Programme scientifique

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jeudi 24 janvier 2019

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)
    • Nicolas Bréchot (Paris / FRANCE)
    • Pha Micheline (Paris / FRANCE)
    • Guillaume Franchineau (Paris / FRANCE)
    • Ania Nieszkowska (Paris / FRANCE)
    • Loic Le Guennec (Paris / FRANCE)
    • Guillaume Hekimian (Paris / FRANCE)
    • Philippe Rouvier (Paris / FRANCE)
    • Hie Miguel (Paris / FRANCE)
    • Matthieu Schmidt (Paris / FRANCE)
    • Alain Combes (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-Daniel Chiche (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) : Fabio Taccone (Bruxelles / BELGIQUE), Stephan Ehrmann (Tours / FRANCE)
  • 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 (Poitiers / 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.
Flash Com
14h10 - 15h10
Forum 6
Médecin : Choc cardiogénique
Modérateur(s) : Alain Combes (Paris / FRANCE), Antoine Kimmoun (Nancy / FRANCE)
  • Characterisation of cardiovascular phenotypes in septic shock. Focus on LV systolic dysfunction and its impact on prognosis
    Orateur(s) :
    • Guillaume Geri (Paris / FRANCE)
    • Philippe Vignon (Limoges / FRANCE)
    • Alix Aubry (Boulogne / FRANCE)
    • Anne-Laure Fedou (Limoges / FRANCE)
    • Cyril Charron (Boulogne / FRANCE)
    • Stein Silva (Toulouse / FRANCE)
    • Xavier Repessé (Paris / FRANCE)
    • Antoine Vieillard-Baron (Boulogne / FRANCE)
    14h10 / 14h18
    Abstract : Left ventricular (LV) systolic dysfunction is frequent in septic shock patients, but its prognostic impact remains unknown.Two published databases from 12 different ICUs including echocardiographic monitoring performed at the initial phase of septic shock were merged. Patients with a history of chronic heart failure or atrial fibrillation or dobutamine infusion at the time of echocardiography were excluded from the analysis. Hierarchical clustering in a principal components approach was used to define five cardiovascular phenotypes using haemodynamic, clinical and echocardiographic parameters. Missing data were imputed. The relationship between cluster and mortality (day-7 and ICU) was evaluated using a multivariable logistic regression.324 patients (median age 64 [55, 74]) were included in the analysis. Five different clusters were individualised: patients well resuscitated (cluster 1, n=76) without LV systolic function, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n=41), patients with hyperkinetic profile (cluster 3, n=70), patients with RV failure (cluster 4, n=76), and patients with persistent hypovolemia (cluster 5, n=61). Day-7 mortality was higher in cluster 2 than in the others (37 vs. 12, 13, 24 and 20%, in clusters 1, 3, 4, and 5, respectively, p=0.04), while ICU mortality did not differ across clusters. In multivariable logistic regression, LV systolic dysfunction was independently associated with increased day-7 mortality (odds ratio 2.80 [95% confidence interval 1.05, 7.76]).Among the five cardiovascular phenotypes individualised in this large cohort of septic shock patients, LV systolic dysfunction was independently associated with day-7 mortality.
  • Impact of hyperoxia on patients hospitalized in intensive care unit for pulmonary congestion due to acute heart failure
    Orateur(s) :
    • Julien NaËl (Paris / FRANCE)
    • Mathilde Ruggiu (Paris / FRANCE)
    • Clotilde Bailleul (Paris / FRANCE)
    • Sofia Ortuno (Paris / FRANCE)
    • Jean-Luc Diehl (Paris / FRANCE)
    • Damien Vimpere (Paris / FRANCE)
    • Aymeric Lancelot (Paris / FRANCE)
    • Amélie Couteau (Paris / FRANCE)
    • Emmanuel Guerot (Paris / FRANCE)
    • Nicolas Danchin (Paris / FRANCE)
    • Etienne Puymirat (Paris / FRANCE)
    • Nadia Aissaoui (Paris / FRANCE)
    14h18 / 14h26
    Abstract : Oxygen therapy(OT) remains a cornerstone of acute heart failure(AHF) therapy in patients with pulmonary congestion(PC). While avoiding hypoxemia has long been a goal of critical care practitioners, less attention has been paid to the potential hazard related to excessive oxygenation and/or hyperoxia. Recent studies highlighted the uselessness or the potential hazard of hyperoxia in patients admitted for acute medical emergencies Our main objective was to evaluate the impact of an early hyperoxia exposure among critically ill patients hospitalized for AHF. In this observational, retrospective study lead in a Parisian medical intensive care unit(ICU), we assessed AHF patients admitted for PC from 01/01/2015 to 12/31/2016. Patients with cardiac arrest, severe chronic obstructive pulmonary disease, and long-term OTwere not included. Hyperoxia was defined as a PaO2>100 mmHg on blood gaz analysis. The hyperoxia group was defined by having at least one PaO2>100mmHg the first day following the ICU admission. The principal endpoint was a 30-day composite one combining all-cause mortality and unplanned hospital admission. The secondary endpoints were occurrence of a pneumonia/bacteriemia, ICU length of stay(LOS) and hospital LOS. Multivariate analysis was performed to determine if hyperoxia was independent risk factor of 30-day mortality. Among the 1541 patients admitted in ICU during the period study, 75 patients with PC due to AHF were included. Forty-one patients(54.7%) required mechanical ventilation. During the first 24 hours, 43 patients(57.3%) presented at least one hyperoxia on ABG [the hyperoxia group(H)] whereas 32 patients(42.7%) did not[the control group(C)]. The baseline characteristics according to the two groups did not differ[Table 1]. The composite primary endpoint did not differ between the two groups(27.9% vs 21.8%,P=0.85). 30-day mortality was 14 % in H versus 12.5 % in C, P=0.85. 30-day unplanned hospital admission was increased in H(16.3 %) compared to C but it did not reach the significance(P=0.21). The secondary endpoints were not significantly different between the two groups[Table 1]. In multivariate analysis, hyperoxia was not associated with 30-day mortality[OR=0.44(95%CI: 0.14-1.40), P=0.44]. Hyperoxia is not useful in critically ill patients with AHF but its benefit on the short-term outcome remains to demonstrate.
  • Incidence, predisposing factors and prognosis of acute postoperative Right ventricular failure in cardiac surgery: a prospective cohort study
    Orateur(s) :
    • Ahlem Trifi (Tunis / TUNISIE)
    • Imen Ben Naoui (Tunis / TUNISIE)
    • Sami Abdellatif (Tunis / TUNISIE)
    • Adel Ammous (Tunis / TUNISIE)
    • Raouf Denguir (Tunis / TUNISIE)
    • Mohamed Sami Mourali (Tunis / TUNISIE)
    • Salah Ben Lakhal (Tunis / TUNISIE)
    14h26 / 14h34
    Abstract : Acute postoperative cardiac surgery (POCS) right ventricular failure (RVF) is uncommon and worsened the patient's prognosis. We aimed to study the incidence, risk factors and outcome of acute RVF in cardiac surgery under extracorporeal circulation (ECC) patients. a prospective cohort study over one year (December 2016-december 2017). Were included, patients candidates for cardiac surgery (CS) with extra corporeal circulation and having a normal RF systolic function. Transthoracic-echocardiography (TTE) Doppler was performed on day 1, day 3, day 7 and 1 postoperative month. TAPSE <13 mm and an S-wave velocity <10 cm/s during the first postoperative week defined the POCS-RVF. Thus, patients were divided into two groups (POCS-RVF group versus non POCS-RVF group) and compared. Outcomes were: catecholamine support, septic events, length of stay (LOS), ventilator days and 30-day mortality. 128 among 131 patients were included (POCS-RVF group, n=49 versus non POCS-RVF, n=79). The incidence of acute POCS-RVF was 38.2%. Acute RVF occurred at the 1st post operative day and remained during 30 days (attached fig). Mitral valve replacement, aortic clamping time above than 90 min, preoperative arrhythmia and bleeding were significantly related to acute POCS-RVF with respectively (OR=11.75 ; IC[2.18-13.16]), (OR=4.36 ; IC[1.01-18.68]), (OR=6.55 ; IC[2.38-17.96]), (OR=3.4 ; IC[2.38-17.96]). Acute POCS-RVF increased mortality [21(43%) vs 16 (20%), p=0.006] and reduced survival time by 5 days but no significant link was showed between POCS-RVF and death. It depended to the left ventricular (LV) systolic function. LV dysfunction in POCS-RVF patients increased the death risk by 3 and its absence improved survival. Other factors were significantly associated to mortality Bentall and coronary tube procedures and ECC time> 120 min. the incidence of acute POCS-RVF is not negligible and several preoperative factors predispose to this phenomenon. LV failure worsened the outcome. These findings should sustain preventive measures to limit myocardial damage during cardiac surgery.
  • High risk of Chronic Kidney Disease after VA-ECMO : Results of one year follow-up of a monocentric cohort of 132 patients.
    Orateur(s) :
    • Camille Vinclair (Paris / FRANCE)
    • Romain Sonneville (Paris / FRANCE)
    • Jean Reuter (Paris / FRANCE)
    • Radj Cally (Paris / FRANCE)
    • Mathilde Neuville (Paris / FRANCE)
    • Jordane Lebut (Paris / FRANCE)
    • Claire Dupuis (Paris / FRANCE)
    • Stéphane Ruckly (Paris / FRANCE)
    • Lila Bouadma (Paris / FRANCE)
    14h34 / 14h42
    Abstract : Veno-Arterial Extra-Corporeal Membrane Oxygenation (VA-ECMO) is a life support technique associated with a major incidence of acute kidney injury (AKI). Risk of chronic kidney disease (CKD) following AKI is high. The objectives of the study were to describe renal natural history within one year following VA-ECMO and to identify early predictors of long-term renal impairment.We retrospectively analyzed consecutive adult patients without preexisting end-stage renal disease (ESRD) who received VA-ECMO for more than 48 hours in the 20-bed medical ICU of a university hospital, in Paris, France, between January 2014 and December 2016. AKI severity during ICU stay was defined according to KDIGO classification. Renal function at 1 year was assessed with estimated glomerular filtration rate (eGFR) using the MDRD equation. The primary endpoint was a composite of poor renal outcome (eGFR ≤ 60 ml/min/1.73m2) or death at one year, defining a bad outcome. Factors associated with bad outcome were identified by multivariate logistic regression analysis. Quantitative variables are reported as median (interquartile range, IQR) and qualitative variables as numbers (percentage). Results of multivariate analysis are reported as odds-ratio (OR) and 95% confidence interval.132 patients with available 1-year follow-up (male sex 75.5%, age 58 [46;66] years, SAPS II 55[38;67], SOFA 9 [6;12], time on ECMO 7.5 [4;12] days) were included in the study. 72 (54%) patients died in ICU and 80 (60.6%) within a year. 121 (92%) patients developed AKI during ICU stay, 73 (55%) required renal replacement therapy. 38 (74%) of survivors had an abnormal decline of eGFR at one year: median decline rate was 30 [18;55] mL/min/1.73m². Four (3%) patients had ESRD at one year, three of them did not required RRT during ICU but experienced recurrent AKI afterwards. In multivariate analysis, a best baseline renal function was protective of a bad renal outcome at one year (OR = 0.981 for a higher eGFR, [0.966;0.996], p=0.01). Severity of AKI in ICU was significantly associated with one year renal outcome. (OR = 67.190 [6.48;697] p< 0.01 for KDIGO stage 3).Among survivors of VA-ECMO therapy, long-term renal impairment is major particularly in those with previous CKD and severe AKI during ICU stay. ESRD is rare and occurs in patient with recurrent AKI.
  • Impact of levosimendan on peripheral veno-arterial extracorporeal membrane oxygenation weaning in intensive care unit
    Orateur(s) :
    • Shamir Vally (Saint-Denis / FRANCE)
    • Cyril Ferdynus (Saint-Denis / FRANCE)
    • Romain Persichini (Saint-Denis / FRANCE)
    • Eric Braunberger (Saint-Denis / FRANCE)
    • Hugo Lo Pinto (Saint-Denis / FRANCE)
    • Bruno Bouchet (Saint-Denis / FRANCE)
    • Olivier Martinet (Saint-Denis / FRANCE)
    • Thomas Aujoulat (Saint-Denis / FRANCE)
    • Jérôme Allyn (Saint-Denis / FRANCE)
    • Nicolas Allou (Saint-Denis / FRANCE)
    14h42 / 14h50
    Abstract : Few data are available concerning the impact of levosimendan in patients with refractory cardiogenic shock supported by peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU).This retrospective cohort study was conducted in a French university hospital, in one ICU from 2010 to 2017. All patients hospitalized in ICU who underwent VA-ECMO were consecutively evaluated. A total of 150 patients with VA-ECMO were eligible for the study. A propensity score matched 38 patients in the levosimendan group and 65 patients in the non-levosimendan group. In patients treated with levosimendan, 24h after infusion of medication left ventricular ejection fraction increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P<0.0001) while aortic velocity-time integral increased from 8.9 ± 4 cm to 12.5 ± 3.8 cm, (P=0.002). After matching on propensity score, levosimendan was the only remaining factor associated with a significant reduction of VA-ECMO weaning failure (Hazard Ratio = 0.16; 95%confidence interval: 0.04–0.7; P = 0.01). Kaplan-Meier survival curves showed that the survival rates at 30 days were 78.4% in the levosimendan group and 49.5% in the non-levosimendan group (P=0.0.37). However, no significant difference was found between the levosimendan and non-levosimendan groups regarding 30 days mortality after propensity score analysis (Hazard Ratio = 0.55; 95% confidence interval: 0.27 - 1.10; P = 0.09).This study suggests that levosimendan could be associated with a beneficial effect on VA-ECMO weaning in ICU patients. However, the use of levosimendan tended to decrease 30 days mortality after propensity matched analysis (P=0.09).
  • Serial neuron specific enolase (NSE) serum levels and neurologic outcome of cardiogenic shock patients treated by venoarterial extracorporeal membrane oxygenation (ECMO)
    Orateur(s) :
    • Jean Reuter (Paris / FRANCE)
    • Katell Peoc'H (Clichy / FRANCE)
    • Lila Bouadma (Paris / FRANCE)
    • Dorothée Faille (Paris / FRANCE)
    • Marie-Charlotte Bourrienne (Paris / FRANCE)
    • Claire Dupuis (Paris / FRANCE)
    • Eric Magalhaes (Corbeil-Essonnes / FRANCE)
    • Sébastien Tanaka (Paris / FRANCE)
    • Camille Vinclair (Paris / FRANCE)
    • Etienne de Montmollin (Paris / FRANCE)
    • Nadine Ajzenberg (Paris / FRANCE)
    • Romain Sonneville (Paris / FRANCE)
    14h50 / 14h58
    Abstract : Cardiogenic shock patients treated with venoarterial ECMO (VA-ECMO) may develop brain injury during ECMO support. We aimed to assess the predictive value of serial measurements of neuron specific enolase (NSE) to identify poor neurologic outcome and CT-defined acute brain injury in this setting.We conducted a prospective cohort study in consecutive adult patients cannulated with VA-ECMO for refractory cardiogenic shock in the medical ICU of a university hospital in Paris, France. Plasma was sampled at predefined time points, 1 day, 3 days and 7 days after VA-ECMO cannulation, until ECMO removal or death. Plasma samples were collected and stored at -80°C. The primary endpoint was poor outcome, a composite endpoint of CT-defined brain injury or death 28 days after VA-ECMO cannulation. The secondary endpoint was CT-defined brain injury. Plasma NSE levels were measured at the end of study. Data are presented as median (interquartile range) or number (percentages). The association between NSE levels and outcome was explored by multivariate logistic regression analysis, with NSE levels being dichotomized according to median values at day 1 and day 3.A total of 104 patients (males (n=67, 64%)) with a SOFA score at admission of 11 (8-14) were included, of whom 26 (25%) underwent cardiopulmonary resuscitation before VA-ECMO cannulation. At VA-ECMO cannulation, all patients were mechanically ventilated, 83 (80%) were sedated, and 81 (78%) were receiving vasopressors. Plasma NSE levels were 36 (26-50) µg/L at day 1, 25 (19-38) µg/L at day 3 and 22 (16-31) µg/L at day 7. A poor outcome occurred in 56 (53%) patients and CT-defined brain injury was observed in 16/45 (36%) patients. Plasma NSE levels at day 1 and day 3 were associated with poor outcome in crude analyses. In multivariate analysis, only NSE levels at day 3 remained independently associated with a poor outcome (table). In patients who underwent brain CT during VA-ECMO support, both NSE levels at day 1 and day 3 were associated with CT-defined brain injury.In cardiogenic shock patients treated by VA-ECMO, plasma NSE levels measured 3 days after VA-ECMO initiation are independently associated with short term acute brain injury or death, irrespective of pre-ECMO characteristics. Patients with persistent elevated NSE levels 3 days after VA-ECMO initiation may benefit from advanced neuromonitoring while on ECMO support.
  • Early predictive factors of 30-days mortality in cardiogenic shock: An analysis of the FRENSHOCK multicenter prospective registry
    Orateur(s) :
    • Clément Delmas (Toulouse / FRANCE)
    • Nicolas Lamblin (Lille / FRANCE)
    • Etienne Puymirat (Paris / FRANCE)
    • Guillaume Leurent (Rennes / FRANCE)
    • Vincent Labbe (Paris / FRANCE)
    • Sebastien Champion (Le Chesnay / FRANCE)
    • Stéphane Manzo-Silberman (Paris / FRANCE)
    • Meyer Elbaz (Toulouse / FRANCE)
    • Laurent Bonello (Marseille / FRANCE)
    • Edouard Gerbaud (Pessac / FRANCE)
    • Francois Roubille (Montpellier / FRANCE)
    • Eric Bonnefoy (Lyon / FRANCE)
    • Patrick Henry (Paris / FRANCE)
    14h58 / 15h06
    Abstract : Cardiogenic shock (CS) remains a severe but poorly understood pathology. Many predictive death scores have been previously described but have focused in ischemic CS and took into account data related to the management of these patients. So, there is an urgent need for simple and objective criteria to assess the short-term CS mortality regardless of the initial etiology. FRENSHOCK registry (NCT02703038) was a large prospective multicenter registry of CS patients admitted in intensive cardiac and general critical care units between April and October 2016 in France. Patients were prospectively included regardless of the CS etiology if they met at least one criterion of (1) low cardiac output (systolic blood pressure (SBP) < 90mmHg and/or the need of amines, or a low cardiac index < 2.2L/min/m2 on echocardiography or right heart catheterization; and (2) clinical, radiological, biological (NtproBNP or BNP), echocardiographical, or invasive hemodynamics overload signs; and (3) a clinical (oliguria, marbling, confusion) and/or biological hypoperfusion (lactates > 2mmol/L, hepatic and/or renal failure). We studied factors related to 30d mortality using Kaplan-Meier analyses and Cox proportional hazards modeling.772 patients were included (male 72%, median age 66yo). Non-ischemic CS were predominant (n=491, 64%) although type 1 infarction was infrequent (n=134, 17%). Mortality at 30-days was 26% (n=201). Non survivors were older, had more previous renal failure, marbles, and atrial fibrillation at admission. They had lower SBP and DBP. Diagnostic tests revealed higher arterial lactate – CRP – natriuretic peptids – kaliemia; and lower pH - prothrombin time – hemoglobin – eGFR but also LVEF. Multivariate analysis retained age (especially > 75y), low systolic blood pressure (especially < 90mmHg), high arterial lactate (especially > 4mmol/l), low eGFR (especially < 30ml/min/m²), low LVEF (especially < 30%) as significant predictors of 30-days mortality. Ischemic etiology or type 1 infarction were not predictive. Our multicentric and prospective design confirmed the heterogeneity of CS in terms of presentation and prognosis. Five simple, practical and easy to find signs were found significant predictors of short term mortality and could be useful in providing a more accurate and stratified definition of CS's patients in order to tailor additional therapies
Session Thématique
15h25 - 16h45
733-734
Kinésithérapeutes : Les outils du kiné en réanimation
Modérateur(s) : Ingrid Koube (Bruxelles / BELGIQUE), Marc Léone (Marseille / FRANCE)
  • Evaluation masse, force, fonction musculaire
    Orateur(s) :
    • Muriel Lemaire (Bruxelles / BELGIQUE)
    15h25 / 15h45
  • Epreuves fonctionnelles respiratoires
    Orateur(s) :
    • Olivier Van Hove (Bruxelles / BELGIQUE)
    15h45 / 16h05
  • Evaluation dysphagie
    Orateur(s) :
    • Thomas Gallice (Bordeaux / FRANCE)
    16h05 / 16h25
  • Evaluation cognition
    Orateur(s) :
    • Marianne Devroey (Bruxelles / BELGIQUE)
    16h25 / 16h45
SOS - Session d'organisation des soins
15h25 - 16h45
735-736
Infirmier(e) : Rôle spécifique des auxiliaires de puériculture
Thématique : Pédiatrie
Modérateur(s) : Berthille Bellier (Paris / FRANCE), Emmanuelle Bertholet (Lyon / FRANCE)
  • Le rôle spécifique de l'auxiliaire de puériculture en réanimation pédiatrique
    Orateur(s) :
    • Shirley Seguin (Paris / FRANCE)
    15h25 / 15h45
    Abstract : Le rôle spécifique de l'auxiliaire de puériculture en réanimation pédiatrique : L'Objectif principal de ce travail est de montrer que l'autonomie et la valorisation du travail des auxiliaires de puériculture permet d'améliorer la rapidité et la qualité de prises en soins en réanimation pédiatrique. Le rôle de l'Auxiliaire de puériculture permet de coordonner les différents soins et d'améliorer la prise en charge des enfants et de leurs parents en réanimation. Au sein du service de réanimation les auxiliaires de puériculture exécutent des taches en lien avec le rôle propre de l'IDE/PDE comme dans toutes structures. En revanche, leur expertise et leur connaissances accrues du matériel, les ont progressivement mené à réaliser des actions sur prescription mais avec vérification médicale obligatoire ; telle que le montage des respirateurs. Avant l'arrivée de l'enfant et le branchement au respirateur, l'interne accompagné du médecin sénior vérifie l'ensemble du montage et ré-effectue les tests. Cette façon de pratiquer nous a permis de sécuriser la prise en charge ventilatoire de l'enfant ; effectivement, il n'était pas rare de s'apercevoir que le ventilateur était monté à l'envers ou alors qu'il n'avait pas été vérifié et donc ne fonctionnait pas à l'arrivée de l'enfant. Ce « glissement de tâches contrôlé », nous permet de gagner un temps précieux à la préparation des chambres de réanimation et d'optimiser les prises en soins. Avant l'arrivée de l'enfant, le médecin sénior et l'interne se doivent de vérifier le montage et de tester le ventilateur afin de sécuriser la prise en charge.
  • Place de l'auxiliaire de puériculture lors de l'accueil des parents
    Orateur(s) :
    • Julia Zamor (Lyon / FRANCE)
    15h45 / 16h05
    Abstract : L'arrivée en Réanimation Pédiatrique peut-être autant « traumatisante » pour les enfants que pour les parents. L'auxiliaire de puéricultrice a alors un rôle prépondérant dans l'accueil de ceux-ci . C'est en effet, en général, la première personne qu'ils vont rencontrer lors de l'attente. Celle-ci va leur présenter les différentes modalités d'accès au service et le fonctionnement de celui-ci. Elle aura ainsi une place particulière dans la prise en charge de l'enfant et l'accompagnement des parents lors du séjour.
  • Place de l'auxiliaire de puériculture au déchoquage
    Orateur(s) :
    • Julie Mantelin (Lyon / FRANCE)
    • Malorie de Monte (Bron / FRANCE)
    16h05 / 16h25
    Abstract : En plus de leurs missions d'accueil et de prise en charge de l'enfant et sa famille au sein du service de Réanimation Pédiatrique de Lyon, les auxiliaires de puériculture ont une mission primordiale lors des déchoquages. Le déchoquage de l'Hôpital Femme Mère Enfant de Lyon accueille environ 400 patients par an dont 150 polytraumatisés. L'auxiliaire de puériculture participe à l'accueil, l'installation et la prise en charge de l'enfant polytraumatisé en collaboration avec l'infirmière des urgences et celle de réanimation pédiatrique ainsi qu'avec le réanimateur. Elle assiste notamment le réanimateur lors de l'intubation, lors de la pose de voies,… Ces missions ne faisant pas partie de son champ de compétences ont été protocolisées dans notre service. Une formation des auxiliaires de puériculture, un an après leur prise de poste dans notre service a donc été mise en place depuis trois ans. Nous souhaitons vous faire partager tout ce travail et ainsi notre expérience.
  • Une auxiliaire de puériculture en réanimation ça ne se ZAP pas !
    Orateur(s) :
    • Lucie Defaye (Bordeaux / FRANCE)
    16h25 / 16h45
    Abstract : De nombreuses idées préconçues existent sur le rôle et la place des AP dans une unité de réanimation pédiatrique. Par exemple : « Elles ne font que du ménage ! » Et pourtant elles sont au centre des prises en charge. Le prolongement des yeux, des oreilles et des mains de la puéricultrice que ce soit pour les soins techniques, la réassurance et/ou l'observation. Une complémentarité indispensable. Toujours disponibles pour de multiples missions qu'elles doivent savoir prioriser et mener avec calme, rigueur et dynamisme. Au croisement des demandes, elles font le lien entre les différents intervenants auprès des patients et des familles, dans une dynamique d'équipe et de prise en charge pluridisciplinaire.
Session Thématique
15h25 - 16h45
737-738
Infirmier(e) : La peau dans tous ses états : optimisation de prise en charge
Thématique : Pédiatrie
Modérateur(s) : Laure de Saint Blanquat (Paris / FRANCE), Christine Fayeulle (Lille / FRANCE)
  • Prise en charge pré-hospitalière du brûlé
    Orateur(s) :
    • Fabien Lespinas (Mont-De-Marsan / FRANCE)
    15h25 / 15h45
  • Principes de prise en charge médicale du brûlé
    Orateur(s) :
    • Nicolas Louvet (Paris / FRANCE)
    15h45 / 16h05
  • Prise en soins infirmière du brûlé
    Orateur(s) :
    • Mathilde Henaff (Paris / FRANCE)
    16h05 / 16h25
  • Le syndrome de Lyell
    Orateur(s) :
    • Nathalia Bellon (Paris / FRANCE)
    16h25 / 16h45
Session Thématique
15h25 - 16h45
741
Médecin : Ces pathologies où il faut aller vite
Thématique : Pédiatrie
Modérateur(s) : Maryline Chomton (Paris / FRANCE), Pierre-Louis Léger (Paris / FRANCE)
  • Purpura fulminans
    Orateur(s) :
    • Jean Bergounioux (Garches / FRANCE)
    15h25 / 15h45
  • Chocs toxiniques
    Orateur(s) :
    • Yves Gillet (Lyon / FRANCE)
    15h45 / 16h05
  • Accidents vasculaires ischémiques
    Orateur(s) :
    • Manoelle Kossorotoff (Paris / FRANCE)
    16h05 / 16h25
  • Traumatisme crânien grave
    Orateur(s) :
    • Etienne Javouhey (Lyon / FRANCE)
    16h25 / 16h45
Session Thématique
15h25 - 16h45
E01
Médecin : Colites à Clostridium difficile en réanimation
Modérateur(s) : Jean-François Timsit (Paris / FRANCE), Gaël Piton (Besançon / FRANCE)
  • L'épidémiologie a-t-elle changé ?
    Orateur(s) :
    • Jeanne Couturier (Paris / FRANCE)
    15h25 / 15h45
  • Stratégie diagnostique
    Orateur(s) :
    • François Barbier (Orléans / FRANCE)
    15h45 / 16h05
  • Traitement
    Orateur(s) :
    • Benoit Guéry (Lausanne / SUISSE)
    16h05 / 16h25
  • Transmission croisée et prévention
    Orateur(s) :
    • Jean-Ralph Zahar (Bobigny / FRANCE)
    16h25 / 16h45
Session Thématique
15h25 - 16h45
E02
Médecin : Insuffisance respiratoire aiguë sur insuffisance respiratoire chronique
Modérateur(s) : Eric Maury (Paris / FRANCE), Jean-Damien Ricard (Colombes / FRANCE)
  • Epidémiologie et pronostic
    Orateur(s) :
    • Nicolas Terzi (Grenoble / FRANCE)
    15h25 / 15h45
  • Stratégie ventilatoire non-invasive
    Orateur(s) :
    • Alexandre Demoule (Paris / FRANCE)
    15h45 / 16h05
  • Epuration extra-corporelle du CO2
    Orateur(s) :
    • Jean-Luc Diehl (Paris / FRANCE)
    16h05 / 16h25
  • Place de la corticothérapie
    Orateur(s) :
    • Fekri Abroug (Monastir / TUNISIE)
    16h25 / 16h45
Session Thématique
15h25 - 16h45
E03
Infirmier(e) : Les familles en réanimation
Modérateur(s) : Marion Letheuré (Paris / FRANCE), Nancy Kentish Barnes (Paris / FRANCE)
  • Ouvrir 24/24 : les clefs de la réussite 
    Orateur(s) :
    • Virginie Souppart (Paris / FRANCE)
    15h25 / 15h45
  • Instaurer la confiance
    Orateur(s) :
    • Elie Azoulay (Paris / FRANCE)
    15h45 / 16h05
  • Présence des familles lors de la Réanimation Cardio Pulmonaire (RCP) : expérience de la pédiatrie et ouverture sur l'adulte
    Orateur(s) :
    • Violaine Mattioni (Paris / FRANCE)
    16h05 / 16h25
  • Journal de bord : quels bénéfices ?
    Orateur(s) :
    • Anne-Sophie Debue (Paris / FRANCE)
    16h25 / 16h45
SOS - Session d'organisation des soins
15h25 - 16h45
E04
Infirmier(e) : Mieux vivre en réanimation 2
Modérateur(s) : Grégoire Demont (Lille / FRANCE), Sarah Dupont (Paris / FRANCE)
  • Mesure de l'impact de la musicothérapie sur la douleur, l'anxiété et le bien-être des patients admis aux soins intensifs en post-opératoire.
    Orateur(s) :
    • Frankina Yeboah (Anderlecht / BELGIQUE)
    15h25 / 15h45
    Abstract : Le séjour à l'unité de soins intensifs (USI) entraîne souffrances et agressions pour les patients, pouvant engendrer un état de stress post-traumatique (ESPT). Dans la conférence de consensus « mieux vivre la réanimation » (SFAR-SRLF, 2010), la musique est considérée un moyen d'améliorer le bien-être du patient. La présente étude mesure l'impact de la « MUSIC CARE © » sur la douleur, l'anxiété et le bien être des patients en soins intensifs, en post-opératoire. L'évolution des paramètres vitaux et les avis des patients sur l'utilisation de la musique de relaxation ont également été observés. Cette étude d'intervention avec échantillon apparié (critères d'inclusion : patient majeur, francophone, conscient, sans trouble d'acuité, ayant subi une intervention chirurgicale, donnant un consentement éclairé) s'est déroulée aux soins intensifs de l'ULB-Hôpital Érasme, sur 24 jours. Un entretien semi-dirigé a été réalisé avant/après la séance de « MUSIC CARE © ». Trente patients ont participé à l'étude (âge moyen de 50 ans, majorité de femmes et 70 % ont subi une neurochirurgie). La « MUSIC CARE © » a permis une diminution statistiquement significative de la douleur (p < 0,001) et de l'anxiété (p<0,001) et une amélioration du bien-être physique et psychique (p < 0,001) : sensation de détente (30 %), de relaxation (13 %) et de déconnexion (20 %). Les paramètres vitaux n'ont pas été influencés. La « MUSIC CARE © » est une technique non médicamenteuse qui permet de diminuer la douleur et l'anxiété et de « mieux vivre la réanimation ».
  • « Mieux prendre soin pour mieux soigner » : Soins esthétiques en service de soins critiques
    Orateur(s) :
    • Nadine Robquin (Villeneuve-Saint-Georges / FRANCE)
    15h45 / 16h05
    Abstract : Le séjour en réanimation est une étape traumatisante avec une détérioration de l'image corporelle, un risque de stress post-traumatique. Les soins d'esthétique, la musicothérapie pourraient-être utilisés à visée anxiolytique, antalgique afin de maintenir les patients dans la vie et ne pas réduire cette période à de la survie. En novembre 2017, est réalisée une étude sur 101 patients conscients durant 36 jours, confirmant la demande chez 51% d'entre eux. En Mars 2018 , a été mis en place une prestation de soins esthétiques (soins du visage, maquillage correcteur, massages, manucure, pédicure, soins capillaire) et musicothérapie, proposée une fois par semaine par une aide-soignante du service avec une compétence d'esthéticienne. Ces soins sont donc proposés en toute sécurité à tous patients de réanimation, conscients et consentants même sous assistance ventilatoire. Tous les patients du service sont évalués le jour du soin pour leur éligibilité. Un outil avec des échelles visuelle numérique(EVN) de douleur et d'anxiété avant, pendant et après les soins (H2) a été créé afin d'évaluer le bénéfice pour le patient. Un outil d'évaluation de l'anxiété de la famille a été créé. De mars à mai 2018, 21 patients ont bénéficié des soins. On note une diminution significative de l'anxiété (EVN moyenne passant de 3.5 à 0.6 puis 0.9) et de la douleur (EVN moyenne passant de 2.5 à 0.9) La mise en place de soins esthétiques entraine une amélioration de la vie en réanimation avec une objectivation d'une baisse de l'anxiété et de la douleur ressentie.
  • L'aromathérapie en réanimation et pourquoi pas ? Anxiété et insomnie, retour à l'essentiel
    Orateur(s) :
    • Malvina Grolier (La Rochelle / FRANCE)
    16h05 / 16h25
    Abstract : AROMAREA Partant du postulat que la réanimation est source d'inconfort et de stress post traumatique pour les patients, nous avons décidé de mettre en place de l'aromathérapie au sein de notre service afin d'améliorer leur confort. Il existe un réel bénéfice pour le patient, sur la perception de l'environnement, la réduction de l'anxiété, la baisse de la pression artérielle et l'amélioration du sommeil lors de l'inhalation d'huile essentielle. Suite à une formation en aromathérapie, j'ai décidé de mettre en place ce support pour travailler sur le stress et l'insomnie, deux axes émotionnels dont souffrent nos patients. Les objectifs sont : - diminuer les risques de décompensation liée à l'angoisse et le manque de sommeil, - limiter le risque de perturbation neurologique lié au manque de sommeil, - proposer un soin de détente dans un milieu stressant, - favoriser l'observance et la compliance aux soins, évitant ainsi les contentions physiques et chimiques ; - limiter la durée de séjour et ses conséquences. Les huiles essentielles d'agrumes apportent tous ces bénéfices et sont sans risques pour les patients et le personnel médical et paramédical. Un protocole a été rédigé pour l'utilisation de ces huiles essentielles. Deux méthodes sont possibles : - L'olfaction : diffusion et sticks, - En toucher massage avec des préparations adaptées. Chaque soin est évalué à l'aide d'outils simples : l'échelle de COVI et des échelles numériques. Cette première expérience encourageante nous a motivé pour lancer une étude de recherche paramédicale orientée sur l'anxiété du patient BPCO en décompensation respiratoire.
  • La socioesthétique pour réhumaniser les soins critiques
    Orateur(s) :
    • Irma Bourgeon-Ghittori (Créteil / FRANCE)
    16h25 / 16h45
    Abstract : Le Service de Réanimation Médicale propose des soins socio-esthétiques aux patients hospitalisés dans le but d'améliorer leur image, de restaurer leur intégrité physique et l'empathie des soignants. Ce projet SERHUMS (la Socio-Esthétique pour Re-HUManiser les Soins critiques) est financé par le Prix première chance 2017 de la Fondation L'Oréal. Il répond à une demande des patients, des familles et des soignants. Une socio esthéticienne intervient en complémentarité avec l'équipe soignante pour réduire les sources d'inconfort et aider les patients à retrouver des sensations agréables. Les soins proposés sont polymorphes avec un aspect relationnel par le toucher bienveillant visant à détendre le patient et à réduire sa douleur et un aspect esthétique visant à restaurer son image corporelle. L'évaluation du projet repose sur l'impact physiologique sur le patient en plus des effets psychologiques sur le patient, les soignants et les familles. La psychologue du service est associée à cette évaluation. les verbatim des patients ayant bénéficié des séances sont élogieux, les proches expriment aussi leur reconnaissance et les soignants observent des effets cliniques. Les changements psychologiques (ex: changement d'attitude du patient qui se redresse dans son lit, devient plus actif et planifie lui-même la prochaine séance)et physiologiques(ex: réduction des signes de détresse respiratoire) observés suggèrent un potentiel majeur. Ces résultats nous conduisent à cibler les interventions de la socio esthéticienne sur trois types de prises en charge critiques et d'en évaluer l'impact sur la performance du patient et sur les relations de soins. L'appréciation du traitement esthétique de la personne est-elle un moyen de mieux vivre la réanimation ?
Meet the experts
15h25 - 16h25
E05
Médecin : Endocardite
Modérateur(s) : Saad Nseir (Lille / FRANCE)
  • Endocardite
    Orateur(s) :
    • Nicolas Bréchot (Paris / FRANCE)
    • [expert] - Michel Wolff (Paris / FRANCE)
    • [expert] - Pierre Tattevin (Rennes / FRANCE)
    15h25 / 16h25
Session Thématique
15h25 - 16h45
E06
Médecin : Insuffisance rénale aiguë
Modérateur(s) : Alexandre Lautrette (Clermont-Ferrand / FRANCE), Emmanuel Canet (Paris / FRANCE)
  • L'insuffisance rénale fonctionnelle : ça existe ?
    Orateur(s) :
    • Lara Zafrani (Paris / FRANCE)
    15h25 / 15h45
  • Comment mesurer la fonction rénale en réanimation ?
    Orateur(s) :
    • Stephan Ehrmann (Tours / FRANCE)
    15h45 / 16h05
  • New treatments for septic acute kidney injury
    Orateur(s) :
    • Peter Pickkers (Nijmegen / PAYS-BAS)
    16h05 / 16h25
  • insuffisance rénale aigüe et mortalité : cause ou association ?
    Orateur(s) :
    • Alexandre Hertig (Paris / FRANCE)
    16h25 / 16h45
Session Thématique
15h25 - 16h45
E07
Infirmier(e) : L'équipe et la communication
Modérateur(s) : Paulo Ferreira (Paris / FRANCE), Stéphanie Bonnel (Paris / FRANCE)
  • Flash info
    Orateur(s) :
    • Annick Delpech (Lyon / FRANCE)
    15h25 / 15h45
    Abstract : Dans le cadre d'un service de réanimation, où les équipes travaillent avec des horaires en 12 heures d'amplitude et des alternances jour/ nuit, les temps de relève sont réduits. Se pose alors la problématique de la transmission des informations autre que celles concernant strictement le suivi des patients. C'est pourquoi il nous a paru intéressant de créer un temps dédié, avec suspension de toute activité (hors urgence) pour communiquer, simultanément, à toute l'équipe présente, les informations autres que les cas de patients stricto sensu. Les "flash info" permettent ainsi de se retrouver aussi autour d'un café et de débriefer. Le principe est de ne pas dépasser les vingt minutes de communication. Cette technique est inspirée de ce qui se fait chez les pompiers.
  • Améliorer les transmissions : éviter les écueils
    Orateur(s) :
    • Sacha Rozencwajg (Paris / FRANCE)
    15h45 / 16h05
  • Réseaux sociaux virtuels en réanimation
    Orateur(s) :
    • Annick Delpech (Lyon / FRANCE)
    16h05 / 16h25
    Abstract : Ce travail est le résultat d'une recherche portant sur l'usage des réseaux sociaux virtuels dans le cadre des pratiques professionnelles paramédicales. En effet, l'usage croissant des dispositifs d'échanges sur internet de la part des professionnels semble tendre vers des analyses de pratiques professionnelles ou des communautés de pratique. La question de départ interroge la contribution des réseaux sociaux et numériques (en particulier des forums d'échanges et de Facebook) dans le développement professionnel des infirmiers et la dynamique d'une équipe. Un focus particulier est fait sur les pratiques au sein d'un service de réanimation chirurgicale, car certaines familles ont demandé à des professionnels d'être leur ami sur Face book. Ce qui a mis en évidence la problématique des frontières entre la sphère professionnelle et le domaine personnel. Une méthode quantitative et une méthode qualitative sont utilisées afin d'explorer cette question de départ. Ce sujet est innovant dans la mesure où, dans un contexte de développement des NTIC et dans la dématérialisation des échanges, il est important de tenir compte de ces nouvelles manières d'échanger, dans la formation initiale et continue des infirmiers et de comprendre quels en sont les enjeux en termes de professionnalisation.