Programme scientifique

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jeudi 24 janvier 2019

E-Poster
14h10 - 15h10
Espace poster 1
Médecin : Ethique et communication
Modérateur(s) : René Robert (Poitiers / FRANCE), Jean-Philippe Rigaud (Dieppe / FRANCE)
  • The fragility and reliability of conclusions of anesthesia and critical care randomized trials with statistically significant findings: A systematic review
    Orateur(s) :
    • François Grolleau (Caen / FRANCE)
    • Gary S. Collins (Oxford / ROYAUME UNI)
    • Romain Pirracchio (San Francisco / ETATS-UNIS)
    • Clément Gakuba (Caen / FRANCE)
    • Isabelle Boutron (Paris / FRANCE)
    • P. J. Devereaux (Hamilton / CANADA)
    • Yannick Le Manach (Hamilton / CANADA)
    14h10 / 14h17
    Abstract : The Fragility Index (FI), which represents the number of patients responsible for a statistically significant finding, has been suggested as an aid for interpreting the robustness of results from clinical trials. A small FI indicates that the statistical significance of a trial depends on only a few events. Our objectives were to calculate the FI of statistically significant results from randomized controlled trials (RCT) of anesthesia and critical care interventions and to determine the frequency of distorted presentation of results or ‘spin'. We systematically searched MEDLINE from 01 January 2007 to 22 February 2017 to identify RCTs exploring the effect of critical care medicine or anesthesia interventions. Studies were included if they randomized patients 1:1 into two parallel arms and reported at least one statistically significant (P<0.05) binary outcome (primary or secondary). Two reviewers independently assessed eligibility and extracted data. The FI was determined for the chosen outcome. We assessed the level of spin in negative trials and the presence of recommendations for clinical practice in positive trials. We identified 166 eligible RCTs with a median sample size of 207 patients (interquartile range [IQR] 109 to 497). The median FI was 3 (IQR 1-7), which means that adding three events to one of the trials treatment arms eliminated its statistical significance. Further, 21 (13%) trials had a FI of zero as the statistically significant outcome was found non-significant when recalculating the P-value using a 2-sided Fisher exact test. High spin was identified in 42% (n=30) of negative RCTs while 21% (n=20) of positive RCTs provided recommendations. Lower levels of spin and recommendations were associated with publication in journals with high impact factors (P<0.001 for both). Statistically significant results in anesthesia and critical care RCTs are often fragile, and study conclusions are frequently affected by spin. Routine calculation of the FI in medical literature may allow for better understanding of trials and therefore enhance the quality of reporting.
  • Limitation of life-support therapy in Tunisian ICUs: A prospective survey
    Orateur(s) :
    • Mariem Tlili (Monastir / TUNISIE)
    • Zeineb Hammouda (Monastir / TUNISIE)
    • Islem Ouanes (Monastir / TUNISIE)
    • Fahmi Dachraoui (Monastir / TUNISIE)
    • Lamia Ouanes-Besbes (Monastir / TUNISIE)
    • Fekri Abroug (Monastir / TUNISIE)
    14h17 / 14h24
    Abstract : The risk of admitting to the ICU patients at end of life has increased with ageing of the population. Yet, it is usually not easy to discern a-priori the hospitalization which presages a fatal outcome from that with a significant potential for recovery. Limitation of life-supporting therapy (LLST) has become of current practice in the ICU, but many countries (including Tunisia) lack legal framework for such practice. The aim of the study is to evaluate the magnitude of LLST among intensivists practicing in different healthcare facilities. A questionnaire was addressed to ICU physicians practicing in university and non-university hospitals in Tunisia. They were invited to participate and respond anonymously to a questionnaire on the limitation and active cessation of care. The questionnaire included description of participants and their workplace characteristics, the frequency of end of life situation in their daily practice, and insights on the way they handle these situations with or without external help from other health workers. 101 intensivists (46% having more than 10 years of experience) practicing principally in ICUs belonging to university hospitals (91%), answered the questionnaire. 69 out of 101 participants found that limitation of life-support therapy was ethically acceptable but active shortening of the dying process was not. The majority were more comfortable with withholding than withdrawing life-supporting therapy. 72 declared they practiced LLST themselves while an additional (22%) said that they were aware of such practice in their ICU. The estimated ICU deaths preceded by LLST were around 20%. A formal written LLST policy was present in 9%, unwritten policy in 52% while 39% declared they did not have any policy. More than one senior ICU doctor usually take part in decision-making regarding LLST in 92%, a single senior ICU doctor in 6 %, ICU nurse(s) caring for the patient in 15%. 70% do consider requests for limitation of life-sustaining therapy from patients, families or surrogates and 25% are rarely comfortable when talking about LLST with the family. 54% strongly agreed on the principle of giving analgesics/ painkillers with LLST to ensure the absence of pain during terminal stages, even if death may be hastened by their use. 69% regret the lack of ethics consultations or committees. Limitation of life-supporting therapy is a frequent practice in Tunisian ICUs although a formal legislative or academic frame is lacking. Intensivists claim a legal framework for this practice.
  • Impact of decisions to forgo life-supporting-therapy on survival in patients admitted to intensive care units for infection
    Orateur(s) :
    • Juliette Perche (Roubaix / FRANCE)
    • Julien Goutay (Lille / FRANCE)
    • Aurélia Toussaint (Lille / FRANCE)
    • Arthur Durand (Lille / FRANCE)
    • Thierry Onimus (Lille / FRANCE)
    • Raphael Favory (Lille / FRANCE)
    • Sébastien Préau (Lille / FRANCE)
    14h24 / 14h32
    Abstract : To evaluate the impact of decisions to forgo life-supporting-therapy (DFLST) on survival in patients admitted in intensive care unit (ICU) for an infection.It was a retrospective, monocentric, observational study, conducted in 2015, in a medical ICU. We included all patients admitted for infection and classified them according to the SEPSIS-3 classification. DFLST were separated into two groups: withholding and withdrawal life-supporting-therapy. We performed logistic regression to identify predictive factors of hospital mortality. On the 444 patients who were included, 124 (28%) had DFLST. Global mortality was 31%. Predictive factors of hospital mortality were on multivariate analysis: DFLST (Odds Ratio (OR) : 42,3, Interval Confidence (IC) 95% [41,50 ;43,05], p<0,01), admission Sepsis-related Organ Failure Assessment (SOFA) score (OR : 1,1, IC 95% [1,05 ;1,24], p=0,04), admission lactatemia (OR : 1,2 IC 95% [1,06 ;1,31], p=0,05), moderate to severe chronic kidney disease (OR : 5,9, IC 95% [4,74 ;7,09], p=0,03), chronic steroids (OR : 3,3, IC 95% [2,25 ;4,43] p=0,02), and chronic hepatopathy (OR :6,7, IC 95% [5,10 ;8,37], p=0,02). According to the subtype of DFLST (withholding or withdrawal), and the subtype of infection (sepsis or septic shock), there were significative statistical differences on hospital mortality: for sepsis, 17 (8%) patients without DFLST, 22 (55%) patients with withholding, and 30 (100%) patients with withdrawal, p<0.05; for septic shock, 20 (23%) patients without DFLST, 14 (73%) patients with withholding, and 32 (100%) patients with withdrawal, p<0.05 (Figure 1). Early predictive factors of DFLST were in multivariate analysis: age (OR : 1,03 IC 95% [1,01 ;1,05], p<0,01), metastatic cancer (OR 5,2 IC 95% [4,12 ;6,12], p<0,01), respiratory (OR 1,3 IC 95% [1,05 ;1,49], p=0,03), renal (OR 1,3 IC 95% [1,16 ;1,54], p<0,01) and neurologic (OR 1,6 IC 95% [1,32 ;1,80], p<0,01) items of initial SOFA score, and fungal infection (OR 7,6 IC 95% [6,16 ;9,14], p<0,01).DFLST are an independent factor of mortality in patients with sepsis and septic shock in ICU. This result may influence our clinical practice and show up the necessity to collect DFLST in studies.
  • Collegial procedures for therapeutic limitations in a French ICU: The perception of the participants
    Orateur(s) :
    • Jacques Boutros (Paris / FRANCE)
    • Julien Charpentier (Paris / FRANCE)
    • Jean-Paul Mira (Paris / FRANCE)
    • Olivier Lesieur (La Rochelle / FRANCE)
    14h32 / 14h39
    Abstract : Since 2005, the medical decision to withhold or withdraw treatments in a patient who is unable to express his wishes has been legally framed by the Leonetti law: such a resolution can only be adopted after a so-called "collegial reflection" procedure. Regarding the deliberation that precedes the decision, the medical societies and ethical reflection committees have issued recommendations in terms of standardization, training and transparency. Our study aims to evaluate the deliberative members' perception of the collegial procedures implemented in a French medical intensive care unit. The main objective of our survey was to assess the role of collegial procedure within the decision-making process, with a core issue: is deliberation perceived as the approval of a decision already taken or as an ethical discussion that lies at the heart of the decision-making?The perception of nurses, nurse aids, residents and doctors was assessed using a five-section questionnaire with open-ended and multiple answer questions. Characteristics of patient admitted to the ICU in 2017, as well as those of the collegial procedures undertaken during the same period, were collected.Of the 230 formal collegial procedures (14.6% of patients admitted) registered in 2017, over 90 % were attended by at least a resident, a nurse and a doctor. The analysis of the 47 questionnaires filled in by 5 doctors, 6 residents, 29 nurses and 10 nurse aids shows global satisfaction regarding the organization, duration, exchanges and consideration of the participants' opinions. While nurse aids are often absent from the deliberations and show moderate implication in the decision making, their contribution on very specific aspects of individual care is desired by other healthcare professionals. Caregivers also deplore the limited involvement of an external consultant whose role would be to provide neutral expertise on the patient's conditions. Based on the examination of responses to the open-ended questions, it seems necessary to reposition the collegial procedure within a complex deliberative process which gradually leads, throughout the hospital stay, to contingent and revocable decisions of foregoing certain treatments deemed "useless, disproportionate or having no other object than the artificial preservation of life". Despite a limited number of participants, this single-center study suggests several refinements and improvements in our collegial reflection procedure in terms of legal and ethical knowledge, organization, and attendance.
  • Organ donation and transplantation: a large survey of knowledge and perceptions among high school students
    Orateur(s) :
    • Khalid Khaleq (Casablanca / MAROC)
    • Reda Hafiane (Casablanca / MAROC)
    • Imane Talhi (Casablanca / MAROC)
    • Z Sgheir (Casablanca / MAROC)
    14h39 / 14h46
    Abstract : Organ donation and transplantation remain below requirements in Morocco. Each year we see the number of patients needing organ transplantation (OD) getting bigger. We are facing a real shortage in OD. Moroccan students, who represent the young generation, could be the key for a future improvement in organ transplantation. We lead a study in order to determine their knowledge and aspirations concerning this life saving therapy.It's a descriptive prospective study: a survey lead in eight higher education institutions. We used a pre-established questionnaire. We analyzed 4 main themes: knowledge assessment, opinions towards OD, its causes and ways of improving it in our country. Data was analyzed using SPSS 20.0 software. We questioned 991 students: 97, 2% had already heard about OD, and 69,9% were aware that it was possible to practice it in Morocco. 80.3% had an idea about lethal diseases requiring the use of transplantation and 75% were able to identify transplantable organs and tissues, 43.5% underestimated the number of people waiting for transplants, 57.6% thought that the acts of organs removal and transplantation are done in private clinics. 62.8% were aware of the law governing OD in Morocco, only 31.4% had trust in this law and 91.3% ignored the registration steps in the donation acceptance register. 71.4% were convinced of the perfect compatibility of OD with Muslim religion, the majority of students (92.5%) were in favor of OD. Among the group of respondents refusing the donation of their organs, the right of refusal and religious obstruction were at the top of the list of the determinants of the refusal with respective prevalence of 47.10% and 24.3%, and only 23.3% of the students had expressed their opinion to their relatives. This study shows that young Moroccans are supportive of OD despite their limited knowledge of the subject. The development of this therapy must go through information and regular motivation of people. General conferences and seminars represent a solution in spreading awareness among generations in order to establish a strong policy of organ donation in an early future.
  • Concept of encephalic death and organ donation to consultants in a Moroccan non university hospital center
    Orateur(s) :
    • Hanane Ezzouine (Casablanca / MAROC)
    • Karim Mediouni (Casablanca / MAROC)
    • Soukaina Benyamna (Casablanca / MAROC)
    • Amine Raja (Casablanca / MAROC)
    • Abdellatif Benslama (Casablanca / MAROC)
    14h46 / 14h53
    Abstract : Encephalic death and organ donation are widely debated.The promotion of organ donation including a brain dead donor requires us to explore the concept among our population.We aimed to evaluate the knowledge and attitude of consultants in a non-university hospital center concerning organ donation and the concept of brain death.We carried out a descriptive study for one year in a Moroccan non-university hospital center. The target population was the consultants of this hospital center. A questionnaire was filled out anonymously and aimed to evaluate organ donation, knowledge of the concept of brain death and organ transplantation in brain-dead patients, the wearing of a voluntary organ donor card, the discussion of donations of family organs, family consent in case of cadaveric donor, receiving organs from a living donor and donation of organs and religion746 people were included. Their average age is 21.30 ±9,2 years with male predominance . The values ​​associated with organ donation are for 38.49% of saving lives for 37.57% a gesture of charity, 12.17% a gesture of altruism and 11.77% a duty.85,81% do not know what it is an encephalic death .70,37% do not know that there were donations of organs of patients in a state of brain death .34,26% know it there are contraindications to the organ donation of patients in a state of encephalic death .55.95% do not agree to donate one of their organs during their lifetime.57.69%are for organ donation for the purpose of treating patients and 27.45% are without opinion. 71.16%. refuse to carry a voluntary organ donor card. 86.24% agree to receive an organ from a living donor and 12.42% to receive an organ from a deceased donor .88.22% have never reported their positions to their loved ones. 73.94% are in favor of organ donation after their death .45.50% replied that the Muslim religion allows living organ donation to live and 21.72% replied that it authorizes the donation of organs from living to organs of a patient in a state of encephalic death to a living.A clear disparity is found in the conception of brain death and organ donation despite information campaigns and media coverage. The population studied has socio-demographic and cultural characteristics that require adapting the information tools with a cultural approach .
E-Poster
14h10 - 15h10
Espace Poster 10
Médecin : Toxicologie 2
Modérateur(s) : Ferhat Meziani (Strasbourg / FRANCE), Jean-Marc Tadié (Rennes / FRANCE)
  • Investigation of the time-course of the serotoninergic syndrome in relation to the plasma MDMA concentrations in the severely MDMA-poisoned patients
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Mathieu Bouthemy (Paris / FRANCE)
    14h10 / 14h17
    Abstract : The recreational use of 3,4-methylenedioxymethamphetamine (MDMA) has become common since the end of the 90s and the number of poisonings has significantly increased during these last years. MDMA is responsible for serotoninergic toxicity leading to the onset of hyperthermia and multiorgan failure. Our objectives were to describe the time course of body temperature, serotoninergic signs and biological parameters in the severely MDMA-poisoned patients in order to understand the evolution of these parameters in relation to the plasma concentration of MDMA and its main metabolite, methylenedioxyamphetamine (MDA).We conducted a retrospective single-centre observational study including all MDMA-poisoned patients admitted to the intensive care unit (ICU) and who developed fever (body temperature >38.5°C) and symptoms/signs of serotoninergic syndrome (according to Sternbach's criteria). Plasma MDMA and MDA concentrations were determined using liquid chromatography coupled to mass spectrometry.Sixteen MDMA-poisoned patients (out of 58 MDMA-exposed patients admitted to the ICU over a 10-year period) who presented serotoninergic syndrome with fever (>38.5°C) attributed to MDMA exposure and treated with supportive care, external cooling and cyproheptadine (a non-specific serotonin receptor antagonist) were included in this study. The patients were 6 females et 10 males, of 22-year old [20; 26] (median [percentiles 25; 75] and had used recreational MDMA and found in a night-club (75%), in the street (19%) or at home (6%). The body temperature reached 39.7°C [38.8; 40.9] and the presentation was complicated by cardiac arrest (19%), cardiovascular failure (44%), aspiration pneumonia (56%), hospital-acquired infections (25%) and fatality (6%). In four patients (25%), worsening in the clinical (heart rate, pyramidal syndrome, EEG encephalopathy) and biological parameters (transaminases, prothrombin index, creatinine phosphokinase) included in the serotoninergic syndrome was surprisingly observed in parallel to the increase in body temperature (due to a concomitant infectious or inflammatory non-toxic event). The observed worsening occurred in the absence of any increase in the plasma MDMA and MDA concentrations (N=2) and even in the presence of undetectable concentrations (N=2). MDMA use results in serotonin syndrome possibly leading to the onset of hyperthermia, organ failure and death, despite optimal care. Worsening in the serotonin syndrome during the ICU stay of severely MDMA-poisoned patients, without increase in plasma MDMA concentration is observed in 25% of the patients. The exact molecular mechanisms involved in this “serotoninergic memory” remain to be clarified.
  • Carbon monoxide induced coma : prognostic factors.
    Orateur(s) :
    • Paris Meng (Garchess / FRANCE)
    • Ophélie Constant (Garchess / FRANCE)
    • David Luis (Garchess / FRANCE)
    • Vivien Hong Tuan Ha (Garchess / FRANCE)
    • Sivanthiny Sivandamoorthy (Garchess / FRANCE)
    • Nicholas Heming (Garchess / FRANCE)
    • Sylvie Chevret (Paris / FRANCE)
    • Djillali Annane (Garchess / FRANCE)
    14h17 / 14h24
    Abstract : Carbon monoxide (CO) is a leading cause of poison related lethality in France. Moreover, survivors may develop severe neuro-cognitive sequelae. Few studies sought to determine prognostic factors related to CO induced coma. The primary objective of our study was to determine prognostic factors for ICU-mortality following CO induced coma. Our secondary objective was to determine prognostic factors of CO related cognitive sequelae, at the time of intensive care unit (ICU) discharge.Retrospective observational study from January 2000 to December 2012. All comatose patients (Glasgow coma score <8) due to carbon monoxide poisoning, treated by hyperbaric oxygen therapy in a tertiary hospital in the greater Paris area were included in the current study. Clinical, biological, iconographic and electrophysiological data were collected from medical files. 184 patients were included, median [IQR] age was 42 [30;56] years, 105 patients (57.4%) were male. Causes of poisoning were mainly CO exposure (n=55; 30.1 %) and smoke inhalation (n=107; 58.5 %). 30 patients (17 %) died during their ICU stay while 26 (14.7 %) presented cognitive sequelae at ICU discharge. Multivariate analysis found that cardiac arrest (OR 1.28; IC95 % [1.14 -1.44] ; p < 0.001), EEG anomalies (OR 1.34; IC95 % [1.21-1.49] p < 0.001), and the Simplified Acute Physiology Score (SAPS II) (OR 1.04; IC95 % [1.01-1.07) ; p = 0.02) were associated with ICU-mortality. Neuroimaging anomalies (OR 1.53; IC95 % [1.36-1.72] ; p < 0.001) were associated with cognitive sequelae at ICU discharge. Neither lactate nor carboxyhemoglobin levels were associated with cognitive sequelae or mortality in our cohort. In our study, predictive factors of ICU-mortality in CO induced comatose patients were a cardiac arrest, EEG anomalies and the SAPS II score. Neuroimaging anomalies were predictive of cognitive sequelae at ICU discharge.
  • Poppers poisoning admitted to the intensive care unit: Is there a methemoglobinemia threshold responsible for tissue dysoxia?
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • May Yaker (Paris / FRANCE)
    14h24 / 14h31
    Abstract : The recreational use of poppers has been increasing in France since the last judgment of the National Council in June 2013 re-authorizing their marketing. Poppers contain various alkyle nitrites which are highly oxidant compounds able to induce methemoglobinemia (MetHb) with deleterious and even life-threatening consequences in humans. Our objective was 1)- to describe the circumstances, complications and outcome of the patients admitted to the intensive care unit (ICU) for MetHb onset attributed to the exposure to poppers and 2)- to investigate the relationship between the serum lactate concentration and the MetHb before treatment.We conducted a retrospective monocentre observational study including all patients admitted to the ICU with increased blood MetHb (> 0.7%) following the exposure to poppers. We investigated the relationships between SpO2, serum lactate concentration and MetHb on ICU admission by calculating the Pearson's coefficients and using the Bartlett's test of sphericity.Twenty-six patients (24 males and 2 females; aged of 42 years (35; 48) [median (percentiles 25;75)]) were included. The poppers had been snorted (77%), ingested (19%) or snorted + ingested (4%), in a recreational multi-drug exposure (65%; mostly accompanied by gamma-hydroxybutyrate use). On admission, MetHb was 20.0% (1.5 ; 44.0). The patients received methylene blue infusion (62%), mechanical ventilation (35%), catecholamine infusion (12%) and exsanguino-transfusion (4%). On admission, the SpO2 was 91% (83; 94) and weakly correlated to the MetHb (R2 = 0.3; p = 0.01) while the serum lactate concentration was 2.2 mmol/L (1.3; 3.9) and highly correlated to the MeHb (R2 = 0.7; p < 0.0001). Plasma lactate concentration of > 2 mmol/L was highly predictive of MetHb > 20%, with 91.7% sensitivity, 90.9%, specificity, 91.7% positive predictive value and 90.9% negative predictive value. The use of poppers is responsible for life-threatening consequences attributed to MetHb. Our data clearly supported the recommendation by the international and French guidelines to administer methylene blue in patients developing MetHb > 20% by evidencing that tissue hypoxia is almost consistently present above this threshold.
  • Hemodynamic profile of acute intoxications
    Orateur(s) :
    • Mohamed Anass Fehdi (Casablanca / MAROC)
    • Amine Raja (Casablanca / MAROC)
    • Amine Zerhouni (Casablanca / MAROC)
    • Mohammed Mouhaoui (Casablanca / MAROC)
    14h31 / 14h38
    Abstract : Cardio-circulatory failure is one of the leading causes of death in acute poisoning. The aim of our work was to analyze the hemodynamic profile of intoxications to non-cardiotropic products, and to identify the prognostic factors.This was a prospective, 1-year study, including any patient over the age of 15 years, in primary admission to the vital emergency room, for non-cardiotropic drug intoxication but also non-drug. The analyzed parameters were: clinical examination, electrical abnormalities, echocardiographic data and troponin level, this evaluation performed with H24 intake. The statistical analysis was univariate with a p <0.05.251 patients were included, with an average age of 29, with a ½ sex ratio. The toxic products found were organophosphorus (39.1%), benzodiazepines (16.4%), aluminum phosphide (14.7%), cocaine (12.3%), carbon monoxide (8.9%), , 8%) and tricyclic antidepressants (5.2%). Cardiocirculatory insufficiency was observed in 62 patients (24.6%), electrical abnormalities in 45 patients (17.9%), elevation of troponin in 22 patients (8.7%) and echocardiographic abnormalities in 20 patients (7.9%).The incidence was particularly high for aluminum phosphide and tricyclic antidepressants.The overall mortality rate was 9% (36 deaths), depending on the offending product: 45.9% for aluminum phosphide, 30.7% for tricyclic antidepressants, 12.9% for cocaine, 8, 1% for organophosphorus compounds and 4.9% for benzodiazepines. (Figure 1)The correlation between clinical and paraclinical abnormalities and the occurrence of death is shown in Table 1In toxicology, the range of cardio-toxic products is much wider than the class of cardiotropic drugs. Indeed, very many products are at the origin of a cardiovascular toxicity. The mechanism of this failure is variable: membrane stabilizing effect (antidepressants, beta-blockers, calcium channel blockers, organophosphorus), diastolic dysfunction, rhythm disorders, toxic myocarditis, myocardial necrosis (Phostoxin, cocaine, CO) or vasodilatation (antihypertensives).The difficulty of accurately assessing the incidence and prevalence of cardio-circulatory failure due to toxic causes is due, among other things, to the lack of validated studies to propose better diagnostic and therapeutic techniques. In our study, the 2 main factors of poor prognosis were cardiocirculatory insufficiency and echocardiographic abnormalities.
  • Cocaine poisoning in the intensive care unit: are there differences between cocaine hydrochloride- and crack-related toxicity?
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Lisa Catherine (Paris / FRANCE)
    • Marion Soichot (Paris / FRANCE)
    • Laurence Labat (Paris / FRANCE)
    • Nicolas Deye (Paris / FRANCE)
    • Isabelle Malissin (Paris / FRANCE)
    • Sébastian Voicu (Paris / FRANCE)
    14h38 / 14h45
    Abstract : Cocaine is the most frequently used psychostimulant illicit drug worldwide. In France, its use has significantly increased during the last ten years, with two main modalities: the recreational snorting of cocaine hydrochloride and the inhalation of smoked “crack” (free-base form of cocaine, obtained by cocaine salification using common baking soda or ammoniac) in highly dependent and dissocialized users. The neurological, cardiovascular, respiratory and metabolic complications of cocaine are relatively well-known; however, differences between cocaine hydrochloride and crack-related toxicities have been poorly investigated. Our objectives were to describe and compare the circumstances and the resulting complications of cocaine use in the patients admitted to the intensive care unit (ICU) in relation to the route of exposure, i.e. snorting versus inhalation. We conducted a retrospective single-centre observational study including all cocaine-poisoned patients admitted to the intensive care unit over an 8-year period (2011-2018). Comparisons between the two routes of cocaine exposure were performed using an univariate analysis (Chi-2 and Mann-Whitney tests, as requested).Seventy-two patients (age, 35 years [30; 46] (median, [percentiles 25; 75]) were included. Toxicity mainly resulted from multidrug use [benzodiazepines (79%), ethanol (32%), methadone (29%), tetrahydrocannabinol (23%) and amphetamines (21%)]. The Glasgow coma score on admission was 10 [3; 15]. Complications included cardiac arrest (N=9), aspiration pneumonia (N=19), acute renal failure (N=15), malignant hypertension (N=7), ischemia/thrombosis events (N=5), seizures (N=5), hyperthermia (N=5), myocardial infarction (N=1) and death (N=5). Users by snorting (N=34) presented significantly more severe symptoms than users by inhalation (N=25), with lower Glasgow coma score (p=0.02), more intense adrenergic syndrome (p=0.009 for tachycardia), more elevated plasma lactate concentration (p=0.002), lower platelet count (p<0.0001) and more marked rhabdomyolysis (p=0.02). Snorting cocaine was less frequently associated with methadone use (p<0.0001). Cocaine snorting patients more frequently developed cardiac arrest (p=0.02), aspiration pneumonia (p=0.04) and requested mechanical ventilation (p=0.0002). Cocaine use may lead to severe complications requiring ICU admission. Our findings suggest that complications attributed to cocaine hydrochloride snorting are more severe than the complications attributed to crack inhalation. Experimental investigations may interestingly complement our study to allow better understanding of the mechanistic reasons supporting these observed differences.
  • Bromazepam poisoning in the intensive care unit: usefulness of the plasma bromazepam concentration for patient management
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Sybille Riou (Paris / FRANCE)
    • Marion Soichot (Paris / FRANCE)
    • Nicolas Péron (Paris / FRANCE)
    • Pierre Mora (Paris / FRANCE)
    • Isabelle Malissin (Paris / FRANCE)
    • Laurence Labat (Paris / FRANCE)
    14h45 / 14h52
    Abstract : Bromazepam is the most commonly used and the most frequently involved benzodiazepine in acute drug poisonings in France. Our objectives were 1)- to report the complications and management of bromazepam-poisoned patients admitted to the ICU; 2)- to investigate bromazepam pharmacokinetics in overdose and the relationships between the coma depth and plasma bromazepam concentration on admission. We conducted a retrospective single-centre observational study including all bromazepam-poisoned patients admitted in 2011-2018, evidenced by at least one plasma bromazepam concentration in the toxic range during their stay. We studied the correlation between the presumed ingested dose of bromazepam, the plasma concentration of bromazepam and the coma depth determined by the Glasgow coma score by calculating the Pearson's coefficients and using the Bartlett's test for sphericity.One-hundred and sixty-four patients [112 females and 52 males; age, 51 years (41-63) (median (percentiles 25-75)] were included. Toxicity resulted from multidrug ingestions (75%), with a presumed bromazepam ingested dose of 180 mg (113-180) and plasma bromazepam concentration on admission of 1.88 mg/L (0.87-2.70). Consciousness impairment was marked [Glasgow coma score, 9 (3-14)], hypotonic coma (43%) and decrease/loss in tendon reflexes (26%)]. Complications included aspiration pneumonia (49%), increase in liver enzyme (79%), cardiovascular (21%) and renal failure (10%). Sino- and atrio-ventricular blocks were found in 17% of the cases. Flumazenil [bolus dose of 0.3 mg (0.2-0.4) followed by infusion rate of 0.4 mg/h (0.3-0.6) during 24h (17-60)] was administered in 28% of the patients while 40% of the patients were intubated and mechanically ventilated. In the subgroup of mono-intoxications with bromazepam, no significant correlation between the coma depth and the plasma bromazepam concentration was observed (R2=0,1; Bartlett's test, p=0.3). Factors associated with the requirement of tracheal intubation (vs. flumazenil use) included lower Glasgow coma score (p=0.002) and more elevated serum lactate concentration (p=0.03). No significant relationship was evidenced between the ingested dose and the plasma concentration of bromazepam on admission.Acute bromazepam poisoning is frequent and may be responsible for life-threatening consequences. The ingested dose and the plasma concentration of bromazepam are not correlated with the coma depth and do not predict the necessity of tracheal intubation, thus suggesting high inter-individual variability in the drug toxicity and optimal management.
  • Ecstasy an unsafe recreational drug: Experience of 10 years ICU practice
    Orateur(s) :
    • Takoua Khzouri (Tunis / TUNISIE)
    • Hela Maamouri (Tunis / TUNISIE)
    • Meriem Fatnassi (Tunis / TUNISIE)
    • Rim Jemmali (Tunis / TUNISIE)
    • Nozha Brahmi (Tunis / TUNISIE)
    14h52 / 14h59
    Abstract : 3.4-Methylenedioxymethamphetamine (MDMA), also known as Ecstasy, is a recreational drug, popular among youth in Europe and America since the 1990s. During the last decade, there has been a remarquable increase in cases of MDMA poisoning admitted in our ICU. The present study aimed to better know the epidemiological, clinical and therapeutic characteristics of this poisoning in order to improve its prognosis.It was an observational retrospective study spread over nine years from 1st January 2010 to 22th September 2018 in a toxicological ICU, including all patients admitted for acute MDMA poisoning.During the study period, MDMA poisoning accounted for 0.15% (n=14) of all the acute poisonings requiring hospitalization in our Intensive Care Unit. Most of them were between 2016 and 2018. Their mean age was of 20 years [15, 30], with a sex-ratio of 6. Eight patients (57%) were drug-addicted. Exposures were single-drug in 4 cases (28.6%). In the other cases, Ecstasy was co-ingested with alcohol in 6 cases, benzodiazepine in 2 cases, trihexyphenidyl in 2 cases and both cannabis and heroin in one case. The supposed ingested dose (SID) was unknown in 4 cases, for the other ones, the median SID was 1 pill and the half [1, 4]. The consultation delay was of 6 ± 3 hours after ingestion. The main symptoms were mydriasis (79 %), agitation (71.4%), tachycardia (64.3%) with an average of 114 bpm [102, 145], hallucinations (57 %) and hypertension (57%). The five coma patients were intubated and required sedation with midazolam in 60%. Only one patient required curare for malignant hyperthermia at42°c. Eleven patients developed rhabdomyolysis with average rates of creatine phosphokinase and lactate deshydrogenase respectively of 9479 UI [326, 54000] and 680 UI [144, 2825]. Two patients developed disseminated intravascular coagulation and fulminant hepatitis with high rates of alanine aminotransferase (4631 UI and 2223 UI), aspartate aminotransferase (3695UI and 1876 UI) and low factorV (5% and 60%] for which they received N-acetylcysteine. One patient received cyproheptadine as antidote at 12 mg a day. Thirteen patients were discharged from the ICU with a mean length of stay of three days. One patient died of hepatic encephalopathy with cerebral herniation.As it was shown, the MDMA poisoning presents a vital risk due to the serotonin syndrome. The clinician must be warned to recognize better its symptoms and its severity in order to improve its management.
E-Poster
14h10 - 15h10
Espace poster 2
Médecin : Infections non bactériennes
Modérateur(s) : Damien Roux (Colombes / FRANCE), Laurent Papazian (Marseille / FRANCE)
  • Important changes in clinical presentation and outcomes of patients treated for severe malaria in a referral French university hospital from 2004 to 2017
    Orateur(s) :
    • Jordane Lebut (Paris / FRANCE)
    • Bruno Mourvillier (Paris / FRANCE)
    • Camille Vinclair (Paris / FRANCE)
    • Radj Cally (Paris / FRANCE)
    • Aguila Radjou (Paris / FRANCE)
    • Claire Dupuis (Paris / FRANCE)
    • Nicolas Argy (Paris / FRANCE)
    • Stéphane Ruckly (Paris / FRANCE)
    • Mathilde Neuville (Paris / FRANCE)
    • Michel Wolff (Paris / FRANCE)
    • Lila Bouadma (Paris / FRANCE)
    14h10 / 14h17
    Abstract : Incidence of imported severe malaria (SM) increased and patients characteristics and prognosis changed since early 2000. Our objective was to analyze changes in clinical presentation and outcomes since artesunate became first-choice treatment of SM.Retrospective observational single-center study in the medical ICU of a referral university hospital conducting on patients admitted for SM over a 14-year period (2004-2017). Demographic variables, severity scores, WHOs severity criteria on admission, ICU and hospital lengths of stay were collected. Patients' characteristics and outcomes were compared between two periods, namely 2004-2012 and 2013-2017 when artesunate has become first-choice treatment. A poor outcome was defined as the composite endpoint of death, or ICU length of stay >2 days, or requirement for vasopressors, invasive mechanical ventilation and/or renal replacement therapy started after the first day in ICU. Univariate analysis and stepwise multivariate logistic regression stratified by period were performed to identify factors associated with a poor outcome. 189 patients were included, 98 before and 91 after 2013. Main epidemiological and clinical characteristics are on Table. Even if the number of WHO criteria for SM was comparable in both groups, SAPS II, SOFA and ICU length of stay were significantly higher before 2013. Patients visiting friends or relatives (VFR) in their home country or living in endemic areas seemed more frequent after 2013 (p = 0.07). Poor outcome occurred in 63 cases before 2013 and 32 cases after 2013 (p< .01). Risk factors of poor outcome were impaired consciousness (adjOR = 3.25 ; 95%CI(1.50-7.07), p = 0.003), shock (adjOR = 3.46 ; 95%CI(1.36-8.85), p = 0.01) and creatinine >265 µmol/L (adjOR = 14.16 ; 95%CI(4.95-40.48), p< .001). Patients VFR or living in endemic areas were associated with a better outcome (adjOR = 0.34 ; 95%CI(0.15-0.77), p = 0.01). In the final model, artesunate therapy did not significantly improve the outcome as compared to quinine-based therapy (adjOR = 0.53 ; 95%CI(0.16-1.71), p = 0.28).Patients with SM admitted in our ICU after 2013 were less severe than those before 2013. These trends could be partially explained by the increasing proportion of immune patients VFR or living in endemic areas. After adjustment on severity and stratification by period, artesunate was not significantly associated with a better outcome than IV quinine.
  • Clostridium bacteriemia in critically ill patients
    Orateur(s) :
    • Guillaume Morel (Paris / FRANCE)
    • Etienne Ghrenassia (Paris / FRANCE)
    • Moustafa Abdel Nabey (Paris / FRANCE)
    • Julien Mayaux (Paris / FRANCE)
    • Naïke Bigé (Paris / FRANCE)
    • Guillaume Dumas (Paris / FRANCE)
    • Amélie Seguin (Nantes / FRANCE)
    • Bruno Megarbane (Paris / FRANCE)
    • Frédéric Pène (Paris / FRANCE)
    • Yacine Tandjaoui Lambiotte (Bobigny / FRANCE)
    • Anne-Sophie Moreau (Lille / FRANCE)
    • Frédéric Wallet (Lille / FRANCE)
    • Djamel Mokart (Marseille / FRANCE)
    • Muriel Picard (Toulouse / FRANCE)
    • David Rousset (Toulouse / FRANCE)
    14h17 / 14h24
    Abstract : Clostridium species are important agents of anaerobic infections that may be associated with a wide range of severe clinical diseases requiring ICU admission. Data focusing on non difficile Clostridium species bacteriemia in ICU are scarce and rely mainly on case reports. We sought to define the clinical and biological characteristics, risk factors for acquisition, Clostridium ecology and outcomes of non difficile Clostridium species bacteriemia in critically ill patients. This is a multi-centric retrospective cohort study (from 6 ICUs) including all patients diagnosed with non-difficile clostridium bacteriemia between January 2002 and June 2018. Fifty patients were included. Median age was 65 (53-80) years old. For 70% of patients, Clostridium bacteriemia occurred the day of ICU admission. Median Charlson score was 5 (3-7). Underlying conditions included: onco-haematological malignancy (38%), chronic alcohol abuse (28%), diabetes (28%), chronic cardiac failure (24%), obesity (24%), cirrhosis (18%), and chronic kidney injury (12%). First symptoms started the day of ICU admission (median 0 (0-1) day between symptoms and ICU admission). Patients presented with fever in only 25% of the cases, hypothermia in 16%, shock in 83%, coma in 40%, acute respiratory failure in 21%, and cardiac arrest in 26%. Digestive symptoms were presents in 52% cases. At ICU admission, median SAPS II score was 69 (49-91), median SOFA score was 11(8-14). Overall, 85% patients required vasopressors, 81% invasive mechanical ventilation, and 44% renal replacement therapy. Twenty-four percent of patients experienced massive hemolysis. Median serum lactate level was 6mM (3-10). Most of infections (44%) were due to C. perfringens, followed by C. ramosum (10%), C. septicum (10%) and C. tertium (8%). Digestive infection was diagnosed in 62% of the cases, and skin infection in 4% of the cases. Gas gangrene was present in 12% of the patients, and surgery was necessary in 28%. Most of species were sensitive to Penicillin (93%). Two third (66%) of patients died in ICU, and hospital mortality was 80%. In non survivors, median time between ICU admission and hospital death was 1 (0-9) days. Alcohol consumption, diabetes and underlying malignancies are the main risk factors of Clostridium bacteriemia. CLinical manifestations are non specific, but digestive symptoms and hemolysis should alert the physicians. Considering the risk of fulminant course and the high lethality of these infections, adequate antibiotics should be started as soon as the diagnosis is suspected.
  • Management of tetanus in an Intensive Care Unit of Centre Hospitalier Universitaire de Libreville : a ten-years retrospective study
    Orateur(s) :
    • Laurence Essola-Rerambiah (Libreville / GABON)
    14h24 / 14h31
    Abstract : tetanus, an infective non-immunizing disease, is still endemic in many developing countries and is responsible for a high mortality. The aim of our work was to describe the management of patients admitted to the ICU for tetanus.this is a descriptive study based on retrospective analysis done over a 10 years period, from january 2008 to december 2017 in Intensive Care Unit. Included were patients admitted for tetanus. Studied variables were sociodemographic characteristics, clinical, therapeutic and prognostic data.53 out of 3031 patients (1.7%) were admitted for tetanus. Mean nage of patients was 21.2 ± 18.1 years. Showing male predominance with a sex ratio of 2.5. Trismus associated to generalised contractures and spasms was present in 32 patients (60.4%). The port of entry was found in 40 patients (75.5%). The mean score of Dakar was 2.3 ± 0.8. To struggle against spasms and contractures, the combination of magnesium sulfate and diazepam was administered in 33 patients (62.3%). Mechanical ventilation was needed in 17 patients (32,1%). The mean length of hospitalisation was 12.8 ± 8.6 days. The lethality was to 51%. : tetanus a pathology still met in our unit. Its lethality remains high. Intensification of the vaccination campaign in necessary to eradicate this disease.
  • The impact of SOFA score and Lymphocytic alveolitis on predicting prognosis and mortality of pneumocystis pneumonia.
    Orateur(s) :
    • Benjamin Gaborit (Nantes / FRANCE)
    • Benoit Tessoulin (Nantes / FRANCE)
    • Lavergne Rose Anne (Nantes / FRANCE)
    • Florent Morio (Nantes / FRANCE)
    • Christine Sagan (Nantes / FRANCE)
    • Cédric Bretonniere (Nantes / FRANCE)
    • Raphael Lecomte (Nantes / FRANCE)
    • Paul Le Turnier (Nantes / FRANCE)
    • Colin Deschanvres (Nantes / FRANCE)
    • Lydie Khatchatourian (Nantes / FRANCE)
    • Nathalie Asseray (Nantes / FRANCE)
    • Charlotte Garret (Nantes / FRANCE)
    • Mickael Vourch (Nantes / FRANCE)
    • Delphine Marest (Nantes / FRANCE)
    • François Raffi (Nantes / FRANCE)
    • David Boutoille (Nantes / FRANCE)
    14h31 / 14h38
    Abstract : Pneumocystis jirovecii pneumonia (PJP) is associated with higher rates of intubation and mortality in non-HIV immunocompromised hosts. The objectives of our study were the establishment of early risk factors of severe PJP and mortality in non-HIV patients, with a focus on the impact of broncho alveolar lavage (BAL) cytology.We prospectively enrolled patients with PJP admitted to Nantes University Hospital from January 2012 to January 2017. Severity was defined as acute hypoxemic respiratory failure (ARF) with high-flow oxygen use (FiO2≥50% or PaO2/FIO2<150). Factors associated with severity and PJP specific death were analysed by non-parametric tests and logistic regression (univariate and multivariate) in whole population and non-HIV patients.Among the 506 patients with pneumocystis identification, 107 patients met criteria for PJP of whom 53 (49.5%) met criteria of severity, 51 patients required ICU admission, 30 of them requiring mechanical ventilation. Death within 90 days post-admission occurred in 45% of severe vs 9% of non-severe cases (p<0.001). Early risk factors associated with severity were: age >55 years (odds Ratio (OR)=2.6, 95% confidence interval (95%CI)= 1.12-6.3, p<0.02), albuminemia <27g/L (OR= 3.3; 95%CI= 1.25-9, p<0.001), blood neutrophil >6.5G/L (OR=6.5; 95%CI=2.4-20, p<0.001), bronchoalveolar lavage (BAL) neutrophil >12% (5.7; 2-18, p<0.001), BAL PJ positive direct examination (OR=2.8; 1.2-6.9, p=0.01), in the overall cohort. In contrast, HIV positive status (OR=0.33; 95% CI=0.1-1, p=0.05), and alveolitis on BAL (0.3; 0.1=0.8, p=0.01) were protective factors for severity. In multivariate analysis among the non HIV patients, the lymphocytic alveolitis (HR=0.22; 95% CI=0.05-0.94, p=4e-2) was associated with improved prognosis, whereas SOFA score≥ 5 on admission (HR=14; 95% CI=6-36, p=6e-9) was associated with pneumocystosis-specific mortality.The initial severity of pneumocystosis evaluated by SOFA score is a major prognostic factor predictive of the global and specific mortality of pneumocystosis. Age, albuminemia, bronchoalveolar lavage (BAL) neutrophil >12%, BAL PJ positive direct examination and SOFA score ≥5 are associated with severe pneumocystosis with the worst prognosis.
  • Significance and value of candiduria for the early diagnosis of invasive candida infection in a Tunisian intensive care unit
    Orateur(s) :
    • Rania Ammar (Sfax / TUNISIE)
    • Bouattour Abir (Sfax / TUNISIE)
    • Chtara Kamilia (Sfax / TUNISIE)
    • Zekri Manel (Sfax / TUNISIE)
    • Hammami Maha (Sfax / TUNISIE)
    • Ben Hamida Chokri (Sfax / TUNISIE)
    • Mabrouk Bahloul (Sfax / TUNISIE)
    • Ayedi Ali (Sfax / TUNISIE)
    • Mounir Bouaziz (Sfax / TUNISIE)
    14h38 / 14h45
    Abstract : Candiduria is increasingly frequent among patients admitted to intensive care unit.There is no clear discriminating threshold that can predict the occurrence of invasive candidiasis.Purpose: To identify the interest of the yeasts numeration in the urine for the early diagnosis of invasive candidiasis.A prospective study was carried out in Sfax-Tunisia intensive care unit over a period of 4 months (March – June 2016). Selection criteria: Patients included were those having at least one major risk factor or two minor risk factors to develop IC (Table I). Once included in the study, a search for Candida in urine was performed on the 3rd day of hospitalization and then once a week. Patients with candiduria carried a multiple mycological samples from other body sites and blood culture. Pittet index was calculated as well as Candida Score. The diagnosis of invasive candidiasis was made on the basis of the presence of candidemia or after expert advice during daily visits to patients with at least one of the following symptom; fever (>38.5 C) or hypothermia (<36 C), unexplained hypotension or absence of response to adequate antibiotic treatment for a suspected bacterial infection. heighty height patient were included. Candiduria was found in 25 patients (28.4%) and 13 patients had candiduria density > 105 CFU/ml. C. albicans was found in 13 patients. The mean interval between admission and the onset of candiduria was 11.92 ± 16.42 days. Seven patients (7, 9 %) developed candidemia; from whom 5 had a concomitant candiduria. The diagnosis of invasive candidiasis was made in 14 patients (15, 9%). The risk factors to develop invasive candidiasis in patients with candiduria were: renal failure (p = 0.17), candida score > 2.5 points (p = 0.04) and Pittet index > 0.5 (p = 0.01). By logistic regression, only renal failure was the independent factor associated with invasive candidiasis in patients with candiduria (p = 0.02, OR 17.6, 95% CI 1.51 - 203.75). An association candiduria> 105 CFU/ml and a Pittet index > 0, 5 were significantly associated with invasive candidiasis (P = 0.04). The mortality rates were at 37.5 %.Candiduria> 105 CFU/ml in the intensive care patients with several risk factors can predict invasive candidiasis. So a permanent mycological surveillance is widely recommended in order to make the early diagnosis and to start appropriate antifungal therapy.
  • Fungal colonization and infection in critically ill patients: epidemiology and risk factors.
    Orateur(s) :
    • Ghada Sbouii (Kairouan / TUNISIE)
    • Ines Fathalah (Ben Arous / TUNISIE)
    • Sahar Habacha (Ben Arous / TUNISIE)
    • Haifa Fazeni (Ben Arous / TUNISIE)
    • Ameni Sgahier (Ben Arous / TUNISIE)
    • Eya Seghir (Ben Arous / TUNISIE)
    • Asma Mehdi (Ben Arous / TUNISIE)
    • Nadia Kouraichi (Ben Arous / TUNISIE)
    14h45 / 14h52
    Abstract : Fungal infections (FI) had risen and caused significant morbidity and mortality in critically ill patients. Our aims were to describe epidemiology of fungal colonization and infection in patients admitted in medical intensive care unit (ICU), and to determinate their risk factors.Retrospective study carried in an ICU from October 2016 to 15 September 2018. Demographic characteristics of patients and risk factors for fungal infection and colonization were evaluated. The data about epidemiology, patient significant clinical data, surgery, mechanical ventilation, dialysis, central venous catheter, urinary catheter, arterial catheter, total parenteral nutrition, leucopenia, neutropenia, previous antimicrobial therapy or prophylaxis were collected.Twenty-three per cent of the 164 patients enrolled in our study, had fungal infection (25 cases) or fungal colonization (13 patients). Median candida score was three [2;3]. Candida albicans was isolated in 60 % of infections cases and 46,1 % in colonization cases. Candiduria was detected in 40 % and candidaemia was observed in 52 % of patients. Patients who had developed fungal infections had central line insertion in (92 %), prolonged length of stay (76%), prolonged antibiotic therapy (68 %), use of corticosteroids (36 %), and neutropenia (12%). Fluconazole was the first line used antifungal treatment (n=23). Amphotericine B was used in three patients.Median hospital stay was 27 [18; 49] days. Multivariate analysis revealed that catecholamine use was associated with fungal infection and colonization (p=0, 04). Fungal infection and colonization were frequent in our population but only use of catecholamine appeared as a risk factor.
  • Evaluation of antifungal therapy in the ICU: A bi-centre Tunisian cohort.
    Orateur(s) :
    • Nouha Bouker (Monastir / TUNISIE)
    • Zied Hajjej (Tunis / TUNISIE)
    • Zeineb Hammouda (Monastir / TUNISIE)
    • Islem Ouanes (Monastir / TUNISIE)
    • Fahmi Dachraoui (Monastir / TUNISIE)
    • Lamia Ouanes-Besbes (Monastir / TUNISIE)
    • Mustapha Ferjani (Tunis / TUNISIE)
    • Fekri Abroug (Monastir / TUNISIE)
    14h52 / 14h59
    Abstract : Invasive fungal infections are increasingly observed in the ICUs where they concern more specifically the non-neutropenic patients. In the absence of simple and accessible techniques for early microbiological diagnosis, the use of antifungals is steadily increasing, with a more frequent use of echinocandins. Little is known on the extent of the problem and the typology of antifungal prescription in Tunisian ICUs. In this bicentre study, we describe the prescription circumstances of antifungals in 2 Tunisian ICUs. During the study period (2014-2017) all prescription of antifungals were analysed. Analysis concerned demographics, clinical circumstances (history and acute disease, procedures, previous drugs, and life-threatening conditions at the time of antifungal therapy), as well as the basis of antifungal prescribing (targeted vs. preemptive/empiric).112 patients were enrolled in the study (64 men, mean age: 56 ± 18 years) were admitted. Leuconeutropenia was present in 5%, and steroids were administered to 20%. The majority of patients were mechanically ventilated (83%), had central venous line (80%), had either severe sepsis or septic shock (86%), were under large-spectrum antibiotherapy (96%) for more than 3 days (72%). Antifungal treatment was started more often on a preemptive/empiric basis (52%) consisting more often in echinocandins (63%). Prescription of azoles was more often a targeted therapy (70%). Antifungal de-escalation was performed in only 2%. Infection resolved in 42%, and overall mortality was 63%. Antifungal prescription is not exceptional in Tunisian ICUs. The preemptive/empirical prescription based primarily on echinocandins reflects the lack of efficient laboratory support prompting physicians to rely on clinical information.
  • Sepsis uncouples C-peptide and insulin levels in critically ill diabetic patients
    Orateur(s) :
    • Laurent Bitker (Heidelberg / AUSTRALIE)
    • Salvatore Lucio Cutuli (Heidelberg / AUSTRALIE)
    • Luca Cioccari (Heidelberg / AUSTRALIE)
    • Eduardo A Osawa (Heidelberg / AUSTRALIE)
    • Lisa Toh (Heidelberg / AUSTRALIE)
    • Nora Luethi (Melbourne / AUSTRALIE)
    • Helen Young (Heidelberg / AUSTRALIE)
    • Leah Peck (Heidelberg / AUSTRALIE)
    • Glenn Eastwood (Heidelberg / AUSTRALIE)
    • Johan Martensson (Stockholm / SUÈDE)
    • Rinaldo Bellomo (Heidelberg / AUSTRALIE)
    14h59 / 15h06
    Abstract : Critically ill patients with type 2 diabetes have an increased risk of infection. Pro-insulin connecting peptide (C-peptide) has protective immunomodulatory features. Its levels may be affected by the presence of sepsis and exogenous insulin treatment. We aimed to assess how sepsis and exogenous insulin administration affected C-peptide levels and C-peptide to insulin ratio in critically ill diabetic patients.We studied 31 critically ill adults with type 2 diabetes. We measured serum insulin, and C-peptide levels during the first 3 days of ICU stay and recorded daily exogenous insulin dose. We obtained control data in eight volunteers. In patients unexposed to exogenous insulin therapy, we first compared those with sepsis to those without. Then, we compared septic patients unexposed to insulin therapy to those with sepsis treated with insulin. We determined parameters associated with C-peptide levels and C-peptide to insulin ratio, using multivariate linear regression.Sepsis was diagnosed in 22 (44%) patients. Diabetic patients with sepsis had significantly higher C-peptide levels compared to healthy controls (2.5 [1.8; 2.8] vs. 0.5 [0.5; 0.6] nmol/L, p<0.01). Diabetic patients with sepsis had a 5-fold higher C-peptide to insulin ratio compared to controls (48 [33; 72] vs. 10 [10; 13], p<0.01), and a 3-fold increase compared to non-septic patients (17 [12; 35], p=0.01). When exposed to insulin therapy, septic patients had a marked decrease in their C-peptide to insulin ratio, compared to septic patients unexposed to insulin (5 [2; 10], p<0.01). On multivariate analysis, C-peptide levels were significantly and negatively associated with exogenous insulin therapy, and positively associated with serum insulin levels and glucose intake. C-peptide to insulin ratio was significantly and positively associated with sepsis, and negatively with exogenous insulin therapy (p=0.03 and p<0.01, respectively).In type 2 diabetic critically ill patients, sepsis is associated with a marked increase in C-peptide and C-peptide to insulin ratio, implying uncoupling of their relative secretion or clearance or both. This uncoupling, however, was markedly inhibited by the administration of exogenous insulin.
  • Prognostic impact of early adjunctive corticosteroid therapy on pneumocystis pneumoniae in non-HIV patients
    Orateur(s) :
    • Mehdi Assal (Marseille / FRANCE)
    • Jérôme Lambert (Paris / FRANCE)
    • Laurent Chow-Chine (Marseille / FRANCE)
    • Magali Bisbal (Marseille / FRANCE)
    • Luca Servan (Marseille / FRANCE)
    • Frédéric Gonzalez (Marseille / FRANCE)
    • Jean Manuel de Guibert (Marseille / FRANCE)
    • Marion Faucher (Marseille / FRANCE)
    • Antoine Sannini (Marseille / FRANCE)
    • Djamel Mokart (Marseille / FRANCE)
    15h06 / 15h10
    Abstract : While adjunctive corticosteroid therapy has been proven effective in HIV-patients with Pneumocystis Pneumoniae (PCP), data remains unclear and controversial concerning non-HIV related-patients. We evaluated the effects on mortality of early adjunctive corticosteroid therapy in non-HIV PCP-related patients.This retrospective cohort study included patients without HIV with PCP diagnosis admitted in Institut Paoli Calmette, a cancer referral centre, from January-1-2010 to december-31-2016. We compared 30-days and 1-year mortality rate, change in the respiratory item of the Sequential Organ Failure Assessment score (delta SOFA-resp), change in the global SOFA score (SOFA-aggravation) and use of intubation between day-1 and day-5 of anti-pneumocystis therapy, and occurrence of coinfections between early adjunctive corticosteroid recipients within 48 hours (landmark analysis) and late or no corticosteroid recipients, using a naïve and Inverse Probability Weighted in survival analysis (IPW).133 HIV-negative patients with PCP were included (early corticosteroid n=88, late or no corticosteroid n=45). The main underlying conditions were haematological malignancies (n=107, 80,5%), solid tumor (n=27, 20,3%) and stem cell transplantation (n=17, 12,8%). Overall 30-days and 1-year mortality was respectively 24,1% and 58,2%. IPW analysis found no differences on 30-days (HR=1.45, 95% CI [0.7 - 3.04], p=0.321) and 1-year (HR=1.25, CI 95% [0.75 - 2.09], p=0.39) mortality rate between the both groups. In the same way, no differences in delta-SOFA-resp, SOFA-aggravation, use of intubation and occurrence of coinfections were found between the both groups.The addition of early adjunctive corticosteroid to anti-pneumocystis therapy in non-HIV patients with PCP was not associated with improved outcomes concerning 30-days and 1-year mortality and respiratory evolution. Further studies are needed to evaluated this therapeutic strategy.
E-Poster
14h10 - 15h10
Espace poster 3
Médecin : Infections communautaires
Modérateur(s) : Saad Nseir (Lille / FRANCE), Jean-Pierre Bedos (Versailles / FRANCE)
  • Diagnostic Accuracy of PCR and B-D-glucan for the diagnosis of pneumocystis jirovecii pneumonia in immunocompromised patients with acute respiratory failure (ARF)
    Orateur(s) :
    • Laure Calvet (Paris / FRANCE)
    • Virginie Lemiale (Paris / FRANCE)
    • Audrey de Jong (Montpellier / FRANCE)
    • Lionel Kerhuel (Paris / FRANCE)
    • Etienne Ghrenassia (Paris / FRANCE)
    • Sandrine Valade (Paris / FRANCE)
    • Bertrand Souweine (Clermont-Ferrand / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    14h10 / 14h17
    Abstract : Accuracy of a test depends on its intrinsic characteristics (sensitivity and specificity) and of disease prevalence. These parameters are uncommonly taken into account when assessing diagnostic accuracy (1,2). To illustrate this relationship in non-HIV patients with pneumocystis pneumonia, whose prevalence is low and where available diagnostic tests have high intrinsic performance. This study aims to assess post-test probability of pneumocystis pneumonia, according to results of PCR and BDG tests in non-HIV patients with ARF.A systematic review was performed to assess diagnostic performance of PCR and Beta-D-Glucan (BDG). Prevalence of Pneumocystis pneumonia was assessed in a dataset of 2243 immunocompromised patients with ARF using supervised classification tree. Prevalence of pneumocystis pneumonia was simulated using r software and assuming a normal distribution in 5000 subjects on the basis of previously observed prevalence. Post-test probability was assessed using Bayes theorem. Analyses were performed using R software. Prevalence of pneumocystis pneumonia in ARF patients was 4.1% (95% CI 3.3-5). Supervised classification identified 4 subgroups : Patients without ground glass opacities (prevalence 2.0%; 95% CI 1.4-2.8), those with ground glass opacities but a) with prophylaxis (Prevalence 4.9%; 95% CI 1.6-11), b) without prophylaxis (Prevalence 10.0%; 95% CI 6.4-14.7), and c) without prophylaxis and with lymphoid malignancy or stem cell transplantation (Prevalence 20.2%; 95% CI 14.1-27.7). In the overall population, positive predictive value (PPV) was 32.9% (95%CI 31.1-34.8) and 22.8% (95%CI 21.5-24.3) for PCR and BDG respectively. Negative predictive value was low (0.10% (95% CI 0.09-0.11) and 0.23% (95%CI 0.21-0.25)) for PCR and BDG respectively. In the highest risk subgroup, PPV was 74.5% (95%CI 72.0-76.7) and 63.8% (95%CI 60.8-65.8) for PCR and BDG respectively. Although both PCR and BDG yield a high intrinsic performance, the low incidence of pneumocystis pneumonia translates into limited PPV, even in the highest risk group. Our results underline the need for adequate pre-test probability assessment. They suggest a method to illustrate pre and post-test probability relationship that may improve perception of diagnostic test performance in patients with predefined clinical vignette.
  • Microbial prediction of community-acquired pneumonia: can physicians or a data-driven method differentiate viral from bacterial pneumonia at the patient presentation?
    Orateur(s) :
    • Claire Lhommet (Tours / FRANCE)
    • Denis Garot (Tours / FRANCE)
    • Cassandra Jourdannaud (Tours / FRANCE)
    • Christophe Faisy (Suresnes / FRANCE)
    • Grégoire Muller (Orleans / FRANCE)
    • Emmanuelle Mercier (Tours / FRANCE)
    • Sylvie Robert (Tours / FRANCE)
    • Philippe Lanotte (Tours / FRANCE)
    • Alain Goudeau (Tours / FRANCE)
    • Helene Blasco (Tours / FRANCE)
    • Antoine Guillon (Boston / ETATS-UNIS)
    14h17 / 14h24
    Abstract : Severe community-acquired pneumonia (sCAP) requires urgent and specific antimicrobial therapy. However, few diagnostic tools are available to diagnose the responsible pathogens when the anti-infective therapeutics must be initiated. Finally, we questioned our ability to predict the microbial etiology of sCAP within the first hours of hospitalization. As emerging evidences recently suggested that artificial intelligence-derived methods could efficiently assisted medical decision process, we wondered if mathematical model of diagnostic prediction could be more efficient than evaluation made by experimented physicians. The objective of this study was to compare the ability of a panel of experts and a mathematical model to predict the microbial etiology of sCAP. We conducted a prospective non-interventional study. First, we included patients hospitalized for sCAP in ICU and recorded clinical/paraclinical data available in the three first hours of care. Final microbial diagnosis was established from microbiological examinations including bacterial cultures and multiplex PCR on respiratory fluids. sCAP with mixed etiology or without microbiological documentation were excluded. Second, we built a mathematical model of prediction (Random Forest method with LOOCV) using all data initially collected. Finally, an independent sample of the study population was used to test the performance of the pathogen prediction by: (i) a panel of 3 experts, (ii) the mathematical algorithm. Both were blind regarding the microbial diagnosis. Positive likelihood ratio (LR+) >10 and negative LR <0.1 were considered clinically relevant. We included 153 patients with sCAP (70,6% men; mean age, 62 [51-73] years; mean SAPSII, 37 [27-47]). Responsible pathogens were: 37% viral, 24% bacterial, 20% mixed etiology and 19% unidentified. The data-driven approach defined five items to create the final mathematical model: BMI, systolic blood pressure, symptom-to-hospitalization time and procalcitonin. Neither the experts nor the algorithm were able to predict the responsible pathogens of the pneumonia. Discriminant abilities of the algorithm were moderate to low (LR+ = 2.12 for viral and 6.29 for bacterial pneumonia) and discriminant abilities of experts were low to very low (LR+ = 3.81 for viral and 1.89 for bacterial pneumonia).Our study shows that neither experts nor mathematical algorithm can predict the microbial etiology of sCAP within the first hours of hospitalization while there is an urge to define anti-infective therapeutic strategy. Our results highlight the need of developing point-of-care tests for rapid microbial diagnosis.
  • Staphylococcus aureus community-acquired bacteriuria in Emergency Department: warning marker for infective endocarditis
    Orateur(s) :
    • Thomas Lafon (Limoges / FRANCE)
    • Lucie Lavaud (Limoges / FRANCE)
    • Ana Catalina Hernandez Padilla (Limoges / FRANCE)
    • Arthur Baisse (Limoges / FRANCE)
    • Olivier Barraud (Limoges / FRANCE)
    • Thomas Daix (Limoges / FRANCE)
    • Marine Goudelin (Limoges / FRANCE)
    • Bruno Evrard (Limoges / FRANCE)
    • Bruno François (Limoges / FRANCE)
    • Philippe Vignon (Limoges / FRANCE)
    14h24 / 14h31
    Abstract : Urinary tract (UT) infection is a frequent diagnosis at the Emergency Department (ED). Staphylococcus aureus (Sa) is an uncommon isolate in urine cultures (0.5–6% of positive urine cultures) and is more frequent in population with risk factors for UT colonization. In the absence of urological invasive procedures or risk factors for Sa colonization, community-acquired Sa bacteriuria may be related to deep-seated Sa infection with septic embolisms and could be considered as trigger symptom. This cohort study aims to assess the prevalence of Infective Endocarditis (IE) in patients with community-acquired Sa bacteriuria in ED.We conducted a prospective single-center study from April 2017 to July 2018. All patients admitted in the ED with Sa bacteriuria (104 CFU/ml Sa isolated from a single urine sample) and without risk factors for UT colonization (i.e., <1 month UT surgery, UT catheterization) were included. Blood cultures were collected in patients with clinical symptoms of infection (SIRS criteria) for concomitant bacteremia (72h). In this case, transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) were performed. Diagnosis of IE was based on the Duke criteria.During the study period, 56 patients with Sa bacteriuria were identified in the ED. After excluding patients with risk factors of UT colonization (UT catheterization n=13, UT surgery n=5), 38 patients were included (27 men; 68 [IQR: 44-80] years-old). Twenty-two patients had clinical symptoms of infection; 7 of them with UT infection. Eleven patients had concomitant Sa bacteremia and TTE or TEE was performed in 10 patients which confirmed IE in 9 patients. IE affected essentially the left heart with the mitral and aortic valves involved. Sa bacteriuria was identified significantly earlier before IE diagnosis with a mean difference of 3 days. Among Duke minor criteria, 89% of patients had septic emboli, 56% fever and 33% predisposing heart condition. The 28-day mortality was 67%.In the absence of risk factors, community-acquired Sa bacteriuria should not be interpreted as an isolated UT infection, but as an early warning of IE, and requires further explorations to accurately and timely begin antibiotic treatment.
  • Unusual bacterial epidemiology of community-acquired bacterial meningitis admitted to intensive care units in the French West Indies
    Orateur(s) :
    • Ulrich Clarac (Les Abymes / GUADELOUPE)
    • Pascale Piednoir (Pointe-À-Pitre / FRANCE)
    • Amélie Rolle (Abymes / FRANCE)
    • Frédéric Martino (Pointe-À-Pitre / FRANCE)
    • Hossein Mehdaoui (Fort-De-France / FRANCE)
    • Sébastien Breurec (Les Abymes / GUADELOUPE)
    • Sylvaine Bastian (Les Abymes / GUADELOUPE)
    • Michel Carles (Pointe-à-Pitre / FRANCE)
    14h31 / 14h38
    Abstract : Spontaneous community-acquired bacterial meningitis (CABM) are rare and of poor prognosis. CABM epidemiology has never been studied in the French West Indies. Thus, we assessed clinical and microbiological characteristics, and outcome of spontaneous CABM in adults requiring admission to intensive care units (ICUs) in French West Indies.Charts of consecutive patients over 18 years old requiring admission to ICUs for CABM in Guadeloupe and Martinique from January 1st, 2012 to December 31th, 2017 were retrospectively analyzed. Patients having meningitis clinical signs and positive bacterial cerebrospinal fluid cultures were included. Data are given in absolute values, percentage or median values [Q1-Q3]. Chi-2 or Mann Whitney tests were used if required. The study protocol was approved by the local ethical committee.During the study period, 25 cases of CABM were identified, due to Streptococcus pneumoniae (n=7; 28%), Klebsiella pneumoniae (n=6; 24%), Staphylococcus aureus (n=5; 20%), Escherichia coli (n=2; 8%), Neisseria meningitidis B (n=2; 8%) Streptococcus spp (n=1; 4%), Pseudomonas aeruginosa (n=1; 4%), Escherichia coli + Streptococcus spp (n=1; 4%). All strains had a wild-type phenotype of antibiotic resistance. All patients were febrile, with neurologic signs (headache 56%, stroke 20%, nuchal stiffness 52%, Glasgow coma scale alteration 10 [9-14]). The median IGS score was 56 [36-57]. The hospital mortality rate was 52%. Patients stayed in ICUs for 10 [3-17] days, requiring mechanical ventilation for 72% of cases. Interestingly 4/5 Staphylococcus aureus CABM were associated with endocarditis. Whatever the bacteria, bacteraemia occurred frequently, i.e. 72% of cases, associated in 4 cases with abscesses. Initial therapeutic regimen was a third-generation cephalosporin (n=24) alone (n=15) or in combination with an aminoglycoside (n = 5), and/or an aminopenicillin (n = 7); an aminopenicillin alone (n=1). In comparison to other CABM (Staphylococcus aureus endocarditis excluded), Klebsiella pneumoniae CABM (n=6) had no specific clinical presentation (p=ns).Conversely to the epidemiology of CABM in Europe and North America, we found a high incidence of Klebsiella pneumoniae as causative microorganisms of CABM among French West Indies population. This epidemiology could be related to the specific bacterial ecology in the Caribbean area. Clinical presentation and outcome seems to be similar whatever the involved bacteria.
  • Pleural Empyema in medical ICU patients
    Orateur(s) :
    • Dhouha Lakhdher (Ariana / TUNISIE)
    • Mohamed Slim Amri (Ariana / TUNISIE)
    • Ghassen Ben Amor (Ariana / TUNISIE)
    • Amira Jamoussi (Ariana / TUNISIE)
    • Samia Ayed (Ariana / TUNISIE)
    • Jalila Ben Khelil (Ariana / TUNISIE)
    • Mohamed Besbes (Ariana / TUNISIE)
    14h38 / 14h45
    Abstract : The clinical presentation of pleural empyema depends upon many factors including the causative infectious agent. Patients with pleural empyema admitted in ICU often present a life threatening complication like respiratory failure or septic shock. The aim of this work was to study the bacteriological profile, the clinical presentation, causes of pleural empyema in MICU and its effect on patient outcomes. We conduced a retrospective, mono-centric and observational study. During eight years period, from April 2010 to July 2018, case notes of patients diagnosed with pleural empyema were reviewed. The following data were collected: clinical informations,severity upon admission, micro-organisms ,treatment and outcome. In total, 42 cases were included; the sex ratio was 2,5. The median age was 40 years old [29;59,5]. Median severity scores were 9 [4,5;19] for APACHE II and 26,5 [16;36] for SAPS II . Most of patients had an acute respiratory failure at the time of admission 76,2% (n=32) and quite all of them (n=41) had an associated pneumonia. Nine patients presented a septic shock and the median rate of lactates was 3,1[1,99;6,67]. Most of pleural empyema cases were suspected by ultrasound 40,5%(n=17), then by X chest ray 37,7%(n=15) then by CT scan 23,8% (n=10). Macroscopic presence of pus was noted in 25 patients (59,6%). We found negative pleural-fluid cultures in 52,4% of patients (n=22), Alpha-hemolytic Streptococcus in ten patients, Klebsiella pneumoniae in two and anaerobic bacteria in three. Drainage of pleural content was performed in 36 patients, 23 had chest drain, three had thoracentesis and ten had both. The median duration of drainage was five days[2,75;9,25]. Eleven patients required invasive mechanical ventilation (26,2%). Most of cases were treated by clavulanic acid + amoxicillin (n=26). Intrapleural fibrinolytic therapy was performed in 15 cases(35,7%). Most of patients 69%(n=29) fully recovered from pleural empyema. The median duration stay in ICU was nine days[3,75;14,25]. Pneumonia was the main cause of pleural empyema. A high SAPS score, a bilateral pneumonia and the presence of septic shock were correlated with a high mortality. Lung abscess and duration of stay in ICU were not correlated to mortality.
  • Predictors factors of mortality during spontaneous bacterial peritonitis with cirrhosis
    Orateur(s) :
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Sana Khedher (Tunis / TUNISIE)
    • Ameni Khaled (Ariana / TUNISIE)
    • Mohamed Salem (Ariana / TUNISIE)
    14h45 / 14h52
    Abstract : Spontaneous bacterial peritonitis (SBP) is serious complication of cirrhosis. Despite standard treatment, mortality remained high. We aimed to evaluate the predictors for the mortality in patients with SBP. It's a retrospective work, carried out over a year. Consecutive patients with approved SBP admitted in our department are included. All clinical and biological data were collected from the medical records. Univariate and multivariate analysis were used to identify the associated factors of death.A total of 64 patients diagnosed with SBP and cirrhosis were enrolled in this study. Mean of age was 62.05 (18-88). Sex ratio = 1. HCV (39%) was the main etiology of cirrhosis. at least one complication occurred during the evolution in 32.8%. The septic shock was found in12.5%. six patients died of SBP (9.4%). There were no significant differences in the sex, aetiology of cirrhosis, ascites abundance, receiving prophylactic antibiotics between the surviving group and the patients who died. However there was a statistically significant association between mortality and onset of complication (P= 0.00), low systolic (P=0.003) and diastolic blood (P= 0.000) pressure and tachycardia ((P=0.005) at admission. empiric antibiotic therapy was statically a preventive factor (P = 0.039). SBP is a serious event in the history of cirrhotic disease. Particular caution must be exercised with regard to any state of hemodynamic instability present at admission. adequate empirical treatment would improve prognosis.
  • Intra-Abdominal Infections in ICU patients (ICUBE) : Epidemiology and Risk Factors for Isolation of Multi-Drug-Resistant Organisms, a preliminary study
    Orateur(s) :
    • Olivier Martin (Bobigny / FRANCE)
    • Nicolas Bonnet (Bobigny / FRANCE)
    • Françoise Jaureguy (Bobigny / FRANCE)
    • Johanna Oziel (Bobigny / FRANCE)
    • Guillaume Van Der Meersch (Bobigny / FRANCE)
    • Yacine Tandjaoui Lambiotte (Bobigny / FRANCE)
    • Florent Poirson (Bobigny / FRANCE)
    • Philippe Karoubi (Bobigny / FRANCE)
    • Yves Cohen (Bobigny / FRANCE)
    14h52 / 14h59
    Abstract : Intra-abdominal infection (IAI) is a common cause of hospitalization in intensive care unit (ICU). The epidemiology of the microorganism depends mainly on the patients bacterial flora causes and risk factors for multi-drug-resistant organisms (MDROs) are difficult to identify. French expert advises have been published but few French studies have investigated the epidemiology of community and nosocomial-acquired IAI and more specifically the incidence of MDROsWe perform a prospective epidemiological multi-center study and included all consecutively hospitalized adult patients with IAI requiring a hospitalization in ICU. Cultures were performed on blood simple and intra-operative samples of peritoneal fluid or purulent exudate/discrete abscesses. We evaluate the epidemiology and the factors associated with the isolation of a MDRO in enrolled patientsAmong 48 patients included in the study, a total of 62 micro-organisms were isolated from intra-peritoneal fluid and blood samples; in 56.3% of cultures, two or more pathogens were identified and in 5% candida spp. were identified. The MDROs represented 9.9% of the total of isolated microorganisms. Among this patients, 75% of MDROs colonization was found before or just after surgery and 25% were acquired during hospitalization. The MDROs were more frequently isolated in patients with health-care-associated IAIs (25.4%). Uninominal logistic regression analysis of risk factors demonstrated that statistically significant risk factors independently associated with the occurrence of MDROs IAI were previous know carrying at MDROs and antimicrobial therapy administered within 3 month before operationThe study showed that MDROs represented a tenth of IAI and knowledge of previous colonization by MDROs or previous antibiotherapy within 3 month might guide to identify patients with IAIs caused by MDROs and therefore permit to introduce adequate empiric antimicrobial therapy
  • Improvement of patient outcomes following centralization of toxic epidermal necrolysis management
    Orateur(s) :
    • Florine Richeux (Lyon / FRANCE)
    • Laure Fayolle-Pivot (Lyon / FRANCE)
    • Marc Bertin-Maghit (Lyon / FRANCE)
    • Olivier Martin (Lyon / FRANCE)
    • Benoit Bensaid (Lyon / FRANCE)
    • Julien Textoris (Lyon / FRANCE)
    • Thomas Rimmele (Lyon / FRANCE)
    14h59 / 15h06
    Abstract : Toxic Epidermal Necrolysis (TEN) is a very rare cutaneous disease (2 cases per million and per year worldwide) but potentially fatal. Morbidity is also high with the persistence of long-term sequelae (ophthalmological and psychological mainly). In November 2016, an Auvergne-Rhone-Alpes reference center was implemented in order to centralize and optimize the care of these patients. The ultimate goal of this initiative was to improve patient outcomes. The aim of this study was to assess the impact of the implementation of this centralized network on patient outcomes. Two groups of patients were compared: the first one from November 2012 to October 2016 before the implementation of the centralized network of care and the second one after the centralization of care, from November 2016 to December 2017. All patients suffering from TEN in the Auvergne-Rhone-Alpes area were included. The primary endpoint was procedural pain assessed by visual analogue scale (VAS). The secondary endpoints were patient recruitment, need for general anesthesia for wound treatment, treatment duration, ICU and hospital length of stay, secondary infection rate, mortality rate at day 28, proportion of patients lost to follow-up at three months, and reported sequelae. Observed mortality was compared to that predicted by SCORTEN tool. Statistical analysis: Student or Wilcoxon test were performed for continuous variables and Chi-2 or Fisher test were performed for qualitative variables p value <0.05 was considered statistically significant. 7 patients were enrolled before and 14 patients after centralization. Demographic characteristics were similar between groups. All results are presented in table 1. No fatality has occurred in the aftercare centralization whereas expected mortality according SCORTEN tool was about 35%. Centralized care of TEN in a reference center led to significant reduction of procedural pain. That seems to decrease too treatment duration, ICU and hospital length of stay, morbidity and mortality. These results are most likely due to the optimization of the patient's course and the growing experience of the caregivers. In our opinion, the increased number of reported sequelae may highlight the under-diagnosis of these complications during the pre-centralization period.The implementation of centralized medical care of TEN in a referrence center leads to a significant decrease of procedural pain for patients, improving their comfort thanks to an experienced team.
E-Poster
14h10 - 15h10
Espace poster 5
Médecin : Insuffisance rénale aiguë
Modérateur(s) : Christophe Vinsonneau (Béthune / FRANCE), Frédérique Schortgen (Créteil / FRANCE)
  • Prediction of acute kidney injury using conventional and novel biomarkers in critically ill patients
    Orateur(s) :
    • Laurent Bitker (Heidelberg / AUSTRALIE)
    • Salvatore Lucio Cutuli (Heidelberg / AUSTRALIE)
    • Lisa Toh (Heidelberg / AUSTRALIE)
    • Intissar Bittar (Heidelberg / AUSTRALIE)
    • Glenn Eastwood (Heidelberg / AUSTRALIE)
    • Rinaldo Bellomo (Heidelberg / AUSTRALIE)
    14h10 / 14h17
    Abstract : Acute kidney injury (AKI) is a rapidly evolving condition, requiring early identification. Urine output and serum creatinine levels are conventional markers of renal function that could help improve AKI detection if measured more frequently. AKI early identification may also be enhanced by measuring urinary tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7). We aimed to assess the performance of conventional and novel biomarkers in predicting AKI in a general ICU population.In this prospective study, we enrolled 96 critically ill adults at risk of developing AKI. We excluded patients with stage 2 or 3 AKI at enrollment. We reported urine output (UO6H) and changes in serum creatinine (sCr6H), measured over the 6 hours preceding inclusion. Urinary levels of TIMP-2 and IGFBP-7 were measured at inclusion. We computed a composite risk score as the ratio of log(sCr6H) to UO6H. AKI was defined as the presence of KDIGO stage 2 or 3 AKI, occurring within 12 hours of inclusion. Biomarkers' performance was expressed using the area under the receiver operator characteristics (AUROC) with 95% confidence interval.AKI occurred in 32 (33%) patients. At inclusion, UO6H was significantly lower, and sCr6H was significantly higher in patients with AKI, compared to non-AKI patients (0.4 [interquartile range, 0.3 to 0.7] mL/kg/h vs. 0.8 [0.5 to 1.1] mL/kg/h; and +10 [+3 to +23] µmol/L vs. +2 [-2.5 to +8] µmol/L). AKI risk prediction of UO6H was fair (AUROC: 0.76 [0.65; 0.86]), and poor using sCr6H (AUROC: 0.69 [0.57; 0.82]). TIMP-2•IGFBP-7 was significantly higher in patients with AKI, compared to those without (0.9 [0.4; 1.8] (ng/mL)2/1000 vs. 0.3 [0.1; 0.7] (ng/mL)2/1000). It had an AUROC to predict AKI of 0.72 [0.62; 0.83]. The composite risk score showed the best AKI risk predictive performance, with an AUROC of 0.80 [0.70;0.90].Combining short-termed urine output with changes in serum creatinine showed good performance for the prediction of AKI in a general ICU population. Our preliminary results suggest that conventional indicators of renal function, if measured 6-hourly, are equivalent to more recent AKI biomarkers.
  • Predicting kidney dysfunction from arterial blood pressure during early septic shock
    Orateur(s) :
    • Karama Bouchala (Sfax / TUNISIE)
    • Rania Ammar (Sfax / TUNISIE)
    • Emna Nouri (Ben Arous / TUNISIE)
    • Hela Kallel (Sfax / TUNISIE)
    • Sabrine Bradai (Sfax / TUNISIE)
    • Mabrouk Bahloul (Sfax / TUNISIE)
    • Olfa Turki (Sfax / TUNISIE)
    • Kamilia Chtara (Sfax / TUNISIE)
    • Chokri Ben Hamida (Sfax / TUNISIE)
    • Hédi Chelly (Sfax / TUNISIE)
    • Mounir Bouaziz (Sfax / TUNISIE)
    14h17 / 14h24
    Abstract : Acute kidney injury (AKI) is a frequent and serious complication in intensive care unit (ICU) patients. Many studies have already demonstrated that sepsis and septic shock are the most important causes of AKI in critically ill patients. There is strong evidence that AKI in septic shock was associated with an important disorders in hemodynamic parameters. Despite extensive research in this field, only few studies identified a target hemodynamic status in patients with septic shock to improve kidney function. Objective: to determine the value of mean arterial blood pressure leading to acute kidney failure during early septic shock and factors associated with mortality. We conduct a prospective study during 6 months (from January to August 2018) including all patients presented septic shock. Patients with cardiogenic or/and hypovolemic shock were excluded. We analyzed demographic characteristics, comorbidities, SAPSII score, respiratory, hemodynamic and neurological parameters, use of noninvasive or invasive ventilation, the impact of hemodynamic status on kidney function, length of stay and mortalityWe include 43 patients, sex ratio was 2.02, and SAPSII at admission averaged 52 ± 14 points. Thirty-seven percent of cases were admitted for respiratory distress. AKI was developed in 74.4%. Multivariable logistic regression analysis revealed that development of septic AKI was associated with older age, pre-existing chronic kidney disease, low mean arterial pressure (MAP) in septic shock day and in 24 hours later. The ROC curve showed that AKI was developed in patients with MAP in septic-shock-day under 53 mmHg and under 75 mmHg 24 hours later. In our study, incidence of AKI was higher in patients whom didn't receive fluid resuscitation (27 vs 5; p= 0,01). Mortality rates was higher in AKI group (p=0, 01). The coexisting AKI, septic myocarditis and septic cholestasis was associated with a low outcome. The development of septic AKI is associated with poor clinical outcomes. Prevention and attenuation of septic AKI need a good fluid management and hemodynamic status adjusting. Despite large researches, the incidence and the mortality of septic AKI are high. Extensive studies to have best histopathologic information may be needed to a better management of kidney dysfunction in patient with septic shock.
  • Evaluation of Sodium flux during hemodialysis and hemodiafiltration treatment of ICU acute kidney injury: Effects of dialysat Na concentration at 140 and 145 mmol/l
    Orateur(s) :
    • Aurèle Buzancais (Nimes / FRANCE)
    • Vincent Brunot (Montpellier / FRANCE)
    • Kada Klouche (Montpellier / FRANCE)
    14h24 / 14h31
    Abstract : Acute kidney injury (AKI) requiring renal replacement therapy (RRT) occurs in 5 to 6% of critically ill patients and is associated with high mortality. Higher sodium (Na) dialysate concentration (145 to 150 mmol/l) is recommended in order to improve intradialytic hemodynamic tolerance but may lead to sodium loading to the patient. Fluid overload has been associated with adverse ICU outcome. We aimed therefore to evaluate the flux of sodium according to 2 Na dialysat concentrations : 140 and 145mmol/L during hemodialysis (HD) and hemodiafiltration (HDF) sessions in ICU AKI patients. All AKI patients requiring RRT were included prospectively in the study. Each patient underwent consecutive HD and HDF sessions with Na dialysate concentrations at 140 and 145 mmol/l. Sodium concentrations were measured in plasma before and after sessions and in affluent and effluent fluids. Flux of sodium during RRT sessions was estimated using mean sodium logarithmic concentration including diffusive and convective influx. We compared flux of sodium between HD 140 and 145, and between HDF 140 and 145 mmol/l Na concentration dialysateFour-teen patients entered the study with KDIGO3 AKI mostly septic of origin. Almost all of the patients required need vasopressor drugs (71%) and mechanical ventilation (79%). They underwent 39 RRT sessions : 9 HD140, 10 HDF 140, 9 HD145 and 11 HDF145. A negative Na gradient from the dialysate/replacement fluid to the patient was observed with each technique and each dialysate sodium concentration inducing a fluid overload. The comparison of HD 145 to HD 140 and HDF 145 to HDF 140 showed that higher Na dialysat induced a significant higher flux of Na to the patient and consequently fluid overload (Table). ICU mortality rate was around 30% and survived patients have a mean creatinine clairance at 38,3ml/min/1,73m2 at ICU discharge.Our study showed that during RRT a substantial Na loading occured and this Na loading increased significantly with elevated Na dialysate concentration from 140 to 145 mmol/l . Clinical and intradialytic hemodynamic tolerance of increased Na dialysate needs however to be further studied and analyzed.
  • Sodium disorders in medical intensive care : who's the friend and who's the foe ?
    Orateur(s) :
    • Hanane Ezzouine (Casablanca / MAROC)
    • Amine Raja (Casablanca / MAROC)
    • Boutaina Labib (Casablanca / MAROC)
    • Amine Korchi (Casablanca / MAROC)
    14h31 / 14h38
    Abstract : Sodium disorders are frequent among intensive care unit patients.We aimed to determine the characteristics and the prognostic factors of the patients who developed sodium disorders in intensive care We conducted a retrospective study for one year in the medical intensive care unit, of Ibn Rushd hospital in Casablanca-Morocco.The epidemiological, clinical, and therapeutic data were collected, studying two categories of patients, those who presented hyponatremia or hypernatremia in intensive care unitThe incidence of hyponatremia was 28.31%. the average age of the patients was 42 years. 36,46% were admitted for respiratory diseases .The mean APACHE II was at 9.9; SAPS II was at 29.21. The mean Charlson comorbidity index was 1.74 .70% of patients experienced early hyponatremia (by day 5).40.6% of patients had mechanical ventilation, 71.9% had received antibiotics. The use of vasoactive drugs was necessary in 22.9% of cases. 36.5% of patients received diuretics, 18.8% received corticoids. 25% of patients received sodium supplementation .The outcome was favorable in 62.5%. The incidence of hypernatremia was18.28%. The average age of the patients was 43years .Endocrine pathology is the main reason for hospitalization .The mean APACHE II 12.39; SAPS II 32.18 and OSF 3.88.The mean Charlson comorbidity index was 4.41.29% of patients experienced early hypernatremia (by day 5). 51.6% of patients had mechanical ventilation, 79% had received antibiotics. Vasoactive drugs were necessary in 29% . 22.60% of patients received diuretics .The outcome was favorable in 59.4%. For patients who presented hyponatremia, the factors associated with mortality were APACHE II scores, reason for admission, oxygen saturation, degree of severity of the hyponatremia, hepatic function , low serum albumin , hyperfibrinigenemia,mechanical ventilation, antibiotics, vasoactive drugs, , blood transfusion and sedation,length of stay, nosocomial infection. For patients who had hypernatremia,the prognosis factors were sex gender , APACHE II score, oxygen saturation, length of stay, severity of hypernatremia, hepatic dysfunction , anemia, low serum albumin,sedation, antibiotics, vasoactive drugs, , blood transfusion Sodium disorders are associated with a high mortality risk. Among patients who presented hyponatremia, APACHE II and SAPS II scores, early hyponatremia, mechanical ventilation, antibiotics, vasoactive drugs, corticoids, blood transfusion and sedation, length of stay, nosocomial infection and sepsis were predictive factors of mortality. On the other hand, low serum albumin, sedation and APACHE II score were associated with mortality among patients who had hypernatremia.
  • Efficacity and tolerance of sustained low-efficiency dialysis (SLED) with calcium free citrate-containing dialysate anticoagulation
    Orateur(s) :
    • Clara Vigneron (Paris / FRANCE)
    • Juliet Schurder (Paris / FRANCE)
    • Eric Rondeau (Paris / FRANCE)
    • Adrien Joseph (Paris / FRANCE)
    • Christophe Ridel (Paris / FRANCE)
    • Matthieu Jamme (Paris / FRANCE)
    • Cédric Rafat (Paris / FRANCE)
    14h38 / 14h45
    Abstract : SLED is a hybrid technique using intermittent hemodialysis (iHD) equipment with lower blood and dialysate flows along with longer dialysis sessions (DS). It has gained popularity as it may allow for more efficient ultrafiltration (UF) and enhanced hemodynamic tolerance in the setting of major fluid overload. Regional citrate anticoagulation (CA) has emerged as the preferred anticoagulation technique in continuous replacement therapy thanks to decreased bleeding risk and increased extracorporeal circuit (ECC) lifetime but at the expense of an augmented risk of metabolic disorder. Herein we describe modified protocol using dialysate as a source of CA.Patients hospitalized in a single center nephrological intensive care who required prolonged DS with UF were included over a 6 months period. Patients treated with curative anticoagulation were excluded. Clinical, biological and metabolic characteristics and coagulation scores were collected. Patients had alternatively iHD during 4h or SLED during 6h. During iHD, we prescribed 250 to 300 mL/min blood flow with a 500 mL/min dialysate flow while during SLED, we used respectively 250 ml/min, 300 ml/min. UF was left at the physician's discretion. The dialysate composition was: potassium 3 mmol/L, sodium 139,75 mmol/L, magnesium 0.5 mmol/L, calcium 0 mmol/L, citrate 0.8 mmol/L and glucose 1 g/L. Calcium and magnesium infusion rates were based on ionic dialysance following a chart previously devised for standard iHD sessions.38 DS prescribed for 4 patients were analysed: 16 iHD, 22 SLED. Weight loss over 24h was significantly increased after SLED (2.25L[1.25; 3]) compared to iHD (0L[0;1.])(p=0.001). Concerning safety, there was no difference of ionized calcium (iCa) measured every hour during the session without citrate overload (table 1). Levels of sodium, magnesium, potassium, phosphate, bicarbonate and anion gap after session were not different. There was no difference regarding pressure profile evolution and early interruption of dialysis or UF, despite higher UF with SLED. iCa measurements from the dialyzer outlet were consistently below the predefined threshold of 0.4 mmol/L. We observed higher scores of membrane clotting but not of ECC clotting with SLED. No bleeding event was observed.SLED using a modified dialysate as a source of CA appears to be a safe and efficient technique to provide UF. It may represent a useful renal replacement therapy in patients with major fluid overload and a high bleeding risk.
  • Management of acute renal failure in severe malaria in children at the Centre Hospitalier Universitaire de Libreville
    Orateur(s) :
    • Laurence Essola-Rerambiah (Libreville / GABON)
    14h45 / 14h52
    Abstract : Acute renal failure is a rare complication of severe malaria in children. The aim of this study was to evaluate the therapeutic management in our context.We have realized an observational, transverse and descriptive study over a 21 months, (January 1st 2015 to September 30, 2017) at the Pediatric Emergency Department and Intensive care unit of the Centre Hospitalier Universitaire de Libreville. All patients having acute renal failure with positive thick film, were included in this study. Studied variables included social and demographic data, clinical, paraclinical, therapeutic and prognostic data.during the study period 1629 patients (35%) were admitted for management of malaria. Among them 12 (0.7%) patients, 6 boys (50%) and 6 girls (50%) presented with acute renal failure due to malaria. Mean age was 102.2 ± 66.7 months. Renal Replacement Therapy, indicated for all patients, was effective in 4 patients (33.3%). Hemodialysis was the only technique used. The mean duration of hospitalization was 10.8 ± 4.3 days and mortality was 33.3%. This study have shown that acute renal failure complicating severe malaria in children is really rare and that renal replacement therapy is only feasible in older children (≥ 11ans). It is essential to improve the facilities for managing children.
  • Cardio renal syndrome and acute exacerbation of COPD (AE/COPD): An ignored combination?
    Orateur(s) :
    • Wafa Zarrougui (Sousse / TUNISIE)
    • Sameh Ben Farhat (Sousse / TUNISIE)
    • Jihene Mahmoud (Sousse / TUNISIE)
    • Rafla Ben Dabebiss (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Said Kortli (Sousse / TUNISIE)
    • Ahmed Seghaier (Sousse / TUNISIE)
    • Houssem Hmouda (Sousse / TUNISIE)
    14h52 / 14h59
    Abstract : Cardio renal syndrome (CRS) is a group of disorders resulting from the pathological interaction between the heart and the kidneys. Studies on the prevalence of CRS in patients admitted for AE/COPD are limited. In this setting, the discovery of a renal dysfunction is not rare, and has important therapeutic implications, particularly when it is a CRS. Its impact on mortality, and its prognostic value in this group of patients deserves a special emphasis. AIM: to evaluate the prevalence of CRS, as well as its impact on mortality in patients admitted for AE/COPD.We retrospectively reviewed the charts of consecutive patients admitted for AE/COPD in a medical ICU from November 2015 to February 2018. We collected clinical features at admission, severity of illness, ICU course, and the occurrence of CRS. Univariate and multivariate regression analyses were performed to identify factors independently associated with CRS, and to determine the risk of mortality secondary to CRS. A total of 21 patients were admitted for AE/COPD. Their main characteristics were: mean age, 63±11 years; male, 91(19%); COPD GOLD D, 14(66.7%); mean APACHE II, 15.8±6.2; pH, 7.32±0,1 ; PaCO2, 65.6±29 mmHg ; PaO2, 163±133 ; initial invasive mechanical ventilation, 12 (57.1%); mean duration of mechanical ventilation, 9.03±7.38 days ; mean length of stay, 12.14±10.8 days; mortality, 3(14.2%). Eight patients (38.1%) developed CRS. Among them, 5 patients (62.5%) had type 1 CRS, 1 patient (12,5%), had type 2 CRS, and 3 patients (37.5%) had type 5 CRS. Underlying Cardiac diseases in patients with CRS were hypertensive cardiomyopathy in 2 cases (25%), ischemic cardiomyopathy in 1 case (12.5%). Pulmonary arterial hypertension was found in all patients having CRS with a mean systolic PAP of 42.6±11.6 mmHg. All patients with CRS had septicemia. Univariate analysis showed a significant association between CRS and acute circulatory failure at admission (p=0.02). The occurrence of CRS was associated with an increased risk of mortality (p=0.017). CRS is frequent in patients admitted for AE/COPD and was significantly associated with circulatory failure at admission, as well as a significant risk of death.
  • The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI 2): where are we for this multicenter randomized controlled trial?
    Orateur(s) :
    • Stéphane Gaudry (Bobigny / FRANCE)
    • David Hajage (Paris / FRANCE)
    • Jean-Pierre Quenot (Dijon / FRANCE)
    • Laurent Martin-Lefèvre (La Roche Sur Yon / FRANCE)
    • Guillaume Louis (Metz / FRANCE)
    • Steven Grange (Rouen / FRANCE)
    • Julien Mayaux (Paris / FRANCE)
    • Beatrice La Combe (Lorient / FRANCE)
    • Nicolas Chudeau (Le Mans / FRANCE)
    • Rémi Bruyère (Bourg En Bresse / FRANCE)
    • Badie Badie (Belfort / FRANCE)
    • Jonathan Messika (Colombes / FRANCE)
    • Karim Lakhal (Saint-Herblain / FRANCE)
    • Dimitri Titeca (Amiens / FRANCE)
    • Nicolas de Prost (Créteil / FRANCE)
    • Guillaume Chevrel (Corbeil-Evry / FRANCE)
    • Yves Cohen (Bobigny / FRANCE)
    • Marion Beuzelin (Dieppe / FRANCE)
    • Julien Bohé (Lyon / FRANCE)
    • Christophe Vinsonneau (Béthune / FRANCE)
    • Karim Asehnoune (Nantes / FRANCE)
    • Didier Thevenin (Lens / FRANCE)
    • Eric Boulet (Beaumont Sur Oise / FRANCE)
    • Bertrand Pons (Pointe-À-Pitre / FRANCE)
    • Saber Barbar (Nimes / FRANCE)
    • Fouad Fadel (Cergy Pontoise / FRANCE)
    • Guillaume Lacave (Versailles / FRANCE)
    • Elisabeth Coupez (Clermont Ferrand / FRANCE)
    • Laurent Argaud (Lyon / FRANCE)
    • Marc Léone (Marseille / FRANCE)
    • Jean-Marie Forel (Marseille / FRANCE)
    • Jeremie Bourenne (Marseille / FRANCE)
    • Sébastien Moschietto (Avignon / FRANCE)
    • Samir Jaber (Montpellier / FRANCE)
    • Kada Klouche (Montpellier / FRANCE)
    • Christian Gouzes (Ales / FRANCE)
    • Guillaume Thiery (Les Abymes / FRANCE)
    • Aline Dechanet (Paris / FRANCE)
    • Jean-Damien Ricard (Colombes / FRANCE)
    • Didier Dreyfuss (Colombes / FRANCE)
    14h59 / 15h06
    Abstract : Timing of renal replacement therapy (RRT) for severe acute kidney injury (AKI) is highly debated. Three multicenter trials assessed this question. Both AKIKI and IDEAL-ICU showed no mortality difference between an early and delayed RRT strategy. Pending results of STARRT-AKI (which is ongoing), the bulk of evidence suggests that, in the absence of severe complications of AKI, delaying RRT is safe. Duration of anuria and serum urea concentration were among criteria mandating RRT in the delayed strategy of AKIKI. The validity of such criteria is open to debate. We designed a study that compares the AKIKI “delayed strategy” with a further delayed one.AKIKI 2 is a prospective, multicenter, open-label, randomized trial. Randomization is preceded by an observational stage where patients receiving (or having received) catecholamines and/or mechanical ventilation and with severe KDIGO3 AKI and no potentially life-threatening condition (severe hyperkalemia, severe acidosis or pulmonary edema resulting in severe hypoxemia) are observed. If one or both of the following criteria occur: serum urea concentration >40 mmol/l and/or oliguria/anuria > 72 hours, patients will be randomly allocated to one of the two arms: 1/ “no further delayed strategy”: RRT will be initiated within 12 hours after documentation of randomization, 2/ “further delayed strategy”: RRT will be initiated only if one or more life-threateningcondition (see above) occur or if serum urea concentration reaches 50 mmol/L. The primary outcome is the number of RRT-free days 28 days after randomization. Considering a mean RRT-free days at day 28 of 17+/-11.4 days in the “No further delayed strategy” (data derived from AKIKI), total sample size of 270 patients is required in the randomized stage to demonstrate an increase of 4 days (25%) in “further delayed strategy”. Approximately one third of patients in observational stage should be eligible for the randomization stage then we expect that to 810 patients will be included in the observational stage. Five months after study beginning, 27 centers are active (on the 43 planned to open), 142 patients were included and 33 randomized. Inclusions should be completed in December 2019.AKIKI 2 will allow a precise description of the natural history of AKI KDIGO3 and will expand results of previous large randomized controlled trials by showing whether or not it is possible to further delay RRT initiation in this population.
E-Poster
14h10 - 15h10
Espace poster 6
Médecin : Organisation et évaluation
Modérateur(s) : Jean Reignier (Nantes / FRANCE), Jean-Daniel Chiche (Paris / FRANCE)
  • Team communication in an acute medical unit: A Social network analysis
    Orateur(s) :
    • Sara Benammi (Rabat / MAROC)
    • N. Madani (Rabat / MAROC)
    • K. Abidi (Rabat / MAROC)
    • T. Dendane (Rabat / MAROC)
    • A. Zeggwagh (Rabat / MAROC)
    • Jihane Belayachi (Rabat / MAROC)
    • R. Abouqal (Rabat / MAROC)
    14h10 / 14h17
    Abstract : Social network analysis seeks to understand networks and their participants and has two main focuses: the actors and the relationships between them in a specific social context. Applications in the health sector remain underutilized. We sought to use Social Network Analysis (SNA) to describe the patterns of communications in teamwork of an acute medical unit (AMU).Network Analysis was conducted to examine network structure of teamwork professional communication in an AMU of a university Hospital. All eligible personnel (n=58) were included in SNA survey. Team members reported the frequency (0 to 10+ times) of professional discussion with every other coworker during the last 48-hours. To examine the structure of the network, density, degree and betweenness centralization, degree and betweenness centrality were calculated. Scores range from 0 to 100%. Higher Value indicated, the more dense, more centralized is the network, and most central are team member in the network respectively. We examined the homophily of the network using E-I index (from -1to 1); where -1represented communication only between staff of different function and 1 communication only between staff with Similar function. P-value was obtained based on 1000 quadratic assignment procedure QAP permutations of the network. The network analysis was used to construct network maps using multidimentional scaling and generates a visual representation of networks through network diagrams.The mean age of participants was 37±13years, there were 460connections (density=28%). The whole network has a moderate degree centralization (37%) and lowerbetweeness centralization (8%). The seven team members most central (centrality degree>50%) to the network included three senior physicians, the head nurse, the physiotherapist, the medical secretary and the archivist. There was evidence regarding homophily in a network indicated by high level of E-I index value 0.44 (P<0.01, by QAP) indicating low degree of communication among different function team member.SNA revealed moderate team member connectedness in the network as measured by density. The AMU Network showed moderate degree of centralization, and low betweenness centralization which supposed that team is connected by well positioned members to support inter-team communication, and a greater number of gatekeepers dominate the network over other members in the network. In effect, five function profile, have a central role in bridging communication. However, this analysis also shows a possible point of weakness of our medical unit, represented by the low degree of communication among different function team member.
  • Adverse events in a Tunisian intensive care unit: frequency, risk factors and outcomes
    Orateur(s) :
    • Said Kortli (Sousse / TUNISIE)
    • Imen Ben Saida (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Nesrine Fraj (Sousse / TUNISIE)
    • Nawres Kacem (Sousse / TUNISIE)
    • Wafa Zarrougui (Sousse / TUNISIE)
    • Mohamed Ahmed Boujelben (Sousse / TUNISIE)
    • Mohamed Boussarsar (Sousse / TUNISIE)
    14h17 / 14h24
    Abstract : Adverse events (AEs) are common. Recognizing and reporting AEs is a crucial step for caregivers to implement adequate strategies to improve patient safety. The aim was to evaluate the rate, risk factors of AEs and their impacts.A prospective study conducted from October 2017 to June 2018 in a 9-bed medical ICU. All included patients were monitored for AEs. Variables found to be statistically significant in univariate analysis were introduced into a multivariate regression model to identify factors independently associated to AEs.137 patients were included. Patients' characteristics were: median age, 60[49-68]years ; female, 29(27.9%) ; median SAPSII, 27[22-33.5] ; Invasive mechanical ventilation (IMV), 57(41.6%) ; vasopressors use, 52(38%) and respiratory disorder was the main reason for admission in 103 patients (75.2%). 177 AEs occurred in 69 patients during a median length of stay (LOS) of 10 [5.5-20]. The most frequent AEs were: ventilator acquired pneumonia, 40(29.2%); removing gastric tube, 25(18.2%) pressure sores, 21(15.3%) ; removing central/peripheral line, 20(14.6%) ; removing bladder catheter, 16(11.7%) ; accidental extubation, 13(9.5%) ; fall,13(9.5%) ; catheter related bloodstream infection, 12(8.8%) ; acute renal failure, 11(8%) and venous thromboembolic events, 6(4.4%). Patients who presented AEs had significantly longer duration of IMV (13.52±110.97 vs 3.5±7.07days, p=0.000), longer LOS (18.20 ±13.34 vs 10.04±9.78days, p=0.000) and higher mortality rate (36.2% vs 13.2%, p=0.008). Univariate analysis revealed the following factors to be associated to AEs respectively : age≥65years, (49.3% vs 13.2%, p=0.044) ; SAPSII (30.67±9.5 vs 24.6±7.9, p=0.000) ; IMV use (88.4% vs 23.5%, p=0.00) ; vasopressors use (56.5% vs 19.1%, p=0.00) ; corticosteroids' use (71.7% vs 50%, p= 0.012) ; sedative agents use ( 71% vs 22.1%, p=0.000) and delirium (50.7% vs 32.4%, p= 0.000). Multivariate regression model identified two factors as independently associated to AEs: delirium (OR, 3.6 ; 95%CI, [1.3- 10] ; p=0.013) and IMV duration (OR, 1.11 ; 95%CI, [1.05- 1.18] ; p=0.000). This study highlights the serious problem of AEs in ICU. Delirium and IMV duration were identified as independently associated to AEs.
  • Impact of early ICU admission on outcome of critically ill and critically ill cancer patients
    Orateur(s) :
    • Yannick Hourmant (Paris / FRANCE)
    • Sandrine Valade (Paris / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    14h24 / 14h31
    Abstract : Early ICU admission has been proposed as a mean to limit risk of clinical worsening and to improve outcome of ICU patients. The aim of this review was to investigate the impact of early ICU admission in the general ICU population and in critically-ill cancer patients (CICP). This systematic review was performed according to PRISMA statements and the protocol was registered in the PROSPERO database (CRD42018094828). Studies reporting impact of delay before ICU on outcome were searched on PubMed (1980- 2017) for adult patients with or without cancer. Differences in term of mortality is reported as Risk Ratio (95%CI). Publication bias was assessed by visually inspecting the funnel plot and summary estimates of relative risk and their 95% confidence interval were calculated using both fixed and random-effects model.Overall ICU population : Among the 663 citations identified for general ICU population, 29 studies reporting on 72,801 patients were included, including 66 768 patients for the early admission group. Early ICU admission was associated with decreased mortality using a random effect model (RR 0.65; 95% confidence interval 0.58-0.73; I²=66%) (figure). CICP : Among the 932 citations identified, 14 studies reporting on 2,414 patients (including 1,272 with early ICU admission) were included. Early ICU admission was associated with decreased mortality using a random effect model (RR 0.69; 95% confidence interval 0.52-0.90; I²=85%). To explore heterogeneity, a meta-regression was performed. Characteristics of the trials (prospective vs. retrospective, monocenter vs. multicenter) had no impact on findings. Publication after 2010 (median publication period) was associated with a lower treatment effect (estimate 0.37; 95%CI 0.14-0.60; P=0.002) in the general ICU population. A significant publication bias was observed. Several sensitivity analyses were performed using trim and fill method, Copas method and taking into account Outcome Reporting Bias, which confirmed findings to be robust in both the general ICU population and the CICP. These results suggest that early ICU admission is associated with decreased mortality in the general ICU population and in CICP. These results were however obtained from high risk of bias studies and a high heterogeneity was noted. Additional studies are required to confirm potential benefit of early ICU admission along with its cost-benefit ratio.
  • ICU Health Care Workers are poorly aware of the costs of the devices they use for patients' care
    Orateur(s) :
    • Paul Gabarre (Paris / FRANCE)
    • Pierre-Yves Boelle (Paris / FRANCE)
    • Muriel Fartoukh (Paris / FRANCE)
    • Christophe Guitton (Le Mans / FRANCE)
    • Guillaume Dumas (Paris / FRANCE)
    • Jean-Rémi Lavillegrand (Paris / FRANCE)
    • Jean-Luc Baudel (Paris / FRANCE)
    • Naïke Bigé (Paris / FRANCE)
    • Daniel Zafimahazo (Paris / FRANCE)
    • Eric Maury (Paris / FRANCE)
    14h31 / 14h38
    Abstract : ICU Heath care workers (ICU HCW) use expensive devices for the care of their patients. Unfortunately lifetime of some of these multi users devices is often shorter than that could be waited for a single user utilization. The aim of this survey was to evaluate ICU HCWs' knowledge of the costs of device they regularly use during and for ICU patients' care.HCWs of three ICUs: medical (1) medico surgical(2) university affiliated (2) were proposed to answer to an anonymous questionnaire aimed at measure their estimation of the cost of 44 devices or systems used in daily patients care. These include catheter, ultrasound device; Renal Replacement therapy device, ventilator..., Costs' estimation are expressed as percentage of real costs. Costs' estimation are compared using median and [1st and 3rd quartile] according to HCW status and magnitude of costs of device .A correct estimation was defined by an estimated cost equivalent to real cost ± 50%128 HCWs accepted to take part to the survey providing more than 5600 costs estimation . Median global cost estimation for all the devices was 50% [14-215]and decreased with the real cost of devices : 428% [375-2500]for a real cost<100 € ,70% [18-210] for a real cost more than 100€ and <1000 €, 52% [12-163] real cost between 10 000 and 100 000€ and 34% [9-78]for devices with a cost more than 100 000€. Accuracy of costs estimation was 6% (real cost ±10%, 15 % for an estimated cost ±25% and 26% for an estimates cost ±50%. Senior physicians performed better than junior physicians. HCWs are unaware of the real cost of the devices they use for ICU patients' care in 75% of the cases
  • Comparison of the mortality prediction of different ICU scoring systems (Apache II, SAPSII, SOFA and CSS) in a low income country medical ICU
    Orateur(s) :
    • Imen Ben Saida (Sousse / TUNISIE)
    • Said Kortli (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Nawres Kacem (Sousse / TUNISIE)
    • Imen El Meknessi (Sousse / TUNISIE)
    • Sana Rouis (Sousse / TUNISIE)
    • Ahmed Khedher (Sousse / TUNISIE)
    • Abdelbaki Azouzi (Sousse / TUNISIE)
    • Khaoula Meddeb (Sousse / TUNISIE)
    • Mohamed Boussarsar (Sousse / TUNISIE)
    14h38 / 14h45
    Abstract : Clinical assessment of the severity of illness is an essential component of medical practice, especially in the intensive care unit (ICU). Multiple scoring systems have been developed for the ICU to risk stratify patient, predict outcome, help care providers in decision making and guide the allocation of resources. The aim of the study was to compare the performance of a local Validated clinical severity score (CSS) to severity scoring systems: Physiology and Chronic Health Evaluation (APACHE) system II, the Simplified Acute Physiology Score II (SAPS II), and the Sequential Organ Failure Assessment score (SOFA).A retrospective study was performed in our MICU between January 2017 and December 2017. Data were collected by reviewing the medical patients' charts. Scoring systems were calculated based on the worst values recorded during the first 24 hour of admission . Discrimination was evaluated using receiver operating characteristic (ROC) curves. A total of 301 patients were enrolled in the study. Mean age was 55.45±19.1. 63.1%(n=190) were male. The most common reasons for admission were acute respiratory failure in 183 (60.8%) patients, neurological and cardiovascular disorders in respectively 46 (15.3%) and 35 (11.6%) patients. 177 patients (58.8%) were intubated and 129 (42.9%) needed vasopressors. Mean length of ICU stay was 11.19 ± 17 days. The mean SAPSII, Apache II, SOFA and CSS were respectively 31.15 ± 12 ; 12.9±6.7 ; 4.38 ± 2.7 and 20.77±11.9. The overall mortality rate was 29.9 %. The best performing ICU scoring system in this study was CSS which had an area under the ROC curve (AUC) of 0. 786 (95% CI: 0.728-0.845) (p=0.000). SOFA, SAPSII and Apache II have respectively an AUC of 0.712 (95% CI: 0.649-0.775) (p=0.00) ; 0.677 (95% CI: 0.61-0.74) (p=0.000) and 0.64 (95% CI: 0.576-0.711) (p=0.000) (figure 1). The findings of the present study showed that SOFA, SAPS II and APACHE II had good accuracy in predicting mortality in ICU. However, they are partially perfect. This emphasize the importance of repeated validations of these scores. CSS is an interesting, not time-consuming, costless and minimally invasive tool for predicting mortality in ICU.
  • Appropriateness of Admission and Hospitalizations Days in an Acute Medical Unit
    Orateur(s) :
    • Sara Benammi (Rabat / MAROC)
    • A. Saadi (Rabat / MAROC)
    • N. Madani (Rabat / MAROC)
    • K. Abidi (Rabat / MAROC)
    • T. Dendane (Rabat / MAROC)
    • A. Zeggwagh (Rabat / MAROC)
    • Jihane Belayachi (Rabat / MAROC)
    • R. Abouqal (Rabat / MAROC)
    14h45 / 14h52
    Abstract : Eliminating unnecessary health care may reduce the cost and improve the quality of healthcare. This study aimed to measure the appropriateness of hospitalization, and to identify patient and hospitalization characteristics associated with appropriateness of hospitalization in an Acute Medical unit of University Hospital.Prospective data including all patients admitted to the Acute Medical unit were collected over 2 months. The appropriateness of 2263 hospital days contributed by 300 patients was assessed by means of Appropriateness Evaluation Protocol. We assessed equity in the distribution of hospital resources among patients, and the cumulative appropriateness of hospitalization by the means of Gini coefficient. The Gini index ranged from 0 to 1, where zero represents perfect equality in the distribution. Predictor variables included patient's anthropometric characteristics, and hospitalization characteristics. Associations between patient-related variables, and inappropriate hospital days related variables were studied using Generalized Estimation Equations for univariate and multivariate logistic regression analysis.Overall, 10% of hospital admissions and 5% of hospital days were rated as inappropriate. In univariate analysis, inapproprite hospital days were more frequent among patients whose admission was inappropriate. Factors significantly related to inappropriate stays: Hospitalization in a single room (OR=0.55;95%CI:0.34to0,88;p=0.01); Absence of previous hospitalization (OR=0.65;95%CI:0.3to0.98; p=0,04); No transfer request to another department(OR=1.88;95%CI:1.23to2.88; p=0,003); No transfer done to another department(OR=2.26; 95% CI:1.28 to 4; p=0,005); Diagnosis of hematological disease (OR=0.53; 95% CI:0.27 to 1.03; p=0.05). In multivariate analysis, only the diagnosis of hematological disease remained significantly related to inappropriate stay (OR=0.4; 95% CI: 0.20 to 0.80; p=0.001). The days of inappropriate hospitalization were less evenly distributed than the appropriate days, the Gini coefficients were 0.34 and 0.26 respectively.This study shows that inappropriate hospitalizations in an acute medical unit are frequent. At admission, one bed out of ten could be free, and one patient out of twenty could have a shorter stay. Considering that emergency departments are chronically saturated and have limited funds, inadequate hospitalization results in unnecessary cost and less efficiency and quality of care in the acute medical unit.
  • Factors predicting mortality in elderly patients admitted to a tunisian medical intensive care unit
    Orateur(s) :
    • Dhouha Ben Braiek (Sousse / TUNISIE)
    • Mohamed Ben Rejeb (Sousse / TUNISIE)
    14h52 / 14h59
    Abstract : With increasing life expectancy, elderly patients will require intensive care unit (ICU) admission more frequently. Age is thought to be strongly associated with ICU mortality, but other clinical variables may be incriminated. Early recognition of patients at high risk of mortality will help outcome prediction, better care planning, and health care cost containment strategies development. The aim of our study was to describe the characteristics of tunisian elderly patients admitted to ICU, and identify predictive factors of ICU mortality. A prognostic study type survival analysis was conducted in a medical ICU of a university hospital during a 4-year period, including patients ≥65 years. Baseline characteristics, clinical and laboratory parameters, treatment, and outcome were recorded. Univariate and multivariate analysis were performed using survival analysis.During the study period, 420 patients were admitted, of whom 25.7% (n=97) were included. The mean age was 75±7 years. The overall ICU mortality was 22%. Acute respiratory failure was the most common reason of hospitalization (78.4%), and community-acquired pneumonia was the main etiology (70.1%). Mean APACHE II, SAPS II and SOFA scores were 22±10; 40±11 and 7±4. Fifty-three per cent required invasive mechanical ventilation, 57.7% required vasoactive drugs. The most common complications were hemodynamic disorders (80.4%) followed by nosocomial infections (51.5%), and renal failure (57.7%). The mean LOS was 12 ±11 days. On univariate analysis, factors associated with mortality were: a past history of chronic renal failure (p=0.006), shock (p=0.036), ARDS (p=0.016), resuscitation for cardiac arrest (p=0.02), severity scores as SOFA (p<10-3), APACHE II (p<10-3), and SAPS II (p<10-3), acute renal failure at admission (p=0.029), vasoactive drugs (p=0.026) and sedation (p=0.014). On multivariate analysis, independent predictive factors of mortality were severity scores SAPS II (HR, 1.06;95%CI [1.02-1.09]; p=0.003) and APACHE II (HR, 1.07; 95%CI, [1.02-1.13]; p=0.01).Even though old age is linked to a high risk of death, age alone does not appear a strong predictor of mortality. Severity of illness on ICU admission was the main predictive factor of death. Further longitudinal studies of long-term survival in the elderly are needed.
  • Out of the ICU shifting by intensivist
    Orateur(s) :
    • Hamid Merdji (Strasbourg / FRANCE)
    • Raphael Clere-Jehl (Strasbourg / FRANCE)
    • Auguste Dargent (Dijon / FRANCE)
    • Pascal Andreu (Dijon / FRANCE)
    • Audrey Large (Dijon / FRANCE)
    • François Lefebvre (Strasbourg / FRANCE)
    • Maleka Schenk (Strasbourg / FRANCE)
    • Julie Helms (Strasbourg / FRANCE)
    14h59 / 15h06
    Abstract : Many studies have focused on the work of hospital doctors, but little is known about the work of Intensive Care Unit (ICU) physicians, especially concerning the medical time spent outside the unit and its workload that has never been evaluated to date. The main objective of our study was to evaluate the time spent by ICU doctors outside the unit, for the management of their patients during the intra-hospital transport (IHT) and for the care of patients in other departments (vital emergency, advices on medical care and ethical discussion). Secondary objectives were to describe the organization and distribution of medical time outside the ICU. In this prospective and observational study, which took place during 5 years, from January 2012 to December 2016 in two academics medical ICU (Strasbourg and Dijon), after each intervention outside the ICU, the intensivist doctor timed the intervention. Every day during the morning medical staff, the anonymized data were collected in a register.During the five years of the study, 2874 hours have been spent by intensivists outside the ICU in Strasbourg and 1740 in Dijon. This corresponds to an average of 574 hours 32 minutes (+/- 175) per year, about 94 minutes per day in Strasbourg, and an average of 349 hours (+/- 82) per year, about 58 minutes per day for Dijon. Over these five years, there were 5463 shifting, which corresponds to an average of 1,092 shifting (+/- 169) per year in Strasbourg. And 3028 shifting in Dijon, which corresponds to an average of 605,6 shifting (+/- 165) per year. About one third of this time was spent in the emergency department, one third in intra-hospital medical wards and the last third during IHT for ICU patients requiring a computerized tomography scan and/or a cardiac catheterization.A better understanding of the different activities and the respective part they occupy in the daily life of intensivists is essential in order to optimize the care for hospitalized patientsThis prospective French bicentric study highlights the fact that the intensivists' medical activity outside their own unit is time-consuming. This part of the intensivist activity is often unrecognized by the hospital administration and should now be taken into account concerning the routine activity of an ICU as well as the care given at the patient's bedside, the time devoted to the reception of families, and the time devoted to meetings.
  • Training of French nursing students on drawing blood culture: results from a broad electronic survey
    Orateur(s) :
    • Barbara Alves (Paris / FRANCE)
    • Benoît Vivien (Paris / FRANCE)
    • Romain Jouffroy (Paris / FRANCE)
    15h06 / 15h10
    Abstract : Bacteraemia induces a high rate of morbi-mortality. Blood cultures (BCs) are the standard method for the diagnosis of bacteraemia. In France, practice recommendations exist concerning BCs with an update in 2016 to avoid inadequate sample resulting in false diagnosis, inadequate antibiotherapy, and prolonged hospital length of stay. Appropriate training for nursing students could promote good clinical practice since, in France, BC are mainly taken by nurses. The aim of this study is to evaluate the theoretical and practical training received by French nursing students at school and at hospital on BC execution as well as related hygiene practices. We performed a cross-sectional study to evaluate the theoretical and practical training received by French nursing students and the hygiene practices concerning BC. The study was based on an electronic survey using a questionnaire sent out to all French nursing students between October 2017 and January 2018. The survey encompassed 22 short answer and multiple-choice questions. One thousand and thirty-six nursing students filled out the survey: 90% female, mean age of 24 ± 6 years. At nursing school, only 57% of the nursing students declared to have received theoretical training only on BC execution, 87% who received practical training only and 30% theoretical and practical training. During internship, 49% declared to have received practical training, 6% theoretical training and 45% declared no training. Among BC execution recommendations, peripheral stick and first aerobic are well known among 88% and 83% of the nursing students, respectively. Similarly, the practice of washing hands and cleaning the venepuncture site prior to BC execution are known among 96% and 94% of the students. In contrast, the practice of wearing gloves (80%) and facial mask (15%) is relatively lower.There are discrepancies between the knowledge base of nursing students and good practice recommendations for blood culture execution and related hygiene practices. Strengthening the teaching practices will likely improve students' knowledge base, reduce blood culture contamination and improve quality of care.
E-Poster
14h10 - 15h10
Espace poster 7
Médecin : Hémodynamique 2
Modérateur(s) : Hafid Ait-Oufella (Paris / FRANCE), Nadia Aissaoui (Paris / FRANCE)
  • Cardiogenic shock in France: what and who are we talking about? A descriptive analysis of the FRENSHOCK multicenter prospective registry
    Orateur(s) :
    • Clément Delmas (Toulouse / FRANCE)
    • Etienne Puymirat (Paris / FRANCE)
    • Meyer Elbaz (Toulouse / FRANCE)
    • Guillaume Leurent (Rennes / FRANCE)
    • Stéphane Manzo-Silberman (Paris / FRANCE)
    • Laurent Bonello (Marseille / FRANCE)
    • Sebastien Champion (Le Chesnay / FRANCE)
    • Nadia Aissaoui (Paris / FRANCE)
    • Francis Schneider (Strasbourg / FRANCE)
    • Edouard Gerbaud (Pessac / FRANCE)
    • Nicolas Lamblin (Lille / FRANCE)
    • Francois Roubille (Montpellier / FRANCE)
    • Patrick Henry (Paris / FRANCE)
    • Eric Bonnefoy (Lyon / FRANCE)
    14h10 / 14h17
    Abstract : Epidemiologic data about cardiogenic shock (CS) are still poor and focused on ischemic CS, forgetting all part of the CS encountered in clinical practice. FRENSHOCK registry (NCT02703038) was a large prospective multicenter registry of non-selected CS patients admitted in critical care units realized between April and October 2016 in France. Patients were included if they met the following three criteria: (1) low cardiac output defined by SBP<90mmHg and/or the need of amines, or a low cardiac output defined by CI<2.2L/min/m2 (TTE or Swan-Ganz); (2) elevation of left and/or right heart pressures defined by clinic/radiology/biology/echocardiography/Swan-Ganz; and (3) clinical and/or biological hypoperfusion.772 patients were included in 49 centers (male 71.5%, mean age of 66y +/-15). Comorbidities were classical: previous coronary revascularization 26%, history of extra cardiac arterial disease 15%, previous renal failure 21% and COPD 6%. Cardiovascular risk factors included diabetes (28%), active tobacco (28%), dyslipidemia (35%) and hypertension (47%). 56% were known for previous cardiomyopathy (especialy 30% ischemic origin). CS etiology often associated several triggers but ischemic was retained for only 36.4% (n=281) of patients with type 1 infarction for 17.4% (n=134). Non-ischemic trigger factors were predominant (n= 491; 63.9%): supra ventricular (13.2%) and ventricular arrythmia (12.6%), infection (11.9%), iatrogenic (6.1%), conductive disorders (2.3%), non-observance (3.5%), and others (13.7%). At admission median SBP was 101mmHg +/-25. Sinusal rhythm was present in only 52%. Right heart failure signs were present in 49% and left signs in 72% (Killip IV for 49%). Biological analysis found signs of hypoperfusion with high lactate (3.0 95% CI [2.0-4.8]), renal (eGFR 49.6 +/-26.8 ml/min/m²) and hepatic alteration (ASAT 90 UI/ml, 95% IC [39-300]; Prothrombin time 57 +/-25 %). Biventricular failure was frequent (LVEF was 26% +/-13; TAPSE 13mm +/-5). When realized (n=399; 52%) coronarography was pathological in 81% (n=321) (monotroncular 31%, bitroncular 35% and tritroncular 34%). A culprit lesion was found in 79% and concern LVA in 48%, RCA in 23% and left main in 15%. This large multicentric and prospective registry confirmed the heterogeneity of CS in terms of etiology, presentation and prognosis with a predominance of non-ischemic CS in practice.
  • Incidence and severity of RV size in patients with distributive shock. Value of tricuspid annular plan systolic excursion (TAPSE)
    Orateur(s) :
    • Amélie Prigent (Boulogne-Billancourt / FRANCE)
    • Philippe Vignon (Limoges / FRANCE)
    • Xavier Repessé (Paris / FRANCE)
    • Gwenaël Prat (Brest / FRANCE)
    • Cyril Charron (Boulogne / FRANCE)
    • Michel Slama (Amiens / FRANCE)
    • Antoine Vieillard-Baron (Boulogne / FRANCE)
    14h17 / 14h24
    Abstract : Experts proposed to define RV failure as a state in which RV is unable to meet the demands for blood flow without excessive dilatation. While TAPSE (tricuspid annular plan systolic excursion) was frequently reported as a pertinent parameter to study the RV function, this is still questionable. Our goal was (i) to report the incidence of RV dilatation and its severity in distributive shock, (ii) to report the distribution of TAPSE in different groups according to the RV size and the serum lactate level.Retrospective analysis of an observational, prospective multicenter study, which included 540 patients admitted in the ICU for shock, under mechanical ventilation, in whom an echocardiography (transthoracic and transesophageal) was systematically performed. After exclusion of cardiogenic, hypovolemic and obstructive shock, 345 patients were screened. Combining the lactate level and the end-diastolic ratio between the right and the left ventricle (RV/LV EDA), 4 groups were defined. Group 1 without RV dilatation (RV/LV EDA ≤ 0.6), group 2 and 3 with a moderate RV dilatation (RV/LV EDA > 0.6 ≤ 0.8) without or with an increased lactate level (≤ or >2 mmol/l) and group 4 with a severe RV dilatation (RV/LV EDA > 0.8).327 patients were analyzed. Median age was 66 [iqr 57-75], SAPS2 57 [iqr 43-72] and SOFA score 10 [iqr 7.5-12]. Cause of shock was septic in 85% of cases. The overall in-ICU mortality was 37.6%. 150 patients (45.9%) were in group 1, 51 (15.6%) in group 2, 53 (16.2%) in group 3 and 71 (22.3%) in group 4. 29.1% patients were ventilated for an ARDS. Median RV/LV EDA was 0.5 [iqr 0.4-0.5], 0.7 [iqr 0.6-0.7], 0.7 [iqr 0.6-0.7] and 0.9 [iqr 0.9-1.1] in groups 1, 2, 3 and 4 respectively. No inter-group difference was observed for TAPSE with the same median value of 18 mm (p=0.48). Central venous pressure was significantly higher in group 4 (12 [9-15] mmHg) compared to group 1 (9 [7-12]), 2 (9 [7-12]) and 3 (9 [7-13]).RV dilatation was observed in 54.1%, moderate in 59% and severe in 41%. TAPSE was not discriminant with a normal value in all groups.
  • Management and outcome of out-of-hospital cardiac arrest in elderly patients: a regional experience in Lower Normandy
    Orateur(s) :
    • Bertrand Sauneuf (Cherbourg / FRANCE)
    • Xavier Souloy (Cherbourg / FRANCE)
    • Maxime Leclerc (St-Lo / FRANCE)
    • Benoit Courteille (Avranches / FRANCE)
    • Julien Dupeyrat (Caen / FRANCE)
    • Michel Ramakers (Saint Lo / FRANCE)
    • Frédéric Godde (Avranches / FRANCE)
    • Cédric Daubin (Caen / FRANCE)
    14h31 / 14h38
    Abstract : In-hospital admission of elderly patients resuscitated from out-of-hospital cardiac arrest (OHCA) has increased. If some authors reported favourable outcomes, others reported an increase risk of death or survival with loss of autonomy. In addition, the benefit of some interventions (i.e. transport to percutaneous coronary intervention (PCI)) and the time and resources associated with, should be evaluated. Consequently, we conducted a study evaluating the prognosis of the elderly OHCA patient in a region, with only one PCI center.We retrospectively included all patients aged 75 or older, admitted in 4 intensive care units (1 university- and 3 non university hospitals) after OHCA between January 2009 and December 2016. Cardiac arrest and patients characteristics have been collected and the Cardiac Arrest Hospital Prognosis (CAHP) score has been calculated. The primary outcome was the neurocognitive function assessed by the cerebral performance category on hospital discharge. During the study period, 176 patients were included (median age 81, [79-84]; 72% male). Most of the patients presented significant comorbid condition (median Charlson index 5 [3-6]). Sixty-eight patients had initial shockable rhythm (38.6%). Hundred sixty-six patients presented without obvious extra-cardiac cause. PCI was performed in 63 (35.8 %) patients. The number of non-neurologic organ failure on admission was lower in patients with favorable outcome. All patients who received renal replacement therapy had an unfavourable outcome. The rate of favorable neurological outcome at hospital discharge was 9 % (16 patients) including 14 patients with initial first shockable rhythm. At 6 months, this rate decreases to 6% (11 patients), including 9 patients with initial first shockable rhythm. According to the CAHP score, 21 patients had a low risk of poor neurological outcome, 44 had an intermediate risk and 70 had a high risk. Based on this CAHP score stratification, 14 patients (66.7%) in the low risk group, 21 patients (44.7) in the intermediate risk group and 18 patients (25.7%) in the high-risk group underwent early PCI. Survival of elderly patients is low after OHCA, especially for patients with first non shockable rhythm. However, patients with first shockable rhythm and low risk of death may have favorable long term outcome. The level of organ failure seems to be strongly associated with prognosis. Stratification by CAHP score suggest that the use of PCI coud be improved with a better selection of patients likely to benefit from it.
  • Healthcare costs and resource utilization associated with treatment of out-of-hospital cardiac arrest
    Orateur(s) :
    • Guillaume Geri (Paris / FRANCE)
    • Damon C Scales (Toronto / CANADA)
    • Maria Koh (Toronto / CANADA)
    • Harindra C Wijeysundera (Toronto / CANADA)
    • Dennis T Ko (Toronto / CANADA)
    • Steve Lin (Toronto / CANADA)
    • Michael Feldman (Toronto / CANADA)
    • Sheldon Cheskes (Toronto / CANADA)
    • Paul Dorian (Toronto / CANADA)
    • Wanrudee Isaranuwatchai (Toronto / CANADA)
    • Laurie J Morrison (Toronto / CANADA)
    14h38 / 14h45
    Abstract : The management of out-of-hospital cardiac arrest (OHCA) patients requires the coordination of prehospital, in-hospital and post-discharge teams. Data reporting a comprehensive analysis of all costs associated with treating OHCA are scarce. We performed an analysis on a merged database of the Toronto Regional RescuNet Epistry database (prehospital data) and administrative population-based databases in Ontario. All non-traumatic OHCA patients over 18 years of age treated by the EMS between January 1, 2006, and March 31, 2014, were included in this study. The primary outcome was per patient longitudinal cumulative healthcare costs, from time of collapse to a maximum follow‐up until death or 30 days after the event. We included all available cost sectors, from the perspective of the health system payer. We used multivariable generalized linear models with a logarithmic link and a gamma distribution to determine predictors of healthcare costs. 25,826/44,637 patients were treated by EMS services for an OHCA (mostly male 64.4%, mean age 70.1). 11,727 (45%) were pronounced dead on scene, 8,359 (32%) died in the emergency department, 3,640 (14%) were admitted to hospital but died before day-30, and 2,100 (8.1%) were still alive at day-30. Total cost was $690 [interquartile range (IQR) $308, $1,742] per patient; ranging from $290 [IQR $188, $390] for patients who were pronounced on scene to $39,216 [IQR 21,802, 62,093] for patients who were still alive at day-30. In-hospital costs accounted for 93% of total costs. After adjustment for age and gender, rate of patient survival was the main driver of total costs: the rate ratio was 3.88 (95% confidence interval 3.80, 3.95), 49.46 and 148.89 for patients who died in the ED, patients who died after the ED but within 30 days, and patients who were still alive at day-30 compared to patients who were pronounced dead on scene, respectively. Factors independently associated with costs were the number of prehospital teams, the need for hospital transfer, coronary angiography and targeted temperature management.Clinical outcome is the main driver of total costs of treating OHCA patients in a large Canadian health system. Potentially modifiable factors include the number of prehospital teams that arrive to the scene of the arrest and the need for between-hospital transfers after successful resuscitation
  • Hyperkalemia is related more to hypercapnia than to acidemia during lactate accumulation after cardiac arrest: impact on clinical management
    Orateur(s) :
    • Matthieu Jamme (Paris / FRANCE)
    • Guillaume Geri (Paris / FRANCE)
    • Thomas Robert (Marseille / FRANCE)
    • Alain Cariou (Paris / FRANCE)
    • Laurent Mesnard (Paris / FRANCE)
    14h45 / 14h52
    Abstract : Low pH/acidemia has been historically described as one of the major factors associated with hyperkalemia. But a few older studies suggested that, in the context of an elevated anion gap metabolic acidosis, acidemia is not linked to hyperkalemia. As a consequence, the administration of sodium bicarbonate, long considered as first-line therapy for acute hyperkalemia, was recently re-assessed for the treatment of either hyperkalemia. Regarding the high prevalence of hyperkalemia and acidemia in resuscitated out-of-hospital cardiac arrest (OHCA) patients, we share here our experience of severe acute type I lactic acidosis, the most frequent cause of metabolic acidosis in this setting.We retrospectively analyzed first arterial blood gas results of 828 successfully resuscitated OHCA patients admitted to a tertiary Parisian intensive care unit. Baseline characteristics were compared according to the presence of hyperkalemia and factors associated with kalemia were identified using multivariable linear regression. sensitivity analysis was repeated in the subgroups of patients without chronic respiratory disease (CRD) and those without acute kidney injury (AKI). Admission blood lactate was below 1.5mmol/L in 88/828 (10.6%) patients and potassium levels were above 5.5mmol/L in 93/828 (11.2%). Patients with hyperkalemia presented more frequently with initial non-shockable rhythm and experienced longer collapse before resuscitation. At ICU admission, patients with hyperkalemia presented with deeper acidemia (7.1 [6.95-7.18] vs 7.23 [7.13-7.32], p < 0.001), higher lactatemia (7.3 [3.7-12.5] vs 5.1 [2.5-9], p < 0.001) and higher serum creatinine level (159 [102-230] vs 103 [77-137], p < 0.001). Following multivariate linear regression, kalemia was only associated with initial non-shockable rhythm (β = -0.34, 95%CI = -0.58;-0.11), higher creatininemia (β = 0.003, 95%CI = 0.002;0.004) and elevated PaCO2 (β = 0.01, 95%CI = 0.005;0.02) but not elevation of lactate levels. Indeed, a statistical negative trend between potassium blood level and lactatemia was observed (β = -0.02, p = 0.07). Sensitivity analyses performed on patients without AKI and CRD showed similar results. Our study demonstrates the absence of an association between blood lactate and potassium levels during acidosis with severe acidemia in the successfully resuscitated OHCA patient setting. This phenomenon appears to be independent of AKI. Our results suggest that kaliemia are in fact strongly linked to arterial PaCO2.
  • Prevalence and risk factors of vascular complications following veno-venous and veno-arterial ECMO weaning
    Orateur(s) :
    • Cécile Bouges (Toulouse / FRANCE)
    • Timothee Abaziou (Toulouse / FRANCE)
    • Jean Porterie (Toulouse / FRANCE)
    • Fanny Vardon (Toulouse / FRANCE)
    • Thierry Seguin (Toulouse / FRANCE)
    • Vincent Minville (Toulouse / FRANCE)
    • Bernard Georges (Toulouse / FRANCE)
    • Jean-Marie Conil (Toulouse / FRANCE)
    • François Xavier Lapebie (Toulouse / FRANCE)
    • Alessandra Bura Riviere (Toulouse / FRANCE)
    • Laurent Brouchet (Toulouse / FRANCE)
    • Bertrand Marcheix (Toulouse / FRANCE)
    • Clément Delmas (Toulouse / FRANCE)
    14h59 / 15h06
    Abstract : Veno-venous (VV-ECMO) and veno-arterial (VA-ECMO) extracorporeal membrane oxygenation are increasingly used for the treatment of refractory acute respiratory distress syndrome, or cardiac arrest and refractory cardiogenic shock respectively. Our aims were to describe the prevalence of vascular complications following ECMO weaning and to identify the associated risk factors.From January 2014 to December 2017, 237 patients were managed by ECMO in our unit (Rangueil University Hospital, Toulouse). Among the 136 weaned patients, 81 benefitted from post-decannulation venous and arterial Doppler ultrasound to assess vascular complications, and were included in this retrospective study.Thirty-one patients (38.3%) showed vascular complications after ECMO cannula withdrawal: Twenty-two patients (27.2%) had arterial complications and 26 (32.1%) had venous complications. In 67.7% of the case, vascular complication were asymptomatic. Patients with vascular complications were younger (48 vs 56 respectively, p=0.029). Patients with deep vein thrombosis (DVT) had longer ECMO duration (12.8 [7.25 – 15.5] vs 6 [4.5 – 9] days, p=0.002) and prolonged ICU length of stay (31.5 [18.3–46.5] vs 17.0 [11.5–35.5] days, p=0.037) compared to patients without DVT. Finally, prevalence of DVT was higher in patients with VV ECMO (50%) compared to patients with VA ECMO (23.6%; p=0,018). Vascular complication occurrence tended to be associated with an increased mortality at 3 months (13% versus 27% p=0.115).VV and VA ECMO are associated with an elevated prevalence of vascular complication. Systematic doppler ultrasound evaluation after weaning could optimize management of these specific patients.
  • Estimation of Pulmonary artery occlusion pressure assessed by tissue Doppler imaging in Ventilated and on catecholamine patients in ICU. A preliminary study
    Orateur(s) :
    • Nicolas Bonnet (Bobigny / FRANCE)
    • Olivier Martin (Bobigny / FRANCE)
    • Marouane Boubaya (Bobigny / FRANCE)
    • Florent Poirson (Bobigny / FRANCE)
    • Johanna Oziel (Bobigny / FRANCE)
    • Yacine Tandjaoui Lambiotte (Bobigny / FRANCE)
    • Guillaume Van Der Meersch (Bobigny / FRANCE)
    • Abdelaziz Bouguerba (Bobigny / FRANCE)
    • Yves Cohen (Bobigny / FRANCE)
    • Philippe Karoubi (Bobigny / FRANCE)
    15h06 / 15h10
    Abstract : Mitral velocity (E wave velocity and A wave velocity), and early diastolic mitral annulus velocity E' assessed by transthoracic echocardiography (TTE) and tissue Doppler imaging (TDI) are correlated to pulmonary artery occlusion pressure (PAOP) in cardiologic patients. These parameters are dependent on loading conditions, modified by mechanical ventilation and the use of catecholamine. In ICU ventilated patients receiving catecholamine, E/A ratio and E' velocity has not been evaluatedThis observational prospective study included 12 consecutives patients (mean age = 61 ± 15.3 years) with septic shock and ARDS. All patients were treated with catecholamines (mean dose (mg/h) = 3.4 ± 3.0) and ventilated (mean FIO2 (%) = 0.8 ± 0.3, mean tidal volume (mL/kg) = 6.2 ± 0.5). A volume expansion was performed with Ringer lactate solution at the discretion of clinician. Echocardiographic, Doppler examinations and hemodynamic measurements were repeated after volume expansion. We obtained 32 measurements. Doppler mitral inflow and TDI mitral annulus velocities were determined and compared with PAOP measured by a Swan-Ganz catheter. All TTE parameters were analyzed off-line by an independent operator, blinded to clinical history and PAOP values. Fluid challenge increased the ScVO2 (from 73.3 +/-10.1 to 76.0 +/-7.8 %) and PAOP (from 11.2 +/- 3.0 to 12.8 +/- 3.4 mmHg). However, there was no difference in cardiac index (from 4.0 +/- 2.1 to 4.0 +/-2.0 l/min/m²).There was no significant correlation between PAOP and the E wave (Beta 4.64 IC 95% [-0.18 ;9.47 ] p=0.079), E/A ratio (beta 1.82 ; IC 95% [-2.21;5.84] p=0.39) and E/E' ratio (beta 0.94 ; IC95% [-2.56; 4.46], p = 0.61).In this preliminary study, no significant correlation was found between E wave, E/A ratio, E/E' ratio and PAOP in ventilated patients receiving catecholamines. More inclusions are needed to confirm or refute this result.
E-Poster
14h10 - 15h10
Espace poster 8
Médecin : Pédiatrie 2
Modérateur(s) : Christophe Milesi (Montpellier / FRANCE), Pierre-Louis Léger (Paris / FRANCE)
  • Evaluation of perfusion practices in the central venous system in pediatric intensive care units in a teaching hospital
    Orateur(s) :
    • Chloé Levenbruck (Lille / FRANCE)
    • Eve-Marie Thillard (Lille / FRANCE)
    • Morgan Recher (Lille / FRANCE)
    • Stéphanie Genay (Lille / FRANCE)
    • Bertrand Décaudin (Lille / FRANCE)
    • Pascal Odou (Lille / FRANCE)
    14h10 / 14h17
    Abstract : The central venous catheter (CVC) allows to infuse several drugs simultaneously in intensive care units thanks to the use of Y-set infusion lines. Many constraints are encountered in the management of pediatric populations: limited infusion rates according to the age of children, maximum infusion volumes in relation to their weight. Indeed, a limitation of the water supplies has to be performed because of the hyper-permeabilization of the vessels in this population. So, optimization of infusion sets is therefore essential to improve and secure this support. Our main objective was to evaluate infusion practices and to identify optimization suggestions.Observation of infusion lines on CVC were conducted for 3 months (December 2017 to March 2018) in the pediatric resuscitation department. A restitution of these observations was carried out in the unit to form a working group to optimize the infusion setups. Several proposals for perfusion set will be discussed.Conducted interviews with nurses lasted approximately 5 to 10 minutes according to a grid composed of multiple-choice questions and open-ended questions. 32 infusion lines were observed and 14 nurses interviewed (34% of the nurses staff). This observation concerned 14 children under 1 year old, 12 children between 1 and 6 years old and 6 children over 6 years old. 37% of CVC were placed in jugular vein, 25% in femoral, 31% in subclavian and 7% other. There were 50% trilumen, 38% bilumen and 12% monolumen CVC. Only 51.9±0.2% of available ports were used on infusion lines. CVC dressings were changed every 4 days or when they were soiled or unstuck. 71% of nurses declared problems with the dressing: dressings are too bigs for the youngers, inadapted for burned children, not yet sticky for those who drool. 79% of nurses have encountered drug incompatibilities during infusion through CVC but all surveyed nurses knew the existence of the unit's drug incompatibilities table.The evaluation of nurses practices highlighted a good knowledge of the types of infusion lines compared to the recommendations. However, efforts must be made to rationalize the number of lines available on the infusion set by integrating infusion devices with optimized geometry to limit drug incompatibilities. A discussion with the medical team about sizes of catheters according to the child weight will be engaged. Smaller dressings have been referenced in the unit and a modification in dessings change frequency was considered at 7 days.
  • Risk factors for not meeting the recommendations for enteral nutrition in critically Ill children
    Orateur(s) :
    • Mylène Jouancastay (Lille / FRANCE)
    • Camille Guillot (Lille / FRANCE)
    • Jean-Benoît Baudelet (Lille / FRANCE)
    • Morgan Recher (Lille / FRANCE)
    • Yasmin Karaca (Lille / FRANCE)
    • François Machuron (Lille / FRANCE)
    • Stéphane Leteurtre (Lille / FRANCE)
    14h17 / 14h24
    Abstract : Malnutrition is prevalent in children admitted to the pediatric intensive care unit (PICU). Inadequacy energy intake is known to be a risk factor for morbidity and mortality in critically children. SFAR (Société Française d'Anesthésie et de Réanimation) published in 2014 European nutritional guidelines. This study aimed to evaluate nutritional practices in a French PICU by comparing energy and protein intake using SFAR's recommendations and 2017 American recommendations and to identify risk factors of inadequate energy intake using SFAR's recommendations.This study was retrospective in one PICU in a University's Hospital from 2014 to 2016. Children aged one month to eighteen years old who were receiving an exclusive enteral nutrition (EN) were included. Patient hospitalized less than 48 hours, patient fed exclusively by oral or parenteral route were excluded. Individual energy and protein intake were calculated for each day and compared to SFAR's recommendations. Satisfactory energy intake was considered to be followed if equal to or greater than 90% of SFAR's recommended intake. Two groups were constituted and compared to identify risk factors between patients following or not the SFAR's recommendations: “optimal EN group” : children who received more than 90% of energy recommendation maintained for a least half of the ICU stay and “no optimal EN” if children didn't.418 patients were involved in this study. Malnutrition at admission occurred in 151 patients (36.6%). Average energy intake were 47.5 Kcal/kg/day (IC95% =27-62) that represented 75% and 87.8% of energy estimated intake by SFAR's recommendations and Schofield equation respectively. Energy intake received was closer to intake estimated using Schofield equation than those recommended by SFAR (Figure 1). SFAR's recommendations were respected for 43% of patients. The 2017 American recommendations were taken on board for 80% of patients. Average protein intake were 1.2g/kg/day (IC95%= 0.6-1.5) that represented 67% of intake recommended by SFAR. 88 patients (21%) had an “optimal EN”. The median time to initiate EN was longer in “no optimal EN” group. Vasopressors were identified to be a risk factor of no meeting the SFAR's recommendations (OR =5.34, IC95% =1-28.4, p=0.04). Only 43% of patients respected SFAR's recommendations. Vasopressor was a risk factor of no meeting SFAR's recommendations. The 2017 American recommendations using Schofield equation were respected in 80% of patients. An enteral feeding protocol could reduce the median time to initiate an EN support.
  • Predicting hemodynamic intolerance to depletion by measuring the variation of the stroke volume index during a calibrated abdominal compression in pediatric ICU : a prospective study
    Orateur(s) :
    • Julie Hentzen (Lyon / FRANCE)
    • Matthias Jacquet-Lagrèze (Bron / FRANCE)
    • Laurent Chardonnal (Bron / FRANCE)
    • Capucine Didier (Bron / FRANCE)
    • Sabine de Lamer (Bron / FRANCE)
    • Dominique Bompard (Bron / FRANCE)
    • Catherine Koffel (Bron / FRANCE)
    • Jean-Luc Fellahi (Bron / FRANCE)
    14h24 / 14h31
    Abstract : Fluid overload (FO) is common in pediatric ICU particularly after septic shock or cardiac surgery and is responsible for acute kidney injury, decreased ventilation-free days, increased length of stay in ICU and generation of morbi-mortality. Predictors of hemodynamic intolerance (HI) to depletion for children don't exist to our knowledge. Another study showed that calibrated abdominal compression (CAC) was able to predict fluid responsiveness in children with acute circulatory failure. The primary objective of our study was to determine if the variation of stroke volume index (SVi) during CAC -our test index- can predict HI to depletion defined as a decrease of 15% of cardiac output after depletion of at least 10 mL/kg in children with FO. We conducted a prospective non-interventional study in a french teaching hospital with a cardiologic ICU. All patients under eight years old who might be suffering from FO and who needed depletion with diuretics were selected. We only included those who had urinated more that 10 mL/kg in less that two hours. We assessed the SVi with the Aortic Flow Velocity Integral by transthoracic echocardiography before depletion, during the CAC and after depletion. We recorded other hemodynamic parameters considered as secondary outcomes.47 patients were included after cardiac surgery. Only six had a decreased cardiac output by more than 15% after depletion. The area under the curve of the receiving operative curve (ROCAUC) of our test index was 0.47, 95%CI[0.23;0.73] (figure 1). Its median values of specificity, sensitivity, positive and negative predictive values were 0.58, 0.66, 0.21 and 0.93 respectively. The ÄSVi-CAC was not significantly correlated to the ÄSVi before and after depletion (r=0.26, 95%CI[-0.03;0.51], p=0.08). However, respiratory variations in aortic blood flow peak velocity (ÄVPeak) and variations of central venous pressure (CVP) during CAC appeared to be good predictors of HI to depletion with ROCAUC of 0.91, 95%CI[0.8;0.98] and 0.84, 95%CI[0.68;0.97] respectively (figure 1). Surprisingly, patients who have shown an HI to depletion had a profile of right ventricular failure instead of the expected profile of hypovolemia.Our test index was inconclusive in predicting HI to depletion in children admitted in ICU, but other variables like ÄVPeak or change in CVP during CAC seemed to be superior.
  • PEDIATRIC SEPTIC SHOCK: time course and prognosis of organ dysfunctions according to different definitions
    Orateur(s) :
    • Luc Panetta (Lyon / FRANCE)
    • Stéphane Leteurtre (Lille / FRANCE)
    • Solenn Rémy (Bron / FRANCE)
    • Alain Duhamel (Lille / FRANCE)
    • Hélène Béhal (Lille / FRANCE)
    • François Machuron (Lille / FRANCE)
    • Florent Baudin (Bron / FRANCE)
    • Etienne Javouhey (Lyon / FRANCE)
    14h31 / 14h38
    Abstract : In 2016 an international task force changed the definitions of sepsis and septic shock in adults, using an organ failure score named the Sequential Organ Failure Assessment (SOFA). The concept of "new and progressive multiple organ dysfunction syndrome" (NPMODS), corresponding to organ dysfunction aggravation, has been proposed as proxy of mortality in some critical diseases. Many criteria exist to define these organ dysfunctions: the Proulx criteria, the Goldstein criteria, the Pediatric Logistic Organ Dysfunction-2 (PELOD2) score, and the Pediatric SOFA score. The aim of the study was to compare these four definitions with each other, to find the best definition of NPMODS that could be used as surrogate outcome in the pediatric septic shock therapeutic trials. This is a retrospective observational study, from January 2011 to December 2016, in a single PICU. Inclusion criteria were age <18 years, hospitalization in PICU for septic shock (2005 definition). The primary outcome measure was PICU mortality. The secondary outcome was an evaluation of morbidity-mortality using the evolution of the Pediatric Overall Performance Category (POPC).149 patients were included. Mean age was 5 years (± 5.5 years), 16 patients (10.7%) were less than 28 days old. 18 patients died (12,1% of fatality rate). 44 patients (29.5%) had a significant worsening delta-POPC. The most common causes of septic shock were meningitis or meningoencephalitis (15.8%), purpura fulminans (15.1%), and intraabdominal infection (15.1%). Patients developed NPMODS in 26.2% according to Proulx criteria, 30.9% according to Goldstein criteria, 30.2% for PELOD2, and 28.9% for pSOFA. The four definitions used to define NPMODS were significantly associated with mortality and delta-POPC (p<0.001). The deceased patients did not have scores that worsened in the first five days, but the scores did not improve. On the contrary, the scores of survivors improved within the first 5 days whatever the definition used.NPMODS definition could be a surrogate outcome of mortality, usable in pediatric septic shock therapeutic trials, whether using the Proulx, Goldstein, PELOD2 or pSOFA criteria. However, this definition only considers the onset or the aggravation of organ dysfunction. Further studies would be needed to create and validate an alternative definition, which incorporates the notion of "non-improvement of organ dysfunction" over time, which would better reflect the natural course of the most severe patients with pediatric septic shock.
  • Comparison of cardiac outpout monitoring between electrical velocimetry and transthoracic echocardiography in the PICU. A pilot Study
    Orateur(s) :
    • Julien Baleine (Montpellier / FRANCE)
    14h38 / 14h45
    Abstract : Electrical velocimetry (EV) is a non-invasive method of continuous left cardiac output monitoring. The main objective was to validate EV by investigating the agreement in cardiac output measurements performed by EV and trans-thoracic echocardiography. We conducted a prospective single-center pilot study in the 8 beds pediatric intensive care unit (PICU). We included children from 28 days to 10 years, with hemodynamic instability or circulatory failure, and excluded children with congenital heart disease or impossible chest access impossible. We simultaneously measured cardiac output by EV and echocardiography. Agreement, bias and precision of the measurements were analyzed by the Bland-Altman method. Bias <10% and percentage error <30% were considered clinically acceptable. Parameters of contractility (ICON for EV and Left ventricular ejection fraction) and preload dependance (Stroke Volume Variation SVV for EV and variation in aortic blood flow velocity in echocardiography ) were compared.10 patients were included (median age 3.5 years [0.8-7], median weight 17.25 kg [5.36-28]), and 38 measurements were performed and analyzed. The bias and percentage error for cardiac output measurement were 0.46% and 21.73%, respectively. There was no correlation between the parameters assessing contractility (left ventricular ejection fraction in echocardiography and contractility index in EV) (r = 0.14, p = 0.38), or those evaluating the preload dependence (variation in aortic blood flow velocity in echocardiography and SVV in EV) (r = 0.193, p = 0.244).EV appears to be a reliable method of continuous CO monitoring compared to trans-thoracic echocardiography, but has its limitations on contractility and preload dependence parameters. The CARDIOREAPED study will follow this pilot study; it will start in November 2018 and will focus on 50 children.
  • Kawasaki Disease in intensive care unit in France : are complete and incomplete forms different?
    Orateur(s) :
    • Hélène Yager (Paris / FRANCE)
    • Bilade Cherqaoui (Paris / FRANCE)
    • Fleur Lebourgeois (Paris / FRANCE)
    • Blandine Vanel (Lyon / FRANCE)
    • Isabelle Kone-Paut (Paris / FRANCE)
    • Maryam Piram (Paris / FRANCE)
    14h45 / 14h52
    Abstract : Kawasaki disease (KD) is a rare acute systemic vasculitis occurring mainly in children under 5 years of age. The major challenge is the cardiac involvement that may require admission in intensive care unit (ICU) and can be life-threatening. It is common that patients requiering ICU don't meet all the American Heart Association (AHA) criteria, vascular damages being then often from the beginning complicated and the differential diagnosis - especially infectious - challenging. The risk is a delay of the treatment, in this case intravenous immunoglobulin (IVIg). The aim of the study was to specify the caracteristics and the outcome of patients admitted to ICU for a potential KD complication and comparing patients who met the AHA criteria (AHA+) with patients who did not (AHA-). To that end, we collected national retrospective cases between 2001 et 2018, following a call from the scholarly associations (SOFREMIP, GFUP). We collected clinical, biological and echocardiography datas. Comparisons were based on Fisher's exact test for categorical variables and the student's t-test for continuous variables. Statistical analyses were performed using PRISM 5.0 and MedCalc; All tests were two-tailed, and P < 0.05 was considered significant. Patients who were not yet KD diagnosed at the admission to ICU presented either a sepsis in 25/48 (52%) (including toxic shock syndrom) or an acute abdomen in 12/48 (25%). Nearly half of the patients received vasoactive drugs. All patients except two received broad-spectrum antibiotics. All patients received at least one IVIG infusion. Resistance to first IVIG infusion was observed in 24/48 patients (50%). A second IVIG infusion was chosen in all of them. A third treatment line was needed in 16/24 (66.7%): IV corticoid infusion was chosen in 15/16, in association with anti-interleukin 1 in 4/15 (Anakinra). 25/78 (52%) patients KD-ICU presented the AHA criteria, compared with 23/48 (48%) who didn't. Patients AHA- were younger, had a lower heamoglobine concentration and have been more intubated for mechanical ventilation. KD-ICU patients had no initial or evolutive differences whether they had complete or incomplete AHA criteria. A strong suspicion of KD in ICU is therefore enough to initiate specific therapeutics such as IVIG. Further analysis will define the phenotype of patients with KD-ICU to target them earlier, comparing them to KD who did not need ICU transfer, via the KAWANET French database.
  • Hyponatremia in critically ill infants with bronchiolitis : occurrence and associated morbidity
    Orateur(s) :
    • Florent Baudin (Bron / FRANCE)
    • Annabelle Huget (Lyon-Bron / FRANCE)
    • Frédéric Valla (Lyon-Bron / FRANCE)
    • Etienne Javouhey (Lyon / FRANCE)
    14h52 / 14h59
    Abstract : Bronchiolitis is the first cause of hospitalization in infants. Six to 20% of them are admitted in a pediatric intensive care unit (PICU). Some will develop complications related to respiratory distress, like seizures and hyponatremia. The aim of our study was to describe the occurrence of hyponatremia in bronchiolitis infants under the age of three months admitted to PICU and the associated morbidity.We conducted a retrospective study including all infants younger than 6 months, admitted to Lyon-France PICU with a diagnosis of bronchiolitis between January 2010 and April 2018. Children with previous history of significant heart diseases or neurological impairment were excluded. The study was approved by the ethical committee of the French society of intensive care. Hyponatremia was defined as a plasma sodium level <135 mmol/L at any time during PICU stay. T test and Chi2 were used to compare the hyponatremia group and the no-hyponatremia group. A p-value below 0.05 was considered significant.A total of 803 infants were included and among them, 726 had at least one available natremia value. hyponatremia occurred in 33.6% (n=244) children and 6.8% (n=50) had a natremia below 130 mmol/L. Age (36 +/- 21 vs 36 +/- 19 days in hyponatremia group, p=0.83) and weight (3879 +/- 884 g vs 3835 +/- 784 g, p=0.49) was similar between the two groups. Comparison on severity factors between the 2 groups are presented in table 1.Hyponatremia occurred in one third of infant younger than 3 months years old admitted to PICU for bronchiolitis. Hyponatremia was associated with other severity factors of bronchiolitis, with more frequent seizures and with longer length of PICU stay. Hyponatremia needs to be monitored, prevented and treated accurately in infants with severe bronchiolitis.
  • Iatrogen hyponatremies in children: circumstances of survival
    Orateur(s) :
    • Samia Benouaz (Sidi-Bel-Abbès / ALGÉRIE)
    • Faiza Nadia Benatta (Oran / ALGÉRIE)
    • Setti Aouicha Zelmat (Oran / ALGÉRIE)
    • Djahida Djamila Batouche (Oran / ALGÉRIE)
    • Ibtissem Bouanani (Sidi-Bel-Abbes / ALGÉRIE)
    14h59 / 15h06
    Abstract : Hyponatremia is a common fluid and electrolyte disorder. Its incidence is estimated at 0. 34% in operated children. 10% of hyponatraemia occur in the postoperative period. Objective: To determine the circumstances of occurrence of this hyponatremia. Retrospective study, from (2015-2017), carried out in the pediatric surgery and multipurpose resuscitation departments of CHU Sidi-Bel-Abbès. Included were all acute hyponatraemia, with or without neurologic symptomatology, following controlled surgery in healthy children and / or with a pathology that did not lead to fluid and electrolyte disturbance.Of all the hyponatraemia identified during the study regardless of the mechanism, 17 children presented with iatrogenic acute hyponatremia. The children were operated on for circumcision (2), fracture reduction (6), orthopedic surgery (clubfoot and LCH) 7cas and thyroglossal cyst (2). The serum sodium ranged from 114 mmol / L to 128 mmo / L. All patients presented with vomiting. Three children had generalized seizures. Brain CT found diffuse cerebral edema. The evolution was favorable in 16/17 cases with one death. In addition to anticonvulsant therapy in 03 patients, the treatment of hyponatremia involved the administration of sodium salts at a rate of 1.5 to 2 mmol / hour to the PES during the 12 hours under control of clinical status. and the ionogram.These children, who presented with iatrogenic acute hyponatremia, underwent simple surgeries, and were, with one exception, children of ASA1 class. They were all perfused in the perioperative period with hypotonic, high-throughput fluid. Blood glucose was moderately high, children were not hypovolemic on arrival. The circumstances of occurrence can be explained by: A dilution related to the infusion of hypotonic solution too abundant with a flow not monitored by our nurses due to lack of personnel. Prolonged preoperative fasting (more than 8 hours) in our series that may be accompanied by hypovolemia responsible for the secretion of ADH, a component added to the iatrogenic factor. Follow-up of good practices for perioperative pediatric perfusion, the use of adapted equipment (precision infusion pump, volumetric pumps), a strict control of the infusion rate, an education of the nursing staff and a permanent abandonment of pseudo prescriptions of the type "to keep the vein" are fundamental to avoid this type of ionic disorder in children postoperatively.
  • Triage of severely injured children admitted to a Level 1 Pediatric Trauma Center: evaluation at different support stages
    Orateur(s) :
    • Sonia Courtil-Teyssedre (Bron / FRANCE)
    • Lucile Genere (Bron / FRANCE)
    • Jean-Christophe Bouchut (Bron / FRANCE)
    • Blandine Gadegbeku (Bron / FRANCE)
    • Hélène Tardy (Bron / FRANCE)
    • Etienne Javouhey (Lyon / FRANCE)
    15h06 / 15h10
    Abstract : In traumatology, triage is a dynamic process that starts at the trauma scene including prehospital care, continues with trauma team activation in a trauma center when required and ends with patient admission to an adequate unit/ hospital. Referral of severely injured children to a level 1 Pediatric Trauma Center (PTC), like the Hôpital Femme Mère Enfant (HFME) (Lyon, France), reduces mortality. In HFME, local guidelines have been established for trauma team activation by prehospital carriers from the trauma scene or by emergency physicians from the emergency department (Level 1 criteria: vital distress, Level 2 criteria: vital distress stabilized after prehospital care, Level 3 criteria: no vital distress but mechanism of injury criteria). We conducted a retrospective study of 215 patients admitted to HFME in 2016 with trauma team activation criteria according to local guidelines. Level 1 or 2 patients, and level 3 patients presenting with an injury severity score (ISS) >15, were considered severely injured. Four types of undertriage were defined at the different stages of support: prehospital undertriage « transport », prehospital undertriage « orientation », « emergency department undertriage » and « final undertriage », considered to be the main undertriage (Figure 1). Eighty eight patients were severely injured. The rates of undertriage were respectively: 23.8% for prehospital undertriage « transport », 15.7% for prehospital undertriage « orientation », 79% for « emergency undertriage » and 18.2% (16/88) for « final undertriage ». Factor associated with « final undertriage » was firefighters prehospital care and transport (without medical transport team intervention): OR 13.55 [2.16-85.00]. Median ISS was lower in the « final undertriage » subgroup: 17 [16-34] versus 23 [16-21] (p<0.05); « final undertriage » was not associated with a higher death rate or a longer hospital stay. However, 31.3% of this patients subgroup required critical care within the 24h after admission. The rate of undertriage in our PTC in 2016 is above recommendations of less than 5%. The prehospital triage seems to strongly impact the course of patient care. Evaluation of the traumatized child is complicated even for professional first-aiders. The high rate of « emergency department undertriage » shows that the triage also needs to be improved in emergency departments.
Flash Com
14h10 - 15h10
Forum 1
Médecin : Insuffisance rénale aiguë
Modérateur(s) : Matthieu Legrand (Paris / FRANCE), Alexandre Lautrette (Clermont-Ferrand / FRANCE)
  • Renal Doppler in predicting acute kidney injury (AKI) within 3 days in critically ill patients without AKI: Results of a multicenter cohort study.
    Orateur(s) :
    • David Schnell (Angoulême / FRANCE)
    • Aurélie Bourmaud (Paris / FRANCE)
    • Marie Reynaud (Saint-Priest-En-Jarez / FRANCE)
    • Stéphane Rouleau (Angoulême / FRANCE)
    • Alexandra Boivin (Strasbourg / FRANCE)
    • Mourad Benyamina (Paris / FRANCE)
    • François Vincent (Paris / FRANCE)
    • Alexandre Lautrette (Clermont-Ferrand / FRANCE)
    • Christophe Leroy (Clermont-Ferrand / FRANCE)
    • Yves Cohen (Bobigny / FRANCE)
    • Matthieu Legrand (Paris / FRANCE)
    • Jérôme Morel (Saint-Priest-En-Jarez / FRANCE)
    • Jeremy Terreaux (Saint-Priest-En-Jarez / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    14h10 / 14h18
    Abstract : Doppler-based resistive index (RI) and semi-quantitative evaluation of renal perfusion using colour-Doppler (SQP) have been suggested as potential predictors of AKI occurrence in ICU patients without renal dysfunction (1). These results are however limited to preliminary data (1). This study aimed at evaluating the performance of RI and SQP to predict AKI within 3 days in critically-ill patients without overt AKI.Post-hoc analysis of a multicentre prospectively collected dataset. Adult patients without cardiac arrhythmia and requiring mechanical ventilation were included. Patients with severe chronic renal dysfunction or known renal artery stenosis were excluded. AKI was defined according both urinary output and serum creatinine criteria of the KDIGO definition. Renal Doppler was performed at study inclusion. Results are reported in n (%) or median (IQR). Adjusted factors associated with AKI development were assessed using mixed logistic regression model taking centre as random effect.Overall, of the 351 patients included in this study, 118 had no AKI at study inclusion and were ultimately included in the post-hoc analysis. Half of the patients were of male gender (55.6%; n=66) and median age was 58 [IQR 44-67]. In addition to mechanical ventilation, 47 patients (39.8%) required vasopressors, and 46 (39.0%) had a sepsis at inclusion. Median LOD score was 7 [IQR 5-9]. Overall, 34 patients developed AKI during the first 3 days of ICU stay (28.8%). Semi-quantitative perfusion score (ranging from 3 – full perfusion to 0 no perfusion) was 2 [2-3] and 2 [1-3] respectively in patients with and without AKI at day 3 (P=0.06). Doppler-based resistive index was 0.64 [0.57-0.70] and 0.67 [0.62-0.70] respectively in patients with and without AKI at day 3 (P=0.18; figure). Area under ROC curve in predicting AKI within 3 days was 0.60 (0.49-0.71) for SQP and 0.58 (0.47-0.60) for RI. After adjustment for confounders, neither SQP (OR 0.58; 95%CI 0.31-1.10) nor Doppler-based RI (OR 29.15; 95%CI 0.12-703) were associated with AKI at day 3.Our results suggest that neither Doppler-based resistive index nor semi-quantitative renal perfusion is accurate in predicting occurrence of AKI in ICU patients requiring mechanical ventilation.
  • Performance of urinary TIMP-2 and IGFBP7 and Doppler-based Resistive Index to predict reversibility of acute kidney injury in critically ill patients
    Orateur(s) :
    • Fanny Garnier (Montpellier / FRANCE)
    • Delphine Daubin (Montpellier / FRANCE)
    • Romaric Larcher (Montpellier / FRANCE)
    • Anne-Sophie Bargnoux (Montpellier / FRANCE)
    • Laura Platon (Montpellier / FRANCE)
    • Vincent Brunot (Montpellier / FRANCE)
    • Yassir Aarab (Montpellier / FRANCE)
    • Noémie Besnard (Montpellier / FRANCE)
    • Anne Marie Dupuy (Montpellier / FRANCE)
    • Boris Jung (Montpellier / FRANCE)
    • Jean Paul Cristol (Montpellier / FRANCE)
    • Kada Klouche (Montpellier / FRANCE)
    14h18 / 14h26
    Abstract : The performance of urinary tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein7 (TIMP-2*IGFBP7) to predict renal recovery has been poorly studied. In preliminary studies, Doppler-based renal resistive index (RI) might help in differentiating transient from persistent acute kidney injury (AKI). The aim of this study was to compare the performance of TIMP-2*IGFBP7 and RI in predicting short-term reversibility of AKI in critically ill patients. This prospective and monocentric study included consecutive critically ill patients with AKI. RI was measured within 12 hours after admission and urinary TIMP-2*IGFBP7 was measured at H0, H6, H12 and H24. Renal recovery was evaluated at day 3. Receiver-operating characteristic curves (ROCs) were plotted to evaluate diagnostic performance of RI and TIMP-2*IGFBP7 to predict a persistent AKI. Of the 100 patients included, 50 had transient AKI and 50 had persistent AKI. The RI was 0.61±0.05 in the transient AKI group and 0.72±0.05 in the persistent AKI group (p<0.001). TIMP-2*IGFBP7 was not significantly different at each time between both groups. The performance of TIMP-2*IGFBP7 was poor with respectively an area under ROC curves of 0.57(95%CI 0.45-0.68), 0.58(95%CI 0.47-0.69), 0.61(95%CI 0.50-0.72), 0.57(95%CI 0.46-0.68) at H0, H6, H12 and H24. The area under the ROC curve for RI was 0.93 (95%CI 0.89-0.98). A RI > 0.685 predicting persistent AKI with 78% (95% CI 64-88) sensitivity and 90% (95%CI 78-97) specificity. The RI was neither correlated with age (rho=0.12, p=0.23), nor with mean arterial pressure (rho=-0.14, p=0.16) nor with quantity of fluid (rho=0.07, p=0.49). Logistic regression found that RI (Odds ratio [OR]=83.29/0.1-unit step, CI95% 14.91-465.14, p<0.0001) and Sepsis-related Organ Failure Assessment score (OR=1.51, CI95% 1.12-2.03, p=0.001) predicted persistent AKI. Doppler-based renal resistive index had the better performance for predicting the reversibility of AKI in critically ill patients. Urinary TIMP-2*IGFBP7 was unable to differentiate transient from persistent AKI. Further studies are needed to precise adequately the factors influencing RI.
  • Renin angiotensin aldosterone system blockers after severe acute kidney injury: use and impact on 2-year mortality
    Orateur(s) :
    • Mathilde Scarton (Colombes / FRANCE)
    • Anne Oppenheimer (Clamart / FRANCE)
    • Khalil Chaibi (Colombes / FRANCE)
    • Didier Dreyfuss (Colombes / FRANCE)
    14h26 / 14h34
    Abstract : Acute kidney injury (AKI) in intensive care units (ICU) carries high mortality and morbidity. Potential activation of the renin angiotensin aldosterone system during AKI may play a role through pro-fibrotic pathways. Renin angiotensin aldosterone blockers (ACEi/ ARB) have well known benefits for chronic kidney diseases but may be potentially nephrotoxic during AKI. Nevertheless, an ancillary study from the FROG-ICU cohort (ICM May 2018) has recently shown a lower mortality after 1 year of follow-up for patients receiving an ACEi/ARB after an episode of AKI (KDIGO 1 to 3) at ICU discharge (20/109 (18%) vs 153/502 (31%), p = 0.001). The present study analyzes the use of ACEi/ ARB after KDIGO 3 AKI and their potential effect on long-term mortality. Ancillary of the AKIKI study (NEJM, 2016; 375:122-133). All patients discharged alive from ICU were included and their long-term prognosis (2-year mortality) was assessed according to treatment with ACEi/ARB at ICU discharge using both univariate and multivariate analyses after adjustment for potential confounding factors. Among 348 patients discharged alive, 45 (12.9%) received an ACEi/ARB at ICU discharge. Table 1 details patient characteristics. Patients without ACEi/ARB were more severe as attested by a higher SAPS 3 (p=0.02) and a higher rate of catecholamine infusion (p=0.008) during AKI. However, 2-year mortality did not significantly differ between the two groups (12/45 (27%) with ACEi/ARB vs 55/303 (18%), p=0.18). Mortality risk was not associated to non-prescription of ACEi/ARB after adjustment for prognostic variables (p=0.16).A substantial proportion of patients received an ACEi/ARB at ICU discharge after an episode of severe AKI. We did not find a difference in mortality in favor of the renin angiotensin aldosterone system blockers, such as observed in the ancillary study of FROG-ICU (including 109 patients with ACEi/ARB whereas the present study included 45). This could be explained by a different population (less severe AKI in FROG-ICU) and/or a lack of power of our study.This study does not confirm a positive effect on long-term mortality. A randomized controlled trial of ACEi/ARB at ICU discharge after an episode of severe AKI is warranted.
  • Kinetic of uremic toxins' concentrations during acute kidney injury and their role during endotoxemia
    Orateur(s) :
    • Pauline Caillard (Amiens / FRANCE)
    • Eleonore Ourouda-Mbaya (Amiens / FRANCE)
    • Youssef Bennis (Amiens / FRANCE)
    • Said Kamel (Amiens / FRANCE)
    • Gabriel Choukroun (Amiens / FRANCE)
    • Ziad Massy (Amiens / FRANCE)
    • Julien Maizel (Amiens / FRANCE)
    14h34 / 14h42
    Abstract : Chronic kidney disease (CKD) is associated with high mortality related to sepsis. Some studies have already shown uremic toxins' action on vascular and immune disorders during CKD but their potential role during acute kidney injury (AKI) is undetermined. The kinetic of uremic toxin's concentrations and their consequences during AKI disserve to be addressed. The aim of our study was to evaluate the kinetic of three uremic toxin's concentrations (Indoxyl sulfate (IS), Para-crésyl sulfate (PCS) and FGF-23) during the first weeks of kidney failure in a uremic mice model and their consequences during endotoxemia.In this study we explored in vivo the kinetic of the three uremic toxins' concentrations between the 7th and 45th days in controls (sham) and after kidney injury induction (KI). KI was obtained by electrocauterization followed by contralateral nephrectomy two weeks later. Uremic toxin's concentrations were determined in sera after sacrifice at 7th, 15th and 45th days after KI induction. LPS challenge was performed (5mg/kg IP) in sham and KI groups at 15th and 45th days for survival follow up. Two other groups of KI mice fed with arabinoxylan-oligosaccharides (a chelator of PCS -group AXOS-) and sevelamer (a chelator of phosphate known to decrease FGF 23 -group sevelamer-) were exposed to LPS at 45th days of KI and followed for survival.PCS, IS and FGF 23 concentrations increased rapidly after kidney injury at day 7 and last until 45th in the KI group compared to the group sham (figure 1). This was associated with the elevation of cytokines concentration in serum (TNFα, IL-1β, and IL-6). At 15th and 45th days, all KI mice exposed to LPS died whereas all sham LPS animals survived (Fig 2). The treatment with Axos and sevelamer during the 45th days preceding the LPS challenge decreased respectively the PCS concentration (AXOS group), the FGF 23 concentration (Sevelamer group) and improved the survival of KI animals.In this experimental study, the accumulation of uremic toxins appeared early in the course of kidney failure and was associated with local expression of pro-inflammatory molecules. This accumulation of toxins was associated with a higher mortality to endotoxemia. Decrease of PCS and FGF 23 concentrations was associated with the improvement of survival to LPS challenge. The early accumulation of uremic toxins and their potential role in sepsis mortality need to be confirmed during AKI in humans.
  • Incidence and patterns of renal recovery in critically-ill patients with hematological malignancies
    Orateur(s) :
    • Arthur Orieux (L'Herbergement / FRANCE)
    • Jean-Baptiste Lascarrou (Nantes / FRANCE)
    • Cyril Touzeau (Nantes / FRANCE)
    • Amélie Seguin (Nantes / FRANCE)
    • Arnaud-Felix Miailhe (Nantes / FRANCE)
    • Maëlle Martin (Nantes / FRANCE)
    • Emmanuel Canet (Paris / FRANCE)
    14h42 / 14h50
    Abstract : AKI is a dreaded complication in patients with hematological malignancies, associated with increased morbidity and mortality. Moreover, AKI may preclude the ability to receive further chemotherapy. However, current knowledge on the kinetics of renal recovery or persistent renal dysfunction is limited.We conducted a retrospective single-center study which included all patients with hematological malignancies admitted to the intensive care unit (ICU) of Nantes University Hospital from January to December 2017. Our purpose was to study the epidemiology of AKI and the occurrence of Major Adverse Kidney Events (MAKE). One hundred and three patients were included, among which 92 (89%) had AKI. Median age was 62,5 (49,75-68) years old and 59 (64%) were male. Most common malignancies were lymphoma (26, 28%), acute myeloblastic leukemia (20, 22%) and myeloma (19, 21%). 17 (18%) patients were newly diagnosed for the malignancy and 25 (27%) had relapsing diseases. Chemotherapy was administered in 64 (70%), 14 (2-31) days before ICU admission. Simplified Acute Physiology Score II (SAPS) at day 1 was 48 (39-62). During ICU stay, 37 (40%) patients received vasopressors and 28 (30%) required invasive mechanical ventilation. ICU, hospital, day-90, and day-180 mortalities were 22%, 33%, 38%, and 43%, respectively. According to the KDIGO criteria, 47 (51%) had AKI stage 1, 16 (17%) AKI stage 2, and 29 (32%) AKI stage 3, of whom 14 (15%) required renal replacement therapy (RRT). ICU mortality of RRT patients was 78%. Overall, median duration of AKI was 5 (3-10) days, and increased from 4 (3-7) days in KDIGO stage 1 patients, to 3.5 (2.8-7.5) days in KDIGO stage 2 patients, and 12 (5-25) days in KDIGO stage 3 patients. Among survivors, renal recovery occurred in 48 (69%) patients at ICU discharge, 35 (61%) patients at day-90, and 32 (60%) patients at day-180. MAKE were reported in 32 (35%) patients at ICU discharge, 35 (38%) patients at hospital discharge, 41 (45%) 90 days after discharge, and 44 (48%) at day-180.Critically-ill patients with hematological malignancies had a high incidence of AKI. Although almost 80% of the patients were discharged alive from the ICU, MAKE at day-90 accounted for roughly 1 in every 2 patients. Further research is needed to identify predictors of MAKE, so as to develop new therapeutic strategies which might translate into better long-term outcomes.
  • Medico-economic impact of renal replacement therapy initiation strategies in the ICU
    Orateur(s) :
    • Abirami Thiagarajah (Colombes / FRANCE)
    • Pierre-Antoine Billiet (Colombes / FRANCE)
    • Anne Oppenheimer (Clamart / FRANCE)
    • Julien Maizel (Amiens / FRANCE)
    • Fouad Fadel (Cergy Pontoise / FRANCE)
    • Eric Boulet (Beaumont Sur Oise / FRANCE)
    • Guillaume Chevrel (Corbeil-Evry / FRANCE)
    • Laurent Martin-Lefèvre (La Roche Sur Yon / FRANCE)
    • Didier Dreyfuss (Colombes / FRANCE)
    14h58 / 15h06
    Abstract : Indications and modalities of renal replacement therapy (RRT) in intensive care unit (ICU) patients with acute kidney injury (AKI) are still debated. The AKIKI trial (1) showed that a delayed RRT strategy (in the absence of life-threatening condition) did not affect mortality but allowed nearly 50% patients to escape RRT compared to an early RRT strategy in patients with KDIGO3 AKI. This has obvious economic counterparts which are evaluated in this study. (1) Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, et al. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med. 2016 Jul 14;375(2):122–33. Financial costs of RRT (both continuous and intermittent) were assessed in 45 patients in seven French ICUs from September 2017 to August 2018 taking into account catheters, circuits, dialyzer membranes and dialysate/replacement fluid prices. Medical and nursing working times including time for venous catheterization and RRT duration (including circuit preparation and restitution time only) were also recorded and their cost was computed. We then extrapolated these figures to the AKIKI population in order to estimate the cost difference between the two strategies (early and delayed). Analysis was restricted to the first 72 hours after inclusion. The mean working time was 121 (+/-60) minutes for intermittent RRT and 119 (+/-91) minutes for continuous RRT. The mean financial costs for the first 72h after RRT initiation were 111.53 (+/-44.91) euros for the intermittent RRT and 636.21 (+/- 254.05) euros for continuous RRT (p< 0.001). Extrapolating these figures to the 619 patients included in AKIKI, revealed that the early strategy was associated with a cost of 104,619 euros and the delayed one with a cost of 54,702 euros during the first 72 hours after randomization. This study highlights the considerable savings that can safely be obtained with a delayed RRT strategy in ICU patients with severe AKI.
  • At-risk drinking is independently associated with acute kidney injury in non-trauma critically ill patients
    Orateur(s) :
    • Arnaud Gacouin (Rennes / FRANCE)
    • Mathieu Lesouhaitier (Rennes / FRANCE)
    • Aurélien Frerou (Rennes / FRANCE)
    • Benoit Painvin (Rennes / FRANCE)
    • Florian Reizine (Rennes / FRANCE)
    • Sonia Rafi (Rennes / FRANCE)
    • Adel Maamar (Rennes / FRANCE)
    • Yves Le Tulzo (Rennes / FRANCE)
    15h06 / 15h10
    Abstract : Unhealthy use of alcohol and acute kidney (AKI) injury both are major public health problems. Chronic alcohol exposure may be directly or indirectly associated with kidney damage but little is known about the impact of current excessive alcohol consumption on kidney function in non-trauma critically ill patients. We aimed to determine whether unhealthy use of alcohol is independently associated with AKI in the intensive care unit (ICU) and worst kidney function at hospital discharge. Prospective cohort study on non-cirrhotic, non-liver transplant recipients, and non-chronically dialyzed patients admitted in a 21- bed polyvalent ICU in a university hospital. The study was designed to have a 90% power to detect a 15% difference in the incidence of AKI between not at-risk drinkers and at-risk drinkers at a two-sided alpha error of 5 %. At-risk dinking was defined according to the National Institute on Alcohol Abuse and Alcoholism criteria and AKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. Patients were followed until hospital discharge or day 60. Over a 30-months period we calculated the cumulative incidence of stage 2-3 AKI in the 320 at-risk drinkers (29%) and 787 in not at-risk drinkers (71%). Stage 2-3 AKI was significantly more frequent at admission to the ICU in at-risk drinkers than in not at-risk drinkers (42.5 % versus 18%, p < 0.0001). The cumulative incidence of stage 2-3 AKI was significantly higher in at-risk than in not at-risk drinkers (Figure 1) (p <0.0001, log-rank test). After adjustment on susceptible and predisposing factors for AKI, at-risk drinking was significantly associated with AKI (Hazard ratio (HR) = 2.53 (2.08-3.08), p< 0.0001). The proportion of patients with stage 2-3 AKI at hospital discharge among survivors was significantly higher in at-risk than in not at-risk drinkers (10% versus 5% respectively, p= 0.01). At-risk drinking remained independently associated with stage 2-3 AKI in the subgroup of 832 patients without stage 2-3 AKI at admission to the ICU (HR= 2.34 (1.68-3.72), p< 0.0001). Our results suggest that kidney dysfunction is significantly more frequent in at-risk than in not at-risk drinkers. We believe that systematic and accurate identification of patients with prior alcohol misuse may allow for prevention of AKI.
Flash Com
14h10 - 15h10
Forum 2
Médecin : Infections virales sévères
Modérateur(s) : Guillaume Voiriot (Paris / FRANCE), Sami Hraiech (Marseille / FRANCE)
  • Incidence, Epidemiology and Prognosis of Viral Respiratory Infections in Severe Acute Respiratory Failure in Human immunodeficiency virus (HIV) infected Adults
    Orateur(s) :
    • Alexandre Elabbadi (Paris / FRANCE)
    • Jérémie Pichon (Paris / FRANCE)
    • Benoit Visseaux (Paris / FRANCE)
    • Quentin Philippot (Paris / FRANCE)
    • Aurélie Schnuriger (Paris / FRANCE)
    • Muriel Fartoukh (Paris / FRANCE)
    • Stéphane Ruckly (Paris / FRANCE)
    • Guillaume Voiriot (Paris / FRANCE)
    14h10 / 14h18
    Abstract : Acute respiratory failure remains the main reason for admission to intensive care in HIV-infected Adults. There is little data on viral epidemiology in lower respiratory tract infections in this population.Cases of acute respiratory failure in HIV-infected adults admitted to two intensive care units between 2011 and 2017, who underwent screening for respiratory virus by multiplex polymerase chain reaction, were retrospectively selected. A total of 123 cases were included. An HIV infection was newly diagnosed in 9% of cases and 72% of the population was taking antiretroviral therapy with treatment compliance in almost 76% of cases. A documented viral respiratory infection was found in 33 patients (27%). Rhinovirus was the main virus, found in 33% of cases (n = 15) followed by Parainfluenza (n = 5) and Influenza A (n = 5). A co-infection was found in 22 patients (67% of cases) with only one virus-virus co-infection. Overall, neither the level of HIV-related immunodeficiency nor the use of ARVs at admission seems to be associated with an increased risk of respiratory viral infection. Nevertheless the subpopulation of Rhinovirus infection was associated with a low CD4 count. Outcome in the ICU was similar regardless of whether or not a respiratory viral infection was present.Respiratory viruses are frequently found during the acute respiratory failure of the HIV subject. This proportion appears to be similar to other studies that have looked at the proportion of respiratory viruses in the general population.
  • Is Human Metapneumovirus identified in the Respiratory Tract of Immunocompromised Patients with Acute Respiratory Failure Clinically Relevant?
    Orateur(s) :
    • Natacha Kapandji (Paris / FRANCE)
    • Jérôme Le Goff (Paris / FRANCE)
    • Maud Salmona (Paris / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    14h18 / 14h26
    Abstract : Human metapneumovirus (hMPV) may be responsible for pulmonary infections in immunocompromised patients. We sought to assess clinical and radiological characteristics associated with the presence of hMPV in the respiratory tract of critically ill immunocompromised patients. This single center retrospective cohort included adult immunocompromised patients admitted to intensive care unit (ICU) in whom hMPV was detected in respiratory tract from September 2010 to June 2018. Results are reported as n (%) and median (IQR). Comparison were performed by Fisher exact test or Wilcoxon test as appropriate.Of the 1185 immunocompromised patients admitted to ICU during this period, 26 (2.1%) patients presented hMPV: 15 (58%) males, aged 66 (IQR 56-74), 21 (81%) with hematological malignancies including 11 (42%) allogeneic stem cell transplant recipients. In addition to respiratory failure, 5 (19%) presented with shock. Clinical picture included fever in 23 patients (89%), cough in 19 (73%), whereas extrapulmonary symptoms were less common (11 to 31%). CT-scan patterns included alveolar consolidations in 14 (54%) patients, ground glass opacities in 10 (38%), and septa thickening in 3 (12%). All but one patient presented another pathogen: bacterial infection in 15 patients (70%), viral infection in 8 (31%) and fungal infection in one (invasive aspergillosis). At ICU admission, SAPS2 score was 41 (IQR 37-58), mechanical ventilation being required in 11 patients (42%), vasopressors in 11 (42%) and renal replacement therapy in 4 (15%). Hospital mortality rates was 31% and was found to be associated with hemodynamic failure, renal replacement therapy and neutropenia. hMPV is found in the respiratory tract of 2.1% of immunocompromised patients with acute respiratory failure, and in all but 8 cases, another pathogen is also identified. CT patterns have nothing unique and could be ascribable to the second pathogen. Whether positive hMPV is a relevant result is unclear and remains unaddressed by this set of data. Comparing clinical and radiographic pictures and outcomes of patients with positive hMPV to matched patients with documented influenza infections is ongoing and will be displayed at the conference.
  • Relative lymphopenia in patients with severe influenza A in ICU: Incidence and relation with severity illness.
    Orateur(s) :
    • Helmi Amri (Ariana / TUNISIE)
    • Amira Jamoussi (Ariana / TUNISIE)
    • Samia Ayed (Ariana / TUNISIE)
    • Takoua Merhebene (Ariana / TUNISIE)
    • Dhouha Lakhdher (Ariana / TUNISIE)
    • Amine Slim (Tunis / TUNISIE)
    • Jalila Ben Khelil (Ariana / TUNISIE)
    • Mohamed Besbes (Ariana / TUNISIE)
    14h26 / 14h34
    Abstract : Relative lymphopenia (RL) is considered when lymphocytes count is ≤ 21 % of all white blood cells. It has been reported as a possible marker of influenza A and especially pandemic influenza A/H1N1 2009 infection. The aim of this study was to assess RL incidence in patients hospitalized in intensive care unit (ICU) for influenza A (H1N1 or H3N2) infection and to find whether it was related to severity illness.This was a retrospective monocentric study conducted in the medical ICU of Abderrahmen Mami hospital in Tunisia, between September 2009 and September 2018. Inclusion criteria were ICU patients admitted for influenza A infection. We collected clinical, biological and outcome data. Then we compared initial severity and outcome between RL patients group and normal lymphocyte count patients group.During the ten-year study period, we collected 72 patients with influenza A infection. The strain detected with PCR technique was H1N1 (n=65) and H3N2 (n=7). The mean age was of 48.2 ± 15.2 years and the sex-ratio M/F was of 1.4 (42/30). Seven women were pregnant. White blood cell (WBC) value was found to be normal in 47.2 % and high in 38.9 % of patients with influenza A infection. Leucopenia was seen in only 10 patients (13.9 %). Thrombocytopenia (≤150 x 103 platelets/mm3) was present in 24 patients (30.6 %). RL was present in 56 patients (77.8 %). Ratio Lymphocyte/Monocyte <2 was noticed in 7 patients (9.7%). At admission, severity was assessed by SAPS II score (31.2 ± 16.5) and APACHE II score (12.5 ± 8.12). The main reason for ICU admission was acute respiratory failure (97.2 %) from whom 35 patients (48.6 %) had ARDS. Non-invasive ventilation was needed in 68 % patients and 45.8 % were intubated. The mean duration of mechanical ventilation was 7.96 days [0-47].The mean length of stay in ICU was 10.56 days [1-65] and the ICU mortality rate was 33.3 %. Comparison of severity illness components according to RL presence are represented in table 1.RL is frequent in ICU patients with influenza A infection. It is significantly more frequent in older patients. RL is associated to higher severity scores, but not to respiratory impairment degree or death.
  • Critically ill influenza patients: co-infections and cardiovascular events
    Orateur(s) :
    • Erwan Begot (Lescar / FRANCE)
    • Renaud Prevel (Bordeaux / FRANCE)
    • Fabrice Camou (Bordeaux / FRANCE)
    • Walter Picard (Pau / FRANCE)
    • Chloé Gisbert-Mora (Bayonne / FRANCE)
    • Alexandre Boyer (Bordeaux / FRANCE)
    • Didier Gruson (Bordeaux / FRANCE)
    14h34 / 14h42
    Abstract : Critically ill influenza patients have a mortality rate about 20%. Co-infections, especially invasive aspergillosis, have recently been documented amongst these patients and are thought to play a major role in the prognosis of these patients. Nevertheless, the need of systematic microbiological documentation is still not widely accepted by ICU health workers. Moreover, a high incidence of cardiovascular events (acute coronary syndrome or stroke) within the first 15 days after the influenza illness has been described for a few years . The aims of our study were to assess the daily practice regarding microbiological investigation of these coinfections and to assess the cardio-vascular events rates.A retrospective, observational study from November 2017 to April 2018 in four French ICUs including all critically ill influenza patients was conducted. Influenza diagnosis was confirmed by polymerase chain reaction or rapid test. Co-infections were confirmed using clinical and standard microbiological criteria. Stroke was diagnosed by sudden neurological symptom with MRI or contrast tomodensitometry confirmation. Acute coronary syndrome was diagnosed according to ESC guidelines.111 patients were included. 98/106 patients (92%) were classified as suffering from Acute Respiratory Syndrome. 69/111 patients (62%) received non invasive ventilation during 5.7 (±2.8) days. 57/111 patients (51%) received invasive mechanical ventilation for 10,5 (± 8.9) days. 76/111 patients (69%) have been treated by oseltamivir for 5.1 (± 1.9) days. 81/111 (73%) were still alive at Day 28. 90/111 (81%) had a bacterial sputum culture with 38/90 (42%) suffering from a bacterial co-infection, mainly S. pneumoniae and Methicillin-Susceptible Staphylococcus aureus. Only 22/111 (20%) patients had a fungal sputum culture and 27/111 (24%) a blood galactomannan dosage. Amongst those 22 patients, 5 exhibited fungi in their sputum culture, 2 of which corresponding to Aspergillus spp. and 3 to Candida spp. Viral co-infection occurred among 14/73 patients (19%), especially by Coronavirus. Regarding cardiovascular events, acute coronary syndrome occurred in 11/111 patients (10%) and stroke in 2/111 patients (1.8%) during the month after the diagnosis of influenza.Critically ill influenza patients are frequently co-infected, by bacteria but also by virus and fungi. Fungal and viral coinfections seem to be still under investigated by ICU workers. Further studies investigating the prophylaxis and management of these coinfections are needed. Cardiovascular events prevention should also be studied among critically ill influenza patients.
  • Human metapneumovirus and risk of lower respiratory tract infection, ICU admission and hospital mortality: results of a systematic review and meta-analysis
    Orateur(s) :
    • Natacha Kapandji (Paris / FRANCE)
    • Virginie Lemiale (Paris / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    14h42 / 14h50
    Abstract : Impact of human metapneumovirus (hMPV) on lower respiratory tract infections is unclear in both children and adult patients. The aim of this review was to evaluate the prevalence of lower respiratory tract infections (LRTI), need for intensive-care-unit (ICU) admission and hospital mortality in immunocompromised adults with previous detection of hMPV.This systematic review was performed according to PRISMA statements and registered in the PROSPERO database (CRD42018106617). Studies reporting rate of LRTI, ICU admission and mortality were searched on PubMed (2008 - 2018) for immunocompromised patients. Prevalence and its confidence interval (95%CI) were plotted. Publication bias was assessed by visually inspecting the funnel plot and summary estimates of relative risk and their 95% confidence interval were calculated using random-effects model. Overall, 42 citations were identified and 29 studies, reporting 1407 patients, were ultimately included (21 cohort studies and 8 case series). Median sample size was 13 patients (IQR 7 - 48) and median admission year was 2009 (IQR 2008 - 2012). Diagnosis of hMPV infection was performed using RT-PCR on nasopharyngeal swab in 22 studies (76%). Proportion of patients with hematological malignancies was 97% (IQR 0 – 100), and proportion of allogeneic stem cell transplantation was 11% (IQR 0 - 47). LRTI prevalence was 60% (95%CI 48 – 73; I2 = 94%). ICU admission was required in 20% of patients (95%CI 14 – 27; I2 = 90%). Last, hospital mortality was 6% (4 – 9; I2 = 79%). Factors associated with heterogeneity were assessed using meta-regression. Heterogeneity of the results were partly explained by study design, proportion of patients with hematological malignancy and proportion of patients with co-infection. In this systematic review, two third of immunocompromised patients in whom hMPV was detected had LRTI, and as many as 20% required ICU admission. A high heterogeneity was noted that may be explained by study design, underlying immune status and underlying disease and rate of co-infections. Most of the included studies were however at high risk of bias justifying need for additional studies in this field.
  • Impact and characteristics of respiratory viruses infection during severe acute respiratory failure in adults
    Orateur(s) :
    • Jérémie Pichon (Paris / FRANCE)
    • Lila Bouadma (Paris / FRANCE)
    • Benoit Visseaux (Paris / FRANCE)
    • Aurélie Schnuriger (Paris / FRANCE)
    • Muriel Fartoukh (Paris / FRANCE)
    • Guillaume Voiriot (Paris / FRANCE)
    14h50 / 14h58
    Abstract : The mPCR (multiplex Polymerase Chain Reaction) tests are widely used in clinical routine. However, clinical and paraclinical features of virus-associated respiratory tract infections in adults are poorly described, especially in acute respiratory failure requiring critical careThis was a prospective non-interventional 2-center clinical study. All adult patients admitted to intensive care unit for an acute respiratory failure and subjected to a multiplex PCR (16 virus, nasopharyngeal swab and/or distal sample) during the first 72 hours of ICU stay were included. Prior to get the mPCR results, clinicians were invited to subject patients to a questionnaire asking for 37 symptoms (respiratory and extra-respiratory) coded from 0 (none) to 4 (maximum). Other sources may be examined, such as patient relatives, general practitioner or medical reportsFrom December 2015 to April 2017, 339 patients were included (209 men, age 63 years [50-73]), of whom 82 were intubated. The final diagnosis was pneumonia in 121 patients, exacerbation of chronic bronchial disease in 117 subjects and another diagnosis in 101 subjects. At least one virus was identified in 121 patients, including 40 Rhinovirus, 34 Influenza, 13 Respiratory syncytial virus, 14 Metapneumovirus and 15 Coronavirus. In univariate analysis, an active smoking, a close contact with somebody ill, a rhinorrhea, a bronchorrhea, an earache, a diarrhea, a lymphopenia, a thrombocytopenia and elevated CPK were associated with the documentation of respiratory viruses within airwaysA phenotype suggesting a virus-associated respiratory tract infection was described. It may help to rationalize the use of mPCR tests
Session Thématique
14h10 - 15h10
S01
Infirmier(e) : Epuration extra-rénale niveau 2
Modérateur(s) : Silvia Calvino-Ghunter (Grenoble / FRANCE), Fatima Douadi (Nice / FRANCE)
  • Timing d'initiation de l'épuration extra-rénale
    Orateur(s) :
    • Stéphane Gaudry (Bobigny / FRANCE)
    14h10 / 14h30
  • Epuration extra-rénale citrate
    Orateur(s) :
    • Joanna Schmitt (Lyon / FRANCE)
    14h30 / 14h50
  • Comment optimiser la durée de vie du filtre
    Orateur(s) :
    • Michael Darmon (Paris / FRANCE)
    14h50 / 15h10
Session Thématique
14h10 - 15h10
S03
Infirmier(e) : Agitation delirium I
Modérateur(s) : Benjamin Sztrymf (Clamart / FRANCE)
  • Epidémiologie et outils diagnostiques
    Orateur(s) :
    • Romain Sonneville (Paris / FRANCE)
    14h10 / 14h30
  • Prévention du delirium
    Orateur(s) :
    • Angelina Barage (Clermont-Ferrand / FRANCE)
    14h30 / 14h50
  • Pronostic
    Orateur(s) :
    • Armand Mékontso-Dessap (Créteil / FRANCE)
    14h50 / 15h10
E-Poster
14h10 - 15h10
Espace poster 4
Médecin : Insuffisance Respiratoire 2
Modérateur(s) : Lamia Besbes (Monastir / TUNISIE), François Beloncle (Angers / FRANCE)
  • Impact of a failed spontaneous breathing trial on dyspnea
    Orateur(s) :
    • Maxens Decavèle (Paris / FRANCE)
    • Emmanuel Rozenberg (Paris / FRANCE)
    • Julien Mayaux (Paris / FRANCE)
    • Julie Delemazure (Paris / FRANCE)
    • Thomas Similowski (Paris / FRANCE)
    • Martin Dres (Paris / FRANCE)
    14h10 / 14h17
    Abstract : Dyspnea is a frequent and potentially intense symptom in mechanically ventilated patients. Whether the presence and intensity of dyspnea could interfere with the result of a spontaneous breathing trial (SBT) is unknown. Alternatively to the use of visual assessment scale of dyspnea that is challenging in critically ill patients, the five-item Mechanical Ventilation – Respiratory Distress Observation Scale (MV-RDOS) has been proposed as a reliable surrogate of dyspnea in non-communicative intubated patients [1]. In the present study, we sought 1) to describe the prevalence and changes in MV-RDOS during a SBT and 2) to evaluate the performance of MV-RDOS to predict SBT failure.Patients from a single center, intubated since more 48 hours were eligible after they failed at a first spontaneous breathing trial (SBT). Dyspnea was assessed with the MV-RDOS at the beginning and the end of the SBT. Dyspnea was define by a MV-RDOS > 2.3 [1]. The area under receiver operating characteristic (ROC) curve of the MV-RDOS measured at the onset of the SBT was computed to predict the risk of SBT failure.Thirty-five patients (39 SBTs) (age 60 [49-68], SAPS II 71 [56-82]; med [IQR]) were included and in total 39 SBTs were analyzed. All patients were deemed ready to be weaned criteria (FiO2 30% [30-40]; positive end expiratory pressure 5 cmH2O [5-6]; respiratory rate 22 cycles/min [17-26]) but dyspnea was present in 22/39 (56%) at the beginning of the SBT. Twenty-three (59%) SBTs lead to failure and 16 (41%) were considered as success. The changes in MV-RDOS in patients who succeeded and failed the SBT are depicted in Figure 1. The proportion of SBT failure was higher in patients who presented dyspnea at the beginning of the SBT (74% vs. 31%, p = 0.008). A MV-RDOS value above 2.47 at the beginning of the SBT predicted SBT failure with a 65% sensitivity and 81% specificity (AUC=0.778; 95%CI [0.634, 0.927]). Despite patients met classical readiness to wean criteria, dyspnea was frequent at the beginning of SBT and increased only in patients who fail the SBT. MV-RDOS could predict SBT failure with good performances. Reference : [1] European Respiratory Journal. 2018 ; Epub ahead of print.
  • Extracorporeal membrane oxygenation in adult cancer patients with severe acute respiratory failure: view of a cancer center
    Orateur(s) :
    • Afef Hammami (Villejuif / FRANCE)
    • Aymen M'Rad (Villejuif / FRANCE)
    • Alain Gaffinel (Villejuif / FRANCE)
    • Lilia Berrahil-Meksen (Villejuif / FRANCE)
    • Annabell Stoclin (Villejuif / FRANCE)
    • Bertrand Gachot (Villejuif / FRANCE)
    • François Blot (Villejuif / FRANCE)
    14h17 / 14h24
    Abstract : Using extracorporeal membrane oxygenation (ECMO) in adult cancer patients is controversial. This study was designed to report outcomes of adult cancer patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) after the failure of optimal conventional therapy. We also identified their pre-ECMO predictors of ICU and 6-month mortality.The charts of all cancer patients admitted to our oncology ICU and receiving ECMO support for ARDS from 2011 to 2017 were retrospectively reviewed. The cases were recorded using both PMSI data and analysis of computerized records by keywords systematic detection. After placement of cannulas, all patients were transferred from our hospital to a specialized ICU for ECMO therapy.Fourteen patients received ECMO during the study period (Table). One patient received venoarterial-venous ECMO because of acute circulatory failure in addition to ARDS. All other patients received venovenous ECMO. ECMO-related major bleeding and ventilator-associated pneumonia were frequent (50% and 42.9%, respectively). Respective median ECMO duration and ICU stay were 10 (5-43) and 27.5 (11-57) days. ICU and 6-month survival was 28.6%. The four survivors had a significantly shorter time interval between ICU admission and start of ECMO therapy (4 vs. 11 days), lower PCO2 at baseline (45 vs. 62 mmHg), and, after ECMO initiation, lower health care-associated infection (1 vs. 9 episodes) and shorter ECMO duration (6 vs. 19 days). The limitations of this study are its retrospective design and the small number of cases involved. Obvious selection bias was induced because only the patients treated with ECMO were included. The systematic computerized analysis ensured the lack of missing data. Despite the high rate of ICU mortality, this study showed that all survivors were still alive 6 months later. Early beginning of ECMO, avoiding ventilator-induced lung injury, was associated with a better prognosis. These findings encourage identifying as soon as possible patients with a favorable prognosis of malignancy and having an isolated respiratory failure, in order to optimize their chances of recovery from ARDS. A close cooperation of intensivists and oncologists is warranted. ECMO therapy may be beneficial in selected cancer patients. Ongoing investigations are needed to better select patients with a likely benefit, and determine optimal timing for initiation of ECMO.
  • Diaphragm and cardiovascular interaction during weaning from mechanical ventilation: a physiological study
    Orateur(s) :
    • Emmanuel Rozenberg (Paris / FRANCE)
    • Maxens Decavèle (Paris / FRANCE)
    • Julien Mayaux (Paris / FRANCE)
    • Julie Delemazure (Paris / FRANCE)
    • Thomas Similowski (Paris / FRANCE)
    • Martin Dres (Paris / FRANCE)
    14h24 / 14h31
    Abstract : Diaphragm dysfunction and weaning induced pulmonary edema (WIPE) are two main causes of weaning failure. Since spontaneous breathing-increased venous return is a key determinant of WIPE, we hypothesized that diaphragm dysfunction could not provide a thoracic depression enabling the occurrence of WIPE. Therefore, the objective of the study was to determine the prevalence of WIPE and diaphragm dysfunction and their coexistence.Patients intubated since more 48 hours were eligible after they failed at a first spontaneous breathing trial (SBT). Before and after the following SBT, diaphragm function was evaluated with the reference method (drop in tracheal pressure induced by a bilateral phrenic nerves stimulation) and cardiac echo (early (E) over late (A) peak diastolic velocities ratio and tissue Doppler imaging of mitral annulus velocities including early (Ea) peak diastolic velocity over A wave ratio) and biological (hemoconcentration) markers of WIPE were searched for. Diaphragm dysfunction was defined by a Ptr,stim<-11 cmH20. WIPE was defined by a failed SBT associated with 1) either the combination of E/A >0.95 and E/Ea >8.5 at the end of the SBT or 2) an increase in plasma protein concentration or in hemoglobin >5% during the SBT.Among 34 patients included, twenty-one (62%) failed in the SBT. WIPE was present in 15/21 (71%) patients who failed. Diaphragm dysfunction was found in 17/21 (81%) patients who failed and both mechanisms were present in 14/21 (67%) patients. Except in one patient, in all patients in whom WIPE occurred, diaphragm dysfunction was found (figure).Coexistence of diaphragm dysfunction and WIPE is frequent at the time of liberation from mechanical ventilation in difficult to wean patients. The presence of diaphragm dysfunction doesn't reduce the risk of WIPE.
  • Acute interstitial pneumonia of systemic lupus erythematosus
    Orateur(s) :
    • Emmanuelle Guérin (Paris / FRANCE)
    • Marc Pineton de Chambrun (Paris / FRANCE)
    • Boussouar Samia (Paris / FRANCE)
    • Mathian Alexis (Paris / FRANCE)
    • Pha Micheline (Paris / FRANCE)
    • Guillaume Franchineau (Paris / FRANCE)
    • Ania Nieszkowska (Paris / FRANCE)
    • Loic Le Guennec (Paris / FRANCE)
    • Guillaume Hekimian (Paris / FRANCE)
    • Rouvier Philippe (Paris / FRANCE)
    • Hie Miguel (Paris / FRANCE)
    • Matthieu Schmidt (Paris / FRANCE)
    • Charles-Edouard Luyt (Paris / FRANCE)
    • Amoura Zahir (Paris / FRANCE)
    14h31 / 14h38
    Abstract : Systemic lupus erythematosus is a chronic autoimmune disease characterised by frequent skin, joint, haematological and renal involvement. Acute interstitial pneumonia (AIP) is infrequent and poorly investigated in this disease. The aim of this study was to describe the clinical characteristics, the course and the outcome of AIP in SLE.We conducted a monocentric retrospective, observational, cohort study between November 1996 and September 2018. We included all patients with SLE (defined using the American College of Rheumatology 1997 criterion) and AIP (defined as acute respiratory manifestation with diffuse pulmonary opacities on chest radiography or lung tomography and exclusion of alternate diagnosis including acute respiratory infection).Fourteen patients (male/female sex ratio, 0.3; mean±SD age, 23.7±10.6 years) presenting 16 episodes were included. AIP was present at disease onset or during the first year after SLE diagnosis in respectively 9/14 (64%) and 5/14 (36%) patients. Eleven (68.8%) episodes required ICU admission because of respiratory failure with 7/11 (63.6%) episodes requiring mechanical ventilation and 2/11 (18.2%) VV-ECMO. Median [IQR25-75] SAPSII and SOFA score at ICU admission were: 32 [27-39] and 4 [2.5-8.5] respectively. Frequencies of associated SLE-related organ involvement were: kidney 13/16 (81.3%), arthritis 13/16 (81.3%), fever 13/16 (81.3%), serositis 12/16 (75%), skin 11/16 (68.7%), haematological manifestation 8/16 (50%) and neurological manifestation 3/16 (18.7%). Median [IQR25-75] SLEDAI-2K was 18.5 [14.75-25.75]. Bronchoalveolar lavage was available for 12 episodes and revealed alveolar haemorrhage in 8/12 (66.7%). Chest tomography revealed bilateral consolidations predominating in the lower parts of the lungs in most patients. SLE treatments were as follow: corticosteroid pulses 16/16 (100%), cyclophosphamides 9/16 (56%), plasmapheresis 4/16 (25%). Evolution was favourable in most patients and 90-day survival was 93.8%. During follow-up, only one patient had asymptomatic residual lung interstitial opacities while all other patient had normal lung CT-scan.AIP is a rare manifestation of SLE that occurs during the first year of SLE onset in young patients. AIP of SLE can be severe, requiring mechanical ventilation and even ECMO. Patients usually exhibit multiple other SLE-related organ involvement. Mortality in our cohort is low and most patients recover completely without chronic interstitial lung disease during follow-up.
  • Implication of unconventional T cells during severe pneumonia
    Orateur(s) :
    • Yonatan Perez (Tours / FRANCE)
    • Florent Creusat (Tours / FRANCE)
    • Chloé Boisseau (Tours / FRANCE)
    • Mustapha Si-Tahar (Tours / FRANCE)
    • Christophe Paget (Tours / FRANCE)
    • Youenn Jouan (Tours / FRANCE)
    14h38 / 14h45
    Abstract : Severe pneumonia is frequently associated with acute respiratory distress syndrome (ARDS). Uncontrolled inflammatory response in the lung is a key factor in the transition from pneumonia to ARDS. However, the underlying mechanisms are still poorly understood. To assess this, a heterogeneous population of T lymphocytes called “unconventional T cells” (UTC) deserves greater attention. These cells comprise Natural Killer T (NKT) cells, mucosal-associated invariant T cells (MAIT) and Gamma Delta T cells. Pre-clinical studies have shown their versatile properties and their key role in immune responses against invading pathogens. Thus, we hypothesize that a tight regulation of their functions is mandatory to fine-tune the host inflammatory response in the infected lungs, and, subsequently to prevent emergence of an aberrant response leading to tissue damages. Despite this strong rationale, human data are however lacking.Single-center prospective study on patients hospitalized in intensive care for severe pneumonia. From blood and respiratory samples, we performed a flow cytometry-based analysis of these cells in order to determine: (1) their frequency at different time-points during hospitalization, (2) the presence of activating/regulating markers (CD69 and PD-1), (3) their ability to produce cytokines involved in ARDS pathogenesis and (4) their cytotoxic capacity. 26 patients have been included to date, that were compared to healthy controls. Half of the patients presented ARDS, and median SAPSII was 35.5 (30-51). In patients with severe pneumonia, we observed a striking decrease in circulating MAIT cells, compared to healthy controls (Fig. 1A), but not for NKT or Gamma Delta T cells. This observation may suggest a recruitment of these cells to inflammatory site since a high proportion of MAIT cells can be detected in respiratory fluids of some patients with ARDS. In addition, circulating MAIT cells of patients expressed high levels of CD69 and PD-1 (Fig. 1B). Interestingly, the proportion of CD69+ MAIT cells decreased with clinical improvement, while proportion of PD-1+ remained stable. Upon ex-vivo stimulation, proportion of IFN-gamma-producing MAIT cells was significantly decreased in patients, compared to healthy controls (Fig. 1C), while proportions of IL-17 and TNF-alpha-producing MAIT cells were similar. MAIT cells are recruited, activated and have an altered cytokine profile secretion during severe pneumonia. These preliminary data justify pursuing in-depth analysis of MAIT cell functions in patients, in correlation with clinical condition.
  • Predictive factors for tracheal intubation in cancer patients presenting with de novo acute respiratory failure (ARF) and treated with high-flow oxygen through a nasal cannula (HFNC)
    Orateur(s) :
    • Morgane Tramier (Marseille / FRANCE)
    • Laurent Chow-Chine (Marseille / FRANCE)
    • Magali Bisbal (Marseille / FRANCE)
    • Frédéric Gonzalez (Marseille / FRANCE)
    • Luca Servan (Marseille / FRANCE)
    • Marion Faucher (Marseille / FRANCE)
    • Jean Manuel de Guibert (Marseille / FRANCE)
    • Antoine Sannini (Marseille / FRANCE)
    • Djamel Mokart (Marseille / FRANCE)
    14h45 / 14h52
    Abstract : For cancer patients presenting with ARF the use of mechanical ventilation (MV) is frequent and associated with high mortality. Preventing endotracheal intubation appears to be a crucial step in the therapeutic strategy. Therapy using HFNC offers an alternative for those patients. The objective of this study was to determine the predictive factors of the endotracheal intubation in cancer patients presenting de novo ARF and firstly treated with HFNC in the intensive care unit (ICU).This retrospective study was conducted in a cancer referral center from 1st January 2012 to end 2016. Data were recorded from 301 consecutive critically ill cancer patients presented with ARF and treated with HFNC. Two groups were compared using non parametric tests: intubated patients versus those that were not. Then, independent predictive factors for tracheal intubation were determined using logistic regression.Two hundred nine patients presented with de novo ARF and were finally selected for analysis. The ICU mortality was 27.5% (n=58), hospital mortality 43.5% (n= 91) and intubation rate 50% (n=104). Median (IQR) age was 63 (53-69), male were 40 % (n=84), haematological disease was present in 68% (n=142) of cases. By multivariable analysis, factors associated with tracheal intubation were: pulmonary infection (OR 2.5, 95%IC [1.1-5.3]), viral infection (OR 3.19, 95% CI [1.18-8.63]), multi-drug resistant bacteria infection (OR 4.9, 95% [1.6 -15]), SAPS II score (OR 1.04, 95% CI [1.01-1.07), Nb of pathologic X-chest quadrants > 2 at HFNC initiation (OR 6.6, 95% CI [3.1- 14.07]) as well as a cardiologic SOFA > 2 at the start of HFNC (OR 3.1, 95% CI [1.1 – 8.6 ]), FiO2 greater > 60 % at the start of HFNC (OR 4.7[2.2-10]), and an SpO2 level < 95% 15 min after starting HNFC (OR 3.3, 95%IC[1.5 -7.1]).For these specific population, intubation rate was about 50%. In this study intubation predictors are clinical parameters easily collected at bedside. In order to improve outcome, these parameters should be used to categorized high risk patients.
  • Optimal positive end-expiratory pressure : Interest of Electrical Impedance Tomography for Veno-Arterial Extracorporeal Membrane Oxygenation–treated patients.
    Orateur(s) :
    • Christelle Soule (Toulouse / FRANCE)
    • Floriane Puel (Toulouse / FRANCE)
    • Laure Crognier (Toulouse / FRANCE)
    • Fanny Vardon (Toulouse / FRANCE)
    • Jean-Marie Conil (Toulouse / FRANCE)
    14h52 / 14h59
    Abstract : Venoarterial ECMO-treated patients present many risk factors of breathing failure associated to heart failure. It seems essential to optimize the ventilatory parameters in order to limit lung injuries. The aim of this study is to evaluate the ability of electrical impedance tomography to set the optimal level of Positive End Expiratory Pressure (PEEP). We performed an alveolar recruitment maneuver followed by a decremental PEEP trial (from 20 to 5 cmH2O) with 5cmH2O decrements. Thanks to clinical and ultrasonographic parameters (heart and lung), we define an optimal PEP according to respiratory criteria (PEEPlung), then an adjustment according to hemodynamic and cardiac tolerances defines the PEPheart+lung. EIT datas (regional distribution of ventilation, z-compliance, overdistension/collapsus ODCL and global inhomogeneity index GI) were recorded during the procedure and analyzed retrospectively to define the optimal PEEPs: PEEPCOMP, PEEPODCL, PEEPGI. A Friedman test compares the different optimal PEEPs between them, as well as the regional ventilation distribution at the 4 PEP levels. Agreement between PEEPlung and other measured PEEPs was analyzed by Cohen's kappa coefficient. 23 patients were included and analyzed during a 9 months period. PEEP decreasing increments ventilation in the ventral region from 12 to 22% (corresponding to overdistension), and a decrease in the dorsal region from 11 to 5% reflecting collapse. The collapse (CL) is maximum at PEEP5 29% [21-45.8], and the distension is maximum at PEEP20cmH20 34% [24.5-40]. There is no significant difference between the different optimal PEEPs. The agreement is average between PEEPlung and optimal PEEP calculated from the EIT parameters (kappas 0.41 and 0.47). Our choice of PEEPlung is questionable because based on the global static respiratory compliance parameter that is measured on a single respiratory cycle. Measuring transpulmonary pressures could precise our measurements. PEPlung is statistically higher than the PEPheart+lung (p <0.05), reflecting a bad hemodynamic tolerance of high levels of PEEP due to a complex phenomenon of heart-lung interactions.EIT helps find the best compromise between overdistension and lung collapse, and detect regional distributions of the mechanical ventilation effects. However, evaluation of the chosen PEEP hemodynamic tolerance is necessary. The association EIT-echocardiography seems to be an efficient tool to provide monitoring of the PEEP effects.
  • Comparison of occlusion pressure at 100 ms measured on Evita XL ventilator, at airway opening and from esophageal pressure in patients at the time of weaning from invasive mechanical ventilation
    Orateur(s) :
    • Claude Guérin (Lyon / FRANCE)
    • Mehdi Mezidi (Lyon / FRANCE)
    • Loredana Baboi (Lyon / FRANCE)
    • Nader Chebib (Lyon / FRANCE)
    • Floriane Lissonde (Lyon / FRANCE)
    • Hodane Yonis (Lyon / FRANCE)
    • Louis Kreitmann (Lyon / FRANCE)
    • Emilie Joffredo (Lyon / FRANCE)
    14h59 / 15h06
    Abstract : Airway pressure 100 ms after airway occlusion (P0.1) assesses the respiratory drive intensity and is measured at the mouth in pulmonary function tests lab. In ICU ventilators P0.1 may not reflect mouth P0.1 due to the compliance of the circuit. We aimed to compare P0.1 measured with the Evita XL ICU ventilator (P0.1,Evita) to airway (P0.1,aw) and esophageal P0.1 (P0.1,es) pressure in ICU patients, during a spontaneous breathing trial.We compared pressure support (PS) 7 cmH2O + PEEP 4 cmH2O (treatment A) to PS 0 cmH2O + PEEP 4 cmH2O + 100% automatic tube compensation (treatment B), each applied for 30 minutes. Before each treatment the baseline PS was applied for 30 minutes. Paw and flow were measured at the proximal tip of the endotracheal tube. Pes was obtained from esophageal balloon whose right position and optimal volume were checked properly. Three to ten P0.1 measurements were performed through the P0.1 built-in function available in the Evita XL ventilator, each separated by 4-8 breaths, in each condition in each patient. P0.1, Evita was read at the ventilator screen, and Paw, Pes and flow signals were recorded with BIOPAC150. Values are expressed as mean±SD. Data were assessed by using Bland and Altman representation. A linear mixed effect model was used to assess the role on P0.1,Evita value of method of P0.1 measurement, rank of measurement and condition (as the fixed variables), the patient being taken as the random variable. Eighteen patients were included totalizing 280 measures. P0.1,es was discarded in 4 instances from 4 different patients for inaccuracy. P0.1,Evita averaged 2.8±2.4, P0.1,aw 2.5±2.1 and P0.1,es 2.5±2.4 cmH2O. Bias and limits of agreement between P0.1,Evita and P0.1,aw and P0.1,Evita and P0.1,es were 0.3 (-1.5;+2.1) and 0.3 (-3.2;+3.9) cmH2O, respectively. Neither method used, rank of the measurement nor condition had a significant effect on P0.1,Evita (Table 1).P0.1,Evita provides a reasonable estimate of P0.1 measured near to the patient.
Flash Com
14h10 - 15h10
Forum 3
Médecin : Onco-hématologie
Modérateur(s) : Lara Zafrani (Paris / FRANCE), Cécile Aubron (Brest / FRANCE)
  • Transfusion of packed red blood cells is associated with an increased risk of ICU-acquired infections and mortality in septic shock patients
    Orateur(s) :
    • Edwige Peju (Paris / FRANCE)
    • Julien Charpentier (Paris / FRANCE)
    • Alain Cariou (Paris / FRANCE)
    • Jean-Paul Mira (Paris / FRANCE)
    • Matthieu Jamme (Paris / FRANCE)
    • Frédéric Pène (Paris / FRANCE)
    14h10 / 14h18
    Abstract : Transfusion of packed red blood cells (RBC) is commonly indicated in septic patients to improve tissue oxygen delivery. Besides uncertain benefits, RBC transfusions carry immunomodulatory properties likely to increase the susceptibility to further ICU-acquired infections or the mortality rate. The aim of this study is to address the impact of RBC transfusion on ICU-acquired infections and mortality in septic shock patients.This was a 10-year (2008-2017) monocenter retrospective study. All consecutive adult patients diagnosed for septic shock within the first 48 hours were included. Septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. The number of packed RBC and the transfusion day were recorded. The diagnosis of nosocomial infections was based on current international guidelines. Patients alive at day 3 were evaluated for the risk of ICU-acquired infections. The determinants of ICU-acquired infections and 30-day mortality were addressed in a multivariate time-dependent Cox regression analysis.Among 1152 patients admitted for septic shock, 63% were males, the median age was 69 (57 – 79) years old and the crude 30-day mortality rate was 31.5%. Overall, 512 patients (44%) received RBC transfusions, with a median of 3 (2 – 6) units. In multivariate analysis, transfusion was independently associated with prior immunosuppression (OR=1,57, 95%IC [1,21 - 2,04], p=0,001), with chronic kidney disease (OR=1,89, 95%IC [1,30 - 2,74], p=0,001) and a higher admission SOFA score (OR=1,03, 95%IC [1,01 - 1,06], p=0,007). 1038 patients were alive at day 3, of whom 253 (24%) developed ICU-acquired infections. Among them, 197 (78%) patients had received RBC prior to the episode of ICU-acquired infection. In multivariate analysis, RBC transfusion was independently associated with the development of ICU-acquired infections (OR=1,88, 95%IC [1,21-2,93], p=0,005). 30-day mortality was significantly higher in patients receiving RBC (37,6% vs. 27,8%, p<0,001). In multivariate analysis, RBC transfusion was independently associated with 30-day mortality (OR=1,50, IC95% [1,07-2,09], p=0,02).Transfusion of RBC in septic shock patients is associated with an increased risk of ICU-acquired infections and 30-day mortality. These results support a restrictive RBC transfusion policy in septic shock patients.
  • Effect of age on mortality in patients with haematological malignancy in intensive care units.
    Orateur(s) :
    • Jean-Edouard Martin (Paris / FRANCE)
    • Djamel Mokart (Marseille / FRANCE)
    • Frédéric Pène (Paris / FRANCE)
    • Achille Kouatchet (Angers / FRANCE)
    • Julien Mayaux (Paris / FRANCE)
    • François Vincent (Paris / FRANCE)
    • Martine Nyunga (Roubaix / FRANCE)
    • Fabrice Bruneel (Versailles / FRANCE)
    • Christine Lebert (La Roche-Sur-Yon / FRANCE)
    • Pierre Perez (Nancy / FRANCE)
    • Anne-Pascale Meert (Bruxelles / BELGIQUE)
    • Dominique Benoit (Ghent / BELGIQUE)
    • Rebecca Hamidfar (Grenoble / FRANCE)
    • Mercé Jourdain (Lille / FRANCE)
    • Lionel Kerhuel (Paris / FRANCE)
    • Laure Calvet (Paris / FRANCE)
    • Etienne Ghrenassia (Paris / FRANCE)
    • Samir Jaber (Montpellier / FRANCE)
    • Audrey de Jong (Montpellier / FRANCE)
    14h18 / 14h26
    Abstract : Respective influence of age and performance status (PS) of critically ill patients with malignancy has been poorly studied. The main objective of this study was to analyse the impact of age on day-90 mortality in this population.We performed a post hoc analysis of prospective multicentre data from France and Belgium to identify the relation between age and day-90 mortality. Five classes of age were computed according to quintile of ages. The best threshold of age was determined using a Youden index analysis. Univariate and multivariate Cox analysis of day-90 mortality were performed. Kaplan Meier curves of day-90 mortality according to age and main risk factors were computed.1011 patients were included. Age categories according to quintile repartition were the following: 18 to 45 years old (y) (n=206), 46 to 56 y (n=194), 57 to 63 y (n=213), 64 to 71 y (n=189), and 72 to 87 y (n=209). Next, two age groups was separated: younger group, age < 64 y and older group age ≥ 64 y with a median age of 52 y (25-75% IQR, 41-59) and 72 y (67-77) respectively. Older age (≥ 64) was significantly associated with higher mortality rate in univariate analysis (HR = 1.54 (1.26 - 1.88), p < 0.0001). After multivariate cox analysis, main risk factor for mortality were age ≥ 64 (HR = 1.55 (1.25 – 1.92), p < 0.0001), PS ≥ 3 (HR = 1.47 (1.40 – 1.87), p = 0.0024) and severity at inclusion assessed by sequential organ failure assessment (SOFA) score at admission in ICU per one unit increase (HR = 1.18 (1.15 – 1.21), p <0.0001). However, haematological malignancy, Charlson comorbidity score index without age and reason for ICU admission were not significantly associated with day-90 mortality. Figure 1 shows the Kaplan Meier survival analysis of the relation between age, PS and day-90 mortality (p < 0.0001). Older age is significantly associated with higher day-90 mortality. A threshold of 64 y was found to be the most accurate to discriminate dead from alive patients. Despite its prognostic impact, survival was meaningful in subgroups of oldest patients with moderately limited autonomy. This study may allow a better selection of oldest patients likely to benefit of ICU admission according to three simple variables: age, PS and SOFA score.
  • Hemodynamic failure in critically ill patients with hemophagocytic syndrome
    Orateur(s) :
    • Thomas Frapard (Paris / FRANCE)
    • Sandrine Valade (Paris / FRANCE)
    • Eric Mariotte (Paris / FRANCE)
    • Jehane Fadlallah (Paris / FRANCE)
    • Lionel Galicier (Paris / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    14h26 / 14h34
    Abstract : Hemophagocytic syndrome (HS) is a rare life-threatening condition that can lead to multi organ failure, including shock. In severe HS, symptomatic treatment relies on Etoposide (VP16) infusion. Hemodynamic instability during HS has been poorly studied. Objectives of this study were to describe the characteristics of HS patients with shock, prognostic factors and the impact of etoposide injection on the hemodynamic parameters.Adult critically ill patients with HS and managed in a multidisciplinary national reference center between 2007 and 2017 were retrospectively included. Patients without vasopressors or not requiring Etoposide infusion were excluded. Forty patients were included. Two-third (n=28) were of male gender and median age was 48y [IQR 37-62]. Shock (n=15, 37%), acute respiratory failure (n=10, 25%) and monitoring (n=8, 20%) were the main reasons for ICU admission. The most common HS-triggers were underlying hematologic disease (malignancies/HHV8-related disease) in 31 patients (77%), infectious diseases in 4 (10%), and systemic rheumatic diseases in 3 (8%). Median SOFA score was 11 [9-13], 85% of the patients required mechanical ventilation (n=34) and median lactate level was 4 mmol/l [2.7-6.9]. Hospital mortality was 47% (n=19) and was associated with severity as assessed by need for mechanical ventilation (100% vs. 73%; P=0.04) and male gender (90% vs. 47% in survivors; P=0.01). Etoposide infusion (H0) was followed by increased norepinephrine doses (P=0.03) and a trend toward higher lactate levels (P=0.07; figure 1). No statistically significant change was observed as regard to mean arterial pressure, heart rate and renal function, assessed by serum creatinine and oliguria. Our results suggest a high severity of HS patients with acute circulatory failure, a high hospital mortality and a hemodynamic worsening in the 24 hours following etoposide infusion. Change in hemodynamic through ICU stay and comparison to patients with cytopenias and shock in the absence of HS are currently ongoing and will be presented at the congress.
  • Long-term prognosis of high-grade glioma admitted in the intensive care unit
    Orateur(s) :
    • Maxens Decavèle (Paris / FRANCE)
    • Nicolas Gatulle (Paris / FRANCE)
    • Nicolas Weiss (Paris / FRANCE)
    • Léa Lemasle (Paris / FRANCE)
    • Ahmed Idbaih (Paris / FRANCE)
    • Julien Mayaux (Paris / FRANCE)
    • Thomas Similowski (Paris / FRANCE)
    14h34 / 14h42
    Abstract : Only limited data are available concerning prognosis of primary malignant brain tumors in the intensive care unit (ICU). Among them, high-grade gliomas (HGG) are the most frequent and those associated with the poorest survival. Whereas long-term prognosis after ICU admission of patients with other malignancies is now better known, no such data exist regarding patients with HGG. The aims of our study were 1) to analyze factors associated with 1-year mortality in patients with HGG admitted to the ICU and 2) to assess the functional status and anti-cancer therapy course in ICU survivors.Eight-year, bicentric, retrospective cohort study. All consecutive patients with HGG, admitted to the ICUs were included. Functional status was assessed with the Karnofsky Performance Status (KPS). Mutation in isocitrate dehydrogenase (IDH) 1 and 2 was also collected. The anti-cancer therapy course after ICU discharge was classified in 1) continued without change, 2) changed (modified or stopped after ICU discharge), and 3) initiated after ICU discharge for a HGG diagnosed during the ICU stay). Seventy-eight patients (age 58 [45-67] year-old, SAPSII 32 [21-52]) were included, of which 62 (79%) were glioblastoma. Main reasons for admission were coma and acute respiratory failure (47 (60%) and 17 (22%), respectively). Mechanical ventilation and vasopressors were required in 40 (51%) and 17 (22%) of cases. ICU and 1-year mortality was 12 (15%) and 62 (79%). Among ICU survivors, anti-cancer therapy course was continued, changed and initiated in 26 (33%), 41 (53%) and 11 (14%) patients, respectively. One-year survival was significantly higher in patients in whom anti-cancer therapy was continued, as compared to others (16 (62%) vs. 46 (92%), p=0.002). Among ICU survivors, the KPS did not vary between 1 month and 1 year after ICU discharge (55 [48-78] vs. 60 [50-58], p=0.212). In multivariate analysis, factor associated with 1-year survival were the KPS at admission (OR 0.894 95%CI [0.807-0.953], p=0.005), and anti-cancer therapy course continued (OR 0.009 [0.001-0.102], p=0.002). The IDH status did not impact on 1-year mortality.Despite high long-term mortality rate, 85% of patients survived to the ICU, near a half continued their planned anti-cancer therapy course and more than 20% were alive 1 year after ICU discharge, with good functional status.
  • Early Identification of Sickle-Cell Disease Patients at Risk for Complicated Outcome in Intensive Care Unit. Aggregation of multiple sickle cell prediction model, updating and validation on CARADBDREPA cohort.
    Orateur(s) :
    • Amélie Rolle (Abymes / FRANCE)
    • N'Guyen Tri Long (Montpellier / FRANCE)
    • Thomas P.a Debray (Utrecht / PAYS-BAS)
    • Zakaria Mahi (Pointe-À-Pitre / FRANCE)
    • Bertrand Pons (Pointe-À-Pitre / FRANCE)
    • Ruddy Valentino (Fort-De-France / FRANCE)
    • Hossein Mehdaoui (Fort-De-France / FRANCE)
    • Michel Carles (Pointe-à-Pitre / FRANCE)
    14h42 / 14h50
    Abstract : Rationale: Sickle cell disease (SCD) is an increasing global health problem. Better prediction of the severity of sickle cell disease could lead to more precise a treatment and management. However, though several prediction models for SCD have been published, their external validity remains unclear. Objectives: The objective of our study was to validate existing prediction models SCD patients at risk for complicated outcome, and to combine and simultaneously update these models into a new so-called ‘meta-model'. Primary endpoint: Composite, binary outcome (‘complicated outcome') defined by intensive care unit stays > 2 days, need for vital support or death.Design, setting and participants: From January 2012 to December 2017, a retrospective cohort study was conducted at the University Hospital of Guadeloupe (French territories in the Americas). It included all patients (children and adults) admitted to this institution. To combine existing prediction models into a ‘meta-model', we performed a systematic review searching in PubMed, EMBASE and bibliographies of articles retrieved. We screened relevant studies that enrolled sickle-cell disease children and adult patients for whom a prediction model was presented.Measurements and main results: Of the 3829 patient admissions in our cohort, 210 (23%) experienced a complicated outcome, defined as death (8 patients, 3.8 %), acute respiratory failure (119 patients, 56%) hemodynamic failure (24 patients, (11%), or renal failure (12 patients, 6 %). Four prediction models were combine to predict patient risk of complicated outcomes. The resulting meta-model demonstrated good predictive performances in terms of discrimination (c-statistic: 0.8) and calibration.Conclusions: Combining existing prediction models might help clinicians obtain valid predictions of complicated outcomes and rapidly improve the quality of care of SCD patients admitted to emergency department.
  • Performances of HLH criteria and H-Score in ICU patients with severe hemophagocytic syndrome
    Orateur(s) :
    • Sandrine Valade (Paris / FRANCE)
    • Grégoire Monseau (Paris / FRANCE)
    • Laure Calvet (Paris / FRANCE)
    • Eric Mariotte (Paris / FRANCE)
    • Virginie Lemiale (Paris / FRANCE)
    • Lara Zafrani (Paris / FRANCE)
    14h58 / 15h06
    Abstract : Hemophagocytic syndrome (HS) is a serious condition that can lead patients to intensive care unit (ICU) admission. Diagnosis may be difficult in these patients who may have multiple organ failures. HLH criteria are the most commonly used, but a new diagnostic score has recently been established (the H-Score). The main objective of this study is to analyze diagnostic performance of these diagnostic scores in ICU patients.Two convenient samples were analyzed including a sample of 150 patients with confirmed HS (HS+). A second sample of 1011 patients without HS (HS-) was obtained from a multicenter cohort of onco-hematological patients. Results are presented as median (interquartile range) and numbers (%).Area under ROC curves were established to assess discriminancy of both scores in diagnosing HS. A sensitivity analysis was performed after propensity score (PS) matching according to temperature and cytopenia. Overall, 1161 patients were included in this study. HS+ patients were younger (median age 48.5 years [38-59] vs 60 [49-70], p<0.001), had more severe cytopenia (hemoglobin 8.3g/dL [7.23-9.17] and platelets 44000/mm3 [21000-79000] vs 62000 [29000-140000]), had more often organomegaly (hepatomegaly in 68.7% vs 8%, splenomegaly in 61.3% vs 9%). Mortality rate was 45.8% in hemophagocytic patients and 38.8% in control patients. Median H-Score was 235 [205-262] in SH+ patients and 42 [18-62] in SH- patients. Number of HLH criteria was 4 [4-5] and 1 [0-1] respectively. Diagnostic performance of both score was excellent with area under ROC curve of 0.99 (95%CI according to DeLong Method of 0.99-0.99) and 0.99 (95%CI 0.99-0.99) for HLH and H-score respectively (figure). After propensity score matching (n = 144*2), the median H-Score was of 234 [205-262] in SH+ patients versus 49 [18-71] in SH- patients. Median number of HLH criteria were 4 [4-5] in SH+ and 1 [0-1] in SH- patients. Area under ROC curve was of 0.98 (CI95% 0.96-0.99) for HLH criteria and 0.99 (CI95% 0.99-1) for H-Score. H-Score and HLH criteria are highly sensitive and specific in ICU patients. Further studies in unselected cohort of consecutive ICU patients with suspected HS are warranted in order to confirm our results and optimal cut-off for these scores.
  • Post-transfusion platelet increments in critically ill cancer patients with hypoproliferative thrombocytopenia
    Orateur(s) :
    • Elodie Baron (Paris / FRANCE)
    • Anne François (Paris / FRANCE)
    • Julien Charpentier (Paris / FRANCE)
    • Amor Habib Ben Hadj (Paris / FRANCE)
    • Bassem Habr (Paris / FRANCE)
    • Alain Cariou (Paris / FRANCE)
    • Jean-Paul Mira (Paris / FRANCE)
    • Matthieu Jamme (Paris / FRANCE)
    • Frédéric Pène (Paris / FRANCE)
    15h06 / 15h10
    Abstract : Thrombocytopenia is a common disorder in intensive care unit (ICU) and is associated with an increased risk of bleeding. Most data about platelet transfusions in the ICU have been obtained from general cohorts with peripheral thrombocytopenia and ongoing active bleeding or subjected to invasive procedures. In patients with hypoproliferative thrombocytopenia, the management of platelet transfusions remains somewhat empirical, derived from studies performed in hematology patients under stable clinical conditions. We herein described and analysed the determinants of post-transfusion platelet increments in cancer patients with hypoproliferative thrombocytopenia in the ICU.This was a single-center retrospective observational study over a 9-year period (2009-2017). Patients with malignancies and hypoproliferative thrombocytopenia who had received at least one platelet transfusion in the ICU were included. For each transfusion episode, a poor platelet yield was defined as a body surface area-adjusted corrected count increment (CCI) < 7, or alternatively as a weight-adjusted platelet transfusion yield (RTP) < 0.2. Patients were considered refractory to platelet transfusions when they experienced poor platelet increments ( CCI < 7 or RTP < 0.2) following two consecutive ABO-compatible transfusions containing at least 0.5×1011 platelets per 10 kg bodyweight.326 patients who received a total of 1470 platelet transfusions were analyzed. Indications for platelet transfusions were distributed into prophylactic (44.5%), securing an invasive procedure (18.1%) and therapeutic for active bleeding (37.4%). Transfusion thresholds were lower for prophylactic indications than for securing an invasive procedure or for therapeutic indications (13 [8-22] G/L vs. 20 [13-31] G/L vs. 21 [11-36] G/L, respectively). Regardless of indications, 54.6% and 55.4% of transfusion episodes were associated with a CCI < 7 or a RTP < 0.2. Compared to prophylactic indications, the transfusion yields were better when securing an invasive procedure. In multivariate analysis, the factors associated with poor post-transfusion increments were lower body mass index (BMI), severity on the day of transfusion, depth of pre-transfusion thrombocytopenia, time between platelet transfusion and post-transfusion platelet count, fever ≥ 39 °C, antibiotic therapy, and storage duration of platelet concentrates. 48 patients developed refractoriness to platelet transfusion, associated with lower BMI, stem cell transplantation and spleen enlargement.Platelet transfusions are often associated with poor increments in critically ill cancer patients with hypoproliferative thrombocytopenia. Our data suggest ways to improve the efficiency platelet transfusion in this setting.
Flash Com
14h10 - 15h10
Forum 4
Médecin : Souffrance du système nerveux central
Modérateur(s) : Tarek Sharshar (Paris / FRANCE), Mauro Oddo (Lausanne / SUISSE)
  • Differential Clinical Characteristics, Management, and Outcome Of Delirium in Ward and ICU Patients
    Orateur(s) :
    • Emmanuel Canet (Paris / FRANCE)
    • Sobia Amjad (Melbourne / AUSTRALIE)
    • Raymond Robbins (Melbourne / AUSTRALIE)
    • Jane Lewis (Melbourne / AUSTRALIE)
    • Michelle Matalanis (Melbourne / AUSTRALIE)
    • Daryl Jones (Melbourne / AUSTRALIE)
    • Rinaldo Bellomo (Heidelberg / AUSTRALIE)
    14h10 / 14h18
    Abstract : To study patient demographics, clinical phenotype, management, and outcomes of patient with delirium in hospital wards compared to the ICU.Cohort of patients admitted to an Australian university-affiliated hospital between March 2013 and April 2017 and coded for delirium using the ICD-10 criteria.Among 61,032 hospitalized patients, 2,864 (4.7%) were coded for delirium. From these, we selected a random sample of 100 ward patients and 100 ICU patients for detailed analysis. Ward patients were older (median age: 84 vs. 65 years; P<0.0001), more likely to have pre-existing neurological disease (53% vs. 13% for ICU patients; P<0.0001) and less likely to have had surgery (24 vs. 62%; P<0.0001). Of ward patients, 74% had hypoactive delirium, while 64% of ICU patients had agitated delirium (P<0.0001). Persistent delirium at hospital discharge was more common among ward patients (66% vs 17%, p<0.0001). On multivariate analysis, age and pre-existing neurological disease predicted persistent delirium, while surgery predicted recovery.Delirium in ward patients is profoundly different from delirium in ICU patients. It has a dominant hypoactive clinical phenotype, is preceded by chronic neurological conditions, is managed with fewer drugs and is less likely to recover at hospital discharge.
  • Traumatic quadriplegia: diagnostic and therapeutic strategy. (About 75 patients)
    Orateur(s) :
    • Amine Benhamed (Oran / ALGÉRIE)
    • Amel Zerhouni (Oran / ALGÉRIE)
    • Medjahed Medjahed (Oran / ALGÉRIE)
    • Lahcen Senhadji (Oran / ALGÉRIE)
    • Radouane Rachi (Oran / ALGÉRIE)
    14h18 / 14h26
    Abstract : trauma to the spine is a common pathology that is constantly increasing in Algeria, mainly to road accidents, they are potentially serious, and associated with a spinal cord injury, they are life-threatening. We treated 75 traumatized cervical and thoracolumbar spine patients in our spine unit at CHU Oran.- Department of orthopedic and traumatological surgery: spine unit of CHU Oran. - Period: 24 months especially during the summer season. - Secondary support after the UAS. - Middle age: 38 years (14-81 years). : 75 quadriplegic patients (58 men and 17 women) aged between 14 and 81 years, 60% of patients were between 14 and 60 years old, 27% between 40 and 60 years old and 13% over 60 years old, the main The causes of these traumatic quadriplegia are mainly due to AVP (67%), falls (27%) and sports accidents (judo, gymnastics) represent 6%. Histopathological lesions are at C1-C2 level in 06 patients (8%) and C3-C7 in 69 patients (92%). clinically 36 patients (48%) already had complete quadriplegia at admission and 39 patients (52%) had incomplete tetraplegia. The neurological involvement was classified according to the FRANKEL classification. Our practical conduct was a decompression, arthrodesis, graft with a screwed plate. 30% of the patients benefited from a conservative treatment in a reduction by cranial traction. the course was marked by recovery in 08 patients (10.6%) who had incomplete tetraplegia and 13 patients (17.3%) died as a result of their complications. traumatic quadriplegia is a major public health problem , few injuries are as devastating as those affecting the spinal cord; adult, youthful and adolescent men have the highest prevalence and suffer most of the time from a permanent deficit; quickly, the quadriplegic or paraplegic becomes aware of its deficit and its consequences. Hospitalization and rehabilitation, through their costs, represent a huge investment. The emotional damage the patient and his family are not measurable. After several weeksTraumatic quadriplegia is a major public health problem, few injuries are as devastating as tho of treatment (surgery, resuscitation, rehabilitation ...) we found adverse results and treatment failure, which further complicated their insertion and care for their families. Traumatic quadriplegia is especially aggravated during transport, the goal of surgery is to decompress the marrow and stabilize the spine
  • Prognostic significance of standard electroencephalography findings in adult patients with delayed awakening in the intensive care unit
    Orateur(s) :
    • Camille Legouy (Paris / FRANCE)
    • Laura Girard-Stein (Paris / FRANCE)
    • Lila Bouadma (Paris / FRANCE)
    • Claire Dupuis (Paris / FRANCE)
    • Sonia Abid (Paris / FRANCE)
    • Camille Vinclair (Paris / FRANCE)
    • Stéphane Ruckly (Paris / FRANCE)
    • Ruben Wanono (Paris / FRANCE)
    • Anny Rouvel-Tallec (Paris / FRANCE)
    • Marie-Pia D'Ortho (Paris / FRANCE)
    14h26 / 14h34
    Abstract : Despite daily interruption of sedative infusions, delayed awakening is frequently observed in critically ill patients requiring invasive mechanical ventilation. We aimed to identify the prognostic significance of standard electroencephalography findings in adult patients with delayed awakening in the intensive care unit.Our retrospective study included consecutive patients under invasive mechanical ventilation in the intensive care unit who underwent standard EEG because of delayed awakening. Delayed awakening was classified in 3 groups: coma, hypo-active delirium or hyperactive delirium according to RASS at inclusion. The primary endpoint was a good neurological outcome, defined as the proportion of patients alive and awake (i.e. responding to simple commands on 2 consecutive days) 7 days after EEG. Secondary endpoints included the prevalence of the different etiologies of delayed awakening, defined in 6 categories (hypoxic; metabolic; septic; antibiotic; sedation; acute brain injury) and the proportion of patients alive and awake at ICU discharge and at 90 days. Data are presented as median (interquartile range) or numbers (percentages). Cause-specific prevalence models were used to identify independent parameters associated with awakening and death, respectively.121 patients (age 64 years [54; 71], SAPS2 score of 61 [45; 76]) with a RASS of -4 [-4; -3] at inclusion were studied. At 7 days, 58 (48%) patients were awake, 40 (33%) were alive but not awake, and 23 (19%) were dead. In univariate analysis, the only parameter associated with awakening was RASS ≥ - 3, whereas parameters associated with mortality were a slow EEG background, a discontinuous EEG background and unreactive EEG background. Multivariate analysis revealed that discontinuous EEG background was associated with mortality (Table). By contrast, background frequency > 4 Hz associated with a preserved reactivity were protective. The etiologies of delayed awakening were: 65 (54%) sepsis, 49 (41%) hypoxia, 32 (27%) sedations, 25 (21%) neurotoxic antibiotics, 14 (12%) metabolic causes, with for some patients a multifactorial origin. Hypoxic encephalopathy was associated with short-term mortality. At the end of ICU stay, 60 (50%) patients were awake, 7 (6%) were alive but not awake and 53 (44%) were dead. At 90 days, 55 (45%) were awake, 6 (5%) were not awake and 60 (50%) were dead.Delayed awakening in ICU is likely of multifactorial origin and characterized by a favorable outcome in about 50% of cases. Background EEG abnormalities (frequency, continuity) and reactivity provide major prognostic information on short-term mortality in this population.
  • Cardiac Arrest in Patients Managed for Convulsive Status Epilepticus: Characteristics, Predictors and Outcome
    Orateur(s) :
    • Stéphane Legriel (Le Chesnay / FRANCE)
    • Edouard Bresson (Le Chesnay / FRANCE)
    • Nicolas Deye (Paris / FRANCE)
    • David Grimaldi (Bruxelles / BELGIQUE)
    • Olivier Lesieur (La Rochelle / FRANCE)
    • Jean-Baptiste Lascarrou (Nantes / FRANCE)
    • Laurent Argaud (Lyon / FRANCE)
    • Jonathan Chelly (Melun / FRANCE)
    • Pascal Beuret (Roanne / FRANCE)
    • David Schnell (Angoulême / FRANCE)
    • Anne-Laure Chateauneuf (Le Chesnay / FRANCE)
    • Mathilde Holleville (Le Chesnay / FRANCE)
    • Francois Perier (Créteil / FRANCE)
    • Cédric Bruel (Paris / FRANCE)
    • Pierrick Cronier (Corbeil-Essonnes / FRANCE)
    • Nicolas Pichon (Limoges / FRANCE)
    • Nicolas Mongardon (Créteil / FRANCE)
    • Nicolas de Prost (Créteil / FRANCE)
    • Alain Cariou (Paris / FRANCE)
    14h34 / 14h42
    Abstract : Cardiac arrest (CA) is among the most catastrophic early complication seen during convulsive status epilepticus (CSE) management. Factors that may contribute to CSE-related CA (CSE-CA) include comorbidities, severe systemic complications (particularly in the event of uncontrolled seizure activity, injuries caused by the loss of consciousness and seizure, treatment complications, and cause of CSE. Although CSE-CA is an event of considerable concern, few studies have assessed its characteristics and long-term survival and functional outcomes. The objective of this retrospective study was to identify early factors associated with CA in adults managed for CSE and admitted to the intensive care unit (ICU). Knowledge of such factors might help to identify areas for improvement in the management of CSE. Retrospective multicenter study including consecutive patients admitted to 17 university or university-affiliated ICUs in France and Belgiumg for management of successfully resuscitated out-of-hospital cardiac arrest complicating the initial management of CSE between 2000 and 2015. Patients were compared with controls without CA identified in a single-center registry of CSE patients, regarding characteristics, management, and outcome. We included 49 cases with CSE-CA and 235 controls. In the cases, median time from medical team arrival to CA was 25 minutes [IQR, 5-85]. First recorded rhythm was asystole in 25 (51%) and pulseless electrical activity in 13 (27%) patients. A significantly larger proportion of patients had a favorable 1-year outcome (Glasgow Outcome Scale score of 5) among controls (90/235, 38%) than among cases (10/49, 21%, P=0.02). By multivariate analysis, independent predictors of CA were pulse oximetry <97% on scene (OR, 2.66; 95%CI, 1.03-7.26, P=0.04), drug poisoning as the cause of CSE (OR, 4.13; 95%CI, 1.27-13.53, P=0.02), and complications during early management (OR, 11.98; 95%CI, 4.67-34.69, P<0.0001). Having at least one comorbidity among cardiac, respiratory, and neurological (other than epilepsy) conditions predicted absence of CA (OR, 0.28; 95%CI, 0.10-0.80, P=0.02).In patients managed for CSE, relative hypoxemia, on-scene management complications, and drug poisoning as the cause of CSE were strong early predictors of CA, suggesting areas for improvement.
  • Feasibility and reliability of somatosensory evoked potentials performed by intensivists in the prognosis of post-cardiac arrest coma
    Orateur(s) :
    • Damien Bouvier (Saint-Brice Sous Forêt / FRANCE)
    • Quentin Levrat (La Rochelle / FRANCE)
    • Virginie Verrier (La Rochelle / FRANCE)
    • Olivier Lesieur (La Rochelle / FRANCE)
    14h42 / 14h50
    Abstract : Post-cardiac arrest coma is a common cause of brain injury in the ICU. Predicting neurological outcome is of crucial importance to provide the most objective information to loved ones and opt for the best therapeutic options (including withholding or withdrawal of treatments deemed hopeless). Among the prognostic tools available, somatosensory evoked potentials have proven efficiency: under certain conditions, the absence of N20 cortical wave is associated with an unfavorable neurological prognosis with a specificity closed to 100% (1). Traditionally, this test requires the expertise and availability of a neurophysiologist. We assume that this technique can also be performed by trained intensivists.Two physicians from our ICU received two days of specific training in a university neurophysiology laboratory by a specialist in the interpretation of evoked potentials. Patients concerned had prolonged post-cardiac arrest coma after cessation of sedation. The records were interpreted and sent to the neurophysiology referral center for review by a specialist within 24 hours. The feasibility and reliability of tests were evaluated retrospectively. From September 2011 to June 2018, somatosensory evoked potentials were recorded in 59 patients (64 [55-74] year old; M/F ratio 3.9). Circulatory arrests were of cardiac origin in 42 % of cases and respiratory in 46 %. All patients underwent electroencephalography and had no reactivity to stimuli. Most of the recordings were made and interpreted easily by intensivists, with a similar conclusion by the neurophysiologist. Only one was doubtful and could only be assessed by the neurophysiologist. N20 wave was present in 26 patients and absent in 31 patients. Only two tests were uninterpretable. Recording somatosensory evoked potentials in the ICU is simple, reliable, reproducible and can be performed by trained critical care physicians. However, its interpretation must be validated by a neurophysiologist given the implications in terms of therapeutic decisions.
  • Sodium disturbances in the neuro-intensive care unit
    Orateur(s) :
    • Mariem Dlela (Sfax / TUNISIE)
    • Manel Zekri (Sfax / TUNISIE)
    • Rania Ammar (Sfax / TUNISIE)
    • Aziza Talbi (Sfax / TUNISIE)
    • Chokri Ben Hamida (Sfax / TUNISIE)
    • Mounir Bouaziz (Sfax / TUNISIE)
    14h50 / 14h58
    Abstract : Sodium disturbances are the most common and probably the most poorly understood electrolyte disorders in neurological diseases. Complications can be minimized by better recognition, diagnosis, and treatment of sodium disorders. In this study, we aim to analyze the incidence, etiologies and impact of dysnatremia on brain damaged population, and we hypothesize that changes in sodium levels could be indicative of recent neurological deterioration. We conducted a six month long prospective cohort, including all brain damaged patients, who were admitted to our ICU between March 1st, 2018 and august 31st, 2018 and with a minimum length of stay (LOS) of 14 days. All patients, included, were screened for sodium disorders in the first 2 weeks of ICU stay. Outcome was measured by incidence of death, Glasgow outcome scale (GOS) on discharge and LOS. Patients were also monitored for neurological deterioration, including cognitive decline, convulsive seizures, increase in cerebral edema and brain herniation that were contemporary to sodium disorders. Both univariate and multivariate analysis were used to determine level of significance. During the study period's, one hundred patients were admitted to our ICU for neuro-intensive care, among which 77 were included in this study. Patients were admitted for traumatic brain injury (TBI) in 75.3% of cases. According to our analysis, 35 (45.45%) patients presented with hyponatremia, 26 (74.3%) among them, were diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH), 8 (22.9%) with corticosteroid deficiency and in one case with cerebral salt wasting syndrome. SIADH was attributed to convulsive seizures in 7(26.9%) cases, meningitis in 3(11.5%) cases and TBI in 11 (42.3%) cases. Hyponatremia was found to be a predictive factor of mortality in ICU (p=0.022), of LOS (p=0.032) and a sign of neurological deterioration (p=0.03) on the day of diagnosis. Our study results' showed an incidence of hypernatremia of 26% (20 cases), among which 55% (11 cases) were attributed to central diabetes insipidus. Hypernatremia was found to be a predictive factor of mortality in ICU (p<0.00), of GOS (p<0.00) and a sign of neurological deterioration (p<0.00) on the day of diagnosis. In summary, this study demonstrates that sodium disturbances are common in neuro-intensive care units and associated with increased ICU mortality. Besides it indicates that changes in sodium levels could be revealing of serious neurological complications.