and surgical techniques (peristomal bleeding, granulomas, tracheomalacia, tracheal stenosis) [1]. The purpose of our retrospective study is to define the prevalence of these complications by comparing the two techniques.

Methods:

60 tracheostomized adult patients (pcs) were divided into 2 groups: group A (percutaneous dilatation technique according to Ciaglia) group B (surgical technique), followed for 4 years (2016-2019), cuffed cannulae, cannula change every 60 days at home, tracheofibroscopic control in Intensive Care Unit (ICU). The results were expressed as a percentage of prevalence and subsequently comparing the two groups.

Results:

30 pcs in group A and 30 pcs in group B. 1440 home tracheostomy cannula replacements, 240 tracheofibroscopy performed in ICU. In group A: 56% had peristomal bleeding, 36% external peristomal granulomas, 16% intra tracheal granulomas, 6% tracheomalacia. In group B: 23% had peristomal bleeding, 16% external peristomal granulomas, 33% intra tracheal granulomas, 13% tracheomalacia, 3% tracheal stenosis.

Conclusions:

Peristomal bleeding resolved independently. The external granulomas were treated with silver nitrate for a month. Intra-tracheal granulomas were treated with laser therapy. Tracheomalacia and tracheal stenosis resolved by placing a reinforced cannula with variable flange under bronchoscopic guidance. Comparing the two groups it emerged that the percutaneous dilatative technique has fewer serious late complications (intra tracheal granulomas, tracheomalacia, tracheal stenosis) than the surgical technique.

References:

1. Cipriano A et al. Int J Crit Illn Inj Sci 5:179–188, 2015

P103 Is there benefit to delaying tracheostomy?

FS Zimmerman, PD Levin

Shaare Zedek Medical Center, Intensive Care Unit, Jerusalem, Israel

Introduction:

Tracheostomies are the most common surgical procedure performed on critically ill patients. Randomized control trials comparing tracheostomy timing in intensive care patients have been equivocal. In order to perform non-urgent tracheostomy in our ICU, consent is required from the patient or a formal guardian appointed ad hoc by the courts. Since tracheostomies are practically the only elective surgery performed in the critically ill, ICU requested guardianship almost always indicates a clinical decision to perform tracheostomy. As appointing a guardian and arranging a tracheostomy takes about a week, the decision to appoint a guardian offers a unique "intention to treat" opportunity to evaluate outcomes in patients for whom tracheostomy is planned.

Methods:

We performed a retrospective analysis over 3 years on patients for whom guardianship was sought excluding those requiring urgent tracheostomy and those with a do-not-resuscitate order. Patients were divided according to outcome (tracheostomy, extubation or death prior to tracheostomy) and compared.

Results:

Guardianship was sought for 233 ventilated patients. A decision to withhold tracheostomy was made for 13 patients, who were excluded, leaving 220 patients for analysis. Tracheostomy was performed for 131/220 (60%) patients, 62/220 (28%) were extubated and 27/220 (12%) died while waiting for tracheostomy (from non-airway related reasons). Tracheostomy was performed on mean ventilation day 16±1. Comparing extubated patients to those who had tracheostomy (Table) shows similar demographics, but significantly lower mortality and hospital length of stay.

Conclusions:

A significant proportion of patients initially planned for tracheostomy were successfully extubated. Despite demographic similarities, mortality in this group was significantly lower than for patients undergoing tracheostomy. For a selected subgroup of possibly difficult to characterize patients, delaying tracheostomy may be beneficial.

Table 1 (abstract P103). Tracheostomy demographics and outcomes

P104

Withdrawn

P105 Retrospective audit of tracheostomy insertion in a training intensive care unit in Singapore

D Bruce-Hickman¹, G Aquino Vergel De Dios², P A Dela Cruz², F Khan³

¹Ng Teng Fong General Hospital, Singapore; ²Ng Teng Fong General Hospital, Respiratory Therapy, Singapore; ³Ng Teng Fong General Hospital, Intensive Care Medicine, Singapore

Introduction:

Percutaneous tracheostomy insertion (PTI) is a core competency for ICU trainees. Standards for insertion are available from Intensive Care Societies and eminence-based groups [1]. Standard of PTI has not previously been analyzed in Singaporean public ICUs.

Methods:

Retrospective analysis was performed of PTIs from September 2015 to 2018. Audit proforma was based on best practice guidelines. PTIs for acute airway scenarios were excluded. Ethical approval was granted via local processes for audit and quality improvement work.

Results:

151 tracheostomized patients were admitted in the study period. After exclusion, 109 patients were audited. 91 patients had a PTI as a bedside procedure by the ICU team, 17 patients had a tracheostomy performed in theatre; data was missing for 1 case. PTI was performed at a mean of 11 days from admission. Trial of extubation occurred in 44% of cases.  Ventilator settings were mostly appropriate (Figure 1). PTIs were analysed by speciality and by outcome. Complications occurred in 6 cases (incidence 6.5%). There were 3 cases of subcutaenous emphysema, 1 pneumothorax (occuring D6 post procedure) and 1 case each of stoma and suture site infection. There was 1 unplanned cannula change within 7 days of insertion. 24% of cases had cuff inflated on discharge from ICU. Handover of care was suboptimal; follow up care plans were documented in 18% of cases. A supervising consultant was present for all PTIs. There was a trend of increased insertion by consultant and increased reliance on theatre, with corresponding decrease in the number inserted by trainees.

Conclusions:

PTI in our training ICU appears safe with low incidence of complications and good senior support for tracheostomy insertion. Emphasis must continue on training junior intensivists in PTI. Transition of care beyond ICU requires further work where currently there is suboptimal handover of care and safety netting for non-ICU colleagues.

References:

1. McGrath B. The National Tracheostomy Safety Project Manual. London. BMJ Books; 2014

Fig. 1 (abstract P105).

Ventilator Settings prior to PTI

P106 Impact of bronchoscopically graded inhalation injury on outcomes in critically ill burns patients: 12-year experience at a regional burns centre

WN Charles¹, K Matwala¹, A Dutt¹, S Mandalia², D Collins³, S Singh⁴

¹Imperial College London, Department of Surgery and Cancer, London, United Kingdom; ²Chelsea and Westminster Hospital NHS Foundation Trust, Department of Research and Development, London, United Kingdom; ³Chelsea and Westminster Hospital NHS Foundation Trust, Department of Plastic and Reconstructive Surgery, London, United Kingdom; ⁴Chelsea and Westminster Hospital NHS Foundation Trust and Royal Brompton and Harefield NHS Foundation Trust, Magill Department of Anaesthesia, Intensive Care and Pain Management, London, United Kingdom

Introduction:

Burns inhalation injury (BI) is suggested to significantly impact burns mortality. Yet, there is inconsistent evidence of how this is influenced by its bronchoscopically graded severity. This study evaluated the effect of different bronchoscopic BI grades on mortality.

Methods:

A retrospective, single-centre cohort study of all patients admitted to the London Burns centre intensive care unit (BICU) over 12 years. Demographic data, burn and BI characteristics, and ICU-related parameters were collected. A bronchoscopy expert retrospectively graded BI using bronchoscopy images and reports. The primary outcome was mortality. Secondary outcomes were hospital and ICU length of stay measures. The impact of pneumonia after 48 hours was determined. Univariate and multivariable Cox’s proportional hazards regression analyses informed factors predicting mortality.

Results:

BI was diagnosed in 84 of 231 (36.4%) critically ill burns patients. Median (IQR) total body surface area burned (TBSA) was 20% (10 to 40). Overall, mortality risk was significantly increased by BI (45.2% vs 23.8%, p<0.001) and pneumonia (27.2% vs 11.3%, p<0.001). Median survival time with BI was significantly lower than without BI (94 vs 131 days, Log-rank test p=0.002). More severe grades of BI (2/3) had significantly increased risk of mortality (adjusted HR=2.14, 95%CI: 1.12-4.09, p=0.022) compared with lower grades (1) (adjusted HR=0.58, 95%CI: 0.18-1.86, p=0.363) (Fig. 1). Facial burns (adjusted HR=3.13, 95%CI: 1.69-5.79, p<0.001), higher TBSA (adjusted HR=1.05, 95%CI: 1.04-1.06, p<0.001) and older age (adjusted HR=1.04, 95%CI: 1.02-1.07, p<0.001) also independently predicted mortality; though, pneumonia did not.

Conclusions:

Moderate to severe bronchoscopically graded BI significantly increased mortality in critically ill burns patients. Facial burns, higher TBSA and age also independently predicted mortality. Further studies on the diagnostic accuracy, reliability and impact of bronchoscopically grading BI are recommended.

Fig. 1 (abstract P106).

Kaplan-Meier log survival plots of the different grades of Burns Inhalation injury (BI)

P107 A quality improvement project to prevent hyperoxia in a developing world intensive care unit

J Harrington, D Hall, TY Wang, M Murali, S Mwansa

University Teaching Hospital, Anaesthesia, Lusaka, Zambia

Introduction:

Supplemental oxygen administration is ubiquitous in the critical care environment, yet evidence is mounting for the deleterious effects of hyperoxia [1]. Concerns over the adverse effects from hypoxaemia often exceed those of hyperoxaemia in developing world settings, and inconsistent availability of blood gas monitoring may limit judicious oxygen titration. The aim of this project was to audit oxygen delivery practice and introduce QI measures to avoid excess oxygen delivery in a tertiary ICU in Lusaka, Zambia.

Methods:

A prospective snapshot of ventilatory parameters were recorded for critically ill patients over a 5-week period, including positive end expiratory pressure (PEEP), FiO₂, and time-course SpO₂. Systematic education was provided through group and one to one tutorials to empower nursing and medical staff to titrate oxygen safely and appropriately. Repeat data collection was then performed over 4 weeks.

Results:

Initially 18/30 patients (60%) were over-oxygenated, as defined by FiO2 >0.5 and SpO₂ consistently >95%. 12/18 patients with an FiO₂ of >0.5 had PEEP ≤ 5cm (67%). No patient had a PaO₂ recorded in the past 24 hours. Education was provided as well as implementation of unit protocols above all patient beds documenting a stepwise approach to titration PEEP and FiO₂. Post intervention fewer patients were over-oxygenated: 7/21 (33%) had FiO2 >0.5 and SpO₂ consistently >95%, and 7/18 with an FiO₂ >0.5 (39%) had a PEEP ≤ 5cm. In addition, 7/21 (33.3%) had a PaO₂ recorded within 24 hours.

Conclusions:

This QI project has shown that nurse engagement and systematic education to titrate FiO2 and PEEP can be achieved in a resource poor setting and may decrease the incidence of hyperoxia in critically ill patients. Availability of blood gas monitoring and knowledge of interpretation was a major barrier to oxygen titration

References:

1. Sinclair SE et al. Crit Care Med 32:2496–501, 2004

P108 Epidemiology and factors associated with tracheal intubation in pediatric burned population

S Lebrun, N Akrout, N Louvet, I Constant

Hopital Armand Trousseau (APHP), Anesthesie-Réanimation, Paris, France

Introduction:

Tracheal intubation (TI) in adult burn patients might be unnecessary in 30 to 40% of cases [1, 2]. In pediatric burn patients, there is little data on both the rate of TI and the rate of early extubation [3]. It has been common practice for a child with a facial burn and/or a suspected airway injury to be intubated early due to the risk of losing airway patency. However this risk should be mitigated against the potential risks of TI and mechanical ventilation in children. Therefore the aim of this study was to describe the airway status of child burn victims taken in charge of in our pediatric burn intensive care unit. Focused on patients arriving with TI, we investigated the rate of early extubation. In addition we compared non intubated patients with those with prolonged TI.

Methods:

This retrospective study described a cohort of 1520 patients hospitalized between 2010 and 2018. Data was retrospectively recorded from the patient’s paper clinical chart.

Results:

The mean age of our patients was 2.8 ±3.1 years [mean±sd] with an average burn area of 14±11%. 86% had scald burns and 45% had facial burns. 4% of the children were admitted in the burn ICU with TI. For 36% of them, tracheal tube was removed within the first 48 hours after admission. The probability of prolonged TI increased independently with the burned skin area (BSA) (p <0.0001), the presence of facial burns (p = 0.001), and in case of flame burns (p = 0.007) (Figure 1). Among patients with more than 70% BSA, 85% were intubated more than 48h. Among patients with less than 20% BSA, 0.5% were intubated more than 48h.

Conclusions:

According to our retrospective data, it seems appropriate to intubate children with 70% and more BSA, while for patient with less than 70% BSA, it might be relevant to seek guidance from physician of the nearest Burn Center. Under 20% BSA, TI seems rarely required.

References:

1. Romanowski KS et al. J Burn Care Res 37:e409-14, 2016

2. Cai AR et al. J Burn Care Res 38:e23-e29, 2017

3. Mosier MJ et al. J Burn Care Res 37:e1-6, 2016

Fig. 1 (abstract P108).

Probability of tracheal intubation depending on burn skin area, facial burns and flame burns (multivariate analysis)

P109 An analysis of the predictive applicability of initial blood gas parameters for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury

C Pirrone¹, M Chotalia², T Mangham¹, R Mullhi¹, K England¹, T Torlinski¹

¹University Hospitals Birmingham, NHS Foundation Trust, Birmingham, United Kingdom; ²University Hospitals Birmingham, NHS Foundation Trust, Critical Care and Anaesthesia, Birmingham, United Kingdom

Introduction:

We hypothesise that initial blood gas parameters have a good predictive applicability in detecting the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. To the best of our knowledge, this has not been directly studied in the literature.

Methods:

Patients with suspected inhalation injury admitted to the ICU at Queen Elizabeth Hospital, Birmingham between April 2016 and May 2019 were included. The initial blood gas parameters analysed were PaO₂ (kPa), PaCO₂ (kPa), pH, carbon monoxide level (COHb; %) and PaO₂/FiO₂ (PF) ratio. Receiver operator characteristics (ROC) for these parameters were plotted against the need for intubation for more than 48 hours and the presence of inhalation injury as detected by bronchoscopy and laryngoscopy. Area under the curve (AUC) for each parameter was calculated.

Results:

85 patients were admitted with suspected inhalation injury to the ICU. 68% were intubated for more than 48 hours. Of patients who were intubated, 69% had inhalation injury as indicated by bronchoscopy or laryngoscopy. Table 1 outlines the AUC for initial blood gas parameters in detecting the need for intubation for more than 48 hours and the presence of inhalation injury. pH was the parameter with the most prominent AUC, with reverse correlation indicating fair accuracy.  No clear inflection point was identified, although all patients with pH < 7.25 required intubation and had inhalation injury. PaCO₂ had a fair predictive applicability in detecting the need for intubation. PF ratio, PaO₂ and COHb had poor accuracy.

Conclusions:

Initial blood gas parameters had a broadly poor predictive applicability for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. Severe acidosis (pH <7.25) was the most useful blood gas parameter. Clinicians should be cautious in using blood gas parameters alone to inform intubation decisions.

Table 1 (abstract P109). AUC for initial blood gas parameters in predicting the need for intubation for more than 48 hours and the presence of inhalation injury

P110 Lung protection during lung cancer surgery by non-intubated spontaneous breathing - a case series

P Friederich¹, F Fuchsgruber², A Hiebinger³, H Angerer², J Bodner³

¹München Klinik Bogenhausen, Technische Universität München, Anesthesiology, Critical Care, München, Germany; ²München Klinik Bogenhausen, Technische Universität München, Anaesthesiology, Critical Care, München, Germany; ³München Klinik Bogenhausen, Technische Universität München, Thoracic Surgery, München, Germany

Introduction:

Lung cancer surgery is associated with a high rate of pulmonary complications including ARDS and mandates lung protective ventilation strategies [1,2]. Such strategies include non-intubated video assisted thoracic surgery (NiVATS) with spontaneous breathing [3]. Currently neither data on respirator settings nor on gas exchange have been reported for applying the latter. This data constitutes a prerequisite for meaningful evaluating the respiratory consequences of non-intubated spontaneous breathing during lung cancer surgery. The aim of this case series was for the first time providing such data from lung cancer surgery including pneumonectomy.

Methods:

During a 12 month period 32 patients without contraindications [3] scheduled for video assisted thoracic surgery (VATS) for non-anatomical and anatomical lung resection including one pneumonectomy (Px) were offered non-intubated spontaneous breathing. All patients gave informed written consent to the procedure as well as for analysis and publication of data. Anaesthetic management included target controlled infusion of propofol and remifentanil, laryngeal mask airway, and pressure support ventilation. Data from 2 patients were excluded due to change of procedure for reasons of surgical access. Data are given as median and range (Figure 1).

Results:

All patients breathed spontaneously during the operation. It allowed for low driving pressures, lung protective tidal volumes, as well as adequate oxygenation also in pneumonectomy. It may result in hypercapnia. Cardiorespiratory complications were not observed.

Conclusions:

Spontaneous breathing during lung cancer surgery is feasible and it may be applied during pneumonectomy. Whether it decreases the rate of pulmonary complications in patients undergoing lung cancer surgery deserves further study.

References:

1. Park et al. Anesthesiology 130: 385-393, 2019

2. Marret et al. Eur J Anaesthesiol 35: 272-735, 2018

3. Moon et al. J Thorac Dis 10: 3490-3489, 2018

Fig. 1 (abstract P110).

Demographics, results of preoperative lung testing, length of hospital stay (LoS), respirator settings, results of intraoperative blood gas analysis, and duration of surgery. Px = Pneumonectomy

P111 The effect of early cuff deflation on weaning in tracheostomized patients requiring ventilatory support on the intensive care unit

C Carroll¹, L Poole², C Lamont², I Welters²

¹University of Liverpool, Liverpool, United Kingdom; ²Liverpool University Hospitals NHS Foundation Trust, Intensive Care Unit, Liverpool, United Kingdom

Introduction:

Prolonged cuff inflation in tracheostomized patients inhibits phonation, contributes to dysphagia, causes psycho-emotional distress and results in diaphragmatic weakness. It also increases the risk of ventilation acquired pneumonia and ventilator induced lung injury. The aims of this study were to determine whether cuff deflation trials had an effect on the length of the weaning period, length of ITU stay and total tracheostomy days.

Methods:

A retrospective audit of all tracheostomized patients admitted to ITU at Liverpool University Hospitals NHS Foundation Trust from 8 January 2017 – 30 August 2019 were reviewed. The exclusion criteria included long term tracheostomies, patients who had a tracheostomy at the point of admission, patients who died or were transferred prior to decannulation and patients with insufficient clinical documentation. Trials of early cuff deflation were introduced to ITU on 26 April 2018. Patients were divided into two groups: the ‘pre-trial group’, consisting of patients who received a tracheostomy prior to 26 April 2018, and the ‘post-trial group’ who received a tracheostomy after 26 April 2018.

Results:

183 tracheostomized patients were identified with 70 patients meeting the inclusion criteria. There were 27 patients in the pre-trial group and 43 in the post-trial group. The mean length of ITU stay (43.33 pre-trial vs 39.21 post-trial, p=0.242), the number of total tracheostomy days (31.99 vs 27, p=0.313) and the mean number of days between first cuff deflation and decannulation (21.77 vs 19.11, p=0.385) was not significantly different between groups. The protocol allowed significantly earlier cuff deflation (12.1 vs 4.8 days).

Conclusions:

We present early data that early trials of cuff deflation within 48 hours of tracheostomy insertion can be achieved using a standardized protocol. Its impact on length of stay, duration of ventilation and patient-centered outcomes needs to be investigated in larger multi-centre trials.

P112 Preventing underinflation of the endotracheal tube cuff with a portable elastomeric device. A randomized controlled study

JE Dauvergne¹, AL Geffray², K Asehnoune², B Rozec¹, K Lakhal¹

¹Hopital Laënnec - CHU de Nantes, Service d´anesthésie-réanimation, Nantes, France; ²Hotel-Dieu - CHU de Nantes, Service d´anesthésie-réanimation, Nantes, France

Introduction:

The management of the endotracheal tube cuff pressure (P_cuff) is routine practice for critical care nursing staff. Underinflation could lead to ventilator-associated pneumonia [1] whereas overinflation exposes to tracheal damage [2]. Multi-daily check and adjustment is recommended to ensure that P_cuff lies between 20 and 30 cmH₂O [3]. To automate this task some devices exist but may be inconvenient, bulky and/or ineffective. Their use is not supported by guidelines. A portable elastomeric device could be appealing for P_cuff automated regulation. This prospective randomized controlled study tested whether the Tracoe Smart Cuff Manager^TM reduced the rate of patients undergoing ≥1 episode of underinflation (P_cuff<20 cmH₂O), as compared with routine manual P_cuff adjustment.

Methods:

Monocentric, randomized controlled study. Patients with acute brain injury and receiving mechanical ventilation were prospectively allocated to one of the two arms: manual reading and adjustment of P_cuff at least every 8h (routine care) or adjunction of the Smart Cuff Manager^TM (intervention). This study was approuved by an institutional review board.

Results:

Among 60 randomized patients (routine care in 32, Smart Cuff Manager^TM in 28), 506 measurements were performed in 48h. With routine care, a higher rate of patients experienced at least one episode of underinflation (62.5 vs. 17.8%;p<0.001). Episodes of underinflation episodes (15% vs. 2%;p<0.001) and manual adjustments (77% vs. 56%;p<0.001) were more frequent with routine care. For overinflation, there was no between-arms difference (p>0.99).

Conclusions:

The adjunction of continuous P_cuff control with the Tracoe Smart Cuff Manager^TM reduced the incidence of P_cuff underinflation as compared with manual intermittent adjustments. Overinflation was not promoted by this device.

References:

1. Rello J. et al. Am J Respir Crit Care Med 154:111-5, 1996

2. Nseir S et al. Crit Care 11:R109, 2007

3. Leone et al. Anaesth Crit Care Pain Med 37:83-98, 2018

P113 Percutaneous tracheotomy in ICU advantage and complications

V Pajtic¹, S Zjalic², B Josipovic², N Ilic², B Radanovic², D Barac², L Gvozdenovic³, S Lovrencic²

¹University of Novi Sad, Faculty of Medicine, Clinic for Anesthesia Intensive and Pain Therapy Clinical Center of Vojvodina, Novi Sad, Serbia; ²Clinic for Anesthesia Intensive and Pain Therapy Clinical Center of Vojvodina, Novi Sad, Serbia; ³University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia

Introduction:

Percutaneous tracheotomy (PT) in patients at the ICU is an invasive method of airway providing. It is requiring prolonged mechanical ventilation. PT as a method has proven to be simpler than surgical tracheosomy (ST), because it is performed in hospital bed without transporting the patient to the operating room, which is important in cases of hemodynamically unstable patients. Original kits, quick training and ability to perform in patient's bed, have imposed PT as the method of choice for ICU patients.

Methods:

In a one-year retrospective study, we have followed 161 patients in 2 groups, at ICU II, Clinical for Anesthesia and ICU and Pain Therapy, Clinical Centre of Vojvodina. Patients in ICU underwent PT with assistance of fiberoptic bronchosce, or ST in the operating room, due to the need for prolonged mechanical ventilation. Ultrasound Doppler examination of the blood vessels in the neek and their relationship with trachea determined the indication for PT or ST. In PT group were 110 patients, in ST 51. We have observed early and late complications and lenght of mechanical ventilation after the tracheostomy was performed.

Results:

On most patients (110) we have made PT assisted by fiberoptic bronchoscope. 51 patients underwent ST. Early complications in PT in terms of minor bleeding (<100ml) from the smaller vein blood vessels of the skin and subcutaneous tissue of the neek were 3,6% during the performance. Serious complication, false route, subcutaneous cannula placement, with subcutaneous emphysema was 0,9%. The late complications of PT in the form of tracheal stenosis are still being monitored, and no reports have been reported so far. Early complications in ST( bleeding, twisting cannula as well as malposition) were 20%.

Conclusions:

PT with assistance of fiberoptic bronchoscop has proven to be a safe and rapid invasive method, with no more complication than ST, in the ICU performed by ICU doctors on patients, in bed without transport to the operating room and as a safe alternative to ST.

P114 A comparison of the intersurgical i-View and Macintosh laryngoscope when used by novice personnel: a manikin study

MO O´Sullivan¹, EO Imhoff-O´Mahony²

¹Mercy University Hospital, Anaesthesiology and Intensive Care, Cork, Ireland; ²Sligo University Hospital, Anaesthesiology and Intensive Care, Sligo, Ireland

Introduction:

Direct laryngoscopy as a technique for tracheal intubation is a potentially lifesaving procedure that healthcare professionals in a variety of fields are taught. However, this skill is challenging to acquire and difficult to maintain. Poorly performed intubation technique can lead to potentially serious complications [1]. The Intersurgical iView video laryngoscope is a new intubation tool which may have advantages over direct laryngoscopes, such as the Macintosh, in the hands of novice personnel.

Methods:

A prospective randomized counterbalanced trial of 30 medical students, who did not have previous airway management experience, was conducted. Each student received brief didactic teaching,following this, participants were directly supervised performing laryngoscopy and intubation using the Macintosh and iView devices in an alternating pattern. Students were permitted up to three attempts to successfully intubate under four conditions, three laryngoscopy conditions using aLaerdal Intubation Trainer and one using a Laerdal SimMan Manikin.

Results:

There was no significant difference in the success rate of intubation or time to intubation between the two devices. The iView outperformed the Macintosh in time to intubation in the normal airway in the final scenario, once students gained experience with both devices. No significant difference was found in the number of optimisation manoeuvres, or intubation attempts between groups. Areas where the iView outperformed the Macintosh included severity of dental trauma and participants’ perception regarding ease of use ofthe device.

Conclusions:

The iView may prove to be a useful teaching tool for novice personnel who are acquiring the skills of tracheal intubation.

References:

1. Mulcaster JT et al. Anesthesiology 98:23-27, 2003

P115 Assessing predictors of success in airway pressure release ventilation (APRV)

SF Villegas¹, M McHendry¹, S Gillon², M Al-Haddad¹

¹Queen Elizabeth University Hospital, Department of Critical Care, Glasgow, United Kingdom; ²Royal Infirmary of Edinburgh, Department of Critical Care, Edinburgh, United Kingdom

Introduction:

Airway pressure release ventilation (APRV) is a mechanical ventilatory mode where elevated continuous positive airway pressure (CPAP) is applied with periodic releases to facilitate CO₂ clearance [1]. To date, there are no clear parameters that predict a positive response to APRV. The purpose of our study was to identify these.

Methods:

This was a retrospective cohort study in a single, large tertiary adult ICU from 2015-2018. Demographic, pathological and physiological data were extracted from the clinical information system CareVue ©. APRV responders were defined as patients remaining on APRV at four hours post initiation with a positive change in PF ratio. The cohort was stratified by responder status; univariate and multivariate analyses were used to identify factors associated with APRV response. Figures are mean (SD). Anonymized data was stored in a password-protected, securely stored computer file.

Results:

103 patients mean age 53.4 (15.5) were ventilated using APRV and 96 fulfilled inclusion criteria. 55% were male, 61% had a primary pulmonary pathology. Total ventilated days were 12.1 (9.6). Prior to APRV, 6% had evidence of left ventricular systolic dysfunction, PaO2 was 9.7 (3.0), PF ratio was 15.1 (9.3), PaCO2 was 7.1 (2.2), H+ was 52 (19), PPeak was 25.9 (5.4), PEEP was 10.5 (3.2), Vt/kg was 7.4 (2.6), CRP was 186 (123). APRV settings were: Phigh 27.5 (4.2), Plow 0 (0.4), Thigh 4.5 (1.1), Tlow 0.5 (0.3). 1% were ventilated prone, 4% had a neuromuscular blocker infused and 11% had a neuroprotective strategy employed at time of APRV. 48 patients responded to APRV (table 1). Hospital mortality was 31.2% in responders vs 54.2% in non-responders (p=0.037).

Conclusions:

Patients with a primary pulmonary pathology were more likely to respond to APRV. This association has not been described before and warrants further multi-centre exploration in a larger patient group.

References:

1. Jain SV et al. Intensive Care Med Exp 4:11, 2016.

Table 1 (abstract P115). Comparison of APRV responder variables (physiology pre-APRV)

P116 Preventing atelectasis during closed endotracheal suctioning

C Lima¹, G Alcala¹, S Gomes¹, R Santiago², M Amato¹

¹University of Sao Paulo Medical School, Pulmonary Division, Heart Institute (InCor), São Paulo, Brazil; ²Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Boston, United States

Introduction:

Airway suctioning is common during mechanical ventilation, using either an open endotraqueal suctioning or closed endotracheal suctioning (CES). Closed circuits were developed to prevent arterial desaturation and atelectasis associated to ventilator disconnection. However, CES may cause substantial loss of lung volume. The purpose of this study was to investigate the effects of a compensation method to prevent the loss in aeration during CES.

Methods:

The suctioning technique was performed for 15 seconds, negative pressures limited at 150 mmHg. Closed suction catheters with 14Fr (Halyard Health, Georgia, EUA) were used. Electrical impedance tomography (EIT) monitoring and arterial blood gas were collected. A NihonKoden Mechanical Ventilator (NKV550, California, EUA) was applied, having a newly developed algorithm for suctioning which overcomes any pressure loss during suctioning (InlineSuction-APP). When activated, the APP delivers PCV ventilation, adding 2 cmH₂O of end-expiratory pressure above PEEP, and delivering driving pressures of 15 cmH₂O.

Results:

Pigs (30±5.4kg) with injured lungs and mechanically ventilated. We tested the aspiration procedures using low PEEP=5cmH₂O, or high PEEP=±12.3cmH₂O with V_T2O), whereas maintenance of compliance was observed when the APP was ON (from12.2±1.4 ml/cmH₂O to 12.5±4.5 ml/cmH₂O. Blood gas in a representative animal showed a drop in PaO₂ when APP was off (from 247, to 149 mmHg after 2 min, and to 176 mmHg after 10 min) (Figure 1). With APP ON the PaO₂ changed from 259 (pre-suction), to 223 (2 min), to 253 mmHg (10 min).

Conclusions:

The new NKsoftware, delivering PCV ventilation during suctioning, could prevent atelectasis and functional loss associated to the procedure.

Fig. 1 (abstract P116).

Representative image showing the ventilation maps before and after closed endotracheal suctioning (CES). A) The drop in the EIT plethysmogram during suctioning, when no Inline Suction App was used – associated with a significant drop of lung compliance. B) A minor change in EIT ventilation map and in the plethysmogram when the Inline Suction APP was ON

P117 Tyrosine kinase inhibitor: an effective tool against lung cancer involvement responsible for acute respiratory failure in ICU

Y Tandjaoui-lambiotte¹, Y Akrour¹, F Gonzalez², A Stoclin³, F El Kouari⁴, A Gibelin⁵, F Wallet⁶, A Oppenheimer⁷, B Duchemann⁸, S Gaudry¹

¹Avicenne Hospital, Intensive Care Unit, Bobigny, France; ²Institut Paoli Calmettes, Intensive Care Unit, Marseille, France; ³Institut Gustave Roussy, Intensive Care Unit, Villejuif, France; ⁴Pitié Salpetrière Hospital, Pharmacy, Paris, France; ⁵Tenon Hospital, Intensive Care Unit, Paris, France; ⁶Lyon Sud Hospital, Intensive Care Unit, Lyon, France; ⁷Versailles-Saint-Quentin University (UVSQ), EA 7285 Research Unit ´Risk and Safety in Clinical Medicine for Women and Perinatal Health´, Montigny-le-Bretonneux, France; ⁸Avicenne Hospital, Oncology, Bobigny, France

Introduction:

Patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (ICU). In the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the ICU. The fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for ICU patients.

Methods:

We performed a national multicentric retrospective study with the participation of the GRRROH (Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie). All patients with non-small-cell lung cancer admitted to the ICU for acute respiratory failure between 2009 and 2019 were included in the study if a Tyrosine Kinase Inhibitor was initiated during ICU stay. Cases were identified using hospital-pharmacies records. The primary outcome was overall survival 90 days after ICU admission.

Results:

Thirty patients (age: 60+/-14 years old) admitted to a total of 14 ICUs throughout France were included. Seventeen patients (59%) were nonsmoker. Adenocarcinoma was the most frequent histological type (n=21, 70%). Most patients had metastatic cancer (n=21, 70%). Epithelial Growth Factor Receptor mutation was the most common oncologic driver identified (n=16, 53%). During the ICU stay, 17 (57%) patients required invasive mechanical ventilation, 13 (43%) catecholamine infusion, 3 (10%) renal replacement therapy and one (3%) extracorporeal membrane oxygenation. Eighteen patients (60%) were discharged alive from ICU and 11 (37%) were still alive after 90 days (see Figure). Moreover, 6 patients (20%) were alive one year after ICU discharge.

Conclusions:

Despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of Tyrosine Kinase Inhibitor should not be refrained in patients with severe condition in ICU.

Fig. 1 (abstract P117).

Probability of survival after ICU admission

P118 Community-acquired pneumonia: factors predicting poor outcome

C Bozikovich¹, A Ramos², A Dogliotti³, B Espinosa¹, N Rodriguez¹, C Lovesio²

¹Sanatorio Parque, Internal Medicine, Rosario, Argentina; ²Sanatorio Parque, Critical Care, Rosario, Argentina; ³Grupo Oroño, Epidemiology and statistics, Rosario, Argentina

Introduction:

Community-acquired pneumonia (CAP) is the most common infectious disease requiring admission to intensive care units (ICUs). The aim of this study was to investigate factors predicting poor outcome: the composite of in-hospital mortality and/or mechanical ventilation, in patients admitted to hospital because CAP.

Methods:

Between june 1, 2014 and september 30, 2018; 312 patients with CAP were prospectively registered. On admission data including patient characteristics, clinical findings, radiologic features and need for mechanical ventilation were assessed and further analyzed. Mechanical ventilation was defined as the requirement of invasive and/or non-invasive ventilation at any time during hospitalization. A multivariate analysis was performed to identify predictors of poor outcome.

Results:

Three hundred and twelve patients were included in the study and 26% of them had a poor outcome. In multivariate analysis, patients with a history of chronic obstructive pulmonary disease (COPD) (p=0.002), and those with elevated values of heart (p=0.001) and respiratory rates (p=0.01), and increased urea levels (p=0.01) had a worse outcome. (AUC ROC 0.83; 95% IC: 0.78-0.87).

Conclusions:

A history of COPD, elevated heart and respiratory rates and increased urea levels at admission were independent variables of poor outcome in patients with CAP.

P119 Mortality study of burn patients with inhalation injury in a critical burn unit

L Cachafeiro¹, A Agrifoglio¹, M Sánchez¹, E Herrero¹, A García de Lorenzo²

¹Hospital Universitario La Paz, Intensive Care Medicine Service, Madrid, Spain; ²Hospital Universitario La Paz, Madrid, Spain

Introduction:

The burned patient is one of the most complex patients whith a very high mortality. Those patients with inhalation injury have a worst prognosis, typically associated with respiratory complications. The aim of our study is to evaluate the mortality of burn patientes with inalation injury in a critical burn unit.

Methods:

A prospective, observational and descriptive study was conducted over a period of 3 years. Inhalation injury was defined with these criteria (≥ 2): history of injury in an enclosed space, facial burns with singed nasal hair, carbonaceus sputum and stridor. If they were intubated it was diagnosed by bronchoscopy. Demographic data, TBSA, ABSI, Baux score, APACHE II, SOFA, mechanical ventilation (MV), complications, length of stay, hospital course and mortality data were collected.

Results:

362 burns patients were admitted. 24% (84 patients) had inhalation injury. Mortality among patients with inhalation injury was 28,6% (24 patients). Most patients were men and those who died were older and with higher severity scores (Fig. 1). We found no significant differences between groups in the need for MV (95% vs. 85%) or in the percentage of tracheostomy performed (33.3 vs. 28.3). However, patients who died had more respiratory complications like ARDS, and also shock, renal failure and need of renal replancement therapies although infectious complications were similar in both groups. There was no statistically significant difference in volume used during initial resuscitation in the different groups.

Conclusions:

Patients with inhalation injury who died had higher severity scores at the begining. Although there were no differences in the need for MV patients who died had more respiratory complications as well as shock, renal failure and need of RRT, but no infectious complications.The volume used during inicial resuscitation, that was always related to the prognosis, was similar in both groups. Further studies are needed to see if this greater initial severity corresponds to the degree of inhalation.

Fig. 1 (abstract P119).

Demographic characteristics and severity scores

P120 Consistency of aerosol dosing during the progression of respiratory therapy in the hospital setting

E Fernandez fernandez¹, G Bennett¹, A Tatham¹, A O´ Sullivan², P McKiernan¹, M Mac Giolla Eain², M Joyce², R MacLoughlin²

¹Aerogen, Medical Affairs, Galway, Ireland; ²Aerogen, Science, Galway, Ireland

Introduction:

Patients with acute exacerbations such as asthma are prescribed aerosol therapy from presentation in the Emergency Department to progression through to the Intensive Care Unit. However, the variability in dose delivery to the lung across the possible patient interventions is not well characterized. Here, we assess the predicted lung dose of a bronchodilator in a simulated spontaneously breathing adult patient via both facemask and nasal cannula, and via tracheostomy during mechanical ventilation.

Methods:

A standard dose of 2.5 mg in 2.5 mL salbutamol was aerosolized using the Aerogen Solo nebulizer (Aerogen, Ireland). For facemask testing, the nebulizer was used in combination with the Aerogen Ultra with 2LPM supplemental oxygen flow. For nasal cannula testing, the nebulizer was used in combination with the Airvo 2 system (Fisher and Paykel, NZ) system at both 10 and 50LPM gas flow rate. Tracheostomy-mediated ventilation was assessed in combination with a HME, with the nebulizer placed between the HME and the tracheostomy tube. International Standard ISO27427 adult breath settings (Vt 500mL, BPM 15, I:E 1:1) were used across all tests, and generated using a breathing simulator (ASL5000, Ingmar Medical, USA) or mechanical ventilator (Servo-U, Maquet, Sweden). The dose delivered to the lung was assessed using a capture filter at the level of the trachea, with drug mass determined using UV Spectrophotometry at 276nm and interpolation on a standard curve.

Results:

The results of testing are illustrated in Figure 1.

Conclusions:

The bronchodilator dose delivered to the simulated patient was seen to be relatively consistent between progressive interventions, except during high flow therapy, with the more clinically relevant 50LPM gas flow rate having a profound effect on the dose. These results may go some way towards explaining how different patient interventions can affect aerosol dose.

Fig. 1 (abstract P120).

Illustration of lung dose for each patient intervention

P121 The underlying inflammatory effect of stable COPD (chronic obstructive pulmonary disease) patient on thrombogenicity and clot microstructure

S Pillai¹, M Lawrence², J Whitley³, K Harrison³, E Evans⁴, A Mughal⁴, S Hilldrup⁴, PR Williams⁵, K Morris⁶, PA Evans³

¹Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, United Kingdom; ²Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, United Kingdom; ³Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, United Kingdom; ⁴Respiratory Medicine, Morriston Hospital, Swansea, United Kingdom; ⁵Swansea University, Swansea, United Kingdom; ⁶Cardiff Metropolitan University, Cardiff, United Kingdom

Introduction:

COPD patients are known to have marked underlying lung parenchymal damage and associated microvascular changes [1]. They have two to four times increased mortality from ischemic heart disease and one fourth of patients develop pulmonary embolism particularly during acute exacerbations. The aim of the study was to demonstrate whether these patients’ underlying inflammatory response promotes thrombotic risk using the functional biomarker (fractal dimension-d_f). The stable COPD patients were divided into four groups based on their Forced Expiratory Volume at one second (FEV1); mild (>80%), moderate (50-80%), severe (30-50%) and very severe (<30%).

Methods:

30 stable ambulatory COPD patients with no evidence of infection or any underlying disease process that affect their coagulation system where recruited from the chest clinic of a tertiary teaching hospital. Blood samples were taken to perform fractal dimension (d_f), full blood count, platelet aggregometry, PT, aPTT, fibrinogen, d-dimer, CRP and Factor XIII.

Results:

The mean d_f in stable COPD patients was 1.690 (normal d_f 1.73 ± 0.04). The very severe group had highest d_f (1.712 ± 0.023, p=0.103), had significantly low FEV1 (24.20 ± 3.70, p<0.001) and significantly low BMI (21.57 ± 1.49, p<0.001). There were no significant rise in inflammatory markers, standard markers of coagulation and d-dimer.

Conclusions:

Ambulatory COPD patients who has a well-controlled disease have a normal coagulation profile despite having known parenchymal and vasculo-inflammatory disease. The clot microstructure (d_f) in these patients are within normal range. The study demonstrates that ambulatory COPD patients are less prone to develop thromboembolism and an increased risk occurs due to an exacerbation, sepsis or increased immobilisation.

References:

1. Davies et al. Intensive Care Med 42:1990-1998, 2016.

P122 Respiratory support for lung cancer patients with acute respiratory failure

HK Atalan¹, ME Kavlak¹, B Gucyetmez², ZT Sarikaya²

¹Memorial Atasehir Hospital, Intensive Care Unit, Istanbul, Turkey; ²Mehmet Ali Aydinlar Acibadem University, Intensive Care Unit, İstanbul, Turkey

Introduction:

The mechanical ventilation (MV) have been identified as an independent factor indicating a worse prognosis for lung cancer patients [1]. This study was conducted in order to assess the results of non-invasive mechanical ventilation (NIV) and/or invasive mechanical ventilation (IMV) modalities in lung cancer patients admitted to the ICU with acute respiratory failure (ARF).

Methods:

In this study, lung cancer patients with respiratory failure who were admitted to the ICU between January 2017 and December 2018 were evaluated retrospectively.

Results:

93 patients were included in the study. The mortality rate was 18.3%. 83 patients had NIV. IMV was applied to 10 patients. In the first 24 hours, 39 of the 83 patients who were initially treated with NIV were administered IMV. The duration of hospital stay, diagnosis of pneumonia and mortality rate were found to be significantly lower in patients treated with NIV alone (p≤0.001, p=0.004, p=0.025), but Glaskow Coma Score (GCS) was significantly higher in this group (p≤0.001). The mortality rate was similar between the patients who were initially treated with IMV and those who were treated with IMV in the first 24 hours. Charlson Comorbidity Index (CCI) and MV duration were significantly higher in patients who died (p=0.01, p=0.021), but GCS was significantly lower in this group (p=0.032). In the linear regression model for the likelihood of mortality, CCl≥9 and unsuccessful NIV increased the mortality rate by 3.4 (1.1-10.5) and 5.2 times (12-23.6) respectively (p=0.036, p=0.032).

Conclusions:

NIV has been an effective modality for respiratory support in most lung cancer patients presenting with ARF. However, failed NIV seems to be a factor for increased mortality. Therefore, the choice of respiratory support modality to be applied in this patient group should be decided by considering the GCS, CCI and etiology of ARF.

References:

1. Roques S et al. Intensive Care Med 35:2044-50, 2009.

P123 Association between PEEP level and renal blood flow in mechanically ventilated patients

A Fogagnolo¹, C Calandra², M Dres³, E Morelli², G Benetto², F Franchi⁴, S Scolletta⁵, CA Volta², S Spadaro²

¹Morphology, Surgery and Experimental Medicine, University Anaesthesia and Intensive Care, Ferrara, Italy; ²Morphology, Surgery and Experimental Medicine, Ferrara, Italy; ³Sorbonne Universités, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; ⁴University Hospital of Siena, Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, Siena, Italy; ⁵University Hospital of Siena, Siena, Italy

Introduction:

The interaction between ventilator settings and the occurrence of acute kidney injury is not fully elucidated. This study aimed at investigating the effect of stepwise increase in PEEP level on the risk of acute kidney injury as evaluated with the renal resistivity index (RRI).The primary outcome is to investigate whether increased levels of PEEP could lead to increase RRI and whether RRI could predict the occurrence of AKI.

Methods:

Patients mechanically ventilated for at least 48 hours and without AKI at admission were included in the study. RRI was calculated at ICU admission. Posterolateral approach was used for kidney ultrasound. The peak systolic velocity (V_max) and the minimal diastolic velocity (V_min) were determined by pulse wave Doppler, and the RRI was calculated as (V_max -V_min)/V_max. The exam was performed modifying the PEEP levels: 5, 10 and 15 cm H₂O in random order for 15 minutes. Occurrence of AKI was defined within 7 days according to KDIGO criteria.

Results:

Sixty-four patients were enrolled in the study and incidence of AKI was 14/64 (22%). Demographical and clinical characteristics are reported in Table 1. Increase in PEEP showed a significant increase in RRI from PEEP 5 to PEEP 10 (p<0.001) and from PEEP 10 to PEEP 15 (p=0.001) (Figure 1). The area under the ROC curve of RRI to predict AKI was 0.845 at PEEP 5, 0.898 at PEEP 10 and 0.894 at PEEP 15 (all p<0.001). The Youden index analysis showed an RRI>0.70 as the best cut off for AKI with a sensibility of 65% and a specificity of 96%. Patients with RRI>0.70 were 11/64 (17%), 13/64 (20%) and 22/64 (34%) at PEEP 5,PEEP 10 and PEEP 15 respectively. Patients ventilated with a PEEP value associated with RRI>0.70 had higher incidence of AKI (11/14 vs 6/50, p<0.001).

Conclusions:

The application of PEEP can increase intrarenal vascular resistance,which is associated occurrence of AKI; PEEP level should therefore be balanced taking into account the RRI. The RRI seems able to predict occurrence of AKI in mechanically ventilated patients.

Fig. 1 (abstract P123).

Demographic and clinical characteristics of the patients (left panel); RRI values in AKI and not-AKI patients at each level of PEEP (right panel)

P124 Alveolar and respiratory mechanics modifications produced by different concentrations of oxygen in healthy rats subjected to mechanical ventilation with protective ventilatory strategy

D Dominguez Garcia¹, R Hernandez Bisshopp¹, JL Martin Barrasa², D Viera Camacho¹, A Rodriguez Gil¹, J Arias Marzan¹, S Garcia Hernandez³, L Perez Mendez⁴, F Valladares Parrilla³, J Villar²

¹Hospital Universitario Ntra. Sra. de Candelaria, Anesthesiology and Surgical Critical Care, Santa Cruz de Tenerife, Spain; ²Hospital Universitario de Gran Canaria Dr. Negrín, Research Unit, Las Palmas de Gran Canaria, Spain; ³University of La Laguna, Anatomy, Pathology and Histology, La Laguna, Spain; ⁴Hospital Universitario Ntra. Sra. de Candelaria, Research Unit, Santa Cruz de Tenerife, Spain

Introduction:

High oxygen can damage tissues [1]. In this study, we analyze the histological and pulmonary mechanics modifications that can occur when identifying different inspiratory oxygen fractions (FiO₂) in lungs of healthy rats during protective mechanical ventilation.

Methods:

We use Sprague-Dawley rat. 4 groups were designed, each with 6 animals, the tidal volume (6 ml/kg), PEEP (3 cmH₂O) and respiratory rate (90 rpm) were kept constant, changing the FiO₂ between the groups. Four groups were established: FiO₂ 0.21, 0.4, 0.6 and 1. After 4 hours, the lungs were removed for histological study and obtaining the wet/dry index. The histological modifications studied were: alveolar septa (AS), alveolar hemorrhages (AH), intraalvelolar fibrin (IF) and inflammatory infiltrates (II). Each parameter was rated from 0 to 3 [2]. Peak pressure (Pp) and pulmonary compliance were monitored every 60 minutes. Different statistical tests will be used to analyze the data.

Results: References to the damage produced in the AS, AH, IF, II and the global histological pattern were identified in the groups with the highest FiO₂ and there was more damage (p <0.00001) (Figure 1). The wet/dry index rose significantly as the oxygen concentration increased (p = 0.001). In the groups to which a FiO₂ of 0.6 and 1 was administered, the Pp selected specific values with respect to the baseline intake from the first 60 minutes, an aspect that was not appreciated in the other groups (p <0.0001). Regarding pulmonary compliance, it will be seen that, in the FiO₂ 0.6 and 1 groups, it decreased from the first 60 minutes, finding differences with respect to the other groups (p <0.0001).

Conclusions: Mechanical ventilation applied for 4 hours in healthy animals produces disorders that are more pronounced as oxygen concentration increase. FiO₂ greater than or equal to 0.6 should be avoided without clinical justification.

References:

1. Hedenstierna G et al. Intensive Care Med Oct:1-4, 2019

2. Matute-Bello G et al. Am J Respir Cell Mol Biol. 44: 725-38, 2011

Fig. 1 (abstract P124).

Distribution of the percentage of global histological involvement among the groups (median and P25-75)

P125 Clinical outcomes among patients requiring prolonged acute vs. short-term mechanical ventilation in the US, 2014-2018: results from a multicenter cohort study

M Zilberberg¹, B Nathanson², J Ways³, A Shorr⁴

¹EviMed Research Group, LLC, Goshen, United States; ²OptiStatim, LLC, Longmeadow, United States; ³Lungpacer Medical Inc., Exton, United States; ⁴Washington Hospital Center, Washington, United States

Introduction:

Patients requiring prolonged acute mechanical ventilation (PAMV, defined as 4+ days on MV) are sicker and incur disproportionate morbidity and costs relative to patients on short-term MV (STMV, <4 days of MV). We quantified specific clinical outcomes among patients requiring PAMV vs. STMV in a contemporary database.

Methods:

We conducted a multicenter retrospective cohort study within ~700 hospitals in the Premier database, 2014-2018. Using ICD-9-CM and ICD-10 codes we identified PAMV and STMV patients, and compared their baseline characteristics and hospital events. Because of the large sample size, we omitted hypothesis testing.

Results:

A total of 691,961 patients met the enrollment criteria, of whom 266,374 (38.5%) received PAMV. At baseline, patients on PAMV were similar to STMV with regard to age (years: 62.0 ± 15.8 PAMV vs. 61.7 ± 17.2 STMV), gender (males: 55.6% PAMV vs. 53.9% STMV), and race (white: 69.1% PAMV vs. 72.4% STMV). PAMV group had a higher comorbidity burden than STMV (mean Charlson score 3.5 + 2.7 vs. 3.1 + 2.7). The prevalence of each of the indicators of acute illness severity – vasopressors (50.3% vs. 36.9%), dialysis (19.4% vs. 10.3%), severe sepsis (20.3% vs. 10.3%), and septic shock (33.5% vs. 15.9%) – was higher in PAMV than STMV, as were hospital mortality and combined mortality or discharge to hospice (Figure 1), extubation failure (12.3% vs. 6.1%), tracheostomy (21.6% vs. 4.5%), development of C. difficile (4.5% vs. 1.7%), and incidence density of ventilator-associated pneumonia (2.4/1,000 patient-days vs. 0.6/1,000 patient-days).

Conclusions:

Over 1/3 of all hospitalized patients on MV require it for 4 days or longer. PAMV patients exhibit a higher burden of both chronic and acute illness than those on STMV. Commensurately, all clinical outcomes examined are substantially worse in association with PAMV than STMV.

Fig. 1 (abstract P125).

PAMV = prolonged acute mechanical ventilation; STMV = short-term mechanical ventilation

P126 Use of spontaneous breathing trials and extubation data in Scottish ICUs - 2018 Scottish Intensive Care Society trainee audit

A Short¹, K Puxty², D Hall³, J Gardner¹, S Chapman⁴, N Lone³, N Stewart⁵

¹QEUH, Intensive Care Unit, Glasgow, United Kingdom; ²Glasgow Royal Infirmary, Intensive Care Unit, Glasgow, United Kingdom; ³Edinburgh Royal Infirmary, Intensive Care Unit, Edinburgh, United Kingdom; ⁴Ninewell Hospital, Intensive Care Unit, Dundee, United Kingdom, ⁵Forth Valley Royal Hospital, Intensive Care Unit, Larbert, United Kingdom

Introduction:

Identifying the readiness of patients recovering from critical illness for liberation from invasive mechanical ventilation (IMV) is not always straightforward [1]. The Scottish Intensive Care Society (SICS) trainee audit 2018 conducted a Scotland-wide study to understand current practices relating to liberation from IMV.

Methods:

Data were prospectively collected on patient demographics, indication for intubation, spontaneous breathing trial (SBT) practices, physiological markers, ICU outcome and ICU LOS. All patients >18 years ventilated with IMV for > 24hrs from the 1^stNov. 2018 – 30^thNov. 2018 were eligible for inclusion. Exclusion criteria included extubation for end-of-life, death whilst intubated and presence of tracheostomy. Logistic regression was performed to detect factors associated with extubation failure (EF). Results were analysed via Excel 2010 and Stata v.14.1. Patient Benefit and Privacy Panel approval was granted.

Results:

Total population of 172 patients were included: 108 (63%) male and median APACHE2 score 19 (IQR 13-23). EF at first attempt occurred on 27 occasions (15.7%), median ICU LOS of 10 days (IQR 7–12), mortality rate 22.2%. The cohort successfully extubated first time had a median ICU length of stay of 5 days (IQR 3–9) and mortality rate of 1.4%. Methods of SBT and extubation outcomes detailed in Table 1. No SBT prior to extubation had higher odds of EF (OR 2.52, CI 1.09-5.84, p=0.03); patient ventilation for < 3 days had a three times higher odds of EF (OR 3.31, CI 1.09-10.1, p=0.03). These were independently associated with EF on multivariate analysis

Conclusions:

We found a reintubation rate of 15.7% in Scottish ICUs. Type of SBT most commonly used is divergent from the methods advocated in the literature. The lack of SBT and early extubation attempt was associated with failure, which in turn was associated with longer ICU LOS and higher mortality.

References:

1. MacIntyre N. Respir Care 58:1074 – 1082, 2013

Table 1 (abstract P126). Extubation outcomes associated to ventilation days and SBT performed

P127 Both right and left ventricular dysfunction are associated with an increased mortality in patients undergoing prolonged invasive ventilation

M Chotalia¹, M Bangash², T Matthews², M Kalla², D Parekh², J Patel²

¹University Hospitals Birmingham, NHS Foundation Trust, Critical Care and Anaesthesia, Birmingham, United Kingdom; ²University Hospitals Birmingham, NHS Foundation Trust, Birmingham, United Kingdom

Introduction:

In patients undergoing prolonged invasive ventilation we hypothesise that abnormal right ventricular (RV) and left ventricular (LV) function are associated with increased 90-day mortality. Whether changes in LV or RV function could aid in the prognostication of these patients has not been directly studied.

Methods:

Patients admitted to the Queen Elizabeth Hospital Birmingham ICU between April 2016 and July 2019 who were intubated and ventilated for more than 7 days and had a formal transthoracic echocardiogram (TTE) whilst in ICU were included. Abnormal RV function was defined by the presence of depressed function, dilated size or moderate to severe risk of pulmonary hypertension. Abnormal LV function was defined by the presence of LV depression (LV ejection fraction £ 45% or grade II or more diastolic dysfunction) or a hyperdynamic LV (formally mentioned in TTE report). Patients who had a neurological cause for prolonged ventilation were excluded. The primary outcome was 90-day mortality. Categorical data is presented as % and analysed using a chi-squared test. Continuous data is presented as median (IQR).

Results:

871 patients required prolonged ventilation, of which 350 (40%) had a TTE. Patients were aged 62 (49-75), were 61% male and had a 36% 90-day mortality. The median ventilator days were 13 (6-20) and 77% required a tracheostomy. Abnormal RV function was present in 26% (n=90) and was associated with an increased 90-day mortality compared to normal RV function (68% vs. 25%, RR 2.71 [2.10-3.50], p<0.0001). LV function was abnormal in 27% (n=95) and was associated with an increased 90-day mortality compared to normal LV function (54% vs 28%, RR 1.91 [1.47 – 2.49], p < 0.0001). Abnormal RV function had a trend towards an increased mortality compared to abnormal LV function (68% vs 54%, RR 1.26 [1.00 – 1.60], p = 0.07).

Conclusions:

In this study, abnormal RV and LV function were present in a quarter of patients undergoing prolonged ventilation and were associated with an increased mortality.

P128 Temporary transvenous diaphragm neurostimulation improves volume distribution during mechanical ventilation

E Rohrs, M Ornowska, T Bassi, K Fernandez, M Nicholas, S Reynolds

Simon Fraser University, BPK, Burnaby, Canada

Introduction:

Tidal volume delivered by mechanical ventilation (MV) in sedated patients is distributed preferentially to ventral alveoli, causing overdistention and associated collapse in dorsal alveoli, driving volutrauma, atelectrauma and ventilator-induced lung injury [1]. Temporary transvenous diaphragm neurostimulation (TTDN) stimulates diaphragm contraction [2]. When used in synchrony with MV, TTDN encourages increased dorsal ventilation due to the change in pressure gradients with diaphragm contraction, mimicking a more normal physiological pattern. This may improve gas exchange and reduce injury.

Methods:

A pilot study was conducted using 50 kg pigs undergoing MV in a mock ICU. Deeply sedated subjects were provided lung-protective volume-control ventilation at 8 ml/kg. TTDN diaphragm contractions were delivered in synchrony with inspiration on every second breath, reducing the ventilator pressure-time-product by 15-20% during MV+TTDN breaths. Tidal volume distribution was recorded in each condition using electrical impedance tomography, and compared to never-ventilated, spontaneously breathing subjects (NV).

Results:

Dorsal ventilation changed from 49% during MV breaths to 54% during MV+TTDN breaths, compared to 60% in the NV group (p=0.035). Ventral ventilation changed from 51% during MV breaths to 46% during MV+TTDN breaths, compared to 40% in the NV group (p=0.042, Figure 1).

Conclusions:

TTDN diaphragm contraction used as an adjunct to MV yields a more physiological pattern of volume distribution. This translates into less overdistension in the ventral areas and less atelectrauma in the dorsal areas and reduces ventilator-induced lung injury. This technology has the potential to provide a novel method of lung-protective ventilation.

References:

1. Schiller HJ et al. Crit Care Med 29:1049-1055, 2001

2. Reynolds SC et al. Am J Respir Crit Care Med 195:339-348, 2017

Fig. 1 (abstract P128).

TTDN redistributes tidal volume during mechanical ventilation toward a more physiological pattern

P129 Assessment of the relation Pswing/tidal volume during spontaneous ventilation test, as a predictor of successful weaning

F Galiotti¹, G Pagella², M Carmona¹, R Paffumi¹, D Minzer¹, G Zakalik¹, P Riera¹, A Chena¹

¹Hospital Luis Carlos Lagomaggiore, UCI, mendoza, Argentina; ²Hospital Luis Carlos Lagomaggiore, Terapia intensiva, Mendoza, Argentina

Introduction:

By measuring the Pes and its derivatives, we can measure the relationship that exist between the diaphragmatic excursion and the oscillation of the esophageal pressure curve: Pswing (PS) so we infer that, just as with the Pes, the variations of it might be related to a weaning failure [1, 2]. However, no nominal value exists in the bibliography to predict the test result.

Methods:

Patients who meet with the inclusion criteria start the weaning process through a test of 30 minutes of spontaneous ventilation, T-Tube (TT). And also the respiratory rate (RR) and the tidal volume (TV). From this analysis, an average PS (APS) is determined for each moment of the test (APS1, initial and APS2, final.).A quotient was obtained in relation to these variables using the value previously obtained (quotient DTV/DPS x100.

Results:

A total of 13 patients were included (n=13).Regarding the evolution during TT, 9 (n=9) (69%) were successful, while 4 (n=4) (30.76%) failed When analyzing a rate that relates the variables TV and PS, a quotient was obtained in relation to these variables using the value previously obtained (quotient DTV/DPS) for patients who were successful and who failed, (DTV/DPS)/100 Successful patients presented a value of 18.75 while those of the failure group presented a value of 45.83, (OR 1,2 – 3 p=0.082) (Table 1).

Conclusions:

When presenting the relationship between TV and PS through the quotient (DVT/DPS)/100, it is observed a tendency to have a higher quotient among patients who failed versus those who did not fail.

References:

1 Akoumianaki E et al. Am J Respir Crit Care Med 189:520-31, 2014.

2 Tobin MJ et al. Weaning from mechanical ventilation. In: Tobin MJ, editor. Principles and practice of mechanical ventilation, 3rd ed. New York: McGraw-Hill; 2012, pp. 1307–1351.

Table 1 (abstract P129). Quotient DTV/DPS for patients who were successful and who failed, (DTV/DPS)/100

P130 Predicting weaning failure in CABG patients: role of echocardiographic evaluation of LVOT-VTI

E Favilli¹, G Brizzi², P Bertini², C Vullo², R Baldassarri², L Doroni², D Amitrano², F Guarracino²

¹Scuola di specializzazione in Malattie dell´Apparato Cardiovascolare, Università di Pisa, Pisa, Italy; ²Department of Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy

Introduction:

The process of weaning from mechanical ventilation imposes an additional workload on the cardiovascular system, which may result in impaired myocardial function, increase in left ventricular filling pressure and respiratory distress. Among surgical patients, those undergoing heart surgery are particularly susceptible to cardiac dysfunction induced by weaning because of inadequate cardiovascular reserve. The aim of our study was to depict the pathophysiological changes assessed by echocardiography during the steps of weaning and to identify possible predictors of weaning failure (WF).

Methods:

We enrolled 34 consecutive patients undergoing isolated coronary artery bypass grafting in our institution. Data were obtained by intraoperative transesophageal echocardiography before sternotomy (T0) and by transthoracic echocardiography at the beginning of weaning (T1) and at the time of extubation (T2). WF was defined as deferral of planned extubation or respiratory failure needing reintubation or non-invasive mechanical ventilation within 48 hours.

Results:

WF occurred in 7 patients (20.6%) and involved manifestations of respiratory distress in 5 (14.7%). We found a significant association between left ventricle outflow tract-velocity time integral (LVOT-VTI) and ventricular-arterial coupling measured at T1 and WF, with LVOT-VTI emerging as the best predictor of WF with an area under ROC curve of 0.8669 (Figure 1); an optimal cutoff value of 15 cm provided 100% sensitivity and 71% specificity. Significant increase in E/e’ measured at T2 (13.44 vs 9.96, P 0.02) suggested a cardiac etiology of respiratory distress in patients who failed the weaning trial.

Conclusions:

Our study showed that serial assessment of hemodynamic parameters by means of echocardiography is feasible in cardiac surgical patients and can provide insight into pathophysiological changes during weaning. Although these preliminary data need to be confirmed in a larger population sample, LVOT-VTI emerged as a promising predictor of subsequent WF.

Fig. 1 (abstract P130).

ROC curve of LVOT-VTI measured at the beginning of spontaneous breathing trial for weaning failure

P131 Compliance with guidelines for respiratory therapy in preclinical emergency medicine

G Jansen, N Kappelhoff, S Rehberg

Protestand Hospital of the Bethel Foundation, Anaesthesiology, Intensive Care and Emergency Medicine, Bielefeld, Germany

Introduction:

Current guidelines on pre-hospital emergency ventilation are based on the guidelines for lung protective ventilation in the intensive care unit. The present survey was designed to determine the accordance of actual pre-hospital emergency ventilation by German emergency physicians (GEP) with these recommendations.

Methods:

Recommendations include a respiratory rate (RR) between 10-16/min, a tidal volume (vt) between 6-8 ml/kg, a maximum pressure (Pmax) <30 mbar and a positive end-expiratory pressure (PEEP) of 5 mbar. An anonymous web-based questionnaire encompassing 7 questions was sent to GEP from September to December of 2018. GEP were asked to specify their level of education, their preferred ventilation settings and the usually chosen parameters employed to guide mechanical ventilation. Statistical analysis was performed using the Ch²-test with a significance level ≤0.05.

Results:

60% of the questionnaires were completed (159/261). 25% of the participants were trainees (Tr), 75% consultants (Co). As target parameters for guidance of ventilation, 87% of the Tr and 91% of the Co use capnometry. The Vt controlled 62% of the Tr and 54% of the Co on the basis of body weight. 81% of the Tr and 81% of the Co reported to control oxygenation using SpO2. Table 1 shows our analysis of the given answers. There were no statistically significant differences between the groups.

Conclusions:

Deviations from the guidelines of pre-hospital emergency ventilation settings are common and mainly concern the use of a guideline-compliant PEEP. In addition, recommended target parameters for guidance of ventilation were not applied in a significant proportion of GEP.

Table 1 (abstract P131). Guideline-compliance of ventilation parameters

P132 Analysis of inflammatory hippocampal cells after 50 hours of lung-protective mechanical ventilation in a preclinical pig model

T Bassi, E Rohrs, K Fernandez, M Ornoswka, M Nicholas, S Reynolds

Simon Fraser University, Physiology, Burnaby, Canada

Introduction:

We hypothesize that hippocampal inflammation occurs as a result of mechanical ventilation (MV). Preclinical studies evaluating neuroinflammation in normal-lung MV models have not been reported. Microglia and reactive astrocytes take part in neuroinflammation and are important targets of investigation. They are responsible for modulating neuronal connections, assisting in establishing stronger synaptic connections and maintaining tissue homeostasis.

Methods:

Our study investigated the percentage of iba-1-positive cells (microglia), and the percentage of GFAP-positive cells (astrocytes) in the total number of cells counted (positive and negative cells per marker) in the hippocampal tissue of human-size pigs with non-injured lungs after 50 hours of lung-protective MV (MV group), compared with never-ventilated (NV) pigs. The cells were counted by machine learning software IMAGEJ. Lung-protective MV was defined as: driving pressure less than 15 cmH₂O, tidal volume of 6ml/kg and peak pressure less than 30 cmH₂O.

Results:

Six NV and six MV pigs were used in this study. The percentages of iba-1-positive cells in the hippocampus were 7% (42705 iba-1-positive cells/589888 total cells) and 32% (65655 iba-1-positive cells/205006 total cells) respectively in the NV and MV groups (p<0.01). The percentages of GFAP-positive cells were 9% (35941 GFAP-positive cells/406235 total cells) and 18% (91156 GFAP-positive cells/502195 total cells) respectively in the NV and MV groups (p<0.01). When comparing the percentage of iba-1-positive cells to that of GFAP-positive cells we calculated the ratios of approximately 0.78 (7/9) and 1.78 (32/18) in the NV and MV groups respectively (p<0.01).

Conclusions:

Our study demonstrated neuroinflammation in pigs after lung-protective MV. A higher presence of microglia and astrocytes in the MV group indicate an inflammatory hippocampal process as a consequence of lung-protective MV.

P133 Predicting weaning from mechanical ventilation after lung transplantation

L Chiscano¹, M García-de-Acilu^1,2, J Sacanell¹, C Laborda¹, L Sánchez³, M Ribas⁴, C Berastegui⁵, R Ferrer^1,6, O Roca^1,6

¹Vall d’Hebron University Hospital, Critical Care Department, Vall d’Hebron Research Institute, Barcelona, Spain; ²Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; ³Vall d’Hebron University Hospital, Department of Respiratory Medicine, Vall d’Hebron Research Institute, Barcelona, Spain; ⁴Vall d’Hebron University Hospital, Department of Thoracic Surgery, Vall d’Hebron Research Institute, Barcelona, Spain; ⁵Vall d’Hebron University Hospital, Department of Anesthesiology, Vall d’Hebron Research Institute, Barcelona, Spain; ⁶Ciber Enfermedades Respiratorias (CibeRes), Instituto de Salud Carlos III, Madrid, Spain

Introduction:

Weaning from mechanical ventilation (MV) is an important issue in the immediate postoperative period following lung transplantation. No predictor of weaning success has been validated in this group of patients. The aim of the study was to establish whether clinical variables and/or the presence of DD may predict extubation failure in LTx patients.

Methods:

Prospective observational study including LTx recipients admitted to our ICU from February2017 to January2019, who underwent a spontaneous breathing trial (SBT) using a T-piece for 30 minutes. Clinical variables and arterial blood gas samples were recorded before starting SBT and after 20 minutes on the T-piece. Diaphragmatic excursion (DE) and thickening fraction (DTF) were also assessed using ultrasound(US) after 20 minutes on the Tpiece. US-DD was defined as DE<10 mm or DTF<0.3 of at least one hemidiaphragm. Patients who successfully completed a SBT, defined according to clinical criteria,were extubated. Extubation failure was defined as the need for reintubation within 48h. Results are expressed as medians (IQR) or frequencies (%).

Results:

193 LTx recipients were admitted to the ICU, 79 of whom underwent an SBT. 51 were male, and the median age was 58y. Main indications for LTx were interstitial lung disease (43.0%), COPD and cystic fibrosis. 59 were bilateral LTx, and 13 and 7 were left and right unilateral LTx respectively. 69 patients were extubated after SBT and 6 required reintubation within 48h. 53 presented US-DD, though there were no differences between patients who succeeded and those needing reintubation. In contrast, patients who succeeded showed higher PaO2/FIO2 after 20 minutes on the T-piece (Table 1). Similarly, higher reductions in deltaPaO2/FIO2 after 20 minutes on the T-piece were observed in patients who failed.

Conclusions:

Oxygenation after SBT performed using a T-piece may predict extubation failure in LTx recipients with successful SBT. US-DD was not associated with the need of reintubation.

Table 1 (abstract P133). Clinical and ultrasound variables

P134 Descriptive study about the relationship between self-extubation episodes and patient-ventilator interaction

S Nogales¹, C De Haro ¹, M Batlle², L Sarlabous³, J Aquino Esperanza³, G Gomà¹, J López Aguilar³, L Blanch³

¹Parc Tauli Hospital Universitari, Intensive care unit, Sabadell, Spain; ²Fundació Althaia. Xarxa Assistencial Universitària de Manresa., Intensive care unit, Manresa, Spain; ³Institut d´investigació i Innovació I3PT, Institut d´investigació i Innovació, Sabadell, Spain

Introduction:

To evaluate the relationship between self-extubation and patient-ventilator interaction, among other physiological variables, in order to predict and to prevent these events. Self-extubation (SE) are quality indicators in patients under invasive mechanical ventilations (IMV) and are related with mortality [1].

Methods:

Planned secondary analysis of a prospective data base of clinical and physiologic signals of patients receiving IMV. We included SE episodes (2012-2018) with continuous record of ventilator and monitor signals (BCLink BetterCare®). We analysed demographic data, physiological parameters (peripheral oxygen saturation SpO2, heart rate HR, respiratory rate RR and media arterial pressure MAP) and patient-ventilator interaction (asynchrony index AI, ineffective efforts during expiration IEE and double cycling DC). We studied a period of 12 hours prior to the SE episode. We used the Wilcoxon non-parametric test and for a proper analysis a Linear Mixed Effects Model.

Results:

We included 21 episodes of SE, mean age 62±13years, 76%men, APACHE II at admission 17±10, 4,6±3,8days under IMV until the episode, reintubation rate 47.6%, ICU stay 20,9±17,6days, ICU mortality 14%. At the time of the SE, 65% were under sedation, 65% with physical restraint. The 67% were in weaning. We observed a trend to increase in SpO2, RR, HR, MAP and asynchronies in the 2-hour period prior to SE episode. We compared these variables from this period with a 2-hour period before and we observed a statistically significant difference in RR, HR, MAP and AI. Clusters of IEE and DC increased its power in the 2-hour period before SE.

Conclusions:

In this preliminary study, patient-ventilator interaction, as well other physiological variables, are related with self-extubation episodes. Further analysis will be needed to analyze the value of these variables as a predictive model.

References:

1. Danielis M et al. Intensive Crit Care Nurs 47:69-77, 2018

P135 Postoperative complications and mortality after transcatheter aortic valve implantation: a retrospective, single Belgian center analysis

E Buts¹, P Vermeersch², S Verheye², C Convens², B Scott², P Dewulf¹, P Rogiers¹

¹ZNA Middelheim, Intensive Care, Antwerp, Belgium; ²ZNA Middelheim, Cardiology, Antwerp, Belgium

Introduction:

The purpose of this study was to review the mortality and early postoperative complication rates after TAVI (transcatheter aortic valve implantation) for severe aortic stenosis in an interventional cardiology center in Antwerp, Belgium with more than 10 years of experience. All patients were postoperatively admitted to the ICU for judicious monitoring. Results were compared to large international registries.

Methods:

A retrospective data analysis by medical record review of 242 patients who underwent a TAVI procedure between april 2008 - april 2019 was carried out. A literature search was executed to compare the results with current published data. Endpoints were mortality (72 hours, 1 week, 30 days, 1 year), bleeding, vascular complications, definitive pacemaker implantation, stroke, conversion and cardiac tamponade. Standardized criteria according to the Valve Academic Research Consortium II recommendations for studies evaluating TAVI were used [1].

Results:

Vascular access was predominantly transfemoral (90.1%), compared to subclavian (7%), carotic (1.7%) and direct aortic (1.2%) approaches. Mean age was 82.6 (range 61-98) years old, with 51.2% female patients. Mortality rates were 1.2, 2, 4.8 and 15.9% at 72 hours, 1 week, 30 days and 1 year respectively. Life-threatening bleeding occurred in 2.9%, major in 10.7% and minor bleeding in 3.3%. The major and minor vascular complication rates were 12.4% and 5.8%. 97.7% was access site related. There were no patients with aortic dissection. The need for definitive pacemaker implantation was 18%. Incidence of stroke and cardiac tamponade was 1.7 and 3.3% respectively. Conversion to open sternotomy was necessary in 0.8%.

Conclusions:

The data presented in this study show that our results are in accordance with the literature with favorable mortality and early postoperative complication rates and support that this procedure is an excellent alternative for surgery in the elderly patients.

References:

1. Kappetein AP et al. Eur J Cardiothorac Surg 42:S45-60, 2012

P136 Deterioration of pulmonary hypertension after TAVI predicts mid- to long-term poor prognosis

H Yamamoto¹, S Kayama¹, Y Watanabe², M Sugi³, T Ikeda⁴, S Sawamura¹

¹Teikyo University Hospital, Anesthesia, Tokyo, Japan; ²Teikyo University Hospital, Cardiology, Tokyo, Japan; ³Tokyo Medical University Hachioji Medical Center, Anesthesia, Tokyo, Japan, ⁴Tokyo Medical University Hachioji Medical Center, Specific intensive care, Tokyo, Japan

Introduction:

It is reported that patients with pulmonary hypertension (PH; systolic pulmonary arterial pressure (sPAP)≥35 mmHg)) have frequent cardiac complications after transcatheter aortic valve implantation (TAVI). PH often gets worse in some patients despite the normal cardiac function after TAVI. No studies have ever examined prognosis after TAVI in patients with or without worsening of PH. Therefore, we retrospectively examined the frequency of mid- to long-term heart failure and cardiac death in patients with and without deterioration of PH after TAVI.

Methods:

Among 113 patients who underwent TAVI at our hospital between February 2014 and March 2016, we analysed 27 patients with PH (sPAP≥35 mmHg) before surgery. sPAP was measured in transthoracic echocardiography before and within 1 week after TAVI. Patients were divided into two groups according to whether sPAP worsened/did not change or improved after TAVI. We examined the frequency of admission due to heart failure or cardiac death (death caused by heart failure, angina, or myocardial infarction) during the period of 3 years after TAVI.

Results:

PH worsened or did not change after TAVI in 9 patients, while it improved in 18 patients. The left ventricular ejection fraction measured within 1 week after TAVI showed no difference between the two groups (56.6±11.9% vs 58.4±10.0%, p=0.71). The worsened/ no change group was higher in frequency of admission due to heart failure (logrank; p<0.05) and cardiac death (logrank; p<0.04).

Conclusions:

Despite successful treatment for AS by TAVI, the frequency of heart failure and cardiac death was higher in patients who did not show improvement of PH after TAVI, even in the absence of cardiac function decrease. Vigorous intervention for PH worsening after TAVI may be helpful to improve prognosis.

P137 The anti-thrombotic effects of different P2Y12 inhibitors in the management of acute ST elevation myocardial infarction

R Quarry¹, M Lawrence², A Sabra², D Obaid², A Chase³, D Smith³, J Whitley², S Pillai³, K Morris⁴, PA Evans²

¹Morriston Hospital, Emergency Department, Swansea, United Kingdom; ²Swansea University, Welsh Centre for Emergency Medicine Research, Swansea, United Kingdom; ³Morriston Hospital, Welsh Centre for Emergency Medicine Research, Swansea, United Kingdom; ⁴Cardiff Metropolitan University, Welsh Centre for Emergency Medicine Research, Cardiff, United Kingdom

Introduction:

There are several different anti platelet drugs that can be used to treat acute cardiac events. Currently there are no effective markers that can assess how these drugs modify coagulation profile and quality. A new functional biomarker that measures Fractal dimension (df ) and clot formation time (TGP) has been developed [1]. df quantifies clot microstructure whereas TGP is a real-time measure of clotting time. We aimed to validate df and TGP in ST elevation myocardial infarction (STEMI) and assess the effect of two P2Y12 inhibitors which have different pharmacological mechanisms: clopidogrel and ticagrelor.

Methods:

We prospectively recruited 72 STEMI patients in the emergency setting. Venous blood samples were collected 12 hours after admission, following treatment with either ticagrelor or clopidogrel, in accordance with the local guidelines at the time. The blood samples were tested using the df and TGP biomarker, platelet aggregometry, clot contraction and standard markers of coagulation.

Results:

36 patients received clopidogrel and 36 received ticagrelor. The df for clopidogrel was higher than ticagrelor (1.75±0.05 vs 1.73±0.06, p=0.18 which corresponds to a decrease in clot mass of 20% Figure 1) and the TGP was reduced (205±91sec vs 257±89 sec, p=0.06 a 20% reduction in time).

Conclusions:

The results of the study suggest that clopidogrel is less powerful in its effects on clotting characteristics compared to ticagrelor. Blood from patients receiving clopidogrel formed quicker and denser clots. This would suggest the risk of secondary events or stent occlusion is lower in those patients on ticagrelor, highlighting that df and TGP may be important in identifying patients at risk of future thrombotic events, the study is ongoing and will investigate the long term outcome in these patients.

References:

1. Knowles RB et al. Platelets 29:162-170, 2018

Fig. 1 (abstract P137).

Visual representation of the relationship between clot microstructure and clot mass

P138 Management of new onset atrial fibrillation in a district general hospital intensive care unit

A Munro, M Yousif, W Du, R Sarkar, N Divekar

Medway Maritime Hospital, Intensive Care Unit, Gillingham, United Kingdom

Introduction:

New onset atrial fibrillation (NOAF) during critical illness frequently resolves prior to discharge. However long-term risks of NOAF (i.e. heart failure, ischemic stroke and death)remains high [1]. Previous studies noted that nearly half of NOAF cases did not have diagnosis recorded [2]. Addressing this may reduce post critical illness mortality by increasing AF surveillance post intensive care (ICU) discharge.

Methods:

Retrospective data was collected from an electronic health record for ICU admissions over a 10 month period from 1^st of January to 31^st of October 2019 at Medway Maritime Hospital. Data collected included; demographics, onset, rate, possible precipitants, attempted electrical or chemical cardioversion, rate control, anticoagulation, rhythm on discharge from ICU and hospital discharge medication. It was recorded if NOAF was documented in ICU and Hospital discharge summaries.

Results:

Over 10 months 429 patients were admitted to ICU. 37 patients developed new onset AF with an average age of 69.2 (±10.3) and 59.4% male. Patients with NOAF had an in-hospital mortality of 43.2% compared to 29.8% . Beta blockers were used in 38% and amiodarone in 59%. 23 patient’s with NOAF survived ICU admission (62%). 13.5% remained in AF on discharge of which 1 patient was discharged from ICU on therapeutic anticoagulation (2 total, 11%). Of those not anticoagulated 19 had a Cha2ds2-VASc of >= 2. On ICU discharge, 23 patients had NOAF. 35% episodes documented on ICU discharge summaries. Thirty three per cent patient had documentation about the reason for choosing rate control approach. On hospital discharge only 28% had documentation of NOAF episode on their hospital discharge summaries.

Conclusions:

Need to implement an automated referral to cardiology to assess long term anticoagulation for patients with NOAF with CHA2DS2-VASc score >=2. For clear documentation of NOAF episode in ICU discharge summaries.

References:

1. Walkey AJ et al. Chest 146: 1187-1195, 2014

2. Moss et al. Critical Care Medicine 45: 790-797,2017

P139 Assessing the role of cardiac biomarkers in the emergency department in a Moroccan hospital

S Abouradi¹, R Benmalek¹, R Habbal¹, M Mouhaoui²

¹Cardiology Department, CHU Ibn Rochd, Casablanca, Cardiology, Casablanca, Morocco; ²Emergency Department, CHU Ibn Rochd, Emergency Department, Casablanca, Morocco

Introduction:

A biomarker is defined as a measurable indicator of some biological state or condition. Combined with a good clinical evaluation, they can enable an early and safe diagnostic, thus a faster management for the patient. Cardiac biomarker testing is not indicated in routine in the emergency department (ED) because of low utility and high possibility of false-positive results. However, current rates of testing are unknown. The aim of our study was to evaluate the importance of measuring cardiac biomarkers especially Troponins, D-dimer, and B-type natriuretic peptide in our daily practice, and to identify the latest recommendations for a better use of these biomarkers in the diagnostic and therapeutic approaches.

Methods:

We conducted a prospective observational study, over a 13 months periods performed in the ED of the university hospital center Ibn Rochd, Casablanca, Morocco, including all patients admitted during our study period and having a blood test for at least one biological marker. The dataset was analyzed by SPSS statistics 21.0.

Results:

A total of 182 patients was enrolled. Troponins were tested in 85.3% patients (High sensitive in 49.5% and troponin I TnI in 35.8%), D-dimer in 30.9%, BNP 19% and NT pro BNP in 9.5% of cases. The diagnostic impact was significant in 94.4% of cases for troponins, 84.6% of cases for D-dimer and 87.5% for BNP. The therapeutic impact was considered important in 80.6% cases for troponins, 69.2% for D-dimer and 87.5% for BNP.

Conclusions:

Cardiac biomarkers have an important role in the ED, not only do they confirm the diagnosis (including the role of troponins in ACS) but also eliminate others (with a strong negative predictive value of D-dimer for thromboembolic disease) and prove the cardiopulmonary origin of acute dyspnea (the significant place of BNP in confirming the diagnosis of acute heart failure).

P140 A multicenter study on the comparison of inter-rater reliability of a new and the original HEART score among emergency physicians from three Italian emergency departments

N Parenti¹, ML Bacchi Reggiani², F Numeroso³, L Bonfanti³, G Farina⁴, V Pezzilli⁵, C Campanella⁶, G Cervellin³, M Cavazza⁵, V Stanghellini⁵

¹Largo Nigrisoli, Internal Medicine, Bologna, Italy; ²University of Bologna Alma Mater, Biostatistics, Bologna, Italy; ³University Hospital of Parma, Emergency Dept, Parma, Italy; ⁴University of Bologna Alma Mater, Emergency Dept, Bologna, Italy; ⁵University of Bologna Alma Mater, Internal Medicine, Bologna, Italy; ⁶Nova Southeastern University USA, Internal Medicine, Davie, Florida, United States

Introduction:

The HEART (based on History,ECG,Age,Risk Factors,Troponin) score is a valid tool to stratify the ACS in chest pain. But some reports suggest that its reliability could be low for heterogeneity in the assignment due to the subjective interpretation of the History. We used the Chest Pain Score for the “History”. In this study we compare the reliability of the new HEARTCPS and original HEART.

Methods:

This is a multicenter retrospective study conducted in 3 Italian ED between July and October 2019 using clinical scenarios. Ten physicians were included after a course on HEART and HEARTCPS score. We used 53 scenarios which included clinical and demographic data. Each participant independently assigned scores to the scenarios using the HEART and HEARTCPS. We tested the interrater agreement using the kappa-statistic (k), the confidence intervals are bias corrected ; we used Stata/SE 14.2 statistical software . A p-value of <0.05 defines statistical significance.

Results:

The overall inter-rater reliability was good for HEART and HEARTCPS: Kappa =0.63 (CI 95%;0.57–0.72)and 0,65(CI95%;0.63 - 0.67); with good agreement among all the class of risk for HEARTCPS but moderate in the medium class for HEART .

We found significant differences of inter-rater reliability among the senior and junior physicians who used the HEARTCPS:K=0.56(CI95%;0.52–0.57)and 0.75(CI95%;0.70-0.79). HEARTCPS score increased its History inter-rater reliability specially among the junior physicians from K=0.35 (CI 95%; 0.27-0.43) to k=0.69(CI 95%;0.62-0.71).The Junior physicians seem to be more reliable than senior with the HEARTCPS:k=0.75 (0.71-0.79) vs K=0.56 (CI95%;0.52-0.57).

Conclusions:

The HEARTCPS showed inter-rater reliability better than original HEART among the medium class of risk and the junior group. It could be proposed to young doctors to stratify the ACS risk of chest pain. Limit: we used scenarios rather than real patients.

P141 A hybrid approach as treatment for coronary artery disease: endo-CABG or PCI first, does it matter?

V Dekoninck¹, A Yilmaz², J Dubois³, JP Ory³, J Vandenbrande³, B Stessel³

¹Jessa, Intensive Care & Anesthesiology, Hasselt, Belgium; ²Jessa, Cardiothoracic Surgery, Hasselt, Belgium; ³Jessa, Anesthesiology & Intensive Care, Hasselt, Belgium

Introduction:

The aim of this study is to discuss the short-term results of a hybrid approach combining minimally invasive endoscopic CABG (EndoCABG) with a percutaneous coronary intervention (PCI). To bypass the disadvantages and potential complications of conventional CABG via median sternotomy, we developed the EndoCABG technique to treat patients with single- and multi-vessel coronary artery disease (CAD). This procedure is performed with three 5-mm thoracic ports and a mini-thoracotomy utility port (3 cm) through the intercostal space. This technique can be combined with PCI: the hybrid approach. The sequence of the 2 procedures (EndoCABG followed by PCI or vice versa) may result in different outcomes.

Methods:

From 02/2016 to 12/2017 data from 81 consecutive patients scheduled for a hybrid technique at Jessa, Belgium, were prospectively entered into a customized database. This database was retrospectively reviewed. Subgroup analysis was performed to compare outcomes of patients who first received EndoCABG with patients who first received PCI. A p-value < 0.05 is considered significant, a p-value < 0.1 is considered as a trend toward significance.

Results:

Four patients underwent revision surgery and 2 patients died within the first 30 days. In 79 patients the left anterior descendens artery (LAD) was grafted with the left internal mammary artery (LIMA), the right coronary artery (RCA) was the most stented vessel using PCI. Patients first treated with PCI received more units of fresh frozen plasma after EndoCABG compared to those who were first treated with EndoCABG (p=0.03). There was also a trend toward significant more transfusion of packed cells in this small subgroup (p=0.07).

Conclusions:

The hybrid approach is a feasible technique as a treatment option for patients with multi-vessel CAD. If CABG follows the PCI, patients are more likely to receive transfusion. A possible explanation could be the need for dual antiplatelet therapy prior to surgery in this group, but this needs further investigation.

P142 Prognostic difference between troponin elevation meeting the MI criteria and troponin elevation due to myocardial injury in septic patients

A Shilova¹, D Shchekochikhin², M Gilyarov³, A Nesterov⁴, A Svet⁵

¹Moscow City Univercity hospital #1 n.a. Pirogov, ICCU, Moscow, Russia; ²Moscow City Univercity hospital #1 n.a. Pirogov, Cardiology, Moscow, Russia; ³Moscow City Univercity hospital #1 n.a. Pirogov, Cardiology, Moscow, Russia; ⁴Moscow City Univercity hospital #1 n.a. Pirogov, Cardiology, Moscow, Russia; ⁵Moscow City Univercity hospital #1 n.a. Pirogov, Management, Moscow, Russia

Introduction:

Troponin T (cTnT) elevation in critically ill patients is common and is associated with poor outcome. Using common assays, 40-50% of patients in the ICU will have elevated troponin level. Our aim was to determine whether there is any prognostic difference between troponin elevation meeting the MI criteria (rise and fall more than 20% together with Echo and ECG new abnormalities) and troponin elevation due to myocardial injury in septic patients.

Methods:

We enrolled 101 patients with sepsis and mean SOFA score 5,2 respectively in which cTnT level was measured more than once and analyzed there ECG and Echo findings. Patients were classified into three groups:definite MI (rise and fall cTnT ≥ 20% and contemporaneous changes on ECG and/or Echo),possible MI (rise and fall cTnT ≥ 20% and no other findings),myocardial injury (cTnT rise less than 20%)

Results:

Data from 101 patients were analyzed (49% female; mean age 61.9 (SD 16.9)). A total of 101 patients had at least one elevated cTnT more than 0.03 mkg/l. In 71 (70%) of patients cTnT level rised more than 20% from the first elevated measurement.64 (63%) of patients met MI criteria considering new ECG and Echo findings. The overall mortality rate in all patients was 53.9%.The mortality rate didn’t differ significantly in three groups: in the definite MI group 62.4%, in the suspected MI group 52%, in the non MI cTnT elevation group 56,4%, p=0,6. Coronary angiography was performed in 46 (73%) of patients from the definite MI group,PCI was performed in 18 (39%) of patients. The mortality rate in the invasive group was not significantly lower comparing to the nonivasive group 29% vs 37,8%, p=0,06. Bleeding complications were significantly more frequent in the definite MI group 13% vs 7% and 8% respectively

Conclusions:

cTnT level elevation is associated with poor outcome regardless coronary or non coronary injury. Myocardial revascularization may be beneficial in patients with sepsis and definite MI, but it is also associated with increased bleeding risk.

P143 Diagnostic interest of "Marburg Heart Score" in patient consulting the emergencies department for acute chest pain

NE Nouira¹, M Lehyeni¹, A Lahouegue¹, K Hamzaoui¹, D Hamdi¹, M Boussen²

¹Mongi Slim Academic Hospital, Emergency Department, Tunis, Tunisia; ²Mongi Slim Academic Hospital, Tunis, Tunisia

Introduction:

Chest pain is a common reason for emergency department visits, although this primarily refers to Acute Coronary Syndrome (ACS), this symptom may be frequently related to other non-ischemic etiologies. The aim was to validate the Marburg Heart Score as a tool to exclude coronary artery disease in emergency department patients with non-traumatic acute chest pain.

Methods:

a prospective, observational, descriptive and analytic cohort study conducted in the emergency department, from February 1st to March 31st, 2019, collecting patients consulting for nontraumatic acute chest pain, the "Marburg Heart" score was calculated for all these patients. Telephone contact was made after 6 weeks to look for an ischemic cardiovascular event.

Results:

We included 171 patients. The mean age was 57 +/- 13 years, the sex ratio was 0.86. The majority of the patients (78.9%) consulted directly to the emergency department, 21.1% were referred by a primary care physician. The median time to consultation after the onset of chest pain was 24 hours. High blood pressure was the most common risk factor (43.9%), followed by smoking (31%), diabetes (24.8%) and dyslipidemia (23.4%). Thirty-five patients (20.5%) had already coronary heart disease, ECG was pathological in 19.3% of patients, 8 patients had an ACS with ST segment elevation. At six weeks, 20.6% of the patients had an acute coronary event. According to the patients' answers on the 5 questions of the Marburg Heart score. The area under the ROC curve of this score was 0.78 with a negative predictive value of 87.2%;

Conclusions:

The "Marburg Heart Score" is a simple, valid and reproducible clinical score with a discriminatory power to rule out the diagnosis of coronary artery disease from the first contact with the patient presenting for chest pain in emergencies.

P144 Fluid management in abdominal aortic aneurysm surgery in elderly patients

D Lončar Stojiljković¹, MP Stojiljkovic²

¹Institut Dedinje, Anesthesia and Intensive Care, Belgrade, Serbia; ²Institut Dedinje, Belgrade, Serbia

Introduction:

The abdominal aortic aneurysm (AAA) surgery is a complex procedure in elderly patients with high cardiovascular risk. Anesthesiological techniques should play special attention to the volume status during cross-clamping as well as to the blood loss. Goal directed fluid therapies (GDT) in AAA surgery in elderly patients decrease the perioperative morbidity and mortality [1]. Aim of this study is to investigate administration of fluid-based on either a GDT approach or a control method (fluid administered based on static preload parameters and traditional hemodynamic) in all phases of AAA surgery and especially in the phase of clamping and de-clamping.

Methods:

A total of 30 patients ASA III, randomly scheduled for elective, open AAA surgery were included in this clinical trial. They were randomly assigned to two groups I – GDT with targeting stroke volume variation (SVV) and II - Control group where fluids were administered at the discretion of the attending anaesthesiologist. In both these groups hemodynamic parameters, central venous pressure (CVP), temperature, blood loss and diuresis were registered during the operation and 48 hours postoperatively. Each group was assessed for postoperative complications.

Results:

GDT group received less fluids and had a higher cardiac index (CI) (3.9± 0.6 vs. 2.9± 0.8 l/minute per m², p < 0.01) and stroke volume index (55.1 ± 5.4 vs. 35.1 ± 5.8 ml/m², p < 0.01) than the control group. There were significantly fewer complications in the intervention than control group (3 vs. 9, p = 0.02).

Conclusions:

GDT fluid administration enables less use of fluids, improved hemodynamic and fewer postoperative complications in elderly patients undergoing AAA surgery.

References:

1. Funk DJ et al. Crit Care 19:247, 2015

P145 Should preoperative antihypertensive agents be hold in high risk hypertensive patients undergoing major noncardiac surgery with neuraxial block?

S Kongsayreepong¹, W Chaisi²

¹Siriraj Hospital, Anesthesiology & Critical Care, Bangkok, Thailand; ²Siriraj Hospital, Bangkok, Thailand

Introduction:

With the benefit of neuraxial block in major noncardiac surgery, but serious cardiac events’re reported in high risk pts receiving preop beta-adrenergic blocking agent. The aim of this study was to study predictors of intraoperative cardiac complications in pts underwent major noncardiac surgery with neuraxial block.

Methods:

This prospective observational study was done in 360 high risk for cardiac complication pts, underwent elective major noncardiac surgery with neuraxial block [spinal, thoracic (TE) or lumbar epidural (LE) anesthesia] alone or combined with GA & admitted to the SICU during Jan 2017-Sep 2019. Pts with ESRD or underwent arterial vas surgery were excluded. Study data included: pts demographic,comorbidities,ASA class, preop hypertensive med (beta adrenergic blocking agent, ACEI/ARB, vasodilator), intraoperative cardiac complications [significant hypotension (SBP<90 mmHg or MAP<65 mmHg>10 mins) requiring fluid resuscitation or inotropic agent, serious cardiac arrhythmias needed medication or intervention, PMI, cardiac failure, cardiac arrest, cardiac death), within 72 hours postoperative organ dysfunction (AKI, stroke) & 30days mortality.

Results:

Among the studied pts (age 65+16yrs), 72% was ASA III, 54% had hx of HTN. 64% underwent major abdominal surgery, 21%, 8% & 72% received spinal, spinal plus GA and TE or LE plus GA subsequently. 79% had serious intraop cardiac complications (80%, 15% & 4% had significant hypotension, PMI & cardiac arrest subsequently), 39%, 3% & 11% had AKI, ischemia stroke&delirium subsequently. 30 days mortality was 13%. From multivariate variate analysis showed age>75 yrs, hx of HTN, preop beta-adrenergic blocking agent, vasodilator, combined beta-adrenergic blocking agent & vasodilator or ACEI/ARB, high dose local anesthetic agent were significant predictors of intraop serious cardiac complications.

Conclusions:

Further study about decrease or withhold preop antihypertensive med in high risk patient undergoing major noncardiac surgery with central neuraxial block is warranted.

P146 Clinical importance of ultrasonographic assessment of skeletal muscle mass in patients after cardiothoracic surgery

V Raidou¹, S Dimopoulos², F Chatzivasiloglou¹, D Elaiopoulos², A Robola², D Markantonaki², E Lyberopoulou², A Marathias², S Nanas¹, A Karabinis²

¹National and Kapodestrian University of Athens, Clinical Ergospirometry, Exercise and Rehabilitation Laboratory, Athens, Greece; ²Onassis Cardiac Surgery Center, Cardiac Surgery ICU, Athens, Greece

Introduction:

Ultrasonography is a valid diagnostic tool, used to measure changes of muscle mass. The aim of this study was to investigate the clinical value of ultrasound-assessed muscle mass, in patients undergoing cardiothoracic surgery that present muscle weakness postoperatively.

Methods:

For this study, 221 consecutive patients were enrolled, following their admission in the Cardiac Surgery Intensive Care Unit (ICU) within 24 hours of cardiac surgery. Ultrasound scans, for the assessment of quadriceps muscle thickness, were performed every 48 hours for 7 days. Muscle strength was also evaluated in parallel, using the Medical Research Council (MRC) scale.

Results:

Of the 221 patients enrolled, ultrasound scans and muscle strength assessment were performed in 165 patients. The muscle thickness of rectus femoris (RF), was slightly decreased by 2.18% ([95%CI: -0.21; 0.15], n=9; p=0.729) and the combined muscle thickness of the vastus intermedius (VI) and RF decreased by 3.5% ([95% CI: -0.4; 0.22], n=9; p=0.530). Patients whose combined VI and RF muscle thickness was below the recorded median values (2.5cm) on day 1 (n=78), stayed longer in the ICU (47 ± 74 vs 28 ± 45 hours, p = 0.015). Patients with MRC score ≤ 48 on day 3 (n=7), required prolonged mechanical ventilation support compared to patients with MRC score ≥ 49 (n=33), (44 ± 14 vs 19 ± 9 hours, p = 0.006).

Conclusions:

The use of muscle ultrasound seems to be a valuable tool in assessing skeletal muscle mass in critically ill patients after cardiothoracic surgery. Moreover, the results of this pilot study showed that muscle wasting of patients after cardiothoracic surgery is of clinical importance, affecting their stay in ICU.

P147 Prediction of cardiac risk after major abdominal surgery

S Musaeva, I Tarovatov, A Vorona, I Zabolotskikh, N Doinov

Kuban State Medical University, Anesthesiology and Intensive Care, Krasnodar, Russia

Introduction:

The aim is to assess the incidence of cardiovascular incidents in major abdominal surgery [1] using the revised Lee index.

Methods:

A study was conducted of 144 elderly patients who underwent major abdominal surgery in the Krasnodar Regional Clinical Hospital No. 2 under combined anesthesia. In the preoperative period, the risk of cardiovascular incidents was assessed using the revised Lee index and the functional status was assessed by MET. Depending on the Lee index, 3 groups were identified: group 1 (n = 69) - low risk (index value - 1), group 2 (n = 52) - intermediate risk (index value -2); group 3 (n = 23) - high risk (index value> 3). We estimated the incidence of critical incidents in groups: hypo-, hypertension, arrhythmias, and bradycardia.

Results:

In the general population, cardiac risk was 2.2 ± 0.7 points; functional status - 7.7 ± 1 MET. The greatest number of critical incidents was recorded in patients with high risk (58.4%), the smallest - in patients with low risk (9.1%), in patients with intermediate risk - 26.5% (n <0, 05 between groups according to Chi-square criterion). In the structure of critical incidents, hypotension was most often encountered - in 62 (43%) patients, while some patients revealed several incidents from the circulatory system (n = 116). Overall, the Lee scale showed good prognostic ability (AUROC = 0.81) in predicting hemodynamic incidents.

Conclusions:

The revised Lee index is a useful tool to help assess the risk of cardiovascular incidents and determine patient management tactics in the perioperative period.

References:

1. Veyler RV et al. Anesteziol Reanimatol 61:352-356, 2016

P148 Cognitive dysfunction in rats after minor and major surgery

V Sharipova, A Valihanov, A Alimov

Republican Research Centre of Emergency Medicine, Anesthesiology, Tashkent, Uzbekistan

Introduction:

Postoperative cognitive dysfunction (POCD) remains an unresolved problem due to lack of consensus on its etiology and pathogenesis. Some believe that POCD is the result of the direct toxic effect of general anesthetics on the nervous system. Others claim that surgical trauma activates proinflammatory factors that induce neuroinflammation.

Methods:

Wistar rats were allocated into 2 groups: 1-minor surgery (n=20), 2-major surgery group (n=20). After 5 days of handling and habituation rats undergone surgery under isoflurane general anesthesia (2 vol.%). Group 1 rats underwent laparotomy with gentle gut massage followed by wound closure. Rats in group 2 undergone left side nephrectomy. Starting from the 4th postoperative day spatial memory in rats was studied in Morris Water Maze which is a cylinder metal pool with a diameter of 1.5 and a height of 0.5 m filled with water (temp.26±1^oC) up to half. It has a platform with a diameter of 12 cm and a height of 1 cm below the water level. Testing was preceded by a training stage, which included 8 sessions daily for 4 days. Thus, rats developed spatial memory to the location of the platform. On the 5th day of the study test stage was conducted to assess spatial memory: rats were launched from 3 points into maze without platform and data were recorded for 60 seconds at each session. Time spent on the target quadrant (TTQ) and the number of target area crossings (TAC) were registered. A second test was conducted 14 days after the first test to evaluate long-term spatial memory.

Results:

The duration of surgery and anesthesia did not differ significantly between groups. There was a significant difference between groups in average TTQ and TAC in test 1 (Table 1). In test 2 minor surgery group showed better results but they were less significant.

Conclusions:

Major surgery is associated with a more pronounced deterioration of spatial memory in rats in early postoperative period compared to minor surgery.

Table 1 (abstract P148). Data are shown as Mean±SD, TTQ-Time spent on the Target Quadrant, TAC- Target Area Crossings

P149 Cardiac inflammatory markers in ICU patients with myocardiac ischemia after non cardiac surgery (a pilot study)

P Manthou¹, G Lioliousis², P Vasileiou³, G Fildissis¹

¹National Kapodistrian University of Athens, Athens, Greece; ²National Kapodistrian University of Athens, General Thoracic Hospital ´´Sotiria´´, Athens, Greece; ³National Kapodistrian University of Athens, University of Athens, Athens, Greece

Introduction:

Patients with known coronary artery disease have higher perioperative risk for myocardial ischemia [1, 2]. Mortality is frequent following cardiac ischemia in the intensive care unit (ICU) after non-cardiac surgery.

Methods:

The first group includes patients admitted to the Intensive Care Unit for post-operative follow-up without myocardiac ischemia in the first 24 hours. The second group includes patients with myocardiac ischemia postoperatively and needs intensive care monitoring. Cardiac risk assessment was made with the Lee Index,hemorrhagic risk assessment with the HAS-BLED bleeding score and thrombotic risk assessment with CHA2DS2-VASc score. Postoperatively, pathological test values such as BNP, troponin, CRP, calcitonin were estimated. The Sequential Organ Failure Assessment (SOFA) systeme was used to assess sepsis. The Nursing Activity Score (NAS) scale was used to measure the workload of various nursing activities in the ICU.

Results:

According to the pilot study, the sample consists of 35 patients. 31.4% had myocardial ischemia. The Lee index was significantly higher in patients with myocardial ischemia. The duration of hospitalization, the high dose of vasoconstrictive drugs, the length of stay in the ICU, the duration of mechanical stay and the nursing workload were higher in patients with myocardial ischemia. CK-MB and troponin levels differed significantly between the two groups. Creatinine, bilirubin and BNP during the 24 hours were significantly higher. Patients with myocardial ischemia had significantly higher mortality.

Conclusions:

Cardiac risk assessment, HAS- BLED score and CHA2DS2-VASc score in combination with cardiac enzymes such as troponin could predict myocardiac ischemia in severely ill ICU patients.

References:

1 2014 ESC/ESA. Eur Heart J 35: 2383–2431, 2014.

2 Spyropoulos JD et al. Blood 120: 2954-2962, 2012

P150 Airway complications after thyroid surgery

V Artemenko¹, A Budnyuk²

¹MC MEDICAP, Anesthesia&ICU, Odessa, Ukraine; ²Odessa Regional Hospital, ICU, Odessa, Ukraine

Introduction:

According to the literature an airway complication followed thyroid gland surgery are: difficult trachea intubation, tracheomalacia, postextubation stridor and bleeding [1,2]. Most common cause of death was problem with respiration and airway obstruction [3]. Subsequent hypoxia could require emergency airway and even tracheostomy [3]. Aim of our study was to determine the most common of airway complications and their association with type of surgery in our region.

Methods:

The retrospective cohort study included 400 pts., (369 women, 31 men) was performed in Odessa regional Hospital, Oncology Centre Odessa. There were three types of patients: with euthyroid goiter - 170 (43%), polynodos goiter - 125(31%) and thyroid cancer - 105 (26%) (Table 1). Airway complications were diagnosed after trachea extubation based on indirect laryngoscope, presence of stridor, desaturation. The Pearson’s criteria was calculated.

Results:

The ratio of airway complications after thyroid surgery was 9.7% (39 pts). The main reasons of airway complications in thyroid surgery included:  laryngeal edema - 22 pts (5.5%); recurrent laryngeal nerve injury - 12 pts (3.0%) and postoperative bleeding 5 pts (1.2%).

Conclusions:

Thyroid gland cancer and polynodosal goiter associated with laryngeal edema and recurrent laryngeal nerve injury (Pearsen criteria were 0.271 -moderate and 0.203 consequentially). It's may require more attention from the anesthetists after extubation and readiness for an urgent airway.

References:

1. Ribakov S et al. Ternopil: TDMU, 2008. p 424.

2. Rosato N et al. World J Surg 28:271-6, 2004

3. Ignjatoviæ M et al. Acta Chir Iugosl 50:155-75, 2003

Table 1 (abstract P150). Association between type of surgery and airway complication

P151 Serum iron level and development of multiple organ dysfunction syndrome in patients in the perioperative period

S Tachyla

Mogilev Regional Hospital, Department of Anesthesiology and Intensive Care, Mogilev, Belarus

Introduction:

Recently there has been attention of researchers to the problem of perioperative anemia. It was found that it increases the risk of death and postoperative complications. Threatening complication is multiple organ dysfunction syndrome (MODS). The objective was to determine the level of serum iron in the perioperative period in patients with endoprosthetics of large joints, and with the presence of MODS in abdominal surgery.

Methods:

A prospective cohort study was conducted in 77 patients, including 18 men and 59 women, age 61.9 ± 15.1 years. Two groups were identified: 1st (control) - patients after endoprosthetics of large joints (n = 40), 2nd (main) - patients in abdominal surgery with the presence of MODS (n = 37). The presence of MODS was established based on the criteria for the 2016 SCCM / ACCP Conference. Serum iron was monitored using an AU 680 analyzer (USA). The study identified several stages: 1st - before surgery, 2nd - 1st day after surgery, 3rd - 3rd day, 4th - 7th day, 5th - 10th day.

Results:

When studying the indicators of serum iron, its significant decrease (p <0.05) in the postoperative period was established. In the 1st group: 1st stage - 15.2 (10-19.4) mmol / L, 2nd stage - 5.2 (3.9-7.6) mmol / L, 3rd stage - 6.6 (5-8.7) μmol / L, stage 4 - 9.7 (8.6-12.1) μmol / L, stage 5 - 9.4 (7.8-11 9) μmol / L. In the 2nd group: 1st stage - 11.9 (10-15) mmol / L, 2nd stage - 3.7 (1.7-4.1) mmol / L, 3rd stage - 3, 6 (2.4-4.5) μmol / L, stage 4 - 6.5 (4.4-8.2) μmol / L, stage 5 - 7.6 (6.5-9 4) μmol / L. Moreover, in both groups, iron increased at the 4th stage against the 2nd stage (p <0.05). When comparing the level of iron between the groups, significant differences were found (p <0.05) at the 2nd, 3rd and 4th stages.

Conclusions:

In patients in the postoperative period, a decrease in serum iron is observed, the level of which rises by the 7th day, but does not reach the initial values. This decrease is more pronounced in patients with the presence of MODS after abdominal surgery.

P152 Infection in simultaneous pancreas-kidney transplantation

T Isidoro Duarte¹, J Marques², J Silva³, J Estevão¹, N Germano¹

¹Curry Cabral Hospital, Central Lisbon University Hospital Center, Intensive Care Medicine Department, Lisboa, Portugal; ²Curry Cabral Hospital, Central Lisbon University Hospital Center, Nephrology Department, Lisboa, Portugal; ³Covilhã Hospital, Cova da Beira Hospital Center, Internal Medicine Department, Covilhã, Portugal

Introduction:

Outcomes of simultaneous pancreas-kidney (SPK) transplantation have been improved over the decades. The increasing success is a result of improved surgical technique, better organ preservation, potent immunosuppression therapy and effective use of antibiotics. Nevertheless, morbidity and mortality following SPK transplantation remain high, mainly owing to infection [1].

Methods:

Retrospective analysis of patients admitted for SPK transplantation from 2013-2018 in an Intensive Care Unit (ICU). Immunosuppression was done with thymoglobulin, tacrolimus, mycophenolic acid and corticosteroids. Ceftazidime and fluconazole prophylaxis were given for 7 days as well as valganciclovir and trimethoprim/sulfamethoxazole. Infections were diagnosed by the presence of fever with clinical findings that could not be attributed to other cause. Microbiological samples were collected at admission and when suspicion of infection was present.

Results:

Total of 90 patients were admitted to ICU after SPK transplantation. Mean age 37.4±6.4 years. Donor’s mean age 34.6±11.6 years. Kidney and pancreatic graft thrombosis happened in 5.6% and 18.9%, respectively, and bleeding in 21.1%. Forty-one (45.6%) developed at least one infection during hospital stay. Infection during ICU was found in 13.3% and main pathogens were gram negative bacilli sensible to beta-lactam. After ICU, the incidence of multi-drug resistant pathogen was 13.5%, predominantly gram negative bacilli. Fungal infection was lower 4%. All-cause hospital mortality rate was 5.6%.

Conclusions:

Infectious complications are the main cause of morbidity and mortality following SPK transplantation. The administration of broad-spectrum prophylactic antibiotics are leading to the appearance of multi-drug resistant pathogens. Knowing local microbiological flora may be helpful, allowing more adequate antibiotic prophylaxis.

References:

1. Michalak G et al. Transplant Proceed 37,3560-3563, 2005

P153 Thrombotic complications predictors in children underwent cardiac surgery with CPB

V Lastovka¹, O Gordeeva², A Bidzhiev²

¹National Medical Research Center for Children´s Health, pediatric ICU, Moscow, Russia; ²National Medical Research Center for Children´s Health, Moscow, Russia

Introduction:

Cardiopulmonary bypass (CPB) is associated with thrombotic complications. Occurrence of thrombosis after CPB is 12% which takes the third place between CPB-associated complications. Our study determined preoperative predictors of thrombosis in children with congenital heart defects.

Methods:

138 patients with congenital heart diseases in age up to 11 months 29 days (median age - 4,7 months, youngest age – 2 days after birth, oldest – 11 months 29 days), underwent cardiac surgery with CPB, were enrolled in this study. All patients were divided into two groups: 1^st-without thrombosis, 2^nd-with thrombosis. Protein C, D-dimer, von Willebrand factor and Plasminogen plasma levels were assessed directly before surgery. Thrombotic cases were proven by performing doppler ultrasound or MRI.

Results:

Thrombotic complications were diagnosed in 30 children (21%). Between all thrombotic complications ischemic strokes were diagnosed in 73% (22 cases), arterial thrombosis in 17 % (5 cases), intracardiac thrombus in 7% (2 cases) and mechanical mitral prosthetic valve thrombosis 3%(1). Receiver operating characteristic (ROC) curves are created for the listed indicators. Area under the Curve (AUC) for Protein C 0,64 (Sensitivity(Sn)- 65%, Specificity(Sp) - 50%), D-dimer is 0,65 (Sn – 65%, Sp 50%), for Plasminogen activity - 0,62 (Sn 60%, Sp 40%) and for von Willebrand factor level - 0,64 (Sn 80%, Sp 55%). An ROC curve was created for all three indicators, the AUC was 0.7 (Sn – 80%, Sp – 40%). These parameters can be recommended as predictors of thrombosis in children after cardiac surgery.

Conclusions:

CPB is related with a large number of life-threatening complications. In our work, preoperative predictors of thrombosis were identified. Based on this data, it is possible to create thrombosis risk scale change the tactics of the anaesthetic approach, the prevention of thrombosis in the postoperative period. Further studies are needed to identify other possible predictors of thrombosis.

P154 C-reactive protein level variation as a predictor of ischemic complications after vascular surgery

SM Fernandes¹, D Conduto², C Candeias¹, JM Ribeiro³

¹Centro Hospitalar Universitário Lisboa Norte, Serviço de Medicina Intensiva, Lisboa, Portugal; ²Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal, ³Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal

Introduction:

Abdominal ischemia occurs in 9% of patients submitted to aortic aneurysm repair. Its early diagnosis requires an elevated index of suspiction, particularly in more severe patients. We hypothesized that earlier increase and higher levels of C-reactive protein (CRP) may help to predict intra-abdominal ischemia.

Methods:

We performed a retrospective study of patients admitted to the intensive care department (ICD) after abdominal aorta aneurism surgery. We included all patients admitted during a two-year period, that survived for more than 48 hours. Primary outcome was splanchnic ischemia assessed by abdominal CT-scan. We also evaluated the presence of bacteremia, abdominal compartment syndrome and ICD mortality. Association between inflammatory parameters and ischemia was evaluated by multivariate logistic regression.

Results:

We included 88 patients (47 elective and 41 emergent) admitted to the ICD after major abdominal vascular surgery. Mean age was 71.0 ± 8.6 and 90% were male. Mean SAPS II value was 44.4 ± 20.6 and admission SOFA 6.7 ± 4.5. CRP levels increased after surgery with peak level at day 3 (26.01 ± 11.3 mg/dL). Suspicion of systemic infection occurred in 19 patients, but none of them had positive blood cultures. Mesenteric ischemia was confirmed in 20 patients (23%); at day 1, there was a higher CRP value in patients that developed ischemia (13.5±8.8mg/dL in ischemia group vs 8.1 ±5.1 mg/dL in non ischemia; p=0.004), as well as in day 3 (p=0.003). These differences remained after adjustment for patient severity, with an OR=1.1 (1.0-1.1; p=0.04). Of note, there were no association of CRP levels with ICD mortality.

Conclusions:

In this retrospective study, patients submitted to abdominal aortic surgery who developed mesenteric ischemia had an earlier and a higher increase in CRP levels. Defining an algorithm for systemic inflammatory biomarkers levels could be useful for early identification of ischemic complications, allowing for earlier diagnosis and treatment.

P155 Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

M Van Winsen¹, ST McSorley², R McLeod¹, A MacDonald³, M Forshaw³, K Puxty¹

¹Dept of Anaesthetics and Critical Care, Glasgow Royal Infirmary and University of Glasgow, Glasgow, United Kingdom; ²Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom; ³Dept of Upper GI Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom

Introduction:

CRP (c-reactive protein) has been shown to be a useful biomarker in identifying complications after major abdominal surgery. Gastrectomy is a high-risk surgical procedure that requires post-operative critical care support to monitor for complications which are predominantly infective in nature. The aims of this study were to determine whether there is a relationship between post-operative CRP levels and patients who developed post-operative infective complications.

Methods:

A retrospective analysis was performed on patients undergoing elective gastrectomy for gastric cancer at a single centre between September 2011 and July 2016. Post-operative CRP levels for each day following resection were analysed for all patients. ROC curve analysis was used to determine which post-operative day (POD) gave the optimal cut-off.

Results:

Of 144 patients included, the majority were male (61.8%), mean age was 68.5 years and 53.5% had node-negative disease. A total of 84 patients (58.3%) had an infective complication, which includes those who experienced an anastomotic leak. CRP levels on post-operative day 3 gave the greatest AUC for the gastrectomy group (0.765). CRP cut-off of 220mg/L was significantly associated with infective complications (OR7.29, 95% CI 3.42-15.58, p= <0.001) and gave a sensitivity of 70% and specificity 76% (PPV 67%, NPV 78%). More patients with a CRP >220 on post-operative day 3 experienced an infective complication (67% vs 21%, p = <0.001) or a leak in particular (17% vs 6%, p = 0.059).

Conclusions:

A CRP level of less than 220 mg/L on POD3 may be useful to predict the development or exclude the likelihood of such infective complications in this group of patients prior to clinical signs (PPV 67%, NPV 78%). This may prompt and facilitate decision-making regarding early investigation and intervention or prevent inappropriate early discharge from critical care, whilst providing more assurance in identifying those who could be stepped down to ward level care.

P156 Renin in cardiopulmonary bypass-associated vasoplegic syndrome

MM Juarez¹, SJ Pearson¹, BM Morrissey¹, NW Flemming², P Devarajan³, LS Chawla⁴, TE Albertson¹

¹University of California, Davis School of Medicine, Department of Internal Medicine, Pulmonary and Critical Care and Sleep Medicine, Sacramento, United States; ²University of California, Davis School of Medicine, Department of Anesthesiology and Pain Medicine, Sacramento, United States; ³Cincinnati Children´s Hospital Medical Center, University of Cincinnati College of Medicine, Division of Nephrology and Hypertension, Cincinnati, United States; ⁴Veterans Affairs Medical Center, San Diego, USA and La Jolla Pharmaceutical Company, San Diego, United States

Introduction:

Vasoplegia is commonly observed after cardiopulmonary bypass surgery (CPB) and associated with high mortality. Chronic use of renin-angiotensin aldosterone system inhibitors (RAASi) is associated with its incidence and ensuing need for vasopressor support after CPB. Renin serves as marker of tissue perfusion [1]. We examined the role of renin in the setting of RAASi exposure and vasopressor needs in the peri-CPB period.

Methods:

Prospective observational study of 31 adult patients undergoing CPB, aged 66.0±10.5 years (22 men, 9 women). Blood was collected 1) post induction, pre-CPB; 2) 30 min post cardioplegia, and 3) immediately post bypass. Vital signs and perioperative medications were recorded. As control, blood was collected from 5 men and 4 women aged 53.5 ±10.7, not diagnosed with lung disease and not prescribed any RAASi.

Results:

Baseline plasma renin in CPB patients tended to be higher than in control subjects (mean=38.5pg/ml±9.2 vs. 17.1 pg/ml ± 3.5, respectively, p=0.670). 30 minutes into CPB, mean renin was increased from baseline (77.6 pg/ml±17.5, p=0.211), and remained elevated immediately post CPB (74.6 pg/ml±19.1). Patients using RAASi prior to CPB tended to have a larger increase in renin post CPB (delta=55.3 pg/ml±30.9) vs. those not previously on RAASi (26.9 pg/ml±9.5, p=0.092). Renin was elevated in patients requiring vasopressor support in the 24 hours post CPB vs. those not requiring pressors (41.4 pg/ml±15.7 vs. 25.1 pg/ml±16.1 p=0.0246). In those prescribed RAASi and requiring pressors post CPB, there was a tendency toward greater renin increase than those not requiring pressors postoperatively (49.9 pg/ml±49.7 vs. 8.5 pg/ml±3.9, p=0.036).

Conclusions:

This study suggests a trend toward higher renin levels, particularly during CPB, in patients prescribed RAASi, and a positive association between renin and postoperative vasopressor needs. We speculate that increased renin levels may predict postoperative vasoplegia.

References:

1. Gleeson PJ et al. Crit Care Med 47;2:152-158, 2019

P157 Blood loss and transfusion in minimal invasive coronary artery bypass surgery

K Buyck¹, J Vandenbrande¹, JP Ory¹, J Dubois¹, A Yilmaz², B Stessel¹

¹Jessa Hospital, Critical Care, Hasselt, Belgium; ²Jessa Hospital, Cardiac Surgery, Hasselt, Belgium

Introduction:

Cardiac surgery is associated with perioperative blood loss and a high risk of allogenic blood transfusion. It has been recognized that high blood product transfusion requirement is associated with adverse clinical outcomes.¹ Guidelines on patient blood management therefor aim at reducing blood loss and blood transfusion requirements in cardiac surgery.² As there remains controversy about the advantage of minimal invasive techniques on blood loss an transfusion requirements,² we wanted to investigate if the average blood loss and transfusion requirement in minimal invasive endoscopic coronary artery bypass graft surgery (endo-CABG) differ from conventional technique. We assessed the influence of pre-operative anticoagulant medication for blood loss. Estimated average blood loss after conventional CABG³ is 400ml (+/-200) and transfusion requirement 3,4 units packed red blood cells⁴.

Methods:

We performed a retrospective cohort study of our cardiac surgical database. From 01/01/2016 to 31/12/2017, we collected data from 423 patients undergoing endo-CABG. We analyzed blood loss, transfusion as well as pre-operative use of anti-coagulants as a risk factor for blood loss.

Results:

We found that mean total blood loss in endo-CABG does not differ from conventional CABG, nonetheless mean transfusion requirement was lower in our cohort. Use of direct oral anticoagulant is aossciated with increased blood loss and transfusion requirements (Table 1).

Conclusions:

Total blood loss is not influenced by minimal invasive technique for CABG (endo-CABG). An explanation for the lower transfusion requirements is the use of a minimal extracorporeal circulation, which is known to reduce the risk of transfusion. Another important factor is the implementation of a standardized transfusion-protocol based on available evidence. Reducing transfusion requirements is an important component in improving patient outcome after cardiac surgery and is related to multiple factors in perioperative care of our patients.

Table 1 (abstract P157). Use of pre-operative anti-coagulant medication

P158 Retinal microvascular damage associated with mean arterial pressure during cardiopulmonary bypass surgery

V Shipulin¹, M Dyakova¹, Y Podoksenov², E Shishneva², Y Svirko³, M Denisko⁴, O Krivosheina⁴, I Mandel⁵

¹Cardiology Research Institute,, Cardiosurgery, Tomsk, Russia; ²Cardiology Research Institute,, ICU, Tomsk, Russia; ³Cardiology Research Institute,, Laboratory, Tomsk, Russia; ⁴Siberian State Medical University, Ophthalmology, Tomsk, Russia; ⁵Sechenov University, Anesthesiology and Intensive Care, Moscow, Russia

Introduction:

Retinal perfusion corresponds to cerebral perfusion and it is very sensitive to hemodynamic disturbances [1, 2]. We investigated the association between retinal microvascular damage and hemodynamic characteristics in patients undergoing coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB).

Methods:

10 patients with coronary artery disease and systemic hypertension were examined. Ophthalmoscopy and optical coherence tomography were performed before and 10-14 days after CABG. The hemodynamic parameters during CPB were analyzed.

Results:

4 (40%) patients had changes in the retinal vessels and in the ganglionic fiber structure on 10-14 day after surgery: in 30% of patients the foci of ischemic retinal oedema appeared, in 10% the decrease of the thickness of ganglionic fiber were observed. These changes may be associated with intraoperative ischemia of the central retinal artery. In 6 (60%) patients the mean arterial pressure (MAP) during CPB was increased up to 90 mmHg. In 4 (67%) of them the association between MAP and foci of ischemic retinal oedema were revealed. The ischemic retinal changes were observed significantly more often if the delta of MAP during CPB was over then 20 mm Hg compared with the patients where the delta of MAP was less than 20 mm Hg (p=0.035). This is probably due to an intraoperative disorders of the myogenic mechanism of blood flow autoregulation in the retinal microvasculature in patients with coronary artery disease [3].

Conclusions:

The level of MAP up to 90 mm Hg during CPB is associated with retinal blood flow impairment and the foci of ischemic retinal oedema. Delta of MAP more than 20 mmHg was associated with the foci of ischemic retinal oedema and decreased ganglionic fiber thickness in 67% of cases.

References:

1. Ascione R et al. Circulation 112:3833-3838, 2005.

2. Murphy GS et al. Anesth Analg 108 :1394-1417, 2009

3. Joshi B. Anesth Analg 114:503-10, 2012

P159 Atrial fibrillation after cardiac surgery: implementation of a prevention care bundle on intensive care unit improves adherence to current perioperative guidelines and reduces incidence

M Buerge¹, R Magboo², D Wills³, I Karpouzis⁴, P Cooper⁵, D Balmforth⁶, N Roberts⁶, B O´Brien³

¹Royal Papworth Hospital NHS Trust, Anaesthesia and Intensive Care, Cambridge, United Kingdom; ²St Bartholomew´s Hospital, Barts Heart Centre, Adult Critical Care Unit, London, United Kingdom; ³St Bartholomew´s Hospital, Barts Heart Centre, Perioperative Medicine, London, United Kingdom; ⁴Gennimatas General Hospital, Cardiology, Athens, Greece; ⁵St Bartholomew´s Hospital, Barts Heart Centre, Pharmacy, London, United Kingdom; ⁶St Bartholomew´s Hospital, Barts Heart Centre, Cardiothoracic Surgery, London, United Kingdom

Introduction:

Atrial fibrillation after cardiac surgery (AFACS) is a very frequent complication affecting 30-50% of all patients. It is associated with an increase in morbidity, mortality and hospital and intensive care unit (ICU) length of stay. We aimed to implement an AFACS prevention care bundle based on a recently published practice advisory [1], focusing on early postoperative (re)introduction of β-blockers.

Methods:

Baseline AFACS incidence and β-blocker administration practices in our centre were audited for all patients undergoing valve surgery or coronary artery bypass graft (CABG) during a 6 weeks period. The AFACS prevention care bundle – an easy to follow graphical tool – was subsequently introduced to the cardiac ICU by a multidisciplinary team and audited following a model of improvement approach. After exclusion of patients with preoperative AF, differences between pre- and post-implementation groups were compared with Chi-square and Fisher’s exact tests for categorical, and One-way ANOVA for continuous variables, using SPSS.

Results:

A total of 384 patients were analysed. Patient and surgery characteristics did not differ between groups. Significantly more patients received postoperative β-blockers after bundle implementation (82.7% pre- vs 91.3% post-bundle, p=0.019) with a higher proportion on day 1 (36.7% pre- vs 67% post-bundle, p<0.001, Figure 1). The incidence of AFACS was significantly reduced from 35.4% to 23.3% (p=0.009), with a particularly marked reduction in the age group 65-75 years and for isolated aortic valve and CABG surgery. There was no significant reduction in hospital length of stay for this cohort.

Conclusions:

Introduction of an AFACS prevention care bundle using a graphical tool improved adherence to current guidelines with regards to early β-blocker administration and significantly reduced AFACS incidence. Future care bundles should include preoperative interventions and might reduce hospital length of stay.

References:

1. O'Brien B et al. J Cardiothorac Vasc Anesth 33:12-26, 2019

Fig. 1 (abstract P159).

Timing of beta-blocker (re)initiation versus incidence of AFACS before and after prevention care bundle implementation, per post-operative day and for postoperative days 1-5 (insets)

P160 Use of hypoxic gas mixture in neonates with single ventricle physiology prior to the Norwood procedure

V Sheward, E Al Mahmoud, K Ramakrishnan

Sheikh Khalifa Medical City Hospital, PCICU, Abu Dhabi, United Arab Emirates

Introduction:

In neonates with univentricular physiology, there is a delicate balance between pulmonary and systemic circulations, with a tendency towards generous pulmonary blood flow, and a risk of systemic underperfusion. Preoperatively, the use of hypoxic gas mixture (HM) has been advocated as a therapy to increase PVR, with the aim of improving systemic oxygen delivery. It is a therapy which has been routinely initiated in our institution in the setting of signs of pulmonary overcirculation.

Methods:

We performed a retrospective analysis of all patients in our institution who underwent a Norwood procedure and who received HM preoperatively. We compared peripheral saturations, arterial blood gas analysis, serum lactate, regional cerebral and renal saturations and invasive blood pressure, prior to, and then 4,8 and 24 hours after HM was commenced.

Results:

Between 2014 and 2018 (inclusive), 49 patients underwent the Norwood procedure. 18 patients received preoperative HM. Average FiO2 was 17% during administration of HM. Average peripheral saturations were 96.1% prior to HM, and dropped to 87.4% at 4 hours, and 88% at 8 and 24 hours after initiation (p < 0.05). There was no change in any of the measured markers of systemic oxygen delivery, including regional cerebral and renal saturations, lactate, urine output or blood pressure. There was an association between an extended period of HM (> 48 hours) and the need for pulmonary vasodilator therapy post Norwood procedure.

Conclusions:

Hypoxic gas mixture in patients with parallel systemic and pulmonary cicrculations causes desaturation and hypoxia. It does not lead to an increase in systemic perfusion and thus an improvement in systemic oxygen delivery. Its ongoing use in this fragile population should be considered.

P161 Multimodal analgesia in neurocritical care patients: complementing therapies to reduce the use of endovenous opioids

M Canitrot¹, J Ramirez², J Serra³, Y Santos³, V Munoz³, F Paravic⁴, S Ugarte³

¹INDISA CLINIC, Critical Care, Santiago, Chile; ²Andres Bello University, NeuroICU, Santiago, Chile; ³INDISA CLINIC, NeuroICU, Santiago, Chile; ⁴INDISA CLINIC, Neurorehabilitation, Santiago, Chile

Introduction:

Analgesia in the critical patient, and especially in the neurocritical patient, is a basic goal in all therapeutic practices. Patients in the ICU are frequently administered prolonged and/or high doses of opioids. Multiple serious complications due to the use of infusion of opioids at large doses has been described. To reduce high doses of intravenous opioids, multimodal forms of analgesia can be used.

Methods:

Prospective observational study of the use of tapentadol enteral and buprenorphine in transdermal patches, at low doses, for the control of pain and its effect on reducing the use of fentanyl infusion in high doses on 84 patients admitted to Neuro ICU of INDISA Clinic during 2 consecutive years (2018-19). Enteral tapentadol (through NG tube) 50 mg/6 hours, was considered in patients who required intravenous fentanyl in continuous administration. Buprenorphine was also added at low doses (5 ug/hr) in a weekly transdermal patch, in cases of neurosurgical spine patients, fractures and long-term neuropathic pain. Pain was controlled on Behavioral Pain Scale (BPS) and Visual Analogical Scale (VAS) scores, according to the conditions of each patient. Their hemodynamic, gastrointestinal complications and the appearance of delirium episodes according to CAM-ICU scale were recorded.

Results:

84 patients received tapentadol. 32 of them also received transdermal buprenorphine. All managed to maintain adequate level of analgesia, not requiring fentanyl at doses greater than 0.5 ug / kg / hr. Distribution by diagnoses: neurotrauma 21 patients, Guillain Barre 12, spine surgery 15, HSA 18, HICE 10, malignant ischemic ACV 8. Complications: gastric retention 12 patients (7%), hypotension 1 (1%), acute hypoactive delirium 3 (3.5%), acute hyperactive delirium 8 (9%). No drug interactions were found.

Conclusions:

The introduction of enteral tapentadol and buprenorphine patches in neurocritical patients was safe and resulted in a decrease in the use of endovenous opioids and its adverse effects.

P162 Assessment-driven, protocol-based pain management post cardiac surgery significantly improves measured pain scores

I Charles, A Johnson, M Govender, M Stevens, M Gohobur, CY Kim, L Campbell, EE Quaynor, H Hideg, G Zilahi

St George´s University Hospital NHS Foundation Trust, CTICU, London, United Kingdom

Introduction:

We hypothesized that changing the pain management for our post cardiac surgical patients to an assessment-driven, protocol-based approach using fast acting and easily titratable agents will significantly improve patient satisfaction by reducing pain intensity in the first 24h after surgery as suggested by Society of Critical Care [1] guideline.

Methods:

We prospectively assessed 101 and 99 (05.2018 vs 06.2019) consecutive patients before and after introducing our pain management protocol. The nursing and medical team received rigorous training on the guideline as well as the correct assessment using appropriate pain scores measured at least hourly (Numeric Pain Score, ≥ 2 is moderate to severe or Critical Care Observation Tool, > 2 is moderate to severe). We introduced a multimodal approach with a combination of fast acting iv, long acting oral opiates, regular paracetamol and rescue iv boluses for difficult to control situations and we created a prescription bundle on our electronic prescribing record. Among other variables we assessed hours spent in moderate to severe pain in the first 24h after surgery and compared to the data collected before the guideline was introduced.

Results:

We analysed 101 patients from 2018 and 99 from 2019. Baseline characteristics were similar between the two groups. In 2018 only 41.6% of the patients spent less than 5 hours and 29.4% spend more than 10 hours in moderate to severe pain. The 2019 data showed significant improvement in that 79.5% of patients spent less than 5 hours and only 5% patients who spent more than 10 hours in moderate or severe pain. (p <0.0001, Chi Square) (Figure 1). Only 9% of the patient needed rescue medications. 3% of time was the protocol inadequate necessitating other approach.

Conclusions:

Introducing an assessment driven, stepwise, protocolized pain management significantly improved patient satisfaction by reducing pain intensity in the first 24h on our Cardiothoracic Intensive Care Unit.

References:

1. Devlin JW et al. Crit Care Med 46:e825–e873, 2018

Fig. 1 (abstract P162).

Hours spent in moderate to severe pain post cardiac surgery in the first 24h

P163 Compartment psoas block efficacy for perioperative analgesia in the elderly with proximal femur fractures

K Bielka, I Kuchyn, I Tokar

Bogomolets National medical university, Postgraduate surgery, anesthesiology and intensive care, Kyiv, Ukraine

Introduction:

Proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. Perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible [1, 2]. The goal of the study was to compare the efficacy and safety of the compartment psoas block for perioperative analgesia in elderly patients with proximal femur fractures.

Methods:

The randomized controlled study was held in medical center "Into-Sana" (Odesa, Ukraine) from January 2018 till July 2019. Patients with proximal femur fractures and older than 60 years were included in the study. They were randomly allocated to 2 groups – compartment psoas block group (bupivacaine analgesia was started as soon as possible before surgery and prolonged during and after surgery with additional ischiadicus block before surgery) and general (inhalational) anesthesia with systemic analgesia perioperatively.

Results:

60 patients were included in this study. Perioperative compartment psoas block was associated better pain control, decreased opioid consumption, better sleep quality, earlier mobilization after surgery, decreased incidence of opioid-associated vomiting/nausea and myocardial injury. There were no difference in the incidence of hospital acquired pneumonia and delirium.

Conclusions:

Perioperative compartment psoas block is effective and safe for perioperative analgesia in elderly patients with proximal femur fractures, and is associated with better pain control and decreased complications incidence.

References:

1. Dixon J et al. Geriatr Orthop Surg Rehabil 9:2151459318806443, 2018

2. Zhang X et al. Ther Clin Risk Manag 9:299–302, 2013

P164 Evaluation of safety and efficacy of concomitant parenteral olanzapine and benzodiazepine for agitation

HH Huynh, TS Lam, JT Jancik, G Betterman

Hennepin County Medical Center, Clinical Pharmacy, Minneapolis, United States

Introduction:

Parenteral olanzapine is frequently used in combination with parenteral benzodiazepines for hospitalized patients with severe agitation. The FDA issued a warning for increased risk of excessive sedation and cardiorespiratory depression with this combination based on post-marketing case reports with overall limited quality of evidence [1]. The purpose of this study is to evaluate the safety and efficacy of concomitant parenteral olanzapine and benzodiazepine for agitation.

Methods:

This retrospective chart review evaluated agitated patients who received concomitant parenteral olanzapine and benzodiazepine within 60 minutes from 1/31/2016 to 9/1/2019 . The primary end points were rate of respiratory depression requiring mechanical ventilation and hypotension requiring vasopressors. The secondary end points were percentage of patients requiring additional sedatives for agitation during the same time frame, cumulative dose of olanzapine and benzodiazepine (midazolam equivalent) received, and rate of cardiac arrest and death.

Results:

A total of 208 patients were included with notable baseline characteristics: median age of 35 years old, 59% with a history of substance abuse, and 40% with a history of psychiatric illness. For the primary outcomes, 2.9% of patients required mechanical ventilation and 0% required vasopressors. Additionally, 27.9% patients received additional sedating agents to control agitation. Refer to Table 1 for more details. No cardiac arrests or deaths were observed.

Conclusions:

Concomitant use of parenteral olanzapine and benzodiazepine within 60 minutes for the treatment of agitation appears to have a small risk of respiratory depression without significant hypotension.

References:

1. Marder SR et al. J Clin Psychiatry 71:433-41, 2015

Table 1 (abstract P164). Results

P165 Could preoperative US guided fascia iliaca compartment block (FICB) decrease opioid consumption and perioperative morbidity of elderly patients with hip surgery for femoral fracture?

D Pavelescu¹, I Grintescu²

¹Emergency Hospital Floreasca, Anesthesiology and Intensive Care, Bucharest, Romania; ²Emergency Hospital Floreasca, Intensive Care and Anesthesiology, Bucharest, Romania

Introduction:

Hip fracture is very common in the elderly,it causes moderate to severe pain often undertreated. FICB is a simple safe method, easy to learn and use. The aim of our study is to assess the efficacy and safety of preoperative FICB compared with intravenous analgesia for elderly patients with femoral fracture and hip surgery in terms of opioid consumption and perioperative morbidity

Methods:

After informed consent obtained,54 patients 50-98 yo ASA I-III with hip fracture were randomized to receive either an US guided FICB(40 ml of ropivacaine 0,35%) or a sham injection with normal saline 30' before surgery. Both groups were operated under general anesthesia. Postoperative analgesia was done according to VAS: VAS 0-30 mm, paracetamol 1g iv at 8 h, VAS 30-60 mm, ketoprofen 100 mg iv at 8 h, VAS>60, morphine 0,1mg/kgBW iv. The primary outcome was the comparison of VAS score at rest over the first 30'following the procedure, at the end of the surgery and at 6h intervals for 24h. The secondary outcome were the incidence of the cardiovascular events, of the PONV and of the confusion episodes, the amount of morphine consumption for 24h

Results:

At baseline, FICB group (A) had a lower mean pain score than the sham injection group (B). The same difference was observed over 24 h of follow-up (p<0.05). There was a significant difference between the two groups in total cumulative iv morphine consumption at 24 h and in the incidence of PONV and confusion episodes (Figure 1).

Conclusions:

FICB provides effective analgesia for elderly patients suffering from hip fractures, with lower morbidity and lower opioid consumption compared with intravenous analgesia.

Fig. 1 (abstract P165).

Results

P166 Pain assessment in chronic disorders of consciousness patients with ANI monitoring

E Kondratyeva, M Aybazova, N Dryagina

Almazov National Medical Reseach Centre, Minimally conscious research group, St Petersburg, Russia

Introduction:

Pain and suffering controversies in DOC to be debated by the scientific, legal and medical ethics communities.

Methods:

ANI (anti nociception index) monitor was used to assess pain in patients with chronic disordersof consciousness (DOC) age range 22 to 56 years - 9 in vegetative state/ unresponsive wakefulness syndrome (VS/UWS) and 20  minimal consciousness state (MCS). Average age: in MCS group 31,8±11,29 and 42,1±8,46 in VS/UWS group. Neurological status was assessed using  CRS-R scale. The average score on the CRS-R scale was 5±1.4 in VS/UWS and 10.45±4.5 in MCS. Pressure on the nail phalanx was used as a pain impulse. ANI and Nociception coma scale was evaluated before the application of pain stimulus, immediately after and  past 30 minutes. Prolactin level was measured before the pain stimulus application and 10 minutes after. ANI less than 50 indicates pain, 70-100 hypoalgesia, 30 severe pain.

Results:

The mean value of the ANI in MCS patients: before the pain stimulus 66.25±14.11, after the pain stimulus application 45±16.12 and 30 minutes later 66.55±18.13. Prolactin level in MCS patients before pain 13.01±9.06 ng/ml; after pain 13.75±8.73 ng/ml (p>0.05). Prolactin in VS/UWS patients before pain 10.79±7.2 ng /ml, after pain 14.5 ±8.88 ng / ml (p> 0.05).

Conclusions:

ANI monitor revealed that VS/UWS and MCS patients react equally to the pain impulse. Prolactin dynamics showed poor statistical mean and can not be consider as a marker of nociception in this group of patients. It is possible that the level of pain impulse was insufficient neuroendocrine response  activation or the increase of prolactin level occurs in the long term (more than 10 minutes). In all patients the basal level of the ANI index was above 66.25, which indicates absence of pronounced pain sensations at rest, but medical manipulations, physical therapy, can deliver pain.

Acknowledgement: The reported study was funded by RFBR project number 19-29-01066/2019

P167 Hemodynamic effects of dexmedetomidine in patients with septic shock: a cohort study of the sedation practice in intensive care evaluation [SPICE III] trial

L Cioccari¹, N Luethi², M Bailey², A Messmer¹, L Peck³, B Howe², Y Shehabi⁴, J Takala¹, S Jakob¹, R Bellomo³

¹University Hospital and University of Bern, Department of Intensive Care Medicine, Bern, Switzerland; ²School of Public Health and Preventive Medicine, Monash University, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; ³Austin Hospital, Department of Intensive Care Medicine, Heidelberg, Australia, ⁴School of Clinical Sciences, Monash University, Monash Health, Critical Care and Perioperative Services, Melbourne, Australia

Introduction:

Septic shock can result in catecholamine hyposensitivity, leading to hemodynamic instability and death. Experimental data suggest that central alpha2-agonists like dexmedetomidine (DEX) increase vasopressor responsiveness and reduce catecholamine requirements in septic shock [1]. However, because it can cause hypotension and bradycardia, clinicians may be reluctant to use DEX in such patients.

Methods:

In this cohort study of the Sedation Practices in Intensive Care Evaluation (SPICE III) trial, an international randomized trial comparing sedation with DEX to usual care, we studied critically ill patients with septic shock admitted to the Austin Hospital, Melbourne, Australia, and the University Hospital of Bern, Switzerland. The primary outcome was mean noradrenaline requirements in the first 48 hours.

Results:

Between November 2013 and February 2018, 417 patients were recruited into the SPICE III trial at both sites. Eighty-three patients with septic shock were included in this sub-study, of whom 44 (53%) received DEX and 39 (47%) usual care. Mean noradrenaline dose during the first 48 hours was 0.03 [0.01, 0.07] μg/kg/min in the DEX group and 0.05 [0.01, 0.15] μg/kg/min in the usual care group (p=0.08). Over the first 48 hours, patients in the DEX group had higher mean arterial pressures (MAP) (Figure 1) and lower vasopressor requirements to maintain the target MAP (expressed by the noradrenaline equivalents to MAP ratio: NEq/MAP) compared to the usual care group (ratio of adjusted difference in geometric means 1.4 [1.1, 1.9], p=0.02).

Conclusions:

In critically ill patients with septic shock, sedation with DEX does not increase noradrenaline requirements in the first 48 hours as compared to usual care. In contrast, DEX appears to be associated with lower vasopressor requirements to maintain the target MAP.

References:

1. Geloen A et al. Crit Care Med 41: e431-438, 2013

Fig. 1 (abstract P167).

Mean arterial pressure in the first 48 hours after randomization

P168 Multimodal analgesia with low dose of ketamine and dexamethasone, an interesting option for patients with total hip arthroplasty?

D Pavelescu¹, I Grintescu²

¹Emergency Hospital Floreasca, Anesthesiology and Intensive Care, Bucharest, Romania; ²Emergency Hospital Floreasca, Intensive Care and Anesthesiology, Bucharest, Romania

Introduction:

Total hip arthroplasty THA is one of the most common major surgical procedures associated with significant postoperative pain that can adversely affect patient recovery and could increase morbidity. Effective perioperative pain management allows an accelerated rehabilitation and improve the functional status of these patients. Multimodal analgesia MMA combines analgesics with different mechanism of action which by synergistic and additive effects enhance postoperative pain management and reduce complications. The aim of our study is to assess if perioperative association of very low dose of ketamine, a potent NMDA antagonist and dexamethasone, by antiemetic and antiinflammatory properties could decrease opioid consumption and postoperative morbidity of patients with THA.

Methods:

After informed consent, 58 patients scheduled for primary hip joint replacement surgery aged 55-91 yo ASA I-III were prospective randomized in two groups. Both groups were operated under general anesthesia fentanyl/sevoflurane. Supplementary, patients in group A received 12 mg iv dexamethasone and 8mg at 12 h and ketamine 10 mg iv bolus at induction and 10mg/h iv during surgery. Postoperative analgesia was done according to VAS, 0-30 mm paracetamol 1 g iv at 8 h, 30-60 mm ketoprofen 100 mg iv at 12h, VAS>60 mm morhine 0,1 mg/kgBW iv. We recorded perioperative opioid consumption, the number of intraoperative cardiac events, VAS score at the end of surgery and at 24 h, the incidence of PONV and persistance of chronic pain at 3 months.

Results:

We obtain a significant less pain score at the end of surgery p<0.05 in group A, no significant difference at 24 h, a significant less chronic pain at 3 months, a fewer NPVO and cardiovascular events in group A, p<0.05 (Figure 1).

Conclusions:

A multimodal approach with very low doses of ketamine and dexamethasone could be efficent in the treatment of pain for elderly patients with hip arthroplasty, decreasing postoperative side-effects and reducing chronic pain persistance.

Fig. 1 (abstract P168).

Results

P169 Analgesia usage in ICU survivors

P Mactavish¹, C Pudrie², M Shaw³, P Henderson², H Devine⁴, T Quasim⁵, J Iwashyna⁶, J McPeake⁴

¹Glasgow Royal Infirmary, Pharmacy, Glasgow, United Kingdom; ²University of Glasgow, School of Medicine, Dentistry and Nursing, Glasgow, United Kingdom; ³NHS Greater Glasgow and Clyde, Clinicial Physics, Glasgow, United Kingdom; ⁴Glasgow Royal Infirmary, Intensive Care Unit, Glasgow, United Kingdom; ⁵University of Glasgow, School of Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom; ⁶VA Ann Arbor Health System, Centre for Clinical Management Research, Ann Arbor Michigan, United States

Introduction:

Treatment in an Intensive Care Unit (ICU) often necessitates uncomfortable and painful procedures for patients. Chronic pain is becoming increasingly recognized as a long term problem for patients following an ICU admission [1]. Throughout their admission patients are often exposed to high levels of opioids, however there is limited information available regarding analgesic prescribing in the post-ICU period. This study sought to examine the analgesic usage of ICU survivors pre and post ICU admission.

Methods:

183 patients enrolled in a post-intensive care programme between September 2016 and June 2018. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE), is a 5-week multicentre, multidisciplinary rehabilitation programme for ICU survivors and their caregivers. Patients’ level of analgesia was recorded pre-admission and upon attending InS:PIRE, their level of prescribed analgesia was categorized using the Word Health Organisation (WHO) analgesic ladder [2].

Results:

33.3% of patients (n=61) were prescribed regular analgesia pre-admission; this increased to 60.7% (n=111) post-admission, representing a significant absolute increase of 27.4% (95% CI: 20.2% - 34.4%, p<0.001) in the proportion of patients who were prescribed regular analgesia pre and post ICU. In addition, pre-admission, 22.4% (n=41) of patients were prescribed a regular opioid (step 2 and 3 of the WHO ladder) compared to 38.7% (n=71) post-admission, representing an absolute increase of 16.3% (95% CI: 9.8% -22.8%, p<0.001).

Conclusions:

This study found a significant increase in analgesic usage including opioids in ICU survivors. Follow-up of this patient group is essential to review analgesic prescribing and to ensure a long term plan for pain management is in place.

References:

1. Battle CE et al. Crit Care 17 :R101, 2013

2. World Health Organization. Cancer pain relief, with a guide to opioid availability. 2nd edition. Geneva: WHO, 1996

P170 Impact of a multifaceted and multidisciplinary intervention on pain, agitation, and delirium management in a Canadian community ICU: a quality improvement study

Z Ma¹, M Carmargo Penuela², M Law², HO Chung³, J Tsang³

¹McMaster University, NIagara Regional Campus, Michael G. DeGroote School of Medicine, St. Catharines, Canada; ²Brock University, Department of Health Science, St. Catharines, Canada; ³McMaster University, Division of Critical Care, Hamilton, Canada

Introduction:

Pain, agitation, and delirium (PAD) are commonly encountered b patients in the Intensive Care Unit (ICU). Delirium is associated with adverse outcomes, including increased mortality and morbidity. Clinical guidelines suggest that routine assessment, treatment and prevention of PAD is essential to improving patient outcomes. Despite the well-established improvements on patient outcomes, adherence to clinical guidelines is poor in community hospitals. The aim of this quality improvement project is to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU.

Methods:

A PAD advisory committee was formed and involved in the development and implementation of the intervention. The 4-week intervention targeted nurses (educational modules, visual reminders), family members (interviews, educational pamphlet, educational video), physicians (multidisciplinary round script), and the multidisciplinary team (poster). An uncontrolled, before-and-after study methodology was used. Adherence to PAD guidelines in the assessment of PAD by nurses was measured 6 weeks pre-intervention and 6 weeks post-intervention.

Results:

Data on 430 patient-days (PD) and 406 PD were available for analysis during the pre- and post-intervention, respectively. The intervention significantly improved the proportion of PD with assessment of pain and agitation at least 4 times per 12-hour shift from 68.0% to 87.5% and from 69.7% to 82.2%, respectively (Figure 1). Proportion of PD with delirium assessment at least once per 12-hour shift did not significantly improve.

Conclusions:

A multifaceted and multidisciplinary PAD intervention is feasible and can improve adherence to PAD assessment guidelines in community ICUs. Quality improvement methods that involve front-line staff can be an effective way to engage staff with PAD.

Fig. 1 (abstract P170).

Pre-intervention and post-intervention PAD assessment rates

P171 Oversedation and ICU-acquired delirium: an observational study

M Marchesi¹, N Latronico¹, F Terranova¹, S Sala¹, M Brognoli², GP Nocivelli², R Bertuetti², E De Peri², F Rasulo¹

¹Università degli studi di Brescia, Anestesia e Rianimazione, Brescia, Italy; ²Spedali Civili di Brescia, Anestesia e Rianimazione, Brescia, Italy

Introduction:

Sedation is a significant part of medical treatment in ICU patients. A too deep sedation is associated with a longer time of mechanical ventilation, lung injury, infections, neuromuscular disease and delirium, which can lead to a longer duration of ICU hospitalization, as well as an increase of morbility and mortality. Many patients spend a considerable amount of time in a non-optimal sedation level. A continuous monitoring system of the sedation level is therefore necessary to improve clinical evaluation.

Methods:

Our goal was to evaluate the incidence of non-optimal sedation (under and over sedation) comparing the parameters expressed from NGSedLine with clinical evaluations and to correlate oversedation and the incidence of delirium. We have studied a cohort of patients admitted to the ICU of Spedali Civili of Brescia University Hospital requiring continuous sedation for more than 12 hours. In addition to standard monitoring, the patients have been studied using Next Generation Sedline (Masimo). Sedation depth was evaluated through RASS scale and the presence of delirium was evaluated with CAM-ICU scale.

Results:

We collected data from 50 adult patients. Our data showed high incidence of oversedation. 45 of our 50 patients had a SR>2 and 48 had a PSI level<30. A logistic regression analysis was performed and it showed statistically significant association between incidence of delirium and the age of the patients (p 0.009). The association between delirium incidence and Suppression Rate time was at the limits of statistics significance (p 0.059) and was statistically significant for non neurocritical patients (p 0.049). Our study didn’t show an association between delirium and the total time of sedation.

Conclusions:

Non-optimal sedation is an unsolved problem in ICU, affecting lot of patients, with a major incidence of over-sedation compared to under-sedation. Our study shows an association between SR levels and the incidence of delirium.

P172 Predictors of delirium after myocardial infarction, insights from a retrospective registry

M Jäckel, V Zotzmann, T Wengenmayer, D Dürschmied, C Von zur Mühlen, P Stachon, C Bode, DL Staudacher

Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany

Introduction:

Delirium is a common complication on intensive care units. Data on incidence and especially on predictors of delirium in patients after acute myocardial infarction (MI) are rare. By analyzing all patients after acute MI, we aim to identify incidence and potential risk factors for delirium.

Methods:

In this retrospective study, all patients hospitalized for acute MI treated with coronary angiography in an university hospital in 2018 were included and analyzed. Incidence of Delirium within the first 5 days of care attributed to the MI and was defined by a NuDesc Score ≥2, which is taken as part of daily care three times a day by especially trained nurses. This research is authorized by ethics committee file number 387/19.

Results:

626 patients with acute MI (age 68.5±13.3 years, 260 STEMI, mortality 3.4%) were analyzed. Delirium occurred in 70 (11.2%) patients and was associated with a longer hospital stay (12±15.9d vs 5.5±4.3d, p<0.001). Patients with delirium were significantly older than patients without (76.3±11.14 vs. 67.5±13.10 years, p<0.001) and had more often preexisting neurological diseases (24.3% vs. 10.8%, p<0.001) and dementia (11.4% vs. 1.4%, p<0,001). Multivariate logistic regression analysis suggested that odds ratio for delirium was higher in patients after resuscitation OR 7.5 (95% CI 2.1-26.7), preexisting dementia OR 28.9 (CI 3.1-268) and in patients with alcohol abuse OR 18 (CI 2.7-120). While maximum lactate was also connected to delirium OR 1.4 (CI 1.1-1.9), infarct size or type had no effect on the incidence of delirium.

Conclusions:

In patients with MI, delirium is frequent. Incidence is associated with clinical instability and preexisting neurological diseases rather than infarct size.

P173 Incidence and risk factors of delirium in surgical intensive care unit

MA Ali, B Saleem

Aga Khan University, Anaesthesia, Karachi, Pakistan

Introduction:

Delirium in the critically ill patients is common and distressing. The incidence of delirium in the ICU ranges from 45% to 87%. Although delirium is highly common among intensive care patients, it is mostly underreported. To date, there have been limited data available related to prevalence of delirium in surgical patients. In a study published in 2008, the risk was observed 73% in surgical and trauma patients [1]. The purpose of this study was to find out the incidence and associated risk factors of delirium in surgical ICU (SICU) of a tertiary care hospital.

Methods:

We conducted prospective observational study in patients with age more than 18 years and who were admitted to the surgical ICU for more than 24 hours in Aga Khan University Hospital from January 2016 to December 2016. Patients who had preexisting cognitive dysfunction or admitted to ICU for less than 24 hours were excluded. Delirium was assessed by Intensive Care Delirium Screening Checklist ICDSC. Incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors.

Results:

Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. Multivariable analysis showed that COPD, pain >4 and hypernatremia were strong predictors of delirium. Midazolam [aOR=7.37; 95%CI: 2.04-26.61] and Propofol exposure [aOR=7.02; 95%CI: 1.92-25.76] were also the strongest independent predictors of delirium while analgesics exposures was not statistically significant to predict delirium in multivariable analysis.

Conclusions:

Delirium is significant risk factor of poor outcome in surgical intensive care unit. . There was an independent association between pain, sedation, COPD, hypernatremia and fever in developing delirium

References:

1. Pandharipande P et al. J Trauma 65:34–41, 2008

P174 Evaluation of delirium risk factors in intensive care patients

S Erel¹, E Macit Aydın¹, B Nazlıel², L Karabıyık¹

¹Gazi University School of Medicine, Anesthesiology and Intensive Care, Ankara, Turkey; ²Gazi University School of Medicine, Neurology and Intensive Care, Ankara, Turkey

Introduction:

Delirium is an acute mental syndrome which may cause negative consequences if it is misdiagnosed [1,2]. The aim of this study was to determine the incidence of delirium in different intensive care units and reveal the risk factors.

Methods:

The study was performed with 212 patients hospitalized in intensive care units of anesthesia, neurology and general surgery departments. Written informed consent was obstained from patients or relatives. Delirium screening test was performed twice daily with CAMICU (Confusion Assessment Method for the ICU). Patients who met the study criterias, were evaluated for the possible risk factors of delirium and the data was recorded daily. Patients were reevaluated after the treatment.

Results:

The incidence of delirium was 32.5%. Delirium was found to increase with the length of stay (p <0.001). The mean age of the patients with delirium was 67.46. this was higher than the patients without delirium (52.48) (p<0.001). Visual impairment (p<0.001), hearing impairment (p=0.001), educational status (p=0.024), hypertension (p=0.002), mechanical ventilation (p = 0.001), oxygen demand (p=0.002), midazolam infusion (p=0.025), propofol infusion (p=0.042), infection (p <0.001), SOFA (p = 0.001), APACHE II (p <0.001), nasogastric catheter (p=0.012), aspiration (p <0.001), number of aspirations (p<0.001), enteral nutrition (p<0.025), albumin (p=0.025), steroid (p=0.024), hypercarbia (p=0.039) hypoxia (p=0.039), sleep disturbance (p<0.001) were found risk factors for delirium. Oral nutrition (p<0.001) and mobilization (p=0.003) were found to prevent delirium development.

Conclusions:

Various factors are important in the development of delirium. These risk factors should be considered in reducing the incidence of delirium in intensive care units.

References:

1. Salluh JI et al. BMJ 350:2538, 2015

2. Kotfis K et al. Anaesthesiol Intensive Ther 50:160-67, 2018

P175

Withdrawn

P176 Delirium tremens in ICU: a descriptive study of clinical practices and patients complications

M Geslain, J Le Roy, P Aries, X Chapalain, T Gargadennec, O Huet, E L´Her, P Bailly

CHRU Brest, Brest, France

Introduction:

Alcohol use disorders (AUDs) is very common in ICU patients (up to 20%). An unplanned and brutal stop of alcohol consumption, as it can occur during ICU admission, may lead to an alcohol withdrawal syndrome (AWS). The most severe clinical manifestation of AWS is described as delirium tremens (DT). There are no current guidelines available for AWS treatment in ICU. The study’s aim was to describe the clinician’s practices for DT treatment and the outcome of DT in ICU patients.

Methods:

Observational retrospective cohort study in two ICUs of a university-affiliated, community hospital in France. Patient diagnosed for DT during their ICU stay, as defined by DSM-V classification, were enrolled in the study.

Results:

61 patients with DT were included between 2014 and 2017. Benzodiazepines was administered to 23% of the patients in order to prevent an AWS. As associated measures, vitamin therapy was administered to 83% of the patients and 59% had an increased fluid intake (mean 2.5L+/-0.7). Concerning the curative approach of AWS, the treatment’s heterogeneity was notable. There was a high frequency of treatment’s association (66% of the patients), every patient had benzodiazepines and the use of second line treatments such as neuroleptic, alpha-2 agonist, propofol was variable (Figure 1).

Complications of DT were the following:

• Need for mechanical ventilation due to unmanageable agitation or acute respiratory distress (33% of the patients)

• Self inflicted injuries such as pulling out of central lines, tubes, surgical drain (46%)

• Falls (7%).

• Seizures (33%).

Conclusions:

Delirium tremens is a severe complication of an untreated AWS, which can lead to serious adverse events in ICU. The current lack of evidence concerning the management of AWS in ICU probably explains the heterogeneity of treatments. Given the potential severity of AWS in ICU, further evidences are required to optimize care of AWS in ICU patients.

Fig. 1 (abstract P176).

DT treatment in ICU from D0 to D5. Most of the patients presenting a DT during their ICU stay were treated with benzodiazepine. A significant number of them received association of different molecules regardless the absence of evidence in the literature

P177 The incidence and related risk factor of delirium in surgical stepdown unit

S Yoon¹, S Yang², G Cho², H Park², K Park², J Ok², Y Jung²

¹Asan medical center, Nursing department, Seoul, South Korea; ²Asan Medical Center, Seoul, South Korea

Introduction:

Step Down Units (SDUs) provide an intermediate level of care between the ICU and the general medical-surgical wards. The Critically ill patients who are in recovery after long-term intensive care or who require monitoring after acute abdominal surgery are admitted to SDUs. Delirium in critically ill patient is common and leads to poor clinical outcomes. It is, however, preventable if its risk factors are identified and modified accordingly.

Methods:

To determine risk factors associated with delirium in critically ill patients to admitted surgical SDU at Asan Medical Center. This is retrospective study conducted on critically ill patients who were admitted to the SDU from September 2018 to April 2019 and able to express themselves verbally. Delirium status was determined using the Short-CAM tool. Data were analyzed by SPSS 13.0 software, using t-test, Fisher's exact test and logistic regression.

Results:

The incidence of delirium was 32.1%(25 of 78 patients) and hypoactive delirium(12case, 48.0%) was the most commonly assessed, followed by hyperactive delirium(9case, 36.0%), mixed type(4case, 5.1%). Risk factors associated with developing delirium identified from univariate analysis were age(P=0.048), admission via ICU (P=0.041), tracheostomy (P=0.037), chronic heart failure (CHF) (P=0.017), invasive hemodynamic monitoring (P=0.041), heart rate (P=0.037). After adjusted in multivariate analysis; factors those remained statistically significant were old age (RR 1.16, 95% Confidence Interval [CI]=1.07-1.25, P=0.041), having a tracheostomy (RR 2.99, 95% CI=1.48-2.08, P=0.028), CHF (RR 4.01, 95% CI=1.98-5.23, P<0.001), and chronic renal failure (RR 4.45, 95% CI=1.12-3.23, P<0.001). Those were significant risk factors of delirium in SDU.

Conclusions:

We identified risk factors consistently associated with incidence of delirium following admitted to surgical SDU. These factors help to focus on patients at risk of developing delirium, and to develop preventive interventions that are suitable for those patients.

P178 Validation of the prediction model for delirium in ICU patients (pre-deliric model) in mechanically ventilated Japanese patients with sepsis

K Miyamoto¹, T Nakashima¹, N Shima¹, S Kato¹, Y Kawazoe², Y Ohta³, T Morimoto⁴, H Yamamura⁵

¹Wakayama Medical University, Department of Emergency and Critical Care Medicine, Wakayama, Japan; ²Tohoku University Graduate School of Medicine, Division of Emergency and Critical Care Medicine, Sendai, Japan; ³Hyogo College of Medicine, Division of General Medicine, Department of Internal Medicine, Nishinomiya, Japan; ⁴Hyogo College of Medicine, Department of Clinical Epidemiology, Nishinomiya, Japan; ⁵Osaka Prefectural Nakakawachi Emergency and Critical Care Center, Higashiosaka, Japan

Introduction:

Patients with sepsis frequently develop delirium during their intensive care unit (ICU) stay, which is associated with increased morbidity and mortality. The prediction model for delirium in ICU patients (PRE-DELIRIC model) was developed to facilitate the effective preventive strategy of delirium [1]. However, the PRE-DELIRIC model has not yet been validated enough outside Europe and Australia. The aim of this study is to examine the external validity of the PRE-DELIRIC model to predict delirium using Japanese cohort.

Methods:

This study is a post hoc subanalysis using the dataset from previous study in nine Japanese ICUs, which have evaluated the sedative strategy with and without dexmedetomidine in adult mechanically ventilated patients with sepsis [2]. These patients were assessed daily throughout ICU stay using Confusion Assessment Method-ICU. We excluded patients who were delirious at the first day of ICU, were under sustained coma throughout ICU stay and stayed ICU less than 24 h. We evaluated the predictive ability of the PRE-DELIRIC model to measure the area under the operating characteristic curve. Calibration was assessed graphically.

Results:

Of the 201 patients enrolled in the original study, we analyzed 158 patients in this study. The mean age was 69.4 ± 14.0 years and 99 patients (63%) were male. Delirium occurred at least once during their ICU stay in 63 patients (40%). To predict delirium, the area under the receiver operating characteristics curve of the PRE-DELIRIC model was 0.60 (0.50 to 0.69). Graphically, the prediction model was not well-calibrated (Figure 1).

Conclusions:

To predict delirium in Japanese ICUs, we could not show the well discrimination and calibration of the PRE-DELIRIC model in mechanically ventilated patients with sepsis.

References:

1. van den Boogaard M et al. Intensive Care Med 40:361-9, 2014

2. Kawazoe Y et al. JAMA 317:1321-8, 2017

Fig. 1 (abstract P178).

Observed and expected incidence of delirium

P179 The effect of dexmedetomidine on the duration of delirium and the use of narcotic analgesics in elderly patients with femur fracture

A Konkayev¹, N Bekamagambetova², M Konkayeva³

¹Astana Medical University, Anaesthesiology and Intensive Care, Nur-Sultan, Kazakhstan; ²Trauma institution, Nur-Sultan, Kazakhstan; ³Astana Medical University, Nur-Sultan, Kazakhstan

Introduction:

Delirium is a serious and common complication and in some cases it treatment is difficult. Aim of the study was an evaluation of the prevalence, structure of delirium and efficacy of dexmedetomidine and haloperidol sedation in geriatric patients after femur fracture.

Methods:

After local ethic committee approval 207 case-records of geriatric patients with femur fracture in the period from 2017 to 2018 in the Institute of traumatology and orthopedics in Astana were analyzed. Patients was divided for 2 groups: in D – patients with delirium treated by i/v dexmedetomidine (0.2-1.4 mkg/kg per hour), in G group patients with delirium treated by i/v galoperidol (0.10-0.15 mkg/kg). Delirium was assessed by RASS at day of permission and every day at 8 a.m. The prevalence, structure of delirium and efficacy of sedation were analysed.

Results:

By anthropometric and gender characteristics of the group did not differ. The average age in the D-group with delirium was 81.8±0.9 years old, which was comparable to the G-group — 79.7±0.7 years old (p = 0.06). All study participants had similar comorbidities. Delirium in all patients debuted at 2.0±1.4 days, with an average duration of 2.2±1.2 days. The effect of dexmedetomidine was better and expressed in 52% decrease in the duration of delirium in compare to haloperidol (p <0.05). Dexmedetomidine provided a more controlled and safe sedation compared with haloperidol. The average consumption of narcotic analgesics in the subgroup with dexmedetomidine was two times less than in the subgroup with haloperidol. Thus, the average consumption of trimeperidine hydrochloride in patients of group D was 6.9 mg versus 14.1 mg in group G (p = 0.004).

Conclusions:

In gerontological patients with femur fracture treatment delirium by dexmedetomidine was more effective in compare with haloperidol. When using dexmedetomidine, the consumption of narcotic analgesics in postoperative period was 50% less than with haloperidol.

P180 Live music therapy in intensive care unit

MC Soccorsi¹, C Tiberi¹, G Melegari¹, J Maccieri², F Pellegrini², E Guerra¹, A Marudi¹, E Bertellini¹

¹Policlinico Teaching Hospital, Modena, Department of Anaesthesia and Intensive Care, Modena, Italy; ²Policlinico Teaching Hospital, Modena, School of Anaesthesia and Intensive Care, Modena, Italy

Introduction:

Intensive care units (ICU) are not comfortable for patients, relatives or next of kin. In the last years many news approaches were described to implement the humanization of medical treatments. The positive effect of music therapy in ICU is well described, especially reducing delirium risk [1]. The aim of this paper is describing the effect in patients and their family of a music live performance in ICU.

Methods:

After Ethical Committee approval (Procedure AOU 0018356/18, Italy) for three months (November 2018-January 2019) patients in ICU were treated twice a week with live music therapy performed by Coral Vecchi-Tonelli of Modena, Italy (Fig. 1). Data were collected all awake and conscious patients. Vitals parameters, GCS, RAAS and CAM ICU were collected before, during and after the treatment, at every performance. After the treatment a feedback questionnaire were given to patients and to next of kin.

Results:

18 subjects were enrolled in the research with mean age of 66.66 years old, delirium rate before the treatment was 16.38% later 15.38%, RAAS does not show any difference. Over 85% of patients were satisfied, and relatives felt less anxiety. We recorded also a satisfaction also in relatives not enrolled.

Conclusions:

The study does not demonstrate a delirium risk reduction for the small sample and the length treatment, anyway it was recorded a low delirium rate. The safety and the potential effect of music therapy are well known, surely the research underlines the feeling of patients and their next of kin: ICU is the most stressful setting for admitted patients and its humanization is a current topic for medical literature. Live performances could be an entertainment moment and probably create a moment of an interaction among patients, their family and medical and nurse: ICU become more Human. The high level of satisfaction push us to continue this experience.

References:

1. Mofredj A et al. J Crit Care 35:195–199, 2016

Fig. 1 (abstract P180).

Live performance of music therapy in ICU

P181 Medical hypnosis and virtual reality glasses are safe and effective tools to alleviate pain and anxiety in patients undergoing medical procedures

EK Okur kavak¹, G Van Berlaer², M Diltoer¹, M Malbrain¹

¹Universitair Ziekenhuis Brussel, Intensive Care, Brussels, Belgium; ²Universitair Ziekenhuis Brussel, Emergency and Disaster Medicine, Brussels, Belgium

Introduction:

Patients undergoing medical procedures benefit from distraction techniques to reduce the need for drugs alleviating pain and anxiety. This study investigates if medical hypnosis or virtual reality glasses (VRglasses) as adjuvant method reduces the need for additional drugs.

Methods:

In a prospective, randomized, interventional trial, patients undergoing procedures were stratified in four age groups, and randomly assigned into three arms by means of a closed envelope system. All patients received standard care for pain before the procedure; the control group received further drugs for pain and stress as indicated by the Visual Analog Scale (VAS; threshold 3/10) and ComfortScore (threshold 14/30), two index groups received either medical hypnosis or VR glasses as a plus before and during the procedure. VAS and Comfort were scored continuously and analysed with the Kruskal-Wallis Test. Patients, parents and healthcare providers scored their satisfaction at the end.

Results:

Of 104 included patients 6 to 86 years old, 47% were female. Regardless of age, pain and comfort scores were similar before and at the start of the procedure (VAS 3.7-4.2; Comfort 16-16.7), but as of one minute after starting the procedure, both VAS and Comfort reduced significantly more in both index groups compared to the control (p<0.001), remaining far below the threshold for both pain and stress (Figure 1). There was no advantage of one index group over the other (p=0.43). There were no adverse effects. Patients in the VR group were more satisfied than in the standard group (p=0.02) or in the hypnosis group (p=0.04). There was no significant difference in satisfaction of parents or healthcare providers.

Conclusions:

From the very start of the intervention, the application of either medical hypnosis or VR glasses significantly reduces pain and anxiety in patients undergoing medical procedures. More studies are needed but both are promising safe adjuvant tools to standard pharmacological treatment.

Fig. 1 (abstract P181).

Evolution of VAS and COMFORT scores during procedures

P182 Music to reduce pain and distress due to emergency care: a randomized clinical trial

NE Nouira, I Boussaid, D Chtourou, S Sfaxi, W Bahria, D Hamdi, M Boussen, M Ben Cheikh

Mongi Slim Academic Hospital, Emergency Department, Tunis, Tunisia

Introduction:

Recent clinical studies have confirmed the benefits of music therapy in managing pain and improving quality of care in the emergency department. The aim wasTo evaluate the impact of receptive music therapy on pain and anxiety induced by emergency care

Methods:

A randomized controlled study in patients consulting the emergency department. Two groups: the music therapy group; Patients needed venous sampling, peripheral venous catheter or arterial catheter. Will bless ten minutes music therapy by headphones and a second control group of patients with the same care without music therapy. Consent was requested from all participants. The level of pain caused by the act of care was assessed by visual analogic scale. Heart rate, blood pressure and the mood of the patient were assessed before and after emergency care. We assessed patient satisfaction, adverse events. Patients admitted to the emergency room, patients with communication difficulties and non-consenting patients were not included

Results:

Two hundred and forty patients were included randomized in both groups, 123 with music therapy and 117 without music therapy, the results showed comparable characteristics between the two groups: demographic data, pathological history, and initial clinical presentation. After the session of music therapy a difference was noted in the evaluation of the mean VAS who was in the group with Music of 2.87 ± 1.82 versus 3.60 ± 2.06 in the control group p< 0.004 CI 95% [-1.23; -0.23], and the mean of diastolic blood pressure which was 71, 07 mmHg in the first group against 74.27 mmHg for the control group p = 0.048 CI 95% [-6.37; -0.25]. As for the mood, the patients were more smiling after the act of care in the group music therapy. All patients were satisfied with their experience and 93% recommend this therapy to their relatives .

Conclusions:

Music therapy may reduce pain and anxiety in patients during emergency care.

P183 Impact of music therapy as non-pharmacological intervention in patients in weaning from mechanical ventilation

M Carmona¹, G Pagella², G Federico³, R Paffumi¹, D Minzer³, G Zakalik¹

¹Hospital Luis Carlos Lagomaggiore, UCI, mendoza, Argentina; ²Hospital Luis Carlos Lagomaggiore, Terapia intensiva, Mendoza, Argentina; ³Hospital Luis Carlos Lagomaggiore, mendoza, Argentina

Introduction:

The music therapy is the intervention of music and/or its elements to achieve individual goals within a therapeutic.the music has proved to have positive physiological and psychological effects on patients [1]. Patients admitted to the Intensive Care Unit (ICU) experience anxiety and stress even when sedated, negatively influencing recovery [2].

Methods:

Two groups are established, a music therapy group (MG) and a control group (CG). The first one undergoes music therapy interventions, it consists of 10-minutes sessions of live music. Patients of the GC will receive the usual treatment established by the service protocol for weaning management and the data are collected during the same time interval. Data collection includes Mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), oxygen saturation (SaO2) and temperature (T).

Results:

A total of 28 patients were recruited, of which 6 patients had to be excluded for meeting any of the exclusion criteria (n=22). Of which 13 (n=13) were randomized in the GM and the rest to the GC (n=9) IC95%. Regarding delirium in GM 9 (40.9%) presented a POSITIVE CAM-ICU, while in the CG were 13 (59.9%) (P=0.09). When analyzing the variables in the CG and GM, it was observed that there were no differences with respect to HR, RR and MAP variable (Figure 1).

Conclusions:

According to the results, we can say that music therapy as a non-pharmacological strategy for management of anxiety and delirium in patients of critical care units, might be an useful tool for the management of patients in weaning of mechanical ventilation

References:

1. Sliwka A et al. Complement Ther Med 22:756–766, 2014

2. Dijkstra BM et al. J Clin Nurs 19:1030-9, 2010

Fig. 1 (abstract P183).

Comparison between MG and CG

P184 Association between severity and coagulopathy in patients with anaphylaxis

S Yamaga¹, Y Yanase², K Ishii², K Hosokawa¹, S Ohshimo¹, N Shime¹, M Hide²

¹Hiroshima University, Department of Emergency and Critical Care Medicine, Hiroshima, Japan, ²Hiroshima University, Department of Dermatology, Hiroshima, Japan

Introduction:

Coagulopathy and basopenia are common features of anaphylaxis, but the role of coagulopathy in anaphylaxis remains uncertain. The aim of this study is to evaluate the association between coagulopathy and clinical severity or basopenia in patients with anaphylaxis.

Methods:

We conducted a single-center, retrospective study of patients with anaphylaxis about their coagulopathy. Levels of fibrin degradation products (FDP) and D-dimer were analyzed with the cause of anaphylaxis, clinical symptoms, medications and outcomes. We also studied the levels of intracellular histamine as a biomarker of basophil degranulation in the peripheral blood in relation to FDP and D-dimer.

Results:

In total, sixty-nine patients were enrolled to the study, and the levels of intracellular histamine were analyzed in 14 patients. The symptoms included respiratory failure (n=47), shock (n=56), abdominal impairment (n=20), and consciousness disturbance (n=37). Thirty-two patients needed continuous intravenous vasopressors for refractory shock. The increase of FDP was significantly associated with consciousness disturbance (p=0.029) and refractory shock (p<0.0001). The increase of D-dimer was also significantly associated with refractory shock (p=0.0066). There was no correlation between the levels of intracellular histamine and either of FDP or D-dimer (p=0.13 and p=0.16, respectively).

Conclusions:

The increase of FDP and D-dimer were associated with severe symptoms of anaphylaxis, while they were not correlated with intracellular histamine. These results suggest that anaphylaxis is closely associated with coagulopathy in a mechanism which is different from basophile degranulation in anaphylaxis.

P185 Cardiac manifestations of H1N1 infection in a Greek ICU population

E Nanou¹, P Vasiliou¹, E Tsigou², V Psallida¹, E Boutzouka², V Zidianakis¹, G Fildissis¹

¹Agioi Anargiroi Hospital, Attiki, Greece; ²Agioi Anargiroi Hospital, ICU, Attiki, Greece

Introduction:

Cardiovascular involvement in influenza infection occurs through direct effects on the myocardium or through exacerbation of pre-existing cardiovascular disease [1]. The aim was to study cardiac manifestations in all pts admitted to the ICU with severe influenza’s attack.

Methods:

Clinical, laboratory, electrocardiographic, echocardiographic and hemodynamic data were retrospectively recorded in all pts admitted to the ICU due to influenza infection (winter 2018-spring 2019). Diagnosis was established by PCR on bronchial aspirates the next 7 days after admission. Myocardial injury was defined by troponin levels >116 pg/ml (10 fold ULN). Left ventricular systolic dysfunction was defined as EF <50% and was characterized as either global or regional. Hemodynamic monitoring by transpulmonary thermodilution method (PICCO) was recorded in pts with shock (norepinephrine >0.1 μg/kg/min). Values are expressed as mean±SD or as median (IR).

Results:

Nine pts (5 males) with a mean age 49.78±17.01 years, APACHE II 19±5.29 and SOFA score 10.50±2.93 were assessed. ICU admission was due to ARDS (7) and COPD exacerbation (2). ICU LOS was 24.44±14.19 days and mortality rate was 18%. No history of vaccination or coronary heart disease was referred. Results are shown in table 1. Levosimendan was administered in 2 pts with severe cardiogenic shock. In all survivors, shock and indices of myocardial dysfunction subsided till discharge. Coronary angiography was performed in 1 pt showing no abnormalities. Mortality was attributed to septic shock and multi-organ failure.

Conclusions:

Myocardial involvement, though common in influenza pts admitted to the ICU, didn’t contribute to a dismal prognosis.

References:

1. Fagnoul D et al. J Crit Care 28: 321–327, 2013

Table 1 (abstract P185). Hemodynamic indices in H1N1 patients

P186 Levosimendan improves oxidative balance in low cardiac output patients

E Grossini¹, S Farruggio¹, V Bolzani², L Rossi², E Monaco³, P Pollesello⁴

¹Università Del Pienmonte Orientale, Department of Translational Medicine, Novara, Italy; ²Azienda Ospedaliero Universitaria, Cardiology Division, Novara, Italy; ³Azienda Ospedaliero Universitaria, Intensive Care Unit, Novara, Italy; ⁴Orion Corporation Orion Pharma, Critical Care Propretary Products, Espoo, Finland

Introduction:

The cardioprotective effects of levosimendan could be related to the modulation of oxidative balance. We aimed to examine the effects of levosimendan in patients with cardiogenic shock or with ejection fraction (EF) lower than 30% on cardiac systo-diastolic function and plasma oxidants/antioxidants (glutathione, GSH; thiobarbituric acid reactive substances, TBARS).

Methods:

In 4 patients undergone coronary artery bypass grafting or angioplasty, cardiovascular parameters were measured at T0 (before the beginning of levosimendan, 0.1mcg/Kg/min), T1(1 h after the achievement of the therapeutic dosage of levosimendan), T2 (at the end of levosimendan infusion), T3 (at 72 h after the end of levosimendan infusion), T4 (at the end of cardiogenic shock). The same time-course was followed for plasma GSH and TBARS measurements.

Results:

We found an improvement in cardiac output, cardiac index and systolic arterial blood pressure. EF increased from mean 25% to 45%. A reduction of central venous pressure and wedge pressure was also observed. Moreover, indices of diastolic function were improved by levosimendan administration (E/E’ from 14 to 6; E/A from >1 to <1) at early T2. It is to note that an improvement of GSH and TBARS was observed early after levosimendan administration (T1), as well (Figure 1).

Conclusions:

The results obtained have shown that levosimendan administration can regulate oxidant/antioxidant balance as an early effect in low cardiac output patients. The modulation of oxidative condition could be speculated to play a role in exerting the cardio-protection exerted by levosimendan in those patients.

Fig. 1 (abstract P186).

Effects of levosimendan on cardiac output (CO), cardiac index (CI), glutathione (GSH) and malonyldialdeide (MDA, which is representative of thiobarbituric acid reactive substances (TBARS). * p<0.05 vs T0. Square brackets indicate significance between groups (p<0.05)

P187 An analysis of the prognostic ability of noradrenaline dose in patients with septic shock

M Chotalia¹, M Bangash², T Matthews², D Parekh², J Patel²

¹University Hospitals Birmingham, NHS Foundation Trust, Critical Care and Anaesthesia, Birmingham, United Kingdom; ²University Hospitals Birmingham, NHS Foundation Trust, Birmingham, United Kingdom

Introduction:

This study analyses the prognostic ability of noradrenaline dose in the first four days following the onset of septic shock.

Methods:

Patients with a diagnosis of septic shock (Sepsis 3.0) admitted to the ICU at Queen Elizbeth Hospital, Birmingham between April 2016 and July 2019 were included. The primary outcome was 90-day mortality. Continuous data is presented as mean (SEM). Categorical data is presented as % and analysed using a chi-squared test. A p value of <0.05 was used to determined significance. To allow for multiple comparison between data, a Bonferroni calculation was used to determine significance at a p value of <0.01. Receiver operator characteristic (ROC) curves were generated for noradrenaline dose and area under the curve (AUC) was calculated.

Results:

847 patients were admitted with septic shock. The majority (61%) were male, with a mean age of 62 (±0.6) and a 90-day mortality of 43%. Median noradrenaline dose had a fair prognostic ability on day 1 (AUC = 0.754 [0.714 – 0.794]) and good prognostic ability on day 2 (AUC = 0.844 [0.810 – 0.878]) (Figure 1). A noradrenaline dose of 0.25μg/kg/min on day 1 and 0.15 μg/kg/min on day 2 had a 70% sensitivity and 70% specificity for mortality. Median noradrenaline dose was an excellent prognostic indicator on day 3 (AUC =0.911 [0.878 – 0.943]) and day 4 (AUC = 0.908 [0.879 – 0.948]). A noradrenaline dose of 0.1μg/kg/min on day 3 and 0.05 μg/kg/min on day 4 had a 90% sensitivity and 90% specificity for mortality. In patients who survived, vasopressors were weaned off within 4 days in 90% of cases. In those who died, death occurred within 4 days 88% of the time.

Conclusions:

Noradrenaline dose has a good prognostic ability in septic shock. In this septic shock cohort, the majority of patients that died did so within 4 days. Furthermore, the majority of survivors were weaned off vasopressors within 4 days. Therefore, by day 3 and 4, small doses of noradrenaline had an excellent prognostic ability for septic shock.

Fig. 1 (abstract P187).

Maximum noradrenaline dose (micrograms/kg/minute) from onset to day 4 of septic shock and % 90-day mortality. (**: p = 0.005; ***: p <0.0001; ns = non-significant)

P188 Early vasopressor use in the emergency department is associated with survival in patients with septic shock

M Chotalia¹, M Bangash², T Matthews², D Parekh², J Patel²

¹University Hospitals Birmingham, NHS Foundation Trust, Critical Care and Anaesthesia, Birmingham, United Kingdom; ²University Hospitals Birmingham, NHS Foundation Trust, Birmingham, United Kingdom

Introduction:

This study evaluates whether vasopressor use in the emergency department (ED) and vasopressor use within four hours of arrival to ED is associated with survival in patients with septic shock.  The optimal timing of vasopressor administration in septic shock is unknown. Emerging evidence suggests early administration in non-intensive care settings may improve outcomes [1].

Methods:

Patients with a diagnosis of septic shock (Sepsis 3) who were admitted to intensive care directly from the emergency department (ED) between April 2016 and July 2019 at Queen Elizabeth Hospital, Birmingham were included.  The primary outcome was 90-day mortality. Early vasopressor use was defined as the administration of metaraminol or noradrenaline within 4 hours from arrival in ED. Continuous data is presented as mean (SEM) and analysed using an unpaired t-test. Categorical data was analysed using Fishers exact test.

Results:

87 patients had septic shock and were admitted to intensive care directly from ED. Patients were 61% male, aged 64.7±1.9 years, and had a 44% 90-day mortality. Seventy-nine percent of patients had vasopressors in ED; 56% within 4 hours. The first vasopressor was metaraminol in 60% of cases. Early vasopressor use was associated with a lower mortality than late vasopressor use (33% vs. 58%; RR 0.56 [0.35-0.92]; p = 0.029). Vasopressor use in the ED was associated with a lower mortality than no vasopressor use in the ED (38% vs 67%; RR 0.56 [0.36-0.88]; p = 0.035). There was no difference in the median MAP in ED between early or late vasopressor use (64.3 [1.2] mmHg vs 63.8 [2.7] mmHg; p = 0.56). A comparison between patients who survived and died is outlined in Table 1.

Conclusions:

Early administration of vasopressors and their use in the emergency department was associated with survival in septic shock. This seemed to be independent of median MAP recorded in the ED.

References:

1. Permpikul C et al. Am J Respir Crit Care Med 199:1097-105, 2019.

Table 1 (abstract P188). A comparison of early vasopressor use in septic shock patients who survived and died

P189 Prevalence and management of tuberculous cardiac tamponade : experience of Casablanca cardiac care unit

R Benmalek¹, H Zahidi², J Hassari³, S Arous³, E Benouna³, R Habbal³

¹CHU Ibn Rochd, Cardiology Department, Casablanca, Morocco; ²Cardiology department, CHU Ibn Rochd, Casablanca, zahidi, Casablanca, Morocco; ³Cardiology department, CHU Ibn Rochd, Casablanca, Cardiology, Casablanca, Morocco

Introduction:

Cardiac tamponade is a life-threatening clinical syndrome caused by an increase in intrapericardial pressure that requires early diagnosis and management. In our Moroccan endemic context, tuberculosis (TB) still remains a real public health issue and its pericardial localization is a serious form of extrapulmonary TB associated with substantial morbidity. However, pericardial effusions causing pericardial tamponade are rare in patients with TB. The aim of our study was to evaluate the prevalence of tuberculous cardiac tamponade, its clinical presentation and evolutive particularities in our cardiac care unit

Methods:

We conducted a cross-sectional prospective study from May 2016 to April 2019 including all the patients admitted in our unit for cardiac tamponade. We excluded all the traumatic or post-myocardial infarction forms.

Results:

Out of 83 patients, the tuberculous etiology was identified in 15 cases (18,1%), mean age was 34 years, 57,8% were men. 9 patients reported a TB contact in their environment, 5 had a medical history of pulmonary TB. After pericardiocentesis, the liquid was citrine yellow in 6 cases and hematic in 5 patients, no patient underwent surgical drainage in our serie. Mycobacterium tuberculosis was found in the expectorations in 4 cases and ADA was positive in 4 patients. HIV serology was negative in all our patients. A 6 months anti bacillary therapy with isoniazid, rifampin, pyrazinamide, and ethambutol was initiated in all our patients with a good evolution in 7 cases, 2 deaths, 1 chronic constrictive pericarditis, 2 small pericardial effusion and 3 lost to follow-up.

Conclusions:

Althought cardiac tamponade is rarely caused by tuberculosis, this condition remains common in endemic countries such as Morocco and affect younger population, hence the importance of a better knowledge of its prevalence and and multidisciplinary management and more importantly the treatment of the underlying cause using Combined antibacillary medication that has shown satisfying results.

P190 Point-of-care ultrasound teaching during anaesthesia and critical care residency: an Italian national survey

F Bonomi, S Mongodi, A Colombo, A Stella, S Pregnolato, G Salve, S Bonaiti, A Orlando, F Mojoli

Fondazione IRCCS Policlinico San Matteo - Università di Pavia, Anaesthesia and Intensive Care, Pavia, Italy

Introduction:

Point-of-care ultrasound (PoCUS) became an invaluable tool in anaesthesia and critical care (ACC) [1]; appropriate training should integrate ACC residency programs [2].

Methods:

On-line surveys sent to 3 groups (ACC schools directors, residents and consultants), as approved by CPAR (Collegio Professori Anestesia Rianimazione), on teaching in vascular accesses-VA, lung ultrasound-LUS, transthoracic echocardiography-TTE, focused-assessment sonography for trauma-FAST, transcranial Doppler- TCD, regional anaesthesia-RA, diaphragm ultrasound-DUS.

Results:

In 270 survey days the form was filled by 568 residents (30/40 universities) 22 directors, 216 consultants (24/40 universities). For all the groups bedside teaching, followed by frontal lectures, is the most frequent tool for all techniques. LUS and DUS more frequently include research activities; AR e VA usually include simulations. Overall, the most neglected technique is FAST. According to directors and consultants, residents are mentored by consultants (96.2%/ 95.4%) and older residents (46.2%/ 26.9%), while according to residents, consultants/older residents mentor in 72%/ 39.6% of cases, while 48,6% of the training is performed with no mentoring. Ultrasound competences evaluation is performed mostly in everyday bedside activity (>55%) for all groups; however, residents report no evaluation in a higher percentage (37.5 vs.7.7%). Perception on adequacy of the training is displayed in Fig 1. The main perceived limiting factor is the absence of a standardized didactic program, followed by mentor’s availability in residents’ perception and by mentor’s experience in consultants’ one.

Conclusions:

PoCUS teaching is present although not optimal and not homogenous in Italian ACC residency schools. Standardisation of residents’ ultrasound curriculum is suggested to improve ultrasound teaching.

References:

1. Mojoli F. Am J Respir Crit Care Med. 199:701-714, 2019

2. Stolz LA. Acad Emerg Med 24:353-361, 2017

Fig. 1 (abstract P190).

Perception of adequacy of training. Red: to be improved, orange: sufficient, green: adequate

P191 Confirming central line position through bedside ultrasound

JD Dillemans, AD Dumoulin, WS Stockman, PL Lormans

AZ Delta, Intensive Care, Roeselare, Belgium

Introduction:

Ultrasound (US) guidance during Central Venous Catheter (CVC) placement is recommended by guidelines and radiographic confirmation of the position is considered as the golden standard. Nevertheless, there is little literature regarding the feasibility of ultrasonic evaluation of the CVC tip position. The main objective was to examine the accuracy of bedside ultrasound for confirmation of the CVC position and exclusion of pneumothorax compared with chest radiography (CXR).

Methods:

The study included a convenience sample of critically ill patients with supradiaphragmatic CVCs and a CXR for confirmation. US is used for direct confirmation of the guidewire in the Internal Jugular (IJV) or Subclavian (SCV) vein and visualizing the guidewire in the right atrium. To evaluate for pneumothorax, “sliding sign” of the pleura was noted on US of the anterior chest.

Results:

34 patients have been included, 35% of the catheters have been placed in the SCV and 65% in the IJV. It was possible to confirm the position of the CVC tip for 70.6% (23 correct, 1 incorrect CXR) of 34 cases by transthoracic echocardiography (TTE) (Figure 1). Overall, it was not possible to identify the guide in the right atrium 11 cases (10 false negatives, 2 of them due to the presence of defibrillator leads). Regarding the 1 case where an incorrect position was seen on CXR it was also detected on ultrasound: US of the inserted vein and a negative TTE confirmation. In all cases it was possible to exclude a pneumothorax by US.

Conclusions:

These results show that bedside ultrasound might be a feasible technique to confirm the CVC positioning. It is important to note that the level of the operator’s expertise is significant when assessing the feasibility of this method. We only had a limited sample size and the occurrence of only one misplaced catheter. These preliminary results need to be confirmed on a larger scale.

Fig. 1 (abstract P191).

TTE confirmation

P192 A systematic review on the comparison of the role of internal jugular vein, inferior vena cava and carotid ultrasound measurements in assessment of patients with heart failure

N Parenti¹, F Musto¹, V Pezzilli¹, G Borelli¹, T Rada¹, F Agrusta², S Menetti², M Nuzzetti², E Romboli¹, M Silingardi¹

¹Hospital Maggiore, Internal Medicine, Bologna, Italy; ²Policlinico Modena, Internal Medicine, Modena, Italy

Introduction:

Recent reports suggested to use internal jugular vein (IJV), inferior vena cava (IVC) and carotid ultrasound measures to confirm congestion and to predict prognosis in heart failure (HF) patients. Our aims were to check the validity of  the previous US measures in predicting HF diagnosis and prognosis.

Methods:

This review was based on the PRISMA guideline . The systematic search of the literature published from 1941 through 30 October 2019 explored the PubMed and Cochrane Library databases. Inclusion criteria: studies who investigated the reliability, the accuracy in predicting HF diagnosis and death or re-hospitalization of the IJV, IVC diameter, IVC collapsibility index (IVC-c = IVC max – IVC min / IVC max X 100) and Common Carotid US measures in adult (>18 yrs)  with HF. Five researchers selected studies using inclusion criteria and then assessed their quality using the QUADAS-2 guidelines. The key words for literature search were: common carotid, internal jugular veins, inferior vena cava, ultrasonography and heart failure.

Results:

We collected 744 studies: 727 excluded with reasons, 18 studies were included for the final analysis: 4 on IJV, 13 on IVC, 1 on Carotid US. A IJV ratio < 4 predicts death and readmission : HR=2.7-10. A IVC ≥2 cm and IVC-c ≤15% showed an high accuracy in HF diagnosis and a moderate validity in predicting death and re-admission : AUC=0.63-0.78; HR=1.1-5.8 for IVC; AUC=0.63-0.74, HR=0.7-6.8 for IVC-c. The LVET ( time interval between end diastole and the dicrotic notch of Common carotid artery Doppler waveform showed a good validity in predicting HF diagnosis: AUC=0.81 (95% CI, 0.72–0.87).The studies collected showed a moderate quality according to QUADAS-2 guidelines.

Conclusions:

Because few reports have been published on this topic the conclusions of this review should be confirmed. The IJV and IVC  ultrasound measures seem to have a moderate accuracy in predicting diagnosis, death and hospitalization in patients with Heart Failure.

P193 Epidemiology of baseline echocardiography among critically ill patients with sepsis

MH Senussi¹, JN Kennedy², M Schmidhofer¹, O Marroquin³, DC Angus², CW Seymour²

¹University of Pittsburgh, Heart & Vascular Institute, Pittsburgh, United States; ²University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, United States; ³University of Pittsburgh, UPMC Department of Clinical Analytics, Pittsburgh, United States

Introduction:

More than 7-million transthoracic echocardiograms are performed annually in the US. These studies may reveal structural and functional cardiac abnormalities that inform clinical care in the intensive care unit. And yet, little is known about the epidemiology of baseline echocardiography, specifically among patients admitted to intensive care with sepsis.

Methods:

We studied electronic health records of 1,076,925 adult patients from 12 hospitals at UPMC from 2013 to 2014. Eligible patients were those with Sepsis-3 at presentation who required intensive care during hospitalization. Demographics, comorbidities, illness acuity, and baseline echo parameters (within 1-year prior to incident sepsis hospitalization) were abstracted. An abnormal echocardiogram was defined as LVEF<50%, LV diastolic dimension >6 cm, moderate/severe RV dysfunction, or moderate/severe valvular stenosis/regurgitation. We compared characteristics of patients who did and did not receive an echo, those with normal and abnormal studies, and patients stratified by in-hospital mortality.

Results:

Among 43,086 adults with sepsis, 8,077 (18%) had baseline echocardiographic data within 1-year of admission, on average 131 (SD 103) days prior to presentation (Figure 1). Most septic patients had abnormal echo studies (N=5782, 72%). Of those who died (2,666 (6.2%)), 1,821(68.3%) had no echo data,192(7.2%) had normal and 653 (24.5%) had abnormal studies, compared to 40,420 (93.8%) survivors of which 7,232 (17.9%) had baseline echo, 2,298 (5.7%) had normal, and 5,779(14.3%) had abnormal echocardiograms. Comparing deaths to survivors, reduced EF<39% (15.7% vs 12.6%, p=0.01), severe RV dysfunction (11.1% vs 8.4%, p=0.52), RV dilation (21% vs 17.2%, p<0.01) and severe tricuspid regurgitation (19.4% vs 13.1%, p<0.001) were more common among deaths.

Conclusions:

Most septic patients admitted to intensive care have abnormal baseline echocardiography. A reduced LV ejection fraction and severe right sided heart disease were more common among deaths than survivors.

Fig. 1 (abstract P193).

Panel A. Patient baseline characteristics. Panel B. Chord diagram showing abnormal echocardiographic parameters by mortality. The ribbons connect from mortality status to individual echocardiographic abnormalities if the group mean is greater or lesser than the overall mean for the entire cohort. For example, patients who died (light blue) are more likely to have RV dysfunction, LV dysfunction, and tricuspid regurgitation but not aortic stenosis or mitral regurgitation

P194 Most guidewires used for central venous catheterization of the right subclavian vein in adults are too short; a CT-based observational study

M Adrian¹, P Bengtsson², O Borgquist¹, G Bozovic², T Kander¹

¹Skåne University Hospital, Anaesthesia and Intensive Care, Lund, Sweden; ²Skåne University Hospital, Diagnostic Radiology, Lund, Sweden

Introduction:

Central venous catheter (CVC) misplacement occurs more frequently after cannulation of the right subclavian vein compared to the other sites for central venous access. Misplacement can be avoided with ultrasound guidance by using the right supraclavicular fossa view to confirm correct guidewire J-tip position in the lower part of the superior vena cava. However, retraction of the guidewire prior to the CVC insertion may dislocate the J-tip from its desired position, thereby increasing the risk of CVC misplacement. The aim of this study was to determine the minimal guidewire length needed to maintain correct guidewire J-tip position throughout an US-guided infraclavicular CVC placement in the right subclavian vein.

Methods:

100 adult intensive care patients with a computed tomography scan of the chest were retrospectively and consecutively included in the study. The distance from the most plausible distal puncture site of the right subclavian/axillary vein to the junction of the right and left brachiocephalic veins (= vessel length) was measured using multiplanar reconstructions. In addition, measurements of the equipment provided in commonly used 15-16 cm CVC kits were performed. The minimal guidewire length was calculated for each CVC kit.

Results:

The guidewires were up to 90 mm too short to maintain correct J-tip position throughout the CVC insertion procedure in seven of nine commercial CVC kits. Four of these are shown in Table 1.

Conclusions:

When US guidance is used to confirm a correct guidewire J-tip position, retraction of the guidewire prior to the CVC insertion must be avoided to ensure correct CVC-tip positioning. This study shows that most of the commonly used 15-16 cm CVC kits contain guidewires that are too short for CVC placement in the right subclavian vein.

Table 1 (abstract P194). Minimal guidewire length = 105 mm (95th percentile of the vessel length) + 30 mm (to ensure that the guidewire J-tip passes the junction of the right and left brachiocephalic veins and the azygos arch into the lower part of the superior vena cava) + steel cannula length (the maximum length that can be inserted into the patient) + CVC full length + 10 mm (the part of the guidewire that must extend from the CVC before CVC-insertion)

P195 The reliability of lung B-lines to assess fluid status in patients with long period of supine position

K Mnif¹, O Doukali², E Unluer³, R Ammar², C Ben hamida², M Bouaziz²

¹University Hospital Habib Bouguiba Sfax, Intensive Care Unit, Sfax, Tunisia; ²university hospital habib bouguiba sfax, intensive care unit, sfax, Tunisia; ³S.B.U Bozyaka Egitim ve Arastirma hastanesi, emergency department, izmir, Turkey

Introduction:

In critically ill patients, due to long period of supine position, lung water accumulation in posterior areas,outside of lung or heart diseases, can be induced and B-lines can be observed. The aim of our study is to find, by transthoracic ultrasound, the correlation between B_lines and fluid status in patients with long period of supine position.

Methods:

This prospective study included 924 assessments performed in 154 patients with length of stay of 10 days or more . Each patient’s fluid status was evaluated in admission and each 48 hours,using B-lines number assessment by lung ultrasound,measurement of inferior vena cava (IVC) diameters, and central venous pressure (CVP) analysis .Patients were stratified into three subgroups according to their B-lines number : mild ≤14, moderate (14–30) and severe (>30).

Results:

There were 530 separate assessments with mild,294 with moderate and 100 with severe B-lines occurrence. There was a significant positive correlation between the log B-lines number and both IVC diameter and CVP values.The correlation between log B-lines number and IVC diameters decreases but not significantly during hopitalization ( r in admission= 0.55, p=0.001 ; r in day 10 =0.43,p=0.035). Correlations between the log B-lines number and CVP during hospitalization yielded similar results (r in admission= 0.75, p=0.001 ; r in day10 = 0.63, p=0.0026).

Conclusions:

B-lines number assessment keeps a significant reliability to reflect hydration status in patients with long period of supine position.

P196 Oblique approach for ultrasound-guided cannulation of femoral vein overlapped by artery

A Kothekar, J George, A Kulkarni, V Patil

Tata memorial center, Homi Bhabha National Institute, Mumbai, India

Introduction:

Ultrasound-guided cannulation is usually done using either longitudinal or transverse approach. The oblique approach utilizes advantages of both these approaches allowing visualization of the entire course of needle including tip and lateral discrimination of artery from vein [1]. The reported incidence of the complete overlap of femoral vein by the femoral artery is 8-10 percent [2,3]. We describe the use of the oblique approach for successful cannulation of such a femoral vein which is not possible by usual approaches (Figure 1).

Methods:

Case 1: A 36-year male, a diagnosed case of carcinoma right buccal mucosa was operated for wide local excision, right-sided neck dissection, and reconstruction. In immediate perioperative period, he sustained cardiac arrest due to exsanguinating bleeding from maxillary artery and pterygoid plexus needing external carotid artery ligation. Later in the course, hemodialysis was planed for acute kidney injury. Case 2: A 25-year male was under evaluation for multiple cervical lymphadenopathies and superior vena cava obstruction (SVCO). He presented to ICU with tumour lysis syndrome and life-threatening hyperkalemia requiring urgent hemodialysis.

Results:

In both the patients, neck vein cannulation was risky and screening ultrasound revealed a complete overlap of the femoral vein by femoral artery precluding its cannulation by traditional longitudinal or transverse approach. However, due to unavailability of safer alternatives, femoral vein cannulation was done under ultrasound guidance using oblique approach technique by the operator experienced in the oblique approach

Conclusions:

Oblique approach allowed successful cannulation of the femoral vein completely overlapped by the femoral artery as it offers both the visualization of the entire course of the needle and lateral discrimination of artery from the vein.

(Written informed consent was obtained)

References:

1. Phelan et al. J Emerg Med 37:403–8, 2009

2. Hughes et al. Anaesthesia 55:1198-202, 2000

3. Warkentine et al. Acad Emerg Med 15:426–30, 2008

Fig. 1 (abstract P196).

Ultrasound image showing the needle path and vessels in the oblique approach

P197 P wave indices in critically unwell patients with new-onset atrial fibrillation (NOAF)

JT Lay¹, B Johnston², K Williams³, I Welters²

¹University of Liverpool, School of Medicine, Liverpool, United Kingdom; ²Royal Liverpool Hospital, Liverpool, United Kingdom, ³University of Liverpool, Institute of Ageing and Chronic Disease, Liverpool, United Kingdom

Introduction:

Previous studies have demonstrated the potential of P wave characteristics to predict atrial fibrillation (AF). However, data on p-wave measurements in critically unwell patients are lacking. This study aimed to determine whether P wave indices in our sample diverged from previously established reference values in healthy subjects.

Methods:

Digital ECG recordings of 49 critically ill patients admitted to the Royal Liverpool University Hospital were collected from the Clinical Information System. 19 patients were excluded due to absent or inadequate data. ECGs of 30 patients were converted to images and analysed with a new technique in ImageJ to allow measurement of P wave indices. P wave indices included P wave axis, PR interval, mean, maximum and minimum durations, dispersion, and P wave terminal force in V1 (PTFV1). Results were compared to reference values described in previous studies [1 - 3].

Results:

Maximum P wave duration (137.4ms ± 19.6) and dispersion (79.5ms ± 16.5) were increased compared to reported values in the literature (103ms and 34ms, respectively) [1]. Mean PR interval (155.4ms ± 26.4) was also decreased [1]. Mean P wave duration (100.6ms ± 17.3) was greatly lower than values recorded in previous studies (66 (59, 72), 123 ± 12, 111.4 ± 14.7) [1,2,3]. Measurements in 6 patients demonstrated abnormal PTFV1 values of ≥4000μVms. Abnormal P wave axis was found in 5 patients. 1 patient displayed both abnormal PTFV1 and P wave axis.

Conclusions:

Our preliminary results demonstrate that mean maximum P wave duration, dispersion, and PR interval were altered in patients with NOAF compared to healthy subjects. 37% of patients had abnormalities in PTFV1 or P wave axis. Further research is warranted to investigate differences of p-wave characteristics in critically ill patients who do and those who do not develop NOAF.

References:

1. Magnani JW et al. Ann Noninv Electrocard 15:344-52, 2010

2. Havmoller R et al. BMC Cardiovasc Dis 7:22, 2007

3. Militaru C et al. Ann Noninv Electrocard 16: 351–6, 2011

P198 Measuring peripheral arterial tone and biomarkers to identify endothelial dysfunction

V Schechten¹, A Larena-Avellaneda¹, B Saugel², R Schnabel³, L Plümer², ES Debus¹, C Zöllner², E Schwedhelm⁴, G Daum¹, MS Winkler⁵

¹University Heart Center, Clinic and Policlinic for Vascular Medicine, Hamburg, Germany; ²University Medical Center Hamburg-Eppendorf, Center for Anesthesiology and Intensive Care Medicine, Hamburg, Germany; ³University Heart Center, Clinic and Policlinic for Cardiology, Hamburg, Germany; ⁴University Medical Center Hamburg-Eppendorf, Institute of Clinical Pharmacology and Toxicology, Hamburg, Germany; ⁵University Medicine Göttingen, Department of Anesthesiology and Intensive Care Medicine, Göttingen, Germany

Introduction:

Endothelial cells play a pivotal role in the atherogenic process. Endothelial cell dysfunction (ED) is the main risk factor for cardiovascular diseases such as hypertension, coronary heart disease (CHD) and peripheral occlusive disease (POD). These diseases significantly increase the risk for perioperative complications. Therefore, identifying patients with ED is important and should influence our prospective perioperative strategy. However, sensitive tools to diagnose ED are still missing and do not belong to our standard of care. Aim of this study was the validation of a new non-invasive method to detect ED and a correlation with a set of established an new endothelial biomarkers.

Methods:

The cohort includes 20 preoperative patients without anamnestic relevant cardiovascular disease and 20 patients with known peripheral occlusive disease (POD). We used non-invasive EndoPAT® Technology from ITAMAR-Medical to measure ED by changes in vascular tone before and after occlusion of the brachial artery and calculate a reactive hyperemia index (RHI). In addition, we measured established markers and alternative biomarkers potentially indicate vascular diseases such as substrates and products from the NO-metabolism L-Arginin, asymmetric/symmetric dimethylarginine (ADMA/SDMA), von-Willebrand factor (vWF) and Sphingosine-1-phosphate (S1P).

Results:

RHI was able to identify patients with POD. RHI was significant lower in patients with clinical signs and symptoms of POD (P<0.05). Among other markers ADMA was significant higher in POD patients compared to controls and correlates with RHI.

Conclusions:

The PAD technology is a helpful non-invasive functional test to measure ED and seems able in identify patients with vascular disease. In future, a combination of anamnesis, new diagnostic tools and biomarkers may further increase our sensitivity in identifying risk-patients.

P199 Single-lumen 5Fr and triple-lumen 6Fr peripherally inserted central catheters (PICCs) for cardiac output assessment by transpulmonary thermodilution

S D´Arrigo¹, C Sandroni¹, S Cacciola¹, AM Dell´Anna¹, M Pittiruti², MG Annetta¹, G Chiuri¹, M Antonelli¹

¹Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anesthesiology, Intensive Care and Emergency Medicine, Rome, Italy; ²Fondazione Policlinico Universitario A. Gemelli IRCCS, Department od Surgery, Rome, Italy

Introduction:

Trans-pulmonary thermodilution (TPTD) using single-lumen 4Fr and double-lumen 5Fr Peripherally Inserted Central Catheters (PICCs) significantly overestimate cardiac index and the other hemodynamic parameters if compared to Centrally Inserted Central Catheters (CICC) [1]. However, the reliability of PICCs of larger size is still unknown.

Methods:

Prospective method-comparison study conducted in a medical-surgical ICU of a teaching hospital. We compared TPTD measurements via single-lumen 5Fr or triple-lumen 6Fr polyurethane power injectable PICCs vs. triple-lumen 7Fr CICC using a TPTD-calibrated Pulse Contour hemodynamic monitoring system (VolumeView/EV1000^TM Edwards ©).

Results:

Out of 160 manual measurements in 15 patients, we did not found any difference in CI between single-lumen 5Fr PICC compared to CICC (3.2±1.04 vs. 3.2±1.06 L/min/m², p=0.824; percentage of error 14.7%); we also found no differences GEDVI, EVLWI, SVI and CVP. CI was slightly higher when using triple-lumen 6Fr PICC than when using CICC (3.3±0.8 vs. 3.0±0.7 L/min/m², p=0.107, percentage of error 19.0%), although this difference did not reach the statistical significance. We found instead a difference in GEDVI (685±133 vs. 632±102 mL/m², p=0.05; percentage of error 19.5%).

Conclusions:

Single-lumen 5Fr PICCs are surely accurate for TPTD use, whereas triple-lumen 6Fr PICCs lead to a slight overestimation (ClinicalTrial.gov NCT03834675).

References:

1. D'Arrigo S et al. Crit Care Med 47:1356-1361, 2019

P200 Pilot study: Advanced hemodynamic monitoring after acute spinal cord injury

N Drotleff¹, O Jansen¹, M Aach², TA Schildhauer¹, C Waydhas¹, U Hamsen¹

¹BG University Hospital Bergmannsheil, Department of General and Trauma Surgery, Bochum, Germany; ²BG University Hospital Bergmannsheil, Department of Spinal Cord Injury, Bochum, Germany

Introduction:

Spinal cord injury causes vasoplegia and bradycardia, therefore severely affecting the cardiovascular system. To date, no publication describes the applicability of advanced hemodynamic monitoring in these patients.

Methods:

From March 2017 onwards we conducted a prospective, single center pilot study including all patients with an acute spinal cord injury. We excluded patients that had a preexisting cardiac condition as well as patients suffering from sepsis. Measurements were performed using the PiCCO system (Pulsion, Munich, Germany) at least 3 times a day.

Results:

Until December 2019 25 Patients (mean age 56 ± 20 years, range 18-82) with a total of 337 measurements were included. In 19 Patients the levels of C2 to C7 were affected. Three patients had a lesion of the thoracic level and 3 subjects suffered from lumbar paraplegia. We observed a mean Cardiac Index (CI) of 4,2 ± 1,2 l/min/m², a mean Stroke Volume Index (SI) of 59 ± 15 ml/m² and a mean Systemic Vascular Resistance Index (SVRI) of 1384 ± 443 dyn*s*cm^-5*m². There were 14 Patients requiring norepinephrine on at least one day of measurements. With vasopressors (n=46) we observed a mean CI of 4,1 ± 1,2 l/min/m², a mean SI of 59 ± 16 ml/m² and a mean SVRI of 1317 ± 572 dyn*s*cm^-5*m². Without catecholamines (n=292) we noted a mean CI of 4,2 ± 1,1 l/min/m², a mean SI of 59 ± 15 ml/m² and a mean SVRI of 1394 ± 418 dyn*s*cm^-5*m².

Conclusions:

Our preliminary results do show a difference of the mean SVRI in patients suffering from acute spinal cord injury when compared to the reference range of healthy individuals. Furthermore, the SVRI is reduced in both subjects under vasopressor therapy and patients that did not receive catecholamines. We assume a complex adaptation of the cardiovascular system that can compensate for the loss of vascular resistance in the absence of vasopressors without affecting the cardiac index.

P201 Establishing a focused critical care echocardiography programme in a developing world intensive care unit

D Hall¹, J Harrington¹, M Murali², TY Wang², N Shamambo²

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²University Teaching Hospital, Lusaka, Zambia

Introduction:

Achieving effective critical care in low- and middle-income countries is a global health goal [1], which includes the provision of effective point of care ultrasound [2]. We sought to establish Zambia’s first focused critical care echocardiography training programme in a 16-bedded ICU at University Teaching Hospital, Lusaka.

Methods:

The programme was accredited by the UK Intensive Care Society FICE programme, with teaching adapted for local disease patterns such as tuberculous pericardial effusions. Parasternal, apical and subcostal windows were used to assess ventricular dysfunction, hypovolaemia, pleural effusion, alveolar interstitial syndrome and pneumothorax. Zambian doctors working with critically ill patients received an intensive one-day course, followed by mentored scanning at the bedside. Teaching was delivered by visiting fellows from the UK who are accredited in echocardiography and experienced ultrasound educators.

Results:

26 Zambian doctors who work with critically ill patients (16 anaesthetists, 8 paediatricians, 2 physicians) were enrolled. Two handheld ultrasounds (GE VScan and Phillips Lumify) were donated to the programme. Feedback from participants indicated high satisfaction with the course: 100% agreed that the course improved their understanding of critical care echocardiography and that it was pitched at the right level. Participants believed the course was essential for developing skills in critical care, and that it was relevant to their clinical practice. Demand for further training is high. Challenges include maintaining sustainability, clinical governance, local accreditation, and servicing of equipment.

Conclusions:

Establishing a training programme in focused critical care echocardiography in a resource poor setting is both feasible and well received. Clinician motivation to gain competence at critical care echocardiography is high in an environment with limited availability of diagnostic services.

References:

1. Turner HC et al. BMJ Global Health 4:e001675, 2019

2. Becker BM et al. Trop Med Int Health 21:294-311, 2016

P202 Association of thermodilution-derived cardiac index, stroke volume index and heart rate with hospital mortality in ICU patients: an observational study

LR Rapp, TL Lahmer, MH Heilmaier, GB Batres-Baires, RS Schmid, WH Huber

Klinikum Rechts der Isar der technischen Universität München, Medizinische Klinik und Poliklinik II, München, Germany

Introduction:

An increasing number of less or non-invasive devices provide estimates of cardiac index CI and stroke volume index SVI with acceptable accuracy (low bias), but low precision (high percentage error).

Nevertheless, the usefulness of more precise measurements by indicator dilution techniques and strict normal ranges are questioned.

Therefore, we investigated the association of CI and SVI derived from transpulmonary thermodilution (TPTD) as well as heart rate HR and their distribution within and without normal ranges (3≤CI≤5L/min; 40≤SVI≤60mL/min; 60≤HR≤90/min) with hospital mortality.

Methods:

We analyzed data of a prospectively maintained database including 927 TPTD-measurements (PiCCO; Pulsion; Germany) of 55 ICU patients. Primary endpoint: hospital mortality of patients with mean values of CI, SVI and HR within and without normal range. Statistics: chi-square test. (SPSS 26).

Results:

Patients: 15 female, 40 male; APACHE II 23±6. Mortality was 61.5%, 30.3%, 55.6% for patients with mean CI below, within and above normal range. Mortality was higher for patients with mean CI outside compared to mean CI inside normal range. (59.1% vs. 30.3%, p=0.034). Mortality was 54.6%, 41,7% and 11.1% for patients with mean SVI below, within and above normal range. Mortality was not different for patients with abnormal mean SVI (41.9% vs. 41.7%, p=0.984). Mortality was 0%, 22.7%, 56.3% for patients with mean HR below, within and above normal range. Mortality was higher for patients with abnormal mean HR (54.6% vs. 22.7%, p=0.019).

Conclusions:

Patients with abnormal mean CI or HR suffer from increased hospital mortality. Abnormality of mean SVI was not associated with mortality. These data support accurate measurement of CI as a hemodynamic target and the normal range defined for CI. Since CI also carries the HR information, CI seems to be the more important target than SVI. Our data cannot necessarily be interpolated to less invasive and less precise measurements of CI.

P203 An evaluative study of the novelty device with the function of auto-aspirating and pressure indicator for safety central venous catheterization

LY Lin, WF Luo, CY Tsao

National Taiwan University Hospital, Taipei, Taiwan

Introduction:

Previous studies have shown that 0.8% of CVC attempts resulted in arterial punctures that were not recognized by blood color. To overcome the problem, our team has developed a concept of pressure detecting syringe that can indicate the artery puncture [1]. Based on previous research, different springs, the actuator of the design, have been evaluated to optimize the proposed device and reduce the risk of CVC procedure.

Methods:

Tested devices - The inner-spring is set between the pressure indicator and plunger (Fig. 1A). Three springs are tested.

Test condition - Blood samples were simulated by glucose solution with absolute viscosities of 2 and 6 mPa-s. Different blood pressures were applied to simulate the artery and vein (Fig. 1B). The response time (RT) is defined as the time required to show the indicating signal (IS) which is the movement of the piston from the position in Fig. 1B: A2-1 to A2-2.

Results:

The RT is strongly influenced by spring (Fig. 1B) but every design can show the IS when pressure is higher than 50 mmHg, the assumed minimum artery pressure. The RT of S1, the strongest spring design, is about 10s in the 50mmHg-pressure and high viscosity condition. During our tests we found the user can realize the IS before the position be fully changed from Fig. IB: A2-1 to A2-2. Thus, we believe the 10s RT, the worst case, is still acceptable. We also found the weak spring force may lead to difficulty to empty the syringe because the spring must to overcome the blood pressure and the friction between the piston and barrel. As a result, it was difficult for S3 to absolutely empty the syringe even if the blood pressure is only 30 mmHg. The spring will be compressed as Fig. 1B: A2-2 and fail to push the piston when pushing the plunger forwardly, which is not acceptable in clinical use.

Conclusions:

The results indicate the feasibility of using the device to facilitate CVC and we believe the S1 or S2 are more suitable for the future application.

References:

1. Lin LY et al. Eur J Anaesthesiol 36, e-Supplement 57:222, 2019

Fig. 1 (abstract P203).

A The illustration of the proposed device; B. the relationship between response time and blood pressure

P204 Cross-correlation features of vital signs enable robust detection of hemorrhage

V Jeanselme¹, A Wertz¹, G Clermont², MR Pinsky², AW Dubrawski¹

¹Carnegie Mellon University, Auton Lab, School of Computer Science, Pittsburgh, United States; ²University of Pittsburgh, School of Medicine, Pittsburgh, United States

Introduction:

Models using standard statistical features of hemodynamic vital sign waveforms (VS) enable rapid detection of covert hemorrhage at a predetermined bleed rate [1]. By featurizing interactions between VS we can train powerful hemorrhage detectors robust to unknown bleed rates.

Methods:

Waveforms (arterial, central venous, pulmonary arterial pressures; peripheral and mixed venous oxygen saturation; photoplethysmograph; ECG) of healthy pigs were monitored 20 min prior and during a controlled hemorrhage at 20 mL/min (N=38) and 5 mL/min (N=13). Two sets of VS features were extracted: statistical features [1] and maximal pairwise cross correlations between pairs of VS within a 5s lag over various time window sizes (30s, 60s, 180s, 300s); and normalized with pre-bleed data of each given animal. For each feature set, a tree-based (ERT) model [2] was trained and tested in a one-animal-out setting to mitigate overfitting on the 20 mL/min cohort, and another trained on the 5 mL/min and tested on the 20 mL/min cohort. We evaluated models with Activity Monitoring Operating Characteristics curves [3] that measure false alert rate as a function of time to detect bleeding.

Results:

Models using cross-correlations show no significant deterioration of performance when applied to detect bleeding at different rates than trained for, while standard models require 64s longer on average to detect hemorrhage at 1% false alert rate in the previously unknown setting (Figure 1).

Conclusions:

Correlations between VS data encode physiologic responses to hemorrhage in a way independent of the actual bleed rates. This enables training effective hemorrhage detectors using only limited experimental data, and using them in practice to detect bleeding that occurs at rates other than used in training.

Acknowledgement: Work was partially supported by DARPA FA8750-17-2-013 and NIH NIGMS 1R01GM117622

References:

1. Wertz et al. Critical Care Explorations 1: e0058, 2019.

2. Geurts et al. Machine Learning 63:3-42, 2006.

3. Jiang et al. AMIA Annu Symp Proc 2009:281–285, 2009

Fig. 1 (abstract P204).

AMOC curves displaying false alarm rate as a function of time to bleeding detection ; Features - 20 mL/min LOOCV: model trained and tested on the 20mL/min cohort using standard statistical features; Features - Transition from 5 to 20 mL/min model trained on standard features on 5 mL/min cohort and tested on 20 mL/min cohort; Cross Correlations: Corresponding models trained on cross-correlation features only

P205 Hemoguide: a new tool for decision-making support in critically ill patients

A Minini¹, SG Sakka², FJ Belda³, M Kirov⁴, JL Teboul⁵, W Huber⁶, A Perel⁷, E Fernández-Mondéjar⁸, Z Molnar⁹, ML Malbrain¹

¹University Hospital Brussels (UZB), Intensive Care Medicine, Brussels, Belgium; ²Universität Witten/Herdecke, Anaesthesiology and Intensive Care Medicine, Witten, Germany; ³Hospital Clinico Universitario, Anaesthesiology and Critical Care, Valencia, Spain; ⁴Northern State Medical University, Anaesthesiology and Intensive Care Medicine, Arkhangelsk, Russia; ⁵Hôpitaux Universitaires Paris-Sud, Médicine Intensive-Réanimation, Le Kremlin-Bicêtre, France; ⁶Klinikum rechts der Isar der Technischen Universität, Intensive Care Medicine, München, Germany; ⁷Sheba Medical Center, Anesthesiology and Critical Care, Tel Aviv, Israel; ⁸Hospital Universitario Virgen de las Nieves, Servicio de Medicina Intensiva, Granada, Spain; ⁹University of Szeged, Anaesthesiology and Intensive Therapy, Szeged, Hungary

Introduction:

Artificial intelligence (AI) is receiving increasing interest in modern ICU. The purpose of this project was to develop an application software for guiding hemodynamic decision support in critically ill patients.

Methods:

We validated a dataset of 634 data lines containing hemodynamic variables and treatment options. We selected nine hemodynamic variables as inputs. Furthermore, data were collected regarding underlying conditions: heart failure, septic shock, renal failure or respiratory failure or a combination. We applied DataStories regression on the dataset (Turnhout, Belgium, www.datastories.com). Six different interventions were analyzed as KPI: administration or removal of fluids, increasing or decreasing inotropes and increasing or decreasing vasopressors. Finally, we elaborated and challenged 63537 predictive models to generate a decision algorithm to predict each KPI. We first looked at how each hemodynamic parameter impacts the prediction of each KPI individually and performed a standard correlation analysis as well as a more involved analysis of the mutual information content between each KPI and all other hemodynamic parameters individually. Confusion matrix and variable importance was obtained for each KPI.

Results:

The baseline hemodynamic parameters were: GEDVi 738±218 ml/m2, EVWLi 11.2±5.5 ml/kg PBW, SVV 14.8±8 %, MBP 77.8±16.5 mmHg, HR 94.2±23.5 bpm, CI 3.3±1.2 L/min.m2. The results of the regression analysis identified the different variables of importance for each of the different interventions (Fig 1A). Based on these results the hemodynamic variables (HR, MBP, GEDVI, ELWI, CI, SVV) were used to develop the final HemoGuide prediction model (Fig 1B).

Conclusions:

The HemoGuide app can be used to advise physicians with respect to basic therapeutic decisions at the bedside or as an educational tool for students. With the collection of new data, the accuracy of the system may grow over time. The next step of the project is to develop a more-sophisticated suite: the ICU cockpit.

Fig. 1 (abstract P205).

A: Key results of the regression analysis; B: HemoGuide Simulator Interface

P206 Feedback function contributes to accurate measurement of capillary refill time

R Kawaguchi¹, TA Nakada², M Shinozaki², T Nakaguchi², H Haneishi², S Oda²

¹Chiba University, Department of Emergency and Critical Care Medicine, Chiba, Japan; ²Chiba University, Chiba, Japan

Introduction:

Capillary Refill time (CRT) is well known as an indicator of peripheral perfusion. However, it has been reported to have an intra-observer variance, partly because of manual compression and naked-eye measurement of the nailbed color change. We hypothesized that a feedback function on a CRT measurement device would lead to an accurate compression.

Methods:

We developed a novel portable CRT measurement device with an OLED display that feedbacks weather the strength of the nailbed compression is enough and counts the time. We settled the target strength and time as 5N and 5seconds according to the study we reported before [1]. 20 examiners measured CRT with and without the feedback function. The pressing strength and time during the measurement were evaluated.

Results:

There was a significant difference among the pressing strength and time between the CRT measurement using the device with and without the feedback function (strength: P<0.001; time: P<0.001). Furthermore, intra-examiner variance was significantly reduced with the feedback function (strength: P<0.001; time: P<0.001). In all measurements without the feedback function, 41% was outside the optimal strength while the measurements with the feedback function 100% achieved the targeted range. Without the feedback function, 12% could not reach the optimal time, while 100% with the feedback function did. In total, 49% of the measurements could not achieve the optimal pressing strength and time.

Conclusions:

The feedback function for CRT measurements, guiding examiners to an optimal pressing strength and time, fulfilled the required measurement conditions and reduced intra-examiner variance. Our novel portable device would assist an accurate CRT measurement regardless of personal work experience.

References:

1. Kawaguchi R et al. Crit Care 23:4, 2019

P207 Course of conjunctival microcirculatory changes in patients with sepsis

J Simkiene¹, Z Pranskuniene², V Pilvinis³, A Pranskunas⁴

¹Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Intensive Care, Kaunas, Lithuania; ²Department of Drug Technology and Social Pharmacy, Lithuanian University of Health Sciences, Kaunas, Lithuania; ³Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; ⁴Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Intensive Care, Kaunas, Lithuania

Introduction:

The aim of the study was to detect the difference of conjunctival microcirculation between septic patients and healthy subjects and evaluate the course of conjunctival microcirculatory changes in survivors and non-survivors over a 24 hours period of time.

Methods:

This single-centre prospective observational study was performed in mixed ICU in a tertiary teaching hospital. We included patients with sepsis or septic shock within the first 24 hours after ICU admission. Conjunctival imaging using IDF videomicroscope as well as systemic hemodynamic measurements were performed at three time points: at baseline, 6 hours and 24 hours later. Baseline conjunctival microcirculatory parameters were compared with healthy control.

Results:

A total of 48 patients were included in the final assessment and analysis. Median APACHE II and SOFA scores were 16 (12-21) and 10 (7–12) respectively. 44 (92%) were in septic shock, 48 (100%) required mechanical ventilation. 19 patients were discharged alive from the intensive care unit. We found significant reductions in all microcirculatory parameters in the conjunctiva when comparing septic and healthy subjects. We found a significant lower proportion of perfused vessels and microvascular flow index (MFI) of small vessels during all three time points in non-survivors compared with survivors. In non-survivors we observed no significant changes in conjunctival microcirculatory parameters over time. However, survivors had significantly improved MFI of small vessels at second and third time points compared to first time point.

Conclusions:

Microcirculatory perfusion in conjunctiva was altered in septic patients. Over 24 hours evaluation survivors in comparison with non-survivors had better microcirculatory flow with incremental improvement of microvascular flow index.

P208 Assessment of right heart function during extracorporeal therapy by modified thermodilution

KF Bachmann¹, L Zwicker¹, K Nettelbeck¹, D Casoni², PP Heinisch³, H Jenni³, M Haenggi¹, D Berger¹

¹Inselspital Bern, University Hospital, Bern, Switzerland, Department of Intensive Care Medicine, Bern, Switzerland; ²University of Bern, Experimental Surgery Facility (ESF), Department for BioMedical Research Faculty of Medicine, Bern, Switzerland; ³Inselspital Bern, University Hospital, Bern, Switzerland, Department of Cardiaovascular Surgery, Bern, Switzerland

Introduction:

Extracorporeal membrane oxygenation (ECMO) therapy is an emerging treatment modality for acute respiratory and/or cardiac failure. Cardiac output monitoring during ECMO therapy remains challenging. This study aims to validate a new method of thermodilution technique during ECMO therapy.

Methods:

16 healthy pigs were centrally cannulated for veno-arterial ECMO and precision flow probes were placed on the pulmonary artery main trunk for reference. 10ml boluses of iced 0.9% saline chloride solution were injected into the ECMO circuit and right atrium at different ECMO flow settings (4, 3, 2, 1 L/min). Rapid response thermistors of standard PA-catheters in the ECMO circuit and pulmonary artery recorded the temperature change. After calibration of the catheter constants for different injection volumes in the ECMO circuit, the distribution of injection volumes passing each circuit was assessed and enabled calculation of pulmonary blood flow. Analysis of the exponential decay of the signals allowed assessment of right ventricular function.

Results:

Calculated blood flow correlated well with true blood flow (r² = 0.74, p < 0.001, Figure 1 Panel A, individual measurements). The calculated changes in blood flow tracked the true changes with 100% concordance (Panel B, average of 5 measurements). Bias was -6 [95% CI -53 – 48] ml/min with clinically acceptable limits of agreement (668 [95% CI 502 – 834]) ml/min, Panel C). Right ventricular ejection fraction (RVEF) was 17 [14 – 20] %. ECMO flow reductions increased end-diastolic (EDV) and end-systolic (ESV) volumes (Panel D) with reductions in pulmonary vascular resistance, but without changing central venous pressure (CVP) and only little changes in RVEF. EDV correlated highly with ESV (r² = 0.98, p < 0.001, Panel D).

Conclusions:

Adapted thermodilution allows reliable measurements of cardiac output and assessment of right ventricular behaviour. During ECMO weaning, the right ventricle dilates even with stable function, possibly due to increased venous return.

Fig. 1 (abstract P208).

Cardiac output monitoring (Panel A, B, C) and right heart function (Panel D) during VA ECMO weaning, assessed by modified thermodilution

P209 Quantifying systemic congestion with point-of-care ultrasound: development of the Venous Excess Ultrasound Score

W Beaubien-Souligny¹, P Rola², K Haycock³, J Bouchard⁴, Y Lamarche⁵, R Spiegel⁶, A Denault⁷

¹Centre Hospitalier de l´Université de Montréal (CHUM), Nephrology, Montréal, Canada; ²Washington Hospital Center, Division of Intensive Care, Washington DC, United States; ³Washington Hospital Center, Department of Emergency Medicine, Loma Linda University School of Medicine, Washington DC, United States; ⁴Washington Hospital Center, Division of Nephrology, Washington DC, United States; ⁵Washington Hospital Center, Department of Surgery and Critical Care, Washington DC, United States; ⁶Washington Hospital Center, Departments of Critical Care and Emergency Medicine, Washington DC, United States; ⁷Washington Hospital Center, Department of Anesthesiology and Intensive Care, Washington DC, United States

Introduction:

Organ congestion is susceptible to be a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop prototypes of congestion scores and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery.

Methods:

This is a post-hoc analysis of a prospective study in 145 patients for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed before surgery and during the first 72 hours after cardiac surgery [1]. Five prototypes of venous excess ultrasound (VExUS) scores combining multiple ultrasound markers were developed (Figure 1). The association between each score and AKI was assessed using time-dependant Cox models as well as conventional performance measures of diagnostic testing.

Results:

A total of 706 ultrasound assessments were analyzed. We found that defining severe congestion as the presence of severe flow abnormalities in multiple Doppler patterns with a dilated IVC (>2cm), corresponding to grade 3 of the VExuS C score, showed the strongest association with the development of subsequent AKI compared with other combinations of ultrasonographic features (HR: 3.69 CI: 1.65-8.24 p=0.001). The association remained after adjustment for baseline risk and vasopressor/inotropic support (HR: 2.82 CI: 1.21-6.55 p=0.016). Furthermore, this VExUS score offered a useful positive likelihood ratio (+LR: 6.37 CI: 2.19-18.50) when detected at ICU admission, which outperformed central venous pressure measurements.

Conclusions:

The VExUS C score combines multiple POCUS measurements and may identify clinically significant venous congestion. Further studies should aim to validate this score in other patient populations.

References:

1. Beaubien-Souligny W et al. J Am Heart Assoc 7:e009961, 2018

Fig. 1 (abstract P209).

Venous Excess Ultrasound Score prototypes combining inferior vena cava (IVC) measurements to pulse-wave Doppler patterns in the hepatic vein, portal vein and intra-renal veins. Portal Doppler is considered mildly abnormal when a variation in the velocities during the cardiac cycle of 30 to <50% are observed while is considered severely abnormal when a variation of more than 50% is seen. Hepatic Doppler is considered mildly abnormal when the systolic component is lower in magnitude than the diastolic component but still toward the liver while it is considered severely abnormal when the S component is reversed (toward the heart). Intra-renal venous Doppler is considered mildly abnormal when it is discontinuous with a systolic and diastolic phase while is it considered severely abnormal when it is discontinuous with only a diastolic phase seen during the cardiac cycle. S: systole, D: diastole

P210 Comparison of superior vena cava & inferior vena cava diameter changes by echocardiography in predicting fluid responsiveness in mechanically ventilated patients

V Upadhyay¹, SS Nath¹, M Tripathi¹, D Malviya¹, A Jha²

¹Dr Ram Manohar Lohia Institute Of Medical Sciences, Department Of Anesthesia And Critical Care, Lucknow, India; ²Dr Ram Manohar Lohia Institute Of Medical Sciences, Department Of Cardiology, Lucknow, India

Introduction:

To assess and compare the efficacy of Superior Vena Cava (SVC) & Inferior Vena Cava (IVC) diameter changes in response to passive leg raise by Echocardiography in predicting fluid responsiveness in mechanically ventilated hemodynamically unstable critically ill patients.

Methods:

30 patients with hypovolemia or septic shock, mechanically ventilated and critically ill were prospectively enrolled over a one-year period in our ICU. Heart rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, respiratory variation in SVC diameter measured by transesophageal echocardiography(TEE), IVC diameter by transthoracic echocardiography(TTE) and change in cardiac index measured by maximal doppler velocity in left ventricular outflow tract were recorded. With formulas, predictive indices like Collapsibility Index of SVC (cSVC) and Distensibility Index of IVC(dIVC) were calculated and measurements were performed at baseline and 1 minute after PLR. Patients were separated into responders(R)(increase in cardiac index ≥10%) and non-responders(NR) (increase in cardiac index <10% or no increase).

Results:

Among 30 included patients, 24 (80%) patients were responders. cSVC was significantly more accurate than dIVC in predicting fluid responsiveness.The areas under the receiver operating characteristic curves for cSVC and dIVC regarding assessment of fluid responsiveness were 1.00 (95% confidence interval(CI):1.00 to1.00) and .66 (95% CI: 0.44 to 0.89) respectively. No significant correlation between cSVC and dIVC was found among R (r=.02, P=0.92) and NR (r=0.46, P=0.35)at baseline.The best threshold values for discriminating R from NR was 35% for cSVC with sensitivity and specificity of being 100% and 25% for dIVC with 54% sensitivity and 86.7% specificity.

Conclusions:

cSVC had the better sensitivity and specificity than dIVC in predicting fluid responsiveness. cSVC had a greater diagnostic accuracy than dIVC in our study.

P211 Changes in the microvascular bed availability as an index of fluid loading

LR Ramahi¹, CM Maimone², VG Giammatteo², RD De Blasi²

¹Sant’Andrea University Hospital- Sapienza University of Rome, Italy, Intensive Care, Rome, Italy; ²Sant’Andrea University Hospital- Sapienza University of Rome, Italy, Rome, Italy

Introduction:

There is an increasing awareness on the consequences of fluid administration in patients leading to the development of methods that evaluate the effects of fluids loading on the cardiocirculatory system. However, most of methods used in the clinical practice investigate the effects of fluids on the cardiac function, instead of investigating those on the determinants of venous return. Besides volume of fluids, the determinants of fluid loading are the blood volume distribution and the availability of vascular bed. In this study we aimed to test non-invasively the effects of fluids administration on the venular compartment in the skeletal muscle. In addition to the mean systemic filling pressure (msfp), we calculated changes in the stressed and unstressed volumes (Vs, Vu) and the venular bed availability.

Methods:

We enrolled 10 critically ill patients in our Intensive Care Unit. We assessed volumes and pressures by the Near Infra-Red Spectroscopy on the forearm using graded venous occlusions in steps of 5mmHg from 50 to 0 mmHg. The msfp, Vu and Vs were measured as previously reported (Microcirculation 2014; 21:606–614). The vascular bed availability was measured by changes in the volume recruited from the occlusion maneuvers. All the measures were done at baseline and after a fluid load ranging from 250 to 500 ml. Values were expressed as median and interquartile range. Wilcoxon test was used to compare data and a p< 0.05 was considered as significant.

Results:

Vascular bed recruited was 33.6% (22.8–42.2) at baseline and 23.9% (19.0–33.4) after a fluid load (p=0.002). The Vs was 0.5mL (0.3 – 0.7) at baseline and 0.6 mL (0.5–0.9) after fluids (p=0.620). The Vu was 1.9mL (1.7-2.5) at baseline and 2.3mL (2.0-2.4) after fluids (p=0.193).

Conclusions:

Following fluid administration the only variable that decreased in all subjects was the vascular bed recruited. This was possibly related to changes in the interstitial pressure due to fluid leakage.

P212 Prediction of post-induction hypotension associated with general anesthesia using point-of-care cardiac ultrasound: the value of two dynamic markers of fluid responsiveness

Y Aissaoui

Avicenna Military Hospital - Caddi Ayyad University, Department of Anesthesiology and Intensive Care, Marrakech, Morocco

Introduction:

Hypotension is a common side effect of general anesthesia (GA) and is associated with organ hypoperfusion and poor perioperative outcome [1]. Post-induction hypotension (PIH) is caused by the depressant cardiovascular effect of anesthetic drugs and could be amplified by hypovolemia. The aim of this study was to assess the ability of two echocardiographic fluid responsiveness markers to predict PIH: the inferior vena cava collapsibility index (IVC-CI) and the velocity time integral change (ΔVTI) after passive leg raising.

Methods:

Sixty patients > 50 years of age and scheduled for elective surgery were included. IVC-CI and ΔVTI were measured before GA induction. Anesthesia protocol, fluid infusion and vasopressor administration were standardized in all patients. PIH was defined as a mean arterial pressure (MAP) <65 mmHg or a relative decline from pre-induction value of at least 30% within 12 minutes of GA induction. Receiver operating characteristic (ROC) curve analysis was used. The optimal cut-off was selected to maximize the Youden index (sensitivity + specificity − 1).

Results:

The measurement of IVC-CI and/or ΔVTI were unsuccessful in seven patients (11.6%). PIH occurred in 32 patients (incidence 53 %). The areas under the ROC curves (Figure 1) were 0.84 [95% CI: 0.72 – 0.96; p<0.0001] for ΔVTI and 0.67 [95% CI: 0.52 – 0.83; p=0.043] for IVC-CI. The optimal cut-off values were 18% for ΔVTI (sensitivity 75%, specificity 91%) and 25% for IVC-CI (sensitivity 75 %, specificity 45%).

Conclusions:

The ΔVTI after passive leg raising was able to predict PIH and performed better than IVC-CI. The use of this marker could help individualize strategies to prevent PIH (pre-induction fluid loading, vasopressors, anesthetic technique and close hemodynamic monitoring).

References:

1. Bijker JB et al. Anesthesiology 107:213–20, 2007

Fig. 1 (abstract P212).

Receiver operating characteristics (ROC) curves of ΔVTI (continuous line) and IVC-CI (Dashed line) for prediction of post-induction hypotension

P213 Pleth varisbility index (PVI) vs. pulse pressure variation (PPV) and stroke volume variation (SVV): an observational study on agreement with PVI including a derivation of comparable thresholds. The Climate-III study

L Offman, U Mayr, T Lahmer, R Schmid, W Huber

Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin II, München, Germany

Introduction:

Pulse pressure variation (PPV) and stroke volume variation (SVV) predict fluid responsiveness. In addition, numerous non-invasive devices provide other dynamic indices such as „Pleth varisbility index (PVI) which is derived from the pulse oximetry plethysmography wave-form. Although several studies showed prediction of fluid responsiveness by PVI, the data are conflicting, and the cut-offs of PVI range from 7 to 20%.

Methods:

We compared 240 measurements of PVI (Massimo; USA) with PPV and SVV simultaneously derived with the PiCCO-device (Pulsion, Germany) in 30 ICU-patients. Primary endpoint: Concordance of measurements within the categories ‘<9%’, ‘9-13%’ and ‘>13%’. Secondary endpoint: Derivation of corrected thresholds for PVI. Statistics: SPSS 26.

Results:

n=30; 15 female, 15 male; mechanical ventilation 240/240 (100%); vasopressors 156/240 (65%). PVI could not be derived in 1 of 240 measurements (0.4%). PVI (14.8±9.3%) was higher (p<0.001) than PPV (11.1±9.0%) and SVV (12.6±7.3%). Classifications within the categories ‘<9%’, ‘9-13%’ and ‘>13%’ agreed in 117 of 239 (49%) measurements for PVI vs. PPV (Kendall-tau r=0.435; p<0.001) and in 131 of 239 (55%) cases for PVI vs. SVV (r=0.431; p <0.001). PVI-values of 14% and 17% had the highest sum of sensitivity and specificity (ROC-analysis; Youden-Index) to predict the established PPV-cut-offs of 9% and 13%. PVI in the corrected categories ‘<14%’, ‘14-17%’ and ‘>17%’ substantially better agreed (166/239; 65%; r=0.500) with the PPV-categories ‘<9%’, ‘9-13%’ and ‘>13%’ compared to the uncorrected PVI categories ‘<9%’, ‘9-13%’ and ‘>13%’ (agreement 117 of 239 measurements (49%); p<0.001 vs. 166 of 239; chi-square-test).

Conclusions:

PVI was significantly higher than PPV and SVV. Only 49% and 55% of PPV- and SVV-values are classified in the same categories ‘<9%’, ‘9-13%’ and ‘>13%’ as PVI. Adjusting the PVI thresholds to 14% and 17% instead of 9 and 13% significantly improves the agreement PVI- with PPV-categories.

P214 Preload responsiveness can be detected by mini and micro fluid challenges monitored with pulse contour analysis

N De Vita, F Gavelli, JL Teboul, A Beurton, A Pavot, R Shi, X Monnet

Hôpital de Bicêtre, Service de médecine intensive-réanimation, Le Kremlin-Bicêtre, France

Introduction:

Preload responsiveness might be detected by the changes of cardiac index (ΔCImini) induced by a “mini-fluid challenge” (mini-FC) of 100 mL or even by the changes (ΔCImicro) in response to a “micro-fluid challenge” (micro-FC) of 50 mL. However, the smaller the fluid challenge, the larger the “grey zone” of diagnostic uncertainty. We tested whether (1) micro- and mini-FC monitored by calibrated pulse contour analysis detect preload responsiveness and (2) adding 50 mL when the result of a micro-FC is within the grey zone improves diagnostic accuracy.

Methods:

In 30 patients with circulatory failure, we infused 50 mL saline over 30s followed by 50 mL over 60s. We measured ΔCImicro and ΔCImini by the pulse contour analysis (PiCCO2). Preload responsiveness was defined by an increase in CI (ΔCIPLR) during a passive leg raising test ≥10%. Diagnostic uncertainty was described by calculating the grey zone after bootstrapping.

Results:

ΔCImicro were larger in responders than in non-responders (5.1[2.5-9.9]% vs. 0[0-0.7]%, respectively; p<0.0001). It was also the case for ΔCImini (9.7[7.0-12.6]% vs. 0.8[0-2.9]%, respectively; p<0.0001). We found a correlation between ΔCImicro and ΔCImini on the one side and ΔCIPLR on the other side (r=0.71 and r=0.82, respectively; p<0.0001 for both). For the micro-FC, the area under the receiver operating characteristic curve was 0.975±0.03 (threshold 1%), while it was 0.955±0.03 for the mini-FC (threshold 4%). For the micro-FC, the grey zone ranged from 0.82% to 3.47% and included 9 (30%) patients. For the mini-FC, it ranged from 2.8% to 6.8% and included 9 (33)% patients, among which 6 were already in the grey zone of the micro-FC.

Conclusions:

When evaluated by pulse contour analysis, micro- and mini-FC reliably detect preload responsiveness but with a large diagnostic uncertainty. It seems that adding 50mL more fluid to a micro-FC when its result is within the grey zone does not improve the diagnostic accuracy. The study is ongoing.

P215 The applicability of fluid responsiveness indices in circulatory failure (AFRIC study)

R Shi, N De Vita, F Gavelli, JL Teboul, A Pavot, S Carelli, X Monnet

Hôpital de Bicêtre, Hôpitaux universitaires Paris-Saclay, Le Kremlin-Bicêtre, Service de médecine intensive-réanimation, Paris, France

Introduction:

Passive leg raising (PLR), pulse pressure variation (PPV), and the end-expiratory occlusion (EEXPO) test are dynamic indices of fluid responsiveness, widely validated in critically ill patients. Our study aims to investigate the prevalence of conditions in which their use is limited.

Methods:

From January to November 2019, patients with acute circulatory failure, defined by the need of either norepinephrine support or fluid administration in the previous 24h, were included. The validity criteria of PLR, PPV and EEXPO were evaluated.

Results:

100 patients were enrolled. Septic shock was present in 79% of cases, cardiogenic and hypovolemic in 8% and 7% respectively, and 6% of shocks were vasoplegic (non-septic). At the time of enrolment, 94% of patients had norepinephrine infusion, 66% were mechanically ventilated (MV) and 28% had acute respiratory distress syndrome. PLR results were not reliable in 34% of cases, due to either compression stockings (14%) or intra-abdominal hypertension (IAH) (11%). In 7% of cases, no cardiac output (CO) monitoring could be obtained. Among MV patients, PPV was not interpretable in 83% of cases mainly due to spontaneous breathing activity (24%) and low tidal volume ventilation (21%). The remaining non-interpretable cases (38%) had multiple concurrent limitations. EEXPO could not be interpreted in 20% of MV patients, because either a 15-s respiratory hold could not be maintained (62%), or CO could not be monitored (38%). PLR and EEXPO were both valid in 33% of patients, while all the 3 tests were valid in 6% of patients (50% and 9% of MV patients, respectively).

Conclusions:

In conclusion, PLR interpretation is not reliable in 34% of shock patients. In MV patients, PPV and EEXPO test cannot be evaluated in 83% and 20% of cases, respectively.

P216 A modified version of the bioreactance device reliably detects preload responsiveness through the end-expiratory occlusion test

F Gavelli, A Beurton, JL Teboul, N De Vita, R Shi, A Pavot, X Monnet

Hôpital de Bicêtre, Service de Médecine Intensive-Réanimation, Le Kremlin-Bicêtre, France

Introduction:

The Starling-SV bioreactance device (Cheetah Medical) reliably detects passive leg raising (PLR)-induced changes in cardiac index (∆CI). We tested whether it can also track the small and short-time ∆CI induced by the end-expiratory occlusion (EEXPO) test, and whether shortening the time over which it averages cardiac output (24 s in the commercial version) improves the detection.

Methods:

In 42 mechanically ventilated patients, during a 15-sec EEXPO, we measured ∆CI (in absolute value and in percentage) through calibrated pulse contour analysis (CI_pulse, PiCCO2 device) and Starling-SV. For the latter, we considered both CI_Starling-24 provided by the commercial version and CI_Starling-8 obtained by averaging the raw data over 8 s. We calculated the correlation between ∆CI_pulse and both ∆CI_Starling-24 and ∆CI_Starling-8, and the area under the receiver operating characteristic curve (AUROC) to detect preload responsiveness, defined by a PLR test.

Results:

When considering absolute values, the correlation coefficient r between ∆CI_pulse and ∆CI_Starling-24 was 0.362 (p=0.02), which was lower than the one between ∆CI_pulse and ∆CI_Starling-8 (rr comparison). When considering percentage changes, no correlation was observed between ∆CI_pulse and ∆CI_Starling-24. Conversely, the correlation coefficient between ∆CI_pulse and ∆CI_Starling-8 was 0.402 (p=0.01), but it was lower than the one obtained for absolute values (p=0.04 for r comparison). EEXPO-induced ∆CI_Starling-8, both in absolute values and in percentage, detected preload responsiveness with AUROCs of 0.90 (sensitivity 83%, specificity 87%) and 0.89 (sensitivity 83%, specificity 79%), respectively.

Conclusions:

Shortening the averaging time of the bioreactance signal increases the reliability of the Starling-SV device to detect EEXPO-induced ∆CI. Moreover, the accuracy of the method is increased when absolute rather than percentage changes of CI are considered.

P217 Detection of the effects of the end-expiratory occlusion test with the plethysmography perfusion index to detect preload responsiveness

A Beurton¹, F Gavelli², JL Teboul², N De Vita², X Monnet²

¹Hôpital de Bicêtre, Service de réanimation médicale, Inserm UMR S_999, Université Paris-Sud, Assistance Publique Hôpitaux de Paris, Service de réanimation médicale, Inserm UMR S_999, Université Paris-Sud,, Le Kremlin Bicêtre, France; ²Hôpital de Bicêtre, Service de réanimation médicale, Inserm UMR S_999, Université Paris-Sud, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France

Introduction:

The end-expiratory occlusion (EEXPO) and end-inspiratory occlusion (EIXPO) tests consist in interrupting mechanical ventilation for 15-sec and observing its effects on cardiac output with direct measurements of CI. The perfusion index (PI) is the ratio between the pulsatile and the non-pulsatile portions of the plethysmography signal. It is in part determined by stroke volume and can detect a positive passive leg raising (PLR) test. We hypothesized that the changes in PI could detect a positive EEXPO test and thus preload responsiveness in a totally non-invasive way.

Methods:

In critically ill patients, we measured PI (Radical 7, Masimo) and CI (PiCCO2, Pulsion Medical Systems) before and during a PLR test, a 15-sec EEXPO and EIXPO tests and, if decided, before and after volume expansion (VE) (500-mL saline).

Results:

We included 31 patients. In 19 patients with a positive PLR test (increase in CI ≥ 10%), CI and PI increased during PLR by 17±7% and 49±23%, respectively, and during EEXPO test by 6±2% and 11±8%, respectively. During EIXPO, CI and PI decreased significantly by 12±4% and 11±9% respectively. In the 12 patients with a negative PLR test, PI did not significantly change during PLR, EEXPO and EIXPO tests. Only four patients received VE, causing an increase of CI and PI by 15±3% and 32±47% respectively. The correlation between the PI and CI PLR-induced changes was significant (r = 0.84, p<0.001). During the EEXPO test, if PI increased by >5%, a positive response of CI (≥5%) to the EEXPO test was diagnosed with a sensitivity of 87 (60-98)% and a specificity of 94 (70-100)% (AUROC curve: 0.92 (0.77-0.99), p<0.0001). During the combination of EEXPO and EIXPO tests, if PI increased by >9%, a positive response of CI to the EEXPO test was diagnosed with the same sensitivity and specificity.

Conclusions:

An increase in PI >5% during an EEXPO test accurately detects a positive response of CI to the EEXPO test.

P218 Does the infusion speed impact the hemodyamic effect of a fluid bolus in septic shock patients? A pharmacodynamic study

AP Pavot, F Gavelli, JL Teboul, S RUI, D Vimpere, I Adda, L Guerin, X Monnet

Bicetre Hospital, Medical Intensive Care, Le Kremlin-Bicêtre, France

Introduction:

Fluids are among the most prescribed drug in intensive care, particularly among patient with circulatory failure. Yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. There is a lack of strong scientific evidence in current guidelines for fluid administration in shock. Several factors may impact the hemodynamic efficacy of fluids among which the infusion rate. The aim of this study was to study the influence of fluids administration rate on their pharmacodynamics in particular by studying mean systemic pressure (P_ms).

Methods:

We conducted a prospective observational study in 17 patients with circulatory failure to compare two volume expansion strategies. When a patient required a fluid bolus, 500 mL of normal saline were administered and several hemodynamic parameters were recorded continuously: cardiac output (CO), arterial pressure (AP), mean systemic pressure (P_ms). Infusion rate was let to the discretion of the attending physician and a “slow” and a “fast” group were determined based on the median of the infusion time. Fluids effect was measured by the area under the curve (AUC), maximal effect (E_max) and time to maximal effect (t_max) for each hemodynamic variable.

Results:

P_ms AUC was higher in the “fast” group compared to the “slow” group (p=0.043). We observed a shorter t_max and a higher E_max for P_ms in the “fast” group compared to the “slow” group (p=0.039 and 0.02 respectively). Regarding CO, t_max was also shorter in the “fast” group (p=0.041). AUC and E_max were similar between the two groups. Fluid effect dissipated within 60 minutes following the end of fluid infusion for every patient in both groups. The decreasing slope from maximal effect was comparable in the groups, for P_ms and CO alike.

Conclusions:

The effect of a 500 mL fluid bolus in septic shock patients vanished within one hour. A faster infusion rate increased maximal effect and shortened the delay to reach it. Study is ongoing.

P219 Fluid management in the control arm of sepsis trials

AA Anparasan, AC Gordon, MK Komorowski

Imperial College London, Department of Surgery and Cancer, London, United Kingdom

Introduction:

In the past, high-volume intravenous fluid resuscitation in severe sepsis and septic shock was common. More recently, concerns over the harmful effects of this practice have led some clinicians to adopt less liberal fluid strategies. We sought to analyse temporal trends in fluid administration in the control arms of recent adult sepsis trials and assess any correlation with patient severity and mortality.

Methods:

A literature search was conducted to identify relevant randomized controlled trials that reported fluid administration published post 2000. We recorded 4 outcomes: total amount of IV fluid administered in the control arms of these trials between hospital admission and hour 6 and hour 72 following trial enrolment, mortality rates at the latest reported time point and APACHE-II score at admission. We computed the Pearson correlation coefficient and linear regression between study dates and the 4 outcomes.

Results:

We identified 9 relevant trials [1-9], which recruited a total of 2,444 patients in their control arms, from 1997 to 2018. The temporal analysis revealed no obvious trend in the in the total volume of IV fluid given by hour 6 following trial enrolment (Correlation p=0.94) (Figure 1). However, the total volume of fluid given by hour 72 decreased significantly over the period of interest (R=-0.78, p=0.02). In parallel, we observed a decrease in mortality (R=-0.6, p=0.08) but there was no evidence of decrease in illness severity over time (p=0.84).

Conclusions:

We found that in published RCTs over the last two decades, the amount of intravenous fluid given to patients with sepsis in the initial 6 hours did not appear to change, however less intravenous fluid was given over the first three days. Upcoming large RCTs will test the safety and efficacy of restrictive fluid administration approaches in sepsis.

References:

1. Rivers E et al. N Engl J Med 345:1368-77, 2001

2. Jansen TC et al. Am J Respir Crit Care Med 182:752-6, 2010

3. The ProCESS Investigators. N Engl J Med 370:1683-1693, 2014

4. The ARISE Investigators. N Engl J Med 371:1496-1506, 2014

5. Andrews B et al. Crit Care Med 42:2315-24, 2014

6. Mouncey et al. N Eengl J Med 372:1301-1311, 2015

7. Andrews B et al. JAMA 318:1233-1240, 2017

8. MacDonald SP et al. Intensive Care Med 44:2070-2078, 2018

9. Corl KA et al. Crit Care Med 47:951-959, 2019

Fig. 1 (abstract P219).

Temporal trends and regression lines of: A) volume of fluid given in control arms from hospital admission and hour 6 or hour 72 post trial enrolment B) Mortality and Apache-II. References 2, 5 and 6 report 28-day mortality; references 1, 3 and 9 report 60-day mortality; references 4, 7 and 8 report 90-day mortality. The size of the circles is proportional to the size of patient cohorts

P220 Fluid bolus resuscitation in pediatric sepsis presenting to community hospitals

IV Evans, J Kennedy, J Carcillo, DC Angus, CW Seymour

University of Pittsburgh, Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, United States

Introduction:

Clinical practice guidelines recommend prompt intravenous (IV) fluid resuscitation for pediatric sepsis, including an initial fluid bolus of 20 mL/kg [1]. However, recent evidence is conflicting as to the effectiveness, volume, and consequences of aggressive fluid resuscitation in septic children. Therefore, we sought to determine the epidemiology of early IV fluid resuscitation in an integrated health system, specifically at community hospital emergency departments (ED).

Methods:

We studied a retrospective cohort of pediatric patients (ages > 1 month to < 18 years) with sepsis identified in electronic health record data at 11 community EDs in southwestern Pennsylvania from 2010 to 2014. Sepsis was defined as 1) suspected infection (combination of fluid culture collection and administration of antibiotics and 2) organ dysfunction (pediatric SOFA score ≥ 1) within 24 hours of suspected infection. Fluid bolus therapy was defined as electronic documentation of administration of 0.9% normal saline IV bolus within 1 hour of the time of sepsis onset.

Results:

Among 1,247 patients with pediatric sepsis, 513 (41%) received IV fluid bolus therapy within 1 hour of time of sepsis onset. The volume of fluid administered ranged from 2 mL/kg to 67 mL/kg (Figure 1, Panel A), corresponding to a median volume of 20 mL/kg (IQR 17-22 mL/kg). Patients who received ≥ 20 mL/kg of fluids (n = 258, 50%) were younger (mean age 5 years, SD 5 vs. 9 years, SD 6; p<0.001), more often had blood cultures collected during evaluation (86% vs. 76%, p=0.003), and were more often transferred to another facility (48% vs. 33%, p<0.001) when compared to patients who received < 20 mL/kg of fluids (n = 255, 50%). Mean fluid bolus volume within 1 hour of time of sepsis onset by hospital ranged from 12 mL/kg to 24 mL/kg (Figure 1, Panel B).

Conclusions:

In a cohort of community emergency departments, 41% of septic children received intravenous fluid boluses within one hour, and of those, only one half received volumes concordant with guidelines.

Fig. 1 (abstract P220).

Overall distribution of fluid bolus volume and mean fluid bolus volume by hospital. A) Frequency of fluid bolus therapy volumes within one hour of sepsis onset. B) Mean fluid bolus therapy volume (SD) within one hour of sepsis onset by hospital

P221 Fluid balance in standard of care treatment in patients with sepsis/septic shock

I Douglas¹, P Alapat², K Corl³, L Forni⁴, M Exline⁵, A Holder⁶, A Khan⁷, J Sahatjian⁸, W Self⁹, D Hasell¹⁰

¹Denver Health Medical Center, Denver, United States; ²Ben Taub Hospital, Houston, United States; ³Rhode Island Hospital, Providence, United States; ⁴Royal Surrey Hospital, Guilford, United States; ⁵Ohio State University, Ohio, United States; ⁶Emory University, Atlanta, United States; ⁷Oregon Health and Sciences University, Oregon, United States; ⁸Cheetah Medical, Newton Center, United States; ⁹Vanderbilt University, Nashville, United States; ¹⁰Massachusetts General Hospital, Boston, United States

Introduction:

Septic shock patients are often at risk for volume overload. We explore a control patient population receiving standard of care (SOC) resuscitation to evaluate fluid balance in patients with sepsis or septic shock.

Methods:

FRESH is a prospective randomized controlled study, evaluating the incidence of fluid responsiveness (FR) and patient centered outcomes in critically ill septic patients (NCT02837731). Patients initially presented to the ER with hypotension and symptoms of septic shock and were admitted to the ICU. Patients randomized to treatment group had a dynamic assessment of fluid responsiveness (Starling SV, Cheetah Medical) to guide their resuscitation. Control patients received resuscitation per Institution standard of care. Patients were broken into sextets based on fluid balance.

Results:

48 patients received SOC treatment across 11 institutions globally. 38% were female, and the average age was 62 years. Patients exhibited 2.8 SIRS criteria with a 2.0 average qsofa score. Patients received a mean of 6.6 ± 3.4L of fluid from hospital arrival until ICU discharge or 72 hours, whichever occurred first. Patients exhibited an average fluid balance of 4.2 ± 3.4 L of fluid at ICU discharge/ 72 hours. Fluid balance ranged from 14.9L to -1.5L (Figure 1).

Conclusions:

A wide range of fluid balance exists in septic shock patients cared for in ICU.

Fig. 1 (abstract P221).

Subjects by fluid balance sextiles with range

P222 Trends of serum albumin in septic and non-septic critically ill patients

A Waite¹, T Steele², M Mogk³, I Welters²

¹Royal Liverpool University Hospital, Intensive Care, Liverpool, United Kingdom; ²Royal Liverpool University Hospital, Liverpool, United Kingdom; ³Moredata GmbH, Moredata GmbH, Giessen, Germany

Introduction:

The link between hypoalbuminaemia and poor outcomes in critical care is well established [1]. Limited data are available on serum albumin trends during critical illness [2]. In this study we assessed trends in serum albumin for up to 7 days in both septic and non-septic critically ill patients.

Methods:

We retrospectively examined the records of 1107 adult patients admitted to critical care at the Royal Liverpool University Hospital between 2008 and 2014. We then excluded patients who did not have albumin data available for the first 7 days, leaving us with 758 patients. 506 patients (66.8%) had sepsis, and of these patients 116 had died by day 28. Of the 252 non-septic patients (33.2%), 40 patients had died by day 28. Albumin levels were collected for 7 days from admission to critical care, in addition to other demographic and biochemical data. Statistical analysis was performed using repeated measures analysis.

Results:

Septic patients had lower serum albumin than non-septic patients throughout the 7 day period (p<0.001). We observed a decrease in albumin by day 2 in all groups, with levels increasing over the subsequent days. There was no difference in daily serum albumin between non-septic patients who survived or died.

Conclusions:

This is the first study, to our knowledge, to compare albumin trends in septic and non-septic critically ill patients over 7 days. Further research is needed to elucidate the optimal recipients and timing of albumin therapy.

References:

1. Vincent JL et al. Crit Care 18:231, 2014

2. Kendall H et al. Biol Res Nurs 21:237-244, 2019

P223 Albumin recruits the microcirculation of burn patients with shock

O Dilken¹, A Dijkstra², G Guven¹, C Ince¹, N Trommel³, M Van Baar³, K Van der Vlies³

¹Erasmus MC, Department of Intensive Care, Rotterdam, Netherlands; ²Maasstad Ziekenhuis, Intensive Care Burn Unit, Rotterdam, Netherlands; ³Maasstad Ziekenhuis, Department of Burn Unit, Rotterdam, Netherlands

Introduction:

Burn injury is characterized by marked inflammation, capillary leakage, and profound hemodynamic alterations. Early albumin resuscitation is avoided fearing a paradoxical fluid escape into the interstitium. On the other hand, administration of crystalloids in massive amounts causes tissue edema and fluid extravasation, which deteriorates tissue perfusion by increasing oxygen diffusion distance. Albumin administration could reduce the amount required to maintain hemodynamic stability in this population. We investigated whether albumin improves tissue perfusion and microcirculation by reducing tissue edema.

Methods:

This is an observational study conducted in the Burn Unit of Maasstad Hospital, Rotterdam. Patients with burns higher than 15% of Total Body Surface Area (TBSA) were included in the study. Sublingual microcirculation was measured at admission (T0), 4(T4), and 12(T12) hours after burn injury. Total Vessel Density (TVD) and Functional Capillary Density (FCD) were analyzed. Fluid Management was calculated according to the modified Parkland formula. Albumin (20%) infusion was started 12 hours after the burn insult.

Results:

A total of nine patients were recruited between January and December 2019. Patients were included in the study after 5.7±2.3 hours of the insult with a mean TBSA of 36±22%. The amount of crystalloid infusion was 2718±3348 ml and 8501±5230 ml at T0 and T12,respectively. Within the first 12h (T12) 502±386 ml albumin was given. TVD decreased from 23.6±2.2 at T0 to 20±1.3 at T4 (p<0.05) (Figure 1). It increased to 22.7±3.2 at T12 (ns vs T0). FCD decreased from 21.2±2.3 at T0 to 18.4±2.1 at T4(p<0.05). It increased to 21.5±3.2 at T12 (ns vs T0). Focus depth increased (117±32 to 143±28) until albumin administration (p=0.23). It decreased to 95±28 μm at T12(p<0.05). Hematocrit decreased after albumin administration (45 to 34%)(p<0.05)

Conclusions:

Resuscitation with crystalloids impaired tissue perfusion. Microcirculation was improved after albumin therapy.

Acknowledgement:

OD was funded by TUBITAK for this study.

Fig. 1 (abstract P223).

Macro- and microhemodynamic parameters

P224 Early albumin infusion leads to a shorter hospital stay in cirrhotic patients hospitalized with spontaneous bacterial peritonitis: real-world evidence in the United States

WR Kim¹, K Raghunathan², G Martin³, EA Davis⁴, N Sindhwani⁴, S Telang⁵, K Lodaya⁵

¹Stanford University School of Medicine, Stanford, United States; ²Duke University, Durham, United States; ³Emory University, Atlanta, United States; ⁴Grifols, Research Triangle Park, United States, ⁵Boston Strategic Partners, Inc., Boston, United States

Introduction:

Spontaneous bacterial peritonitis (SBP) accounts for ≥24% of the bacterial infections that occur in patients with cirrhosis, and SBP has a high mortality rate (20% to 50%). Albumin infusion has been shown to improve the outcome of SBP. The aim of this study is to examine the impact of albumin infusion on hospital length of stay (LOS) for cirrhotic patients with SBP.

Methods:

We utilized a nationwide Electronic Health Record data set (Cerner Health Facts®) to extract real-world data on adult patients (≥18 years old) with cirrhosis and SBP who received antibiotics and admitted between January 1, 2009, and April 30, 2018. International Classification of Diseases (ICD-9/10) codes were used to identify cirrhosis and SBP. We used laboratory data for calculation of the Model for End-stage Liver Disease Sodium (MELD-Na) score and vital signs data for calculation of the quick Sepsis Related Organ Failure Assessment (qSOFA) score at baseline for each encounter. A generalized linear model was used to assess the relationship between albumin infusion and hospital LOS.

Results:

There were 2,131 encounters that identified patients with SBP and cirrhosis, of which 1,661 survived hospitalization. Albumin was infused within 24 hours of admission ('early albumin') in 43% (n=718), after 24 hours in 31% ('late albumin', n=517), and not administered in 26% ('no albumin', n=426). MELD-Na was higher at presentation in early albumin cases versus late- or no-albumin cases (mean 24.0 and 19.5). Unadjusted LOS was lower in patients receiving early albumin (8.7 days versus 10.4 days). Risk-adjusted analysis demonstrated that early albumin led to a 17.5% reduction in LOS (95% CI 12.6%-22.2%, p = <0.0001).

Conclusions:

In these real-world data, albumin infusion within 24 hours of admission in patients with cirrhosis and SBP was associated with a shorter hospital stay despite more severe illness. Early albumin may not only improve clinical outcomes but may also reduce the costs of hospitalization in cirrhotic patients with SBP.

P225 Early albumin use in patients with septic shock is associated with a shorter hospital stay: real-world evidence in the United States

G Martin¹, J Kempker¹, K Raghunathan², EA Davis³, N Sindhwani³, S Telang⁴, K Lodaya⁴

¹Emory University, Atlanta, United States; ²Duke University, Durham, United States; ³Grifols, Research Triangle Park, United States; ⁴Boston Strategic Partners, Inc., Boston, United States

Introduction:

Septic shock is among the most common critical care illnesses and incidence is rising, with mortality in excess of 35%. Septic shock predisposes patients to multiple organ failure. While albumin is effective in management of circulatory dysfunction in septic shock, its utilization in this population is understudied in the US. We evaluated the impact of albumin utilization on hospital length of stay (LOS) among septic shock patients.

Methods:

We used a nationwide Electronic Health Record data set (Cerner Health Facts®) to extract real-world data on adult patients (≥18 years old) with severe sepsis or septic shock, admitted between January 1, 2013, and April 30, 2018, identified by International Classification of Disease (ICD-9/10) codes, and receipt of antibiotics and vasopressors. We calculated the Charlson Comorbidity Index (CCI) and the Acute Physiology Score (APS) at baseline. A generalized linear model was used to examine the association between albumin and hospital LOS, especially accounting for the timing of albumin infusion.

Results:

We identified 3,156 unique visits for septic shock patients that survived to discharge. Albumin was infused within 24 hours of admission ('early albumin') in 15%, after 24 hours ('late albumin') in 20%, and not administered in 65%. Both CCI and APS were higher, at presentation, in early albumin cases than late- or no-albumin cases (mean: 7.49 and 7.17, and 51.50 and 43.23, respectively). Unadjusted LOS was slightly lower in patients receiving early albumin (11.81 days versus 11.84 days). A risk-adjusted analysis demonstrated that early albumin was associated with 4.92% shorter LOS (95% CI 0.43%-9.22%, p = 0.0322).

Conclusions:

Albumin infusion within 24 hours of admission was associated with a shorter length of hospital stay. Early albumin infusion may lead to better outcomes and reduced costs in patients with septic shock. Further research is being conducted to assess other potential benefits of early albumin administration in this patient population.

P226 Minute-to-minute urine flow rate and urine flow rate variability fluctuations during septic event in critically ill patients

E Brotfain

Ben Gurion University of the Negev, Department of Anesthesiology and Critical Care, Beer Sheva, Israel

Introduction:

Every new septic event follows by hemodynamic instability may lead sequentially to decreased organ perfusion, multiple organ failure. Acute renal failure is recognized clinical feature during sepsis (up to 40-50% in all cases). Furthermore, urine output close monitoring is a cornerstone diagnostic clinical tool in each septic critically ill patient. In present study, we analyzed the dynamic minute-to-minute changes in the urine flow rate (UFR) and also the changes in its minute-to-minute variability (UFRV) during new septic event in critically ill patients.

Methods:

Demographic and clinical data were extracted from the of 50 critically ill patients who were admitted to the ICU and developed new septic event (followed by fever and leukocytosis) and analyzed. A Foley catheter was inserted into the urinary bladder of each study patient. The catheter was then connected to electronic urinometer, a collecting and measurement system which employs an optical drop detector to measure urine flow. The urine flow rate variability (UFRV) is defined and calculated as the change in UFR from minute to minute.

Results:

UFR and UFRV both decreased significantly immediate after new septic episode until beginning fluid resuscitation (ppvalues <0.001) (Figure 1). Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFR, UFRV and the decrease in the MAP (R=0.03, p=0.003; R=0.03, p=0.004) (Figure 1), and heart rate (R=0.12,p=<0.001) since systemic pressure starts to drop. UFRV and UFR demonstrated good clinical response to fluid administration despite the fact that systemic blood pressure did not improve (Figure 1).

Conclusions:

We consider that dynamic changes in UFRV and UFR could potentially serve as a more sensitive signals ofclinicaldeterioration during the new septic event in critically ill patients.We also suggest that those parameters mightbeable to identify the optimal end-point of fluid resuscitative measures in septic critically ill patients.

Fig. 1 (abstract P226).

Clinical correlation between urine flow rate variability (UFRV) and UFR and mean arterial blood pressure over new septic event (black arrows) and and after initial fluid resuscitation (red arrows). Note: The UFRV and UFR decreased progressively in parallel with the falling mean arterial blood pressure and, than, rose again after the administration of fluids

P227 Impact of urinary output on incidence and 30-day mortality of acute kidney injury during ICU admission

J Montomoli¹, G Guven², F Termorshuizen³, F Raiez³, MP Hilty⁴, A Donati⁵, NF De Keizer³, C Ince²

¹Academic Medical Center, Department of Translational Physiology, Amsterdam, Netherlands; ²University Medical Center Rotterdam, Department of Intensive Care, Erasmus MC,, Rotterdam, Netherlands; ³Amsterdam Public Health Institute, AmsterdamUMC, Department of Medical Informatics, Amsterdam, Netherlands; ⁴University Hospital of Zurich, Institute of Intensive Care Medicine, Zurich, Switzerland; ⁵Università Politecnica delle Marche, Ancona, Italy, Anesthesia and Intensive Care, Department of Biomedical Sciences and Public Health, Ancona, Italy

Introduction:

Diminished urinary output (UO) is largely used as marker of acute kidney injury (AKI) in critically ill patients. We aimed to explore the role of urinary output on incidence and mortality of AKI developed during ICU admission.

Methods:

The study population consists of all patients admitted between 2007 and 2018 to one of the Dutch ICUs included in the NICE database with an ICU length of stay of at least 48 hours, having daily measurement of creatinine and UO. Only patients without renal replacement therapy that have a serum creatinine lower than 1.1 mg/dl (97.5 μmol/L) or a UO above 0.5 ml/kg/h on the day of the index ICU admission were considered at risk for AKI. Patients were followed during their ICU stay and classified according to the highest KDIGO criteria reached based on creatinine alone (model 1) and creatinine plus UO (model 2) using ICU admission serum creatinine as baseline. In both models, patients were classified as: no AKI, renal impairment at the first day of ICU admission, AKI stage 1, AKI stage 2, and AKI stage 3.

Results:

We identified 52,863 patients (60% male, mean age 63 years, median ICU-LOS 4 days). Of those, 51.2% of patients had renal impairment at the first day of ICU admission. Among the remaining patients, 44.4% in model 1 and 29.9% in model 2 were classified as having no AKI, 2.6% and 1.4% as AKI stage 1, 0.7% and 9.3% as AKI stage 2, and 1.1% and 8.2% as AKI stage 3, respectively. Survival at 30-day markedly differed according to the AKI classification model used (Figure). Similarly, adjusted HRs for 30-day mortality differed among patients with and without AKI compared to patients with renal impairment at the first day of ICU admission (Figure 1).

Conclusions:

Among patients admitted to the ICU 50% had renal impairment at the first day of ICU admission. Our findings suggested that UO plays an important role both on AKI incidence and mortality and should be carefully interpret in the clinical setting especially in AKI stage 2 classification.

Fig. 1 (abstract P227).

Thirty-day survival according to AKI classification model 1 and model 2. Hazard Ratios (HRs) for 30-day mortality adjusted by sex, age, type of admission, APACHE IV score, SOFA score at day of admission (excluded renal SOFA score) for patients with AKI classified with model 1 and model 2

P228 Furosemide stress test predicts the progression of acute kidney injury

W Farouk¹, H Saber¹, M Bayoumy², H Khaled¹

¹Faculty of Medicine Cairo university, Critical Care Medicine, Cairo, Egypt; ²Nasser institute, Critical Care Medicine, Cairo, Egypt

Introduction:

Acute kidney injury (AKI) mostly attributed to renal tubular damage, has a high morbidity and mortality outcome [1], so a sensitive tool to assess the degree of tubular affection is needed for early detection and management of this condition.

Methods:

We investigated the ability of furosemide stress test (FST) (one-time bolus dose of 1mg/kg or 1.5 mg/kg if on prior furosemide-intake) to predict progression to AKIN Stage-III in critically ill subjects with early AKI.

Results:

We studied 80 subjects; 40 consecutive patients in group I receiving FST and 40 consecutive patients in group II receiving standard medical management for AKI;15 patients (37.5%) and 20 patients (50%) met the primary endpoint of progression to AKIN-III in groups I and II respectively. Patients with progressive AKI had significantly lower urine output following FST in the first 6 hours (p<0.033). The area under the ROC curves for the total urine output over the first 2 hours following FST to predict progression to AKIN-III was 0.87 (p = 0.001). The ideal-cutoff for predicting AKI progression during the first 2 hours was a urine volume of less than 325 milliliters with a sensitivity of 87.1% and specificity 84.1% group receiving FST. On the other hand, statistically significant hypotension, hypo-(kalemia, phosphatemia and magnesemia) occurred in group I.

Conclusions:

The FST in patients with early AKI could predict liability for progression of AKI, however it should be performed under adequate monitoring.

References:

1. Bellomo R et al. Lancet 380: 756-766, 2012

P229 Furosemide does not protect the kidney from ischemia reperfusion injury

B Ergin, O Dilken, C Ince

Erasmus MC, Department of Intensive Care, Rotterdam, Netherlands

Introduction:

Ischemia-Reperfusion (IR) causes renal dysfunction and damage. IR induces renal tubular injury triggered by hypoxia and hyperoxia, mediated by oxidative stress and inflammation. Furosemide inhibits Na⁺-K⁺-2Cl^- cotransporter in the thick ascending limb of the renal medulla to decrease Na⁺ reabsorption, reducing oxygen consumption. We investigated if furosemide could improve renal oxygenation, function and damage by reducing O₂ consumption and oxidative stress after IR.

Methods:

24 Wistar albino rats were divided into 4 groups, with 6 in each group; Sham-operated Control (C), Control + Furosemide (C+F), IR and IR+F. After anaesthesia (BL), 45 min supra-aortic occlusion was applied to IR and IR+F groups followed by 15 min (T1) and 2 hours of reperfusion (T2). Furosemide 50μg/kg/h infusion was simultaneously administered to C+F and IR+F after ischemia. Systemic hemodynamic, renal blood flow (RBF), renal vascular resistance (RVR), renal oxygen delivery (DO_2ren), renal oxygen consumption (VO_2ren), creatinine clearance (Ccr), sodium handling, urine output (UO), cortical (CμO2) and medullar (MμO2) microvascular oxygenation were measured.

Results:

RBF was reduced in IR (2.1±1) and IR+F (2.3±1) at T1 (p<0.05) but it was further reduced in IR+F (1.9±1) (p<0.05) at T2 compared to C and C+F. RVR was increased in IR (5338±2860) and IR+F (5123±2517) at T1 compared to C. RVR was normalized in IR (2198±879) but not in IR+F (4232±2636) at T2 compared to C (p<0.05). CμO₂ and MμO₂ did not differ between groups after IR insults (Figure 1). Tissue O₂ was reduced at the medulla, but not at the cortex in IR+F group compared to IR. DO_2ren and VO_2ren were reduced in IR (56±17 and 26±12 ml/min) and IR+F (34±20 and 21±14) at T2 (p<0.05). PC was higher in IR+F (37.33±4.27) compared to IR 29.67±3.39 (p<0.05). VO₂/TNa⁺ was increased in IR+F compared to IR. No change in Ccr and UO was observed.

Conclusions:

Furosemide after IR causes further impairment of renal perfusion, energy utilization and renal oxygenation resulting in renal damage.

Fig. 1 (abstract P229).

Cortical and medullar oxygenation. C: Control, C+F: C+Furosemide, IR: ischemia reperfusion, IR+F: IR + furosemide *: p<0.05 vs BL +: p<0.05 vs T1 #: p<0.05 vs C

P230 Acute renal failure induced by hypoxemia: incidence and correlation study

A Trifi¹, H Fazzeni², A Mehdi², C Abdennebi², F Daly², Y Touil², S Abdellatif², S Ben Lakhal²

¹La Rabta hopital, Medical intensive care unit., Tunis, Tunisia; ²La Rabta hopital, Tunis, Tunisia

Introduction:

Acute renal failure (ARR) is a common complication in ICUs and usually caused by hypoperfusion. ARF induced by hypoxemia is a concept rarely reported in ICU. Its incidence and pathogenesis are not well understood. We aimed to study the relationship between hypoxemia and the occurrence of ARF.

Methods:

Retrospective cohort study including patients with hypoxemia whatever its etiology between January 2016 and August 2019. Patients with chronic renal failure were excluded. ARF was defined and ranked according to the KDIGO criteria 2012. Arterial blood gas, urea, creatinine and clearance were reordered on the first, third and seventh days of evolution.

Results:

50 patients were included and 2 groups were obtained: group of hypoxemic patients with ARF (ARF+, n=30): versus group of hypoxemic patients without ARF (ARF-, n= 20). The incidence of hypoxemie-induced ARF was therefore 60%. Clinical characteristics were comparable in both groups with a mean age of 47 ± 16 and a sex ratio of 1.77. The comparative study showed in ARF+ group: a lower pH (7.20 [7.8-7.33] vs.7.34 [7.27-7.41], p = 0.003) and a higher C reactive protein (CRP) in the same group (201 [129.75-325.75] vs. 117.5 [29.5-225.25], p = 0.023). The most significant correlation was showed with MDRD clearance at day 3 and P/F ratio at day 1 (Rho = 0.338, p = 0.038). Multivariate analysis found that septic shock and non invasive ventilation in hypoxemic patients were the factors related to ARF with respectively OR=11.08, 95% CI=1.56-83.84, p=0.016 and OR=6.18, 95% CI=1.16-34.07, p=0.033. Overall mortality was 68% (n=34) and ARF was an independent factor of mortality: OR=6, and 95% CI=1.35-26.64, p = 0.017.

Conclusions:

Hypoxemia-induced ARF is a common complication associated with excess mortality. Our study suggests that renal function is correlated with the degree of hypoxemia and that this correlation is rather distinct 48 hours from hypoxemia.

P231 Metformin reduces mortality and development of severe AKI in diabetic patients with sepsis

G Del Rio-Pertuz¹, CL Manrique-Caballero², P Priyanka², CH Chang², R Murugan², BS Zuckerbraun³, DC Angus⁴, JA Kellum², H Gomez²

¹Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, United States; ²Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, United States; ³Department of Surgery, University of Pittsburgh, Pittsburgh, United States; ⁴Department Of Critical Care Medicine, University of Pittsburgh, Pittsburgh, United States

Introduction:

In preclinical models of sepsis, we have previously demonstrated that activation of AMP activated protein kinase (AMPK) using metformin, improves survival and organ function. Thus, AMPK activation is a potential therapeutic target in sepsis, and we hypothesize that exposure to metformin during sepsis is associated with decreased AKI and mortality

Methods:

Retrospective analysis of a 13-hospital cohort of adult ICU patients with type 2 diabetes mellitus (T2DM) who presented sepsis. We investigated if exposure to metformin during the hospitalization was associated with reduced 90-day mortality and AKI. We used 1:4 Propensity Score Matching (PSM), Propensity Score Stratification (PSS) and Propensity Score Weighting (PSW) based on the probability to be exposed to metformin using 55 covariates. For PSM an exact match for insulin, amputation, cardiovascular diseases, retinopathy, Charlson Index, eGFR, HbA1C, and APACHE III, were used. Sepsis was defined using sepsis 3 criteria, and AKI as KDIGO stage 2 or 3.

Results:

From 164,910 patients, we found 673 diabetic adults exposed to metformin during hospitalization and 14,174 who were not. PSM included 523 treated vs 1,680 no treated patients and resulted in an OR of 0.54 (95%CI 0.41-0.71, p<0.001) for 90-day mortality favoring metformin exposure (Figure 1). PSS: (OR: 0.49, 95%CI 0.34-0.63, p<0.001) and PSW (OR: 0.58, 95%CI 0.55-0.61, p<0.001) confirmed this protective effect. Metformin exposure also had a protective effect on stage 2-3 AKI (PSM: OR 0.82, 95%CI 0.67-0.99, p=0.04; PSS: OR 0.83, 95%CI: 0.71-0.98, p=0.02; PSW: OR 0.72, 95%CI 0.69-0.76 p<0.001).

Conclusions:

Metformin exposure during hospitalization is associated with decreased 90-day mortality and AKI in septic adult patients with T2DM. These findings suggest that metformin may constitute a potential therapeutic strategy in sepsis, and the potential role of AMPK activation as a protective mechanism. However, studies are needed to confirm this association and the specific mechanisms of action.

Fig. 1 (abstract P231).

Survival estimates (90 days) by metformin exposure

P232 Development and internal validation of a model to predict acute kidney injury recovery at hospital discharge

CY Huang, F Güiza Grandas, M Schetz, J Gunst, M Casaer, G Van den Berghe, G Meyfroidt

KU Leuven, Laboratory of Intensive Care Medicine, Leuven, Belgium

Introduction:

Acute kidney injury (AKI) may occur up to 50% in the intensive care unit (ICU). Predicting AKI recovery may allow for risk stratification of patients, patient and family counseling, and early post-discharge renal care planning. However, predicting AKI recovery at an early stage remains a challenge.

Methods:

This is a retrospective study of the EPaNIC multicenter randomized controlled trial database [1], which was split into development (n=2194) and validation (n=2446) cohorts, and patients experiencing AKI stage 3 and/or renal replacement therapy (RRT) in the ICU were included [2]. AKI recovery was defined as being alive, without any stage of AKI, and without need of RRT at hospital discharge. A logistic regression model with backward feature elimination was developed. The model performance was assessed by discrimination, calibration, and net benefit analysis, and internally validated with ten-fold cross validation.

Results:

Only the results in the development cohort are reported. Of the 229 patients who developed AKI3, 86 patients (37.55%) recovered from AKI. The multivariable model selected age, bilirubin, heart rate, mean arterial blood pressure, surgical diagnostic group on ICU admission, mechanical hemodynamic support on ICU admission, suspected sepsis on ICU admission as AKI recovery predictors. The model had a mean area under the receiver operating characteristic curve (AUROC) of 0.75 (Standard deviation (SD) 0.01), mean calibration slope of 1.02 (SD 0.04), and mean calibration-in-the-large of <0.01 (SD 0.01) (Figure 1). At the classification threshold that maximized sensitivity and specificity, mean net benefit with respect to treat-none was 0.16 (SD 0.01) and mean net benefit with respect to treat-all was 0.11 (SD 0.01).

Conclusions:

By using the routinely collected clinical data, the developed prediction model can fairly identify patients with a higher chance of AKI recovery at hospital discharge.

References:

1. Casaer MP et al. N Engl J Med 365:506-17, 2011

2. Kellum JA et al. Kidney Int Suppl 2:1–138, 2012

Fig. 1 (abstract P232).

Internally validated model performance: (top row) ROC curve; (middle row) calibration curve; (bottom row) decision curve

P233 Sepsis induced acute kidney injury: incidence, risk factors and prognostic impact in critically ill patients

K Mnif¹, R Ammar², M Bahloul², O Doukali², C Ben Hamida², M Bouaziz²

¹University Hospital Habib Bouguiba Sfax, Intensive Care Unit, Sfax, Tunisia; ²university hospital habib bouguiba sfax, intensive care unit, sfax, Tunisia

Introduction:

Acute kidney injury (AKI) is a frequent complication in critically ill patients and is associated with increased morbidity and mortality. Sepsis is one of the most Common cause of AKI.

Methods:

A prospective study was conducted over 6 months (January 01–June 30, 2018).We included patients with septic shock at admission or at any time during hospitalization.The AKI staging was based on KDIGO criteria.Patients were divided into two groups, a group with AKI (AKI+) and a group without AKI (AKI-).Then we compared the baseline characteristics, laboratory and physiologic data. Patients with AKI (AKI+) were subdivided according to their prognosis.

Results:

Were enrolled 75 patients. The mean (SD) age was 56.43(±18) years.Sex ratio was 1.91. Fifty-two (70%) patients developed AKI.SAPSII and SOFA score in admission were higher in patients with kidney injury [59 Vs 44 points (p= 0.002), 6.5 Vs 4 points ;(p=0.003)] respectively.The serum lactate level was significantly higher in (AKI +) group patients during the first day of septic shock [6.12± 1.38 mmol/l (AKI+)Vs 4.11± 0.79 mmol/l(AKI-);(p=0.002) ] and its clearance was lower [(32±10.99% (AKI +)Vs 61±13%(AKI-);(p=0.001)]. A significant difference was observed in C reactive protein level [224±114 mg/l (AKI +) Vs 124±77 mg/l (AKI-) ; (p=0.004)].Among (AKI+) patients, KADIGO III was observed in 59.6% of cases.Nineteen (36.5%) patients received hemodialysis.A normal kidney function was recovered in 40.4% of cases.AKI+ patients had a higher occurrence in Disseminated intravascular coagulation (32 Vs 3 patients, p=0.002),acute respiratory distress syndrome (18 Vs 2 patients; p=0.023) and cardiac dysfunction (20 Vs 1 patient, p=0.001).Mortality was higher in AKI group (67% Vs 9%; p=0.001).

Conclusions:

The development of septic AKI was associated with poor outcomes and prognosis.A better understanding of sepsis induced AKI pathway will enable us to develop targeted therapeutic protocols.Newer tools,permitting AKI early detection, may make these therapies more fruitful.

P234

Withdrawn

P235 Contrast induced acute kidney injury (CIAKI) – fact or fable?

P Pekic¹, M Percic², D Ljubas³, M Mackovic⁴, N Maric⁴

¹Univ. Hospital “Sveti Duh”, Department for cardiovascular disease - Cardiac intensive care and arrhythmology unit, Zagreb, Croatia; ²Univ. Hospital “Sveti Duh”, Zagreb, Croatia; ³Institute for Emergency Medicine of Zagreb County, Zagreb, Croatia; ⁴Univ. Hospital “Sveti Duh”, Intensive Care Unit, Zagreb, Croatia

Introduction:

This study aims to show that contrast procedures do not significantly increase the risk of renal injury and should not be deferred. Traditionally CIAKI is the most important cause of in-hospital renal failure after nephrotoxic drugs and shock. Problem is also the non-uniform definition of CIAKI proposed by three different initiatives (AKIN, ESUR and KDIGO). AKIN, being the most rigorous, defines CIAKI as an increase in serum creatinine >0.3 mg/dL or >50% of baseline within 48hours.

Methods:

A retrospective observational single-centre cohort study analyzed 82 patients who underwent a contrast procedure with Iomeron 350. The first group underwent a CT pulmonary angiography (CTPA), and the second a coronary angiography with PCI. No patient was previously prepared (RAAS blockade removal, crystalloid administration etc). We studied demographics, history of CKD and comorbidities and their impact on the CIAKI by the AKIN criteria.

Results:

A total of 82 patients were divided into two groups (CTPA and PCI). CTPA group (20M, 21F) all had acute PE and the PCI group (28M, 13F) were treated for ACS. The mean age was 69 and 65 years respectively. CKD was more prevalent in the PCI group (8pt vs. 3pt) possibly explained by the more advanced atherosclerotic disease. Advanced CHD (NYHA III/IV) was found in 3pt (PCI) vs. 2pt (CTPA) while diabetes and shock were equally distributed (11pt and 5pt) in both groups. The mean amount of contrast was significantly higher in the PCI group (242.3mL vs. 60mL). The mean creatinine/eGFR measured before and after contrast in the CTPA group was 87.3/71.7 vs. 75.1/83 and in the PCI group 91.4/75.9 vs. 105.3/76.1. None of the patients, according to the AKIN definition, developed any significant rise in creatinine/eGFR despite existing comorbidities and risk factors.

Conclusions:

Contrast procedures with non-ionic contrast in patients with significant comorbidities and risk factors for secondary AKI pose minimal risk for CIAKI and therefore should not be deferred in clinical practice.

P236 Estimating the GFR and predicting the AKI in cardiac surgery patients: role of bioelectrical impedance derived fat free mass

V Vicka, E Januskeviciute, J Krauklyte, D Ringaitiene, J Sipylaite

Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Department of Anesthesiology and Intensive Care, Vilnius, Lithuania

Introduction:

The goal of this study was to determine whether changing the body mass (BM) with fat-free mass (FFM) in Cockcroft-Gault (CG) formula could provide a more accurate prediction of AKI in obese patients undergoing cardiac surgery.

Methods:

In this retrospective study, we reviewed institutional data of patients who underwent elective cardiac surgery in a tertiary referral university hospital. Baseline patient creatinine value was collected and GFR was estimated using the MDRD, CKD-EPI and CG formulas. CG formula was further modified by replacing the BM with FFM derived from the bioelectrical impedance analysis. Postoperative AKI was defined by KDIGO creatinine change definitions. Accuracy of the eGFR values to predict the AKI was calculated with ROC-AUC analysis. All the calculations were performed in different categories of BMI.

Results:

476 patients were included in the study, 67.2% of them were men, mean age was 64.5±10.8y. Median Euroscore II was 1.69 [IQR: 1.05-2.49]; 66.4% patients underwent CABG. Total of 138 patients were diagnosed with postoperative AKI (28.99%). The mean measured eGFR varied according to equation: MDRD 74.74±0.9, CKD-EPI 76.79±0.9, CG 86.42±1.4, mCG 61.19±1.0. When comparing AUC in different categories of BMI, the mCG appeared to be the only statistically accurate formula in patients with BMI 30–34.9 (Figure 1).

Conclusions:

The eGFR is a poor predictor of AKI in obese patients undergoing cardiac surgery. The FFM modified Cauckraft-Gault formula yield more accuracy in this specific group.

Fig. 1 (abstract P236).

When comparing AUC in different categories of BMI, the mCG appeared to be the only statistically accurate formula in patients with BMI 30–34.9

P237 RetroAKI: a ten-year retrospective study of acute kidney injury in intensive and progressive care units

A Gardon, VZ Zorio, MB Bodinier, MD Dutour, CM Monard, JC Crozon, GM Marcotte, JT Textoris, TR Rimmelé

Edouard Herriot Hospital, Hospices Civiles de Lyon, Department of Intensive Care, 5 Place d´Arsonval, France

Introduction:

Acute kidney injury (AKI) is a frequent condition in intensive care units (ICU) and progressive care units (PCU), affecting 15% to 70% of the patients, depending on the studied population and AKI definition. AKI has been identified as an independent risk factor of ICU mortality and development of chronic kidney desease. The objective of this study was to describe the incidence of each AKI stages as defined by KDIGO definition (with evaluation of urine output, serum creatinine and initiation of renal replacement therapy (RRT)), in a mixed medical and surgical population of patients hospitalized in ICU and PCU over a 10-year period (2008-2018).

Methods:

We included all patients who stayed more than 12 hours in ICU or PCU of Edouard Herriot Hospital from May 2008 to January 2019. Data used to classify the patients were the urine output over a six-hour period, serum creatinine and the need for RRT, according to KDIGO classification

Results:

18,882 hospital stays were analyzed. Median ICU/PCU length of stay was 3 days [IQR: 1.5-6.6]. Among ICU patients, 74% had at least one AKI episode graded 1, 2 or 3 and 49% had at least one severe episode (stage 2 or 3). Among PCU patients, 44% had at least one episode of AKI and 20% a severe episode of AKI. Patients had an average of 1.9 episodes of AKI per stay. Table 1 represents the incidence of maximal AKI stage during one stay. We found that urine output was the more frequent criteria to make diagnosis of AKI stage 1 or 2 whereas RRT was more frequent for AKI stage 3.

Conclusions:

This retrospective study reports a more important AKI incidence in our ICU/PCU than in previous studies. The difference could be explained by the difficulty to collect urine output from conventional database. Serum creatinine and the use of RRT are often the only two criteria used to define and classify AKI. These results confirm the high incidence of AKI in ICU and PCU and the importance to make an early AKI screening of patients for whom preventive nephroprotective actions are needed.

Table 1 (abstract P237). Incidence of highest AKI stage reached during one ICU/PCU stay. AKI = AKI stage 1, 2 or 3 ; severe AKI = AKI stage 2 or 3

P238 Epidemiology and outcomes of infection in AKI patients

S Cattoir¹, P Depuydt¹, L De Bus¹, E Hoste²

¹Ghent University Hospital, Dept. of Intensive Care Medicine, Ghent, Belgium; ²Ghent University Hospital, Dept. of Intensive Care Medicine/Research Foundation Flanders (FWO), Ghent, Belgium

Introduction:

ICU-patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT) are at risk for infections [1,2]. In this study we evaluated the incidence of infection in ICU patients with and without less severe AKI. Finally, impact on outcomes was explored.

Methods:

This is a retrospective study on the PDMS (Protection Data Management System) of the 4 adult ICUs of a University Hospital. AKI was assessed on KDIGO criteria (creatinine (Scr) and urine output), during the first 7-d of ICU stay. Infection was validated in the PDMS by a team of ICU specialists.

Results:

During a 4-year period, a total of 7485 subjects were enrolled. AKI was diagnosed in 64.7% of patients during ICU stay. AKI patients were older (63 vs. 59 y, p=0.001), had higher SAPS 2 (57 vs. 41, p<0.001), and had more urgent ICU admission (64% vs. 48%, p<0.001). More AKI patients had mechanical ventilation (55% vs. 41%, p<0.001) and vasopressors on d-1 (47% vs. 23%, p<0.001). AKI stage 1, 2, and 3 was present in 25.5%, 28.0% and 11.1% of patients. More AKI patients had infection (57% vs. 28%, p<0.001) and increasing AKI stages were associated with higher infection rates (AKI-0: 28%; AKI-1: 55%, AKI-2: 55%, AKI-3: 69%, p<0.001) (Figure 1). We observed 2-3 times higher mortality in AKI patients with infection, and a stepwise increase of mortality with increasing AKI stages. After correction for infection and other confounders we found that all AKI stages were associated with in-hospital mortality (ORs AKI-1: 1.7, AKI-2: 2.0, AKI-3: 3.6, all p< 0.001).

Conclusions:

Over half of AKI patients experienced an episode of infection and increasing AKI severity was associated with higher infection rate. AKI patients with infection had marked higher mortality, suggesting that infection was an important driver of outcome. However, after adjustment, AKI stages had strong association with hospital mortality.

References:

1. Reynvoet E et al. Crit Care Med 37:2203–9, 2009.

2. Hoste EAJ et al. J Am Soc Nephrol 15:454–62, 2004

Fig. 1 (abstract P238).

In-hospital mortality in patients with and without infection and different AKI stages. AKI, acute kidney injury; Mort, mortality

P239 Prediction of outcome by routine measurement based of TIMP-2 (tissue inhibiting metalloproteinase 2) and IGFBP7 (insulin-like growth factor binding protein 7) by NephrocheckTM

V Eising, A Beitz, B Henschel, M Messer, T Lahmer, RM Schmid, W Huber

Klinikum rechts der Isar der TU München, II Medizinische Klinik und Poliklinik, München, Germany

Introduction:

Several new biomarkers have been introduced to improve early diagnosis of acute kidney injury (AKI). “NephroCheck” (NC; Astute Medical, USA) is a bedside test calculating “AKIRisk” (product of urinary concentration of the cell cycle arrest-markers TIMP-2 and IGFBP7). Several studies suggest the usefulness of NC in selected populations. However, the value of early routine measurement of NC is unclear.

Methods:

Therefore, we compared the prediction of a combined endpoint (CEP: death <60 days and/or requirement of renal replacement therapy RRT) by NC within 12h of ICU admission (NC1) and 24h later (NC2) with admission values of serum-creatinine, BUN, cystatin C, urinary NGAL, APACHE II and SOFA (ROC-analysis). As a secondary endpoint we investigated the additional value of pathological measurements of NC1≥0.3 and/or NC2≥0.3 (NC+) in addition to AKI defined as KDIGO≥1 in a combined model (Kaplan-Meier-analysis). Statistics: SPSS 26.0.

Results:

106 patients of a general ICU (63±17 years; APACHE II 18±8; SOFA 6±4). ICU-mortality was 14/106 (13,2%), mortality <60d 33/106 (31,1%). De novo or acute on chronic (AoC) AKI according to KDIGO≥1: 65/106 (61,3%). Requirement of RRT 21/106 (19.8%). CEP 40/106 (37.3%). NC2 provided the largest ROC-AUC regarding the CEP (AUC=0.716; p<0.0001). Furthermore, cystatin C (AUC=0.715; p<0.001), BUN (AUC=0.700; p=0.001), creatinine (AUC=0.700; p=0.001), NC1 (AUC=0.659; p=0.008) and APACHE-II (AUC=0.651; p=0.012) significantly predicted the combined endpoint. Kaplan-Meier-analysis (p=0.024) demonstrated the lowest survival time for patients with both AKI and elevated NC1and/orNC2 (AKI+/NC+: 36±4d) compared to AKI+/NC- (42±8d), AKI-/NC+ (49±4d) and AKI-/NC- 54±4d).

Conclusions:

1) NC1 and NC2 were significant predictors of the combined endpoint CEP. However, their predictive capacity was not superior to cystatin C on admission. 2) By contrast, combination of NC with AKI according to KDIGO improves prediction of the combined endpoint vs. KDIGO alone.

P240 The role of renal artero-venous coupling (RAVC) in the prediction of acute kidney injury in post-surgical critical care patients

L Tecchi¹, S Maiorano¹, C Brusasco², F Forfori¹, F Corradi³

¹Azienda Ospedaliero Universitaria Pisana, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy., Pisa, Italy; ²Ospedali Galliera. Mura delle Cappuccine 14, 2. Anaesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Genova, Italy., Genova, Italy; ³Azienda Ospedaliero Universitaria Pisana, Pisa, Italy

Introduction:

Objective: This study aimed to explore the diagnostic performance of a novel Doppler index expression of renal artero-to-venous coupling (RAVC) in the prediction of acute kidney injury (AKI-3) in post-surgical critically ill patients compared with systolic time intervals derived from electrocardiographic-gated intrarenal artery Doppler (STI), renal venous impedence index (VII) and renal Doppler resistive index (RDRI) [1, 2].

Methods:

Design: Prospective observational study including 45 critically ill patients. Doppler were measured within 6hours following admission to the intensive care unit (ICU). AKI was defined according to the Kidney Disease Improving Global Outcomes criteria (KDIGO). The new Doppler index RAVC was calculated as follows: (Cardiac Cycle Time – venous flow time)/Arterial Total Ejection time – Pre-Ejection Time).

Results:

Mean RAVC was 4.7±3.4 in patients with AKI 0–2 and 0.8±2.3 in patients with AKI 3 (P<0.001).  Mean STI was 0.82±0.60 in patients with AKI 0–2 and 0.50±0.27 in patients with AKI 3 (P<0.001). Median VII was 0.81±0.19 in patients with AKI 0–2 and 0.43±0.24 in patients with AKI 3 (P<0.001). Mean RDRI was 0.81±0.14 in patients with AKI 0–2 and 0.71±0.08 in patients with AKI 3 (P<0.001). As assessed by the area under the receiver operator characteristic curves (AUC), RAVC performed best in diagnosing AKI 3 [AUC=0.95 (95% CI: 0.83–0.99)] if compared with STI [AUC=0.90 (95% CI: 0.79–0.99)], VII [AUC=0.92 (95% CI: 0.83–0.99)] and RDRI [AUC=0.67 (95% CI: 0.43–0.92)] (Figure 1).

Conclusions:

In our study, artero-venous renal coupling has been shown to be the best predictor for AKI stage 3.

References:

1. Nijst P et al. JACC Heart Fail 5:672-681, 2017

2. Lee WH et al. Sci Rep 6:29293, 2016

Fig. 1 (abstract 240).

ROC

P241 Influence of urinary creatinine excretion on augmented creatinine clearance in critically ill patients

C Mendes Silva, JP Baptista, P Martins

Centro Hospitalar e Universitário de Coimbra, Serviço de Medicina Intensiva, Coimbra, Portugal

Introduction:

The first days of critical illness are associated with increased protein catabolism [1]. Urinary creatinine excretion (UCE) may be a predictor of endogenous protein catabolism [2]. This study aimed to evaluate the relation between UCE and creatinine clearance (CrCl), in particular, with augmented renal clearance (ARC), during intensive care unit (ICU) admission.

Methods:

Retrospective study in adult patients admitted to a multipurpose ICU of a tertiary center during 12 months. Urine was collected for an 8-h period and daily UCE was calculated by extrapolation to 24h. Relative UCE was calculated as a percentage of theoretical values obtained with equations proposed by Walser [3].

Results:

A total of 407 patients were included, with a mean age of 62.3±17.3 years, and 35.4% were female. Mean CrCl in the first 2 days of admission was <60, 60-129 and ≥130mL/min/1.73 m² in 35.4%, 35.9% and 28.6% of patients, respectively. Considering only patients with a CrCl ≥60mL/min/1.73 m², an analysis by age categories (20-39, 40-64 and 65-89 years), showed significant higher incidence of trauma on admission and higher CrCl in younger patients. Relative UCE in the first 2 days of admission was 119.4±37.5%, 114.5±39.5% and 115.0±42.6% for 20-39, 40-64 and 65-89 years groups (p=0.795) and decreased for all groups in the 3-7 days of admission period, with lower values for older patients (p=0.011). Relative UCE was positively associated with the presence of ARC in the different periods of time evaluated. In a multivariate logistic regression, 90-day mortality was not associated with relative UCE ≥ 100% or ARC.

Conclusions:

Critically ill patients showed increased relative UCE in the first days of ICU admission, which may be attributed to higher protein catabolism. Increased relative UCE was associated with ARC and both had no effect on 90-day mortality.

References:

1. Sharma K et al. Nutr Clin Pract 34: 12-22, 2019

2. Carlotti A et al. Q J Med 101: 197-205, 2008

3. Walser M. J Parenter Enteral Nutr 11:73S, 1987

P242 Long-term outcomes of community- versus hospital-acquired acute kidney injury: a retrospective analysis of a large cohort in a German tertiary care center

D Khadzhynov¹, L Lehner², D Schmidt², K Eckardt², K Schmidt-Ott²

¹Charité Universitätsmedizin Berlin, Department of Nephrology and Internal Intensive Care, Berlin, Germany; ²Charité Universitätsmedizin Berlin, Medical Department, Division of Nephrology and Internal Intensive Care Medicine, Berlin, Germany

Introduction:

This study compared epidemiology, short- and long-term outcomes for patients with community-acquired (CA) and hospital-acquired (HA) acute kidney injury (AKI).

Methods:

We retrospectively analyzed all episodes of AKI over a period of 3.5 years (2014–2017) on the basis of routinely obtained serum creatinine measurements in 103,161 patients whose creatinine had been measured at least twice and who had been in the hospital for at least two days. We used the “Kidney Disease: Improving Global Outcomes” (KDIGO) criteria for AKI and analyzed the first hospital admission. A total of 103161 were admitted in hospital and fulfilled the inclusion criteria. Average observation period per patient was 248 days.

Results:

The incidence of CA-AKI among included hospital admissions was 9.7% compared with an incidence of 8.6% of HA-AKI, giving an overall AKI incidence of 18.3%. Patients with CA-AKI were younger than patients with HA-AKI (64 vs 66.2y) and had significantly less comorbidities, including preexisting cardiac failure, ischemic heart disease, hypertension, diabetes. Patients with CA-AKI were more likely to have stage 1 AKI (69,3 vs 58,4%, p<0.001) and had significantly shorter lengths of hospital stay than patients with HA-AKI (14 vs 24d, p<0.001). Those with CA-AKI had better survival than patients with HA-AKI (Figure 1; p<0.001). Patients with CA-AKI were less likely dialysis dependent before discharge (1.9 vs 4.8% in HA-AKI; p<0.001). Patients with HA-AKI received more often administrative coding of AKI (29.3% vs 26.5% in CA-AKI patients; p<0.001)

Conclusions:

Patients with CA-AKI sustain less severe AKI than patients with HA-AKI, accordigly showing better short- and long-term outcomes. However, patiens with CA-AKI are at risk of inadequate clinical perception of AKI.

Fig. 1 (abstract P242).

Long-term survival

P243 Fluid removal practices during renal replacement therapy – a European survey of critical care practitioners

N Seylanova¹, L Tovey², P McCready², R Murugan³, M Ostermann²

¹Sechenov First Moscow State Medical University, Moscow, Russia; ²Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom; ³University of Pittsburgh School of Medicine, Pittsburgh, United States

Introduction:

The evidence base for management of fluid removal during renal replacement therapy (RRT) is limited. A recent international survey revealed the extent of practice variation worldwide [1]. Our aim was to summarise the responses from Europe-based healthcare professionals who participated in the survey.

Methods:

The international self-administered, cross-sectional, internet-assisted, open survey was disseminated between January 2018 and January 2019 via website links and emails to members of different critical care societies.

Results:

485 participants from 31 European countries completed the survey of whom 365 (75%) were intensivists and 306 (63%) worked in university-based hospitals. Persistent oliguria / anuria was the most common indication for fluid removal (51% responders). The parameters which guided fluid removal included hemodynamic status (47% responders), cumulative fluid balance since admission (23% responders), and 24-hour fluid balance (17% responders). 90% of participants reported using CRRT with a median net ultrafiltration rate 98 mL/hr (IQR 51–108mL/hr) for hemodynamically unstable and a rate of 300 mL/hr (IQR, 201–352mL/hr) for hemodynamically stable patients. Only 26% of practitioners checked net fluid balance hourly (70% nurses, 16% physicians). New hemodynamic instability, defined as new onset or worsening tachycardia, hypotension, or need to start or increase the dose of vasopressors was reported to occur in 20% patients (IQR 10.0–30.0). Different strategies to re-gain hemodynamic stability were used. (Figure 1) Main barriers to fluid removal were patient intolerance (72% physicians, 85% nurses) and interruptions in fluid removal (43% physicians, 64% nurses). The majority of participants agreed that guidelines and protocols would be beneficial.

Conclusions:

The practice of fluid removal during RRT is very variable across European countries. Nurses and doctors identified a need for evidence-based protocols and clear guidelines.

References:

1. Murugan R et al. Crit Care Med 48:e87-e97, 2020

Fig. 1 (abstract P243).

Common measures to correct hemodynamic instability during fluid removal

P244 Comparing of regional citrate and systemic heparin anticoagulation methods in continuous renal replacement therapies on critically ill patients

P Kucukdemirci kaya, FS Kahveci, P Rahimi, N Kelebek Girgin, R Iscimen

Bursa Uludag University, Anesthesiology and Intensive