Programme scientifique

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mercredi 23 janvier 2019

Communications orales
14h10 - 15h10
E08
Médecin : Nouveaux outils de monitorage en ventilation
Modérateur(s) : Claude Guérin (Lyon / FRANCE), François Beloncle (Angers / FRANCE)
  • Diaphragm thickening fraction correlates with diaphragm electrical activity in patients under mechanical ventilation
    Orateur(s) :
    • Suela Demiri (Paris / FRANCE)
    • Bruno-Pierre Dube (Montreal / CANADA)
    • Julien Mayaux (Paris / FRANCE)
    • Elise Morawiec (Paris / FRANCE)
    • Thomas Similowski (Paris / FRANCE)
    • Martin Dres (Paris / FRANCE)
    14h10 / 14h25
    Abstract : The evaluation of patient's inspiratory effort is helpful to optimally tailor ventilator settings. While diaphragm electrical activity has been proposed as a valuable tool to assess inspiratory effort, it requires a dedicated tool, namely the NAVA (Neurally Adjusted Ventilatory Assist) catheter that is not widely available. By contrast, the use of ultrasound to evaluated diaphragm contractile activity has been growing in the ICU. However, the relationship between diaphragm contractility activity, i.e. diaphragm thickening fraction (TFdi) and diaphragm electrical activity (EAdi) has not been explored so far. Our hypothesis was that TFdi correlates with EAdi. In the present study, we sought to investigate the correlation between TFdi and EAdi through several conditions of ventilatory assistance. Patients intubated and ventilated for at least 24 h were eligible for inclusion in the study if they had been previously mechanically ventilated with NAVA mode and the NAVA catheter had been left in place. Ultrasound measurements of diaphragm contractile activity were made synchronously with the measurement of maximal EAdi (EAdimax) during 6 consecutive, randomly assigned ventilatory conditions (NAVA 1μV/ml, pressure support levels of 5, 10, 15 and 20 cmH2O (with Positive end exipartory pressure PEEP of 5 cm H2O), and zero PEEP with 7 cm H2O pressure support. Overall correlation between EAdimax and TFdi was assessed using Spearman's correlation coefficient. We also sought to determine the correlation between EAdimax and TFdi for each condition. Twenty patients 60 (53-67) years old were enrolled in the study after a median (25-75 IQR) period of mechanical ventilation of 6 days (3-67). Overall, the correlation between TFdi and EAdimax was r=0.34, p<0.001, as shown in Figure 1. The Spearman's correlation coefficient decreased when the level of ventilatory assistance increased. It was 0.54 (p=0.03) for zero PEEP with 7 cm H2O pressure support and 0.53 (p= 0.03), 0.53 (p=0.3), 0.34 (p=0.2) and 0.15 (p=0.57) for a level of pressure support of 5, 10, 15 and 20 cmH2O with PEEP of 5 cmH2O and 0.38 (p=0.14) in NAVA.There was a moderate correlation between diaphragm thickening fraction and diaphragm electrical activity. Our findings suggest that diaphragm thickening fraction behaves as a relevant surrogate of patient's inspiratory effort but the determinants of this correlation deserve further studies.
  • Transpulmonary pressures and computed tomography in experimental ARDS
    Orateur(s) :
    • Jean-Christophe Richard (Lyon / FRANCE)
    • Maciej Orkisz (Villeurbanne / FRANCE)
    • Marcela Hernandez Hoyos (Bogota / COLOMBIE)
    • Alfredo Morales Pinzon (Bogota / COLOMBIE)
    • Claude Guérin (Lyon / FRANCE)
    14h25 / 14h40
    Abstract : Esophageal pressure to compute transpulmonary pressure (TPP) is an appealing technique to individualize PEEP in ARDS. TPP can be computed 1. as the difference between airway and esophageal pressures (absolute measurement PLABS); 2. as the product of airway pressure by the ratio of lung to respiratory system elastance (elastance-derived measurement PLEL). The aim of the study was to evaluate the relationships between both TPP measurements and computed tomography (CT) in an experimental model of ARDS.ARDS was performed by saline lavage on 16 piglets. A recruitment maneuver was performed followed by mechanical ventilation with VT 6 ml/kg body weight. PEEP was set to 20 cmH2O then decreased by 2 cmH2O-steps down to 2 cmH2O. Piglets were then randomized into 3 PEEP groups based on best compliance during PEEP trial, best end-expiratory lung volume during PEEP trial, or a PEEP-FiO2 table. Finally, 7 levels of VT ranging from 4 to 20 ml/kg were applied at optimal PEEP. TPP measurements and CT were performed at end-expiration and end-inspiration after ARDS onset, during the PEEP trial, 1 hour after setting optimal PEEP, and during the variable VT trial.PLABS ranged from -6 to 58 cmH2O, and PLEL ranged from 1 to 65 cmH2O. PLABS and PLEL were significantly correlated (R2=0.87, p<0.001). Bias between PLEL and PLABS amounted to 4 cmH2O (limits of agreement ranging from -2 to 11 cmH2O). Non-inflated compartment significantly increased in deciles of end-expiratory PLABS and PLEL below 4.6 cmH2O and 11.8 cmH2O, respectively (cf. figure). The table provides the diagnostic performance of end-expiratory PLABS and PLEL to detect a non-inflated compartment below 5% and 10% of total lung volume. Overinflated compartment significantly increased in deciles of end-inspiratory PLABS and PLEL above 25.8 cmH2O and 30.7 cmH2O, respectively. ROC curve identified an end-inspiratory PLABS above 19.6 cmH2O and an end-inspiratory PLEL above 24.6 as best thresholds to identify an overinflated compartment greater than 2% of total lung volume. Both TPP measurement techniques have similar diagnostic performance to identify near complete alveolar recruitment at end-expiration and hyperinflation at end-inspiration. Near complete alveolar recruitment may be achieved with PLABS or PLEL greater than 5 and 10 cmH2O, respectively.
  • Prone positioning monitored with electrical impedance tomography on patients with severe ECMO-supported ARDS
    Orateur(s) :
    • Guillaume Franchineau (Paris / FRANCE)
    • Nicolas Bréchot (Paris / FRANCE)
    • Guillaume Hekimian (Paris / FRANCE)
    • Guillaume Lebreton (Paris / FRANCE)
    • Simon Bourcier (Paris / FRANCE)
    • Côme Bureau (Paris / FRANCE)
    • Loic Le Guennec (Paris / FRANCE)
    • Ania Nieszkowska (Paris / FRANCE)
    • Pascal Leprince (Paris / FRANCE)
    • Alain Combes (Paris / FRANCE)
    • Matthieu Schmidt (Paris / FRANCE)
    14h40 / 14h55
    Abstract : Prone positioning (PP) during veno-venous extracorporeal membrane oxygenation (ECMO) is feasible but its relative effects have never been thoroughly described.Objectives are to describe through electrical impedance tomography (EIT) the impact of PP on regional ventilation and optimal PEEP level, and to derive from EIT baseline predictive factors to identify “PP responders” on ECMO. ECMO-supported severe ARDS patients, ventilated with a pressure-controlled mode, a 14cmH2O driving pressure, and an EIT-based “optimal PEEP” were included. Before, during, and after a 16 hour-PP session, EIT based distribution and variation of tidal impedance, centre of gravity index, end-expiratory lung impedance (EELI), and static compliance were collected. “PP responders” were identified as patients who increased their static compliance by more than 3ml/cmH2O after 16 hours of proning. Thirteen (62%) out of 21 studied-patients were considered as “PP responders” on ECMO. “PP responders” had a greater body mass index, more frequently a viral pneumonia and a shorter ECMO duration compared to “PP non-responders” (p<0.01). For both groups, tidal volume and EELI were redistributed from ventral to dorsal regions during PP. However, “optimal PEEP” was significantly lower in PP than in supine position with 14 (12 -16) and 11 (8 – 14.5) vs 12 (10 – 14) and 8 (7.5 -10.5) cmH2O in “PP responders” and “PP non-responders”, respectively (figure 1). Lastly, baseline center of gravity index was lower in “PP responders” (p=0.03).EIT allows monitoring PP impact on ventilation and seems to be a relevant tool to identify patients who will more likely respond to PP on ECMO.
  • Respiratory muscles contraction after successful ventilator liberation trial predicts extubation failure
    Orateur(s) :
    • Martin Dres (Paris / FRANCE)
    • Domenico Luca Grieco (Toronto / CANADA)
    • Wissalle Ouechani (Paris / FRANCE)
    • Irene Telias (Toronto / CANADA)
    • Detajin Junhasavasdikul (Toronto / CANADA)
    • Luana Melo (Toronto / CANADA)
    • Thomas Piraino (Toronto / CANADA)
    • Felipe Damiani (Toronto / CANADA)
    • Lilya Sergenyuk (Paris / FRANCE)
    • Lauriane Degravi (Paris / FRANCE)
    • Tai Pham (Toronto / CANADA)
    • Thomas Similowski (Paris / FRANCE)
    • Laurent Brochard (Toronto / CANADA)
    14h55 / 15h10
    Abstract : Even for patients who successfully pass a ventilator liberation trial, the period after extubation is at risk of complications. In the present study we investigated whether assessment of respiratory muscles contraction within 2 hours after extubation could predict extubation failure (acute respiratory failure, re-intubation or death during a 7-days period following extubation). Patients from two intensive care units who were intubated since at least 48 hours and who successfully passed a ventilator liberation trial were enrolled in the study. Within the two hours following extubation, right hemi-diaphragm (TFdi) and right upper intercostal muscle thickening fraction (TFci) were obtained with ultrasound. TFdi and TFic were compared between patients with and without extubation failure (unpaired test). Receiver operating characteristic (ROC) curves were constructed to predict the risk of extubation failure for each indice. Of the 122 patients who participated in the study, 22 (18%) had extubation failure. Respectively in patients with and without extubation failure, TFdi was 11.9% (9.8–19.4) and 21.5% (15.8–26.3) (p<0.01) and TFic was 12.8% (8.2–22.2) and 6.5% (4.2–9.1) (p<0.01). AUC of the ROC curves were 0.73 (0.59–0.86) and 0.76 (0.60–0.91) for TFdi and TFic respectively (p=0.54). A value of TFdi lower than 16% predicted extubation failure with a sensitivity of 70% (46–88) and a specificity of 73% (63–82). A value of TFic greater than 9% predicted extubation failure with a sensitivity of 75% (51–91) and a specificity of 74% (63–82).  Eventually, TFdi/TFic ratio was 3.4 (2.0–5.4) and 0.8 (0.3–2.6) in patients with and without extubation failure respectively (p=0.003). The AUC of the ROC curve for TFdi/TFic was 0.82 (0.70–0.94) providing a sensitivity of 71% (60-81) and a specificity of 74% (49-91)to predict extubation failure with a cut-off of 2.2.Assessment of respiratory muscles contraction within two hours after extubation could be used to identify patients at risk of extubation failure. The potential interest of our cut-offs could be used at the time of considering preventive post extubation ventilation strategy.
E-Poster
14h10 - 15h10
Espace poster 1
Médecin : Toxicologie 1
Modérateur(s) : Eric Maury (Paris / FRANCE), Nicolas Lerolle (Angers / FRANCE)
  • Opioid overdoses admitted to the intensive care unit over a 10-year period: clinical features and involved toxicants
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Rhianna Willems (Paris / FRANCE)
    14h10 / 14h17
    Abstract : An opioid overdose crisis is currently ongoing in the North-American continent in relation to the misuse of opioid analgesics and the spread of new fentanyloids on the recreational scene. Data regarding the opioid overdoses in France remain scarce. Our objectives were to describe the opioid overdoses admitted to the intensive care unit (ICU) and characterize the involved compounds, the consequent clinical features, the resulting complications and the patient management. We conducted a retrospective single-centre observational study including all patients admitted in the ICU during a 10 year period (2008-2018) for an oipioid overdose evidenced by the typical opioid toxidrom (coma, pinpoint pupils and bradypnea) associated to a compatible blood and urine toxicological screening. In 10 years, 231 patients (147 males and 84 females; age, 38 years (33-46) [median (percentiles 25-75)]) were admitted for opioid intoxication in the ICU. The patients presented consciousness impairment [Glasgow coma score of 6 (3-10)], respiratory rate of 11 /min (8-15) and pinpoint myosis (90%). Naloxone (64%) and flumazenil (20%) were administered to avoid tracheal intubation; but mechanical ventilation was requested in 36% of the patients [duration: 20 h (11-72)]. Duration of ICU stay was 41 h (24-72). The observed complications included aspiration pneumonia (35%), rhabdomyolysis (26%), acute respiratory distress syndrome (13%), cardiovascular failure (11%), withdrawal syndrome (8%), hospital-acquired infection (4%) and death (1%). Toxicity was related to opioid misuse (52%) versus opioid overdose (48%). Multidrug exposure was found in 100% of the cases and the involved opioids as follows: morphine (44%), heroin (32%), buprenorphine (30%), methadone (26%), codeine (24%), tramadol (6%), d-propoxyphene (6%), fentanyl (1%) and oxycodone (0.5%). Prevalence of the different opioids was mainly influenced by the banning of propoxyphene from the market in 2011 and the consecutive increase in tramadol prescriptions. Our large cohort of opioid poisonings clearly supports the risks of life-threatening consequences in case of misuse or overdose. Mixed opioid use and combination to other legal and illegal drugs are frequent supporting the role of drug-drug interactions in the onset of toxicity in these multidrug poisonings.
  • Seizures resulting from ethanol withdrawal: management and prognosis in the intensive care unit
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Camille Tacquin (Paris / FRANCE)
    14h17 / 14h24
    Abstract : In France, excessive ethanol use represents a major public health problem with resulting morbidities and social and medical expenses. Chronic alcohol drinking induces dependence and tolerance and may thus be responsible for withdrawal syndrome complicated by seizures, explained by ethanol-induced alterations in the brain neurotransmitters including at the gamma-aminobutyric acid/glutamine balance. Our objective was to describe the patient's characteristics, morbidities, management and final outcome of the patients admitted to the intensive care unit (ICU) due to ethanol withdrawal complicated by seizures. We conducted a retrospective monocentre observational study including all presumed chronic alcoholic patients admitted to the ICU from 2014 to 2018 for ethanol withdrawal-induced seizures. The diagnosis was considered by the physicians in charge based on the results of all useful clinical, biological, imaging and EEG data usually required to rule out alternative diagnoses. Fifty-three patients [45 males (85%) and 8 females (15%); age 49 years (12) (median (interquartile range)] were included in the study. The patients were homeless (44%) and jobless (52%). They had previously presented ethanol withdrawal syndrome (62%) including seizures (53%). Patients developed status epilepticus (70%) associated to delirium tremens (13%). Complications included aspiration pneumonia (49%), cardiovascular failure (18%, mainly vasoplegic shock requiring norepinephrine infusion), neurological deficits (8%) and skin compression lesions (19%). Patients requested mechanical ventilation (53%) during 3 days (12). All patients were treated with anticonvulsive drugs of which the two mostly used were levetiracetam (Keppra®, 80%) and clonazepam (Rivotril®, 72%). Two patients (4%) died. Readmission to the emergency department (49%) and re-hospitalization in an ICU or medical ward (38%) were remarkable during the first year following their ICU admission, while only 13% had psychological and addictological follow-up.Ethanol withdrawal may be responsible in the chronic alcoholic for seizures requiring ICU admission with life-threatening complications and death. Our data support once again the absolute necessity to strengthen the fight against excessive ethanol drinking in our society.
  • Quetiapine poisoning admitted to the intensive care unit: complications and usefulness of plasma concentration measurement
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Lamia Sara Chenafi (Paris / FRANCE)
    • Karim Jaffal (Paris / FRANCE)
    • Marion Soichot (Paris / FRANCE)
    • Laurence Labat (Paris / FRANCE)
    14h24 / 14h31
    Abstract : Since its marketing in France in 2011, prescriptions of quetiapine, a second generation antipsychotic drug, has exponentially increased with the risk of increase in the number of acute poisonings. Data regarding acute quetiapine overdose are scarce. Our objectives were 1)- to describe the features, complications and management of acute quetiapine poisonings admitted to the intensive care unit (ICU) ; 2- to evaluate the prognostic contribution of plasma quetiapine concentration on ICU admission and model quetiapine pharmacokinetics in overdose. We conducted a retrospective single-center observational study. All quetiapine-poisoned patients (evidenced by measurement of plasma concentration in the toxic range) admitted to the ICU during a 6-year period (2013-2018) were included. Severe extra-neurological complications were defined as the onset of major ECG abnormalities, catecholamine requirement, cardiac arrest and death. Plasma quetiapine concentration was determined using high-performance liquid chromatography coupled to tandem mass spectrometry. Thirty-eight quetiapine-poisoned patients (11 males and 27 females; median age of 45 years [interquartile range, 16]; presumed ingested dose of 3.0 g [6.9]) were included. Poisoning resulted from multidrug ingestions (97%). The patients presented consciousness impairment (Glasgow coma score of 12 [8] requesting mechanical ventilation in 47% of the cases), seizures (8%), hyperglycemia (68%), hypokalemia (18%), intra- (17%) and atrio-ventricular blocks (7%) and QTc prolongation on the ECG (28%). Complications included cardiovascular failure (13%), aspiration pneumonia (39%) and cardiac arrest (5%). One patient died. The length of ICU stay was 58 h [57]. The plasma quetiapine concentration on admission (685 ng/ml [1631]) did not allow predicting the onset of severe complications in the ICU. Delayed quetiapine peak was observed at 27 h [23] post-ingestion suggesting prolonged gastrointestinal absorption while quetiapine elimination was prolonged in comparison to the pharmacological conditions. Quetiapine poisoning is relatively rare but may lead to life-threatening cardiovascular and neurological features. The plasma concentration on admission is not helpful to predict the onset of complications, thus suggesting marked inter-individual variability.
  • ABOUT THIRTEEN CASES OF ALUMINUM PHOSPHIDE POISING.‎
    Orateur(s) :
    • Mohamed Walid Mhajba (Tunis / TUNISIE)
    • Hela Maamouri (Tunis / TUNISIE)
    • Aziz Ben Slimen (Tunis / TUNISIE)
    • Nozha Brahmi (Tunis / TUNISIE)
    14h31 / 14h38
    Abstract : Aluminum phosphide is a solid fumigant pesticide that can cause serious and potentially ‎life-threatening poisoning. Poisoning is a medical emergency, requiring early and adequate ‎management in a specialized resuscitation environment. The objective of this work was to ‎determine the profile of Aluminum phosphide poisoning and to assess the factors related ‎to mortality.‎This is a retrospective study of patients admitted to intensive care unit between 2006 and ‎‎2018. The inclusion criteria were based on anamnestic and clinical data of poisoning by ‎Aluminum phosphide.‎Thirteen cases of aluminum phosphide poisoning were identified. There were 7 women ‎and 6 men. The average age was 27 ± 11 years with extremes of 16 and 51 years. The ‎poisoning was accidental by inhalation for 9 patients and voluntary by ingestion as part of ‎a suicide attempt for 4 patients. The delay between intoxication and admission was, on ‎average, 5 ± 2 hours. The Glasgow coma score averaged 14 ± 1. Respiratory signs were ‎at the forefront of inhaling dyspnea and irritative cough, whereas each patient which ‎ingested the toxic were in a shock stage. Abdominal pain and vomiting were present for 8 ‎patients. Electrical abnormalities were present for 5 patients with conduction disturbances ‎‎(n = 3) and repolarization disorders (n = 2). The increase in troponin was observed with ‎the four patients who ingested the toxic.‎ Mechanical ventilation was necessary in 5 cases and the use of vasoactive amines for 4 ‎patients. The use of extra-renal cleansing and ECMO were performed for one patient. ‎Four patients died (30%); the highest mortality was observed after ingestion of Aluminum ‎phosphide (75%). The factors which were significantly related to mortality in univariate ‎analysis, were: oral poisoning (p<0,001), cardiogenic shock (p<0,001), elevation of ‎troponin (p=0,001), and use of ventilatory support (p<0,004).‎ Acute aluminum phosphide poisoning remains grafted with heavy mortality, especially in ‎developing countries. In the absence of antidotal treatment, rapid hemodynamic ‎management may help improve the prognosis, including the use of circulatory assistance.‎
  • Poisoning-associated rhabdomyolysis: Risk factors for acute kidney injury and prognosis
    Orateur(s) :
    • Bruno Megarbane (Paris / FRANCE)
    • Pierre François Rogliano (Paris / FRANCE)
    • Jean-Louis Laplanche (Paris / FRANCE)
    • Isabelle Malissin (Paris / FRANCE)
    • Sébastian Voicu (Paris / FRANCE)
    • Nicolas Deye (Paris / FRANCE)
    • Laurence Labat (Paris / FRANCE)
    14h38 / 14h45
    Abstract : Acute kidney injury (AKI) is the major complication after rhabdomyolysis. The risk factors in case of poisoning-related rhabdomyolysis are unknown. Our objectives were 1)- to describe the toxicants involved in the poisoning-associated rhabdomyolysis and the resulting complications; and 2)- to identify the predictive factors of AKI in this setting. We conducted a monocentre retrospective observational cohort study including all poisoned patients admitted in the intensive care unit (ICU) from 01/01/2012 to 30/06/2018 and presentencing rhabdomyolysis defined by elevated phosphocreatinine kinasee (CPK) >1000 IU/L. AKI was defined using the KDIGO criteria. Factors associated to AKI onset were identified using a multivariate analysis based on a step-by-step logistic regression and their characteristics determined using the Receiver operating characteristic (ROC) curves. Two hundred and thirty-seven patients (138 males/99 females; age: 43±15 years) were included. The main involved toxicants were benzodiazepines (14%), antipsychotics (10%), opioids (9%) and serotonin reuptake inhibitors (8%). AKI occurred in 88 patients (37%), requiring hemodialysis in 43 patients (49% of them). The associated complications included sepsis (51%), cardiovascular failure (14%), cardiac arrest (3%), disseminated intravascular coagulation (2%) and compartment syndrome (1%). The overall mortality rate (13%) was higher in the presence of ARF (32% vs. 2%, p<0.001). Peak serum creatinine and peak serum CPK were significantly correlated (r²=0.3, p<0.0001; linear regression) Based on a multivariate analysis, the age (p<0.01), female gender (p<0.01), lithium intoxication (p<0.001), hypocalcemia (p<0.05), hyperphosphoremia (p<0.05), elevated serum lactate (p<0.01) and creatinine concentrations (p<0.0001) were the independent predictive of AKI on ICU admission. The area under the ROC curve of our predictive model was 0.951. Elevation in serum creatinine concentration >125 µmol/L has the best accuracy (area under the curve: 0.871), sensitivity (0.71) and specificity (0.92). We identified the predictive factors of AKI in the poisoned patient admitted to the ICU and presenting rhabdomyolysis. They may help improving the patient prognosis by intensifying the prevention in the selected patient subgroup at risk of AKI.
  • ACUTE POISONING IN TUNISIA: WHICH EPIDEMIOLOGICAL PROFILES IN 2017?‎
    Orateur(s) :
    • Mohamed Walid Mhajba (Tunis / TUNISIE)
    • Hela Maamouri (Tunis / TUNISIE)
    • Hind Allouche (Tunis / TUNISIE)
    • Nozha Brahmi (Tunis / TUNISIE)
    14h45 / 14h52
    Abstract : Acute poisoning is a real public health problem. Its epidemiological profile varies by ‎region and by time. The objective of this study was to study the epidemiological-clinical, ‎evolutionary and therapeutic profile of acute intoxications admitted to the CAMU ‎resuscitation department.‎This is a retrospective study conducted in the intensive care unit between January 1st and ‎December 31st, 2017 and includes cases of acute intoxication hospitalized in intensive ‎care.‎Seven hundred and sixty-two patients were included in this study with an average age of ‎‎31 ± 14 years. There was a clear female predominance with a sex ratio of 0.47. Two ‎hundred and forty-three addicts (32%) had a psychiatric history and 137 (18%) already ‎had a history of attempted suicide. The average time to treatment was 4 +or- 2 hours. Four ‎hundred and seventy-one patients (62%) were admitted through CAMU emergencies. ‎Intoxication was voluntary in 85% of the cases and secondary oral ingestion in 91% of ‎them.‎ Toxicology analysis showed that drugs ranked first (n = 486; 64%), pesticides second (n ‎‎= 179; 23.5%) and carbon monoxide third (n = 56; 7%).‎ For drugs: psychotropic drugs, anticonvulsants, cardiotropics, antidiabetics and ‎paracetamol were the most common causes of drug poisoning with a frequency of ‎respectively 58%, 22%, 21%, 14% and 11%. Whereas for pesticides, rodenticides were ‎predominant (n = 140, 78%) followed by chloralose (n = 137) and organophosphorus (n ‎‎= 29, 16%). Illegal drugs were criminalized in 15 patients (2%).‎ The predominant toxidrome were respectively anticholinergic (18%) serotoninergic (7%) ‎and cholinergic (6%) toxidrome.‎ Lactic acidosis was the most common biological abnormality (9%) followed by biological ‎inflammatory syndrome (7%) and rhabdomyolysis (7%). Mechanical ventilation was ‎required in 290 cases (38%) with the use of vasoactive amines in 7% of the cases. An ‎antidote was prescribed in 190 cases (25%) and a transit accelerator in 32 patients (4%). ‎The evolution was beneficial for 752 patients (98.4%).‎ The general epidemiological profile in 2017 has shown that psychotropic drugs still ‎predominate with a marked increase in the frequency of cardiotropic and antidiabetic ‎poisoning. In contrast, for pesticides, there is a clear decrease in the number of poisoning ‎by organophosphorus in favor of chloralose.‎
  • STATE OF PLAY ON PESTICIDE INTOXICATION IN TUNISIA.‎
    Orateur(s) :
    • Mohamed Walid Mhajba (Tunis / TUNISIE)
    • Hela Maamouri (Tunis / TUNISIE)
    • Aziz Ben Slimen (Tunis / TUNISIE)
    • Nozha Brahmi (Tunis / TUNISIE)
    14h52 / 14h59
    Abstract : Pesticide poisoning has experienced some stability over the years, especially in developing ‎countries. Our objective is to determine the epidemiological, therapeutic and prognostic ‎profile of the most widespread pesticide poisoning in Tunisia for the year of 2017.‎This was a descriptive retrospective study of all cases of acute intoxication by pesticides ‎admitted to ICU resuscitation care in 2017.‎One hundred seventy-nine cases of pesticide intoxication were admitted during the study ‎period which represents 23.5% of all acute intoxication cases admitted to intensive care.‎ The average age of the addicts was 30 ± 13 years with a sex ratio of 0.47. The poisoning ‎were occurring at home in 138 of the cases (77%) or in a public space in 41 of them ‎‎(23%). The poisoning were voluntary in 174 of the cases (97%) and accidental in 5 of ‎them. Patients came directly from emergencies in 40% of the cases and were transferred ‎from other hospitals in 60% of the cases.‎ Rodenticides were the most implicated type of pesticide (n = 140; 79%) with chloralose ‎as leader (n = 137, 76%) followed by organophosphorus (n = 29; 16%) and carbamates ‎‎(n = 8; 4%). Neurological signs of tremor and loss of consciousness were predominant (n ‎‎= 144; 80%) followed by tachycardia (n = 45; 25%) and digestive signs (n = 27; 15%). ‎Respiratory distress was present in 11 patients (6%) and hemodynamic failure in three. ‎Inhalation pneumonia complicated poisoning in 51 cases. The use of mechanical ‎ventilation was necessary in 80% of the cases, the use of vasoactive drugs in 5.6% and ‎the use of antibiotic therapy in 28.5%. Gastric lavage was performed in 9 patients (5%). ‎Atropine was administered in 30 patients (16%). The median length of stay was 2.5 days ‎and the overall mortality was 1.1% (n = 2).‎ Pesticide poisoning is a reality in Tunisia. They are characterized by the variability of the ‎toxic substances available in our country with neurological signs in the foreground. This ‎can be at the origin of major and fatal complications if they are not taken care of in due ‎time and in the appropriate place.‎
E-Poster
14h10 - 15h10
Espace Poster 10
Médecin : Pédiatrie 1
Modérateur(s) : Renaud Blondé (Mayotte / FRANCE), Maryline Chomton (Paris / FRANCE)
  • Survey on the availability of physiological markers that may guide red blood cell transfusion in critically ill children, on behalf of the Paediatric Intensive Care Society Study Group
    Orateur(s) :
    • Camille Jutras (Montreal / CANADA)
    • Geneviève Du Pont-Thibodeau (Montreal / CANADA)
    • Marisa Tucci (Montreal / CANADA)
    • Simon Stanworth (Oxford / ROYAUME UNI)
    • Samiran Ray (Londres / ROYAUME UNI)
    • Patricia Fontela (Montreal / CANADA)
    • Helen Trottier (Montreal / CANADA)
    • Stacey Valentine (North Worcester / ETATS-UNIS)
    • Scot Bateman (North Worcester / ETATS-UNIS)
    • Jacques Lacroix (Montreal / CANADA)
    14h10 / 14h17
    Abstract : There is uncertainty regarding the best measure of the need for red blood cell (RBC) transfusions. Many “physiologic markers” are advocated to support this assessment, in addition to the common standard of haemoglobin level in critically ill children. This survey aims to describe which physiologic markers are measured and available in British and Canadian paediatric intensive care units (PICU). A pre-piloted self-administered questionnaire was electronically sent out thrice, using Survey Monkey, from November 2017 to February 2018, to the director of 16 Canadian and 27 British PICUs. The list of 17 physiologic markers included in the survey was developed by a group of 42 experts who participated in the “Transfusion and anemia expertise initiative” (Pediatr Crit Care Med 2018 Sept;19(9S Suppl 1)). Respondents were asked to indicate if the markers listed were available in their PICU. Replies were received from 12 Canadian and 25 British PICUs (37/43 = 86%); three declined the invitation because only premature infants and newborns were admitted into their unit. Results are presented in Table 1.Many physiologic measurements advocated by paediatric intensivists to support RBC transfusion decision are not routinely available at the bedside. Studies to explore the role of physiologic markers to better define the need for RBC transfusion, in addition to haemoglobin concentration, should include the following more commonly available parameters: pulse oximetry, oxygenation index, oxygenation saturation index, blood lactate and troponin level.
  • The socioprofessional impact on parents after the admission of their child in pediatric intensive care
    Orateur(s) :
    • Nabil Tabet Aoul (Oran / ALGÉRIE)
    • Ali Douah (Oran / ALGÉRIE)
    • Zakaria Zohir Addou (Oran / ALGÉRIE)
    • Houari Youbi (Oran / ALGÉRIE)
    • Mohamed Moussati (Oran / ALGÉRIE)
    • Kamel Belhabich (Oran / ALGÉRIE)
    • Amel Zerhouni (Oran / ALGÉRIE)
    • Sanae Abada (Oran / ALGÉRIE)
    • Souad Mir (Oran / ALGÉRIE)
    • Nabil Aouffen (Oran / ALGÉRIE)
    14h17 / 14h24
    Abstract : Resuscitation services receive children with one or more acute short-term life-threatening failures Our goal is to focus on the experience of families and the socio-professional consequences that admitted a child in intensive care unit Descriptive retrospective study over a period of 03 months from April 2017 to June 2017, in the pediatric resuscitation unit of the pediatric EHS Pr Boukhrofa AEK including children aged under 15 years for management of vital distress.We have 78 children, the average age is 4.5 years (1 to 15 years), the sex ratio is 0.46. 25% of parents have a low intellectual level and 15% a very average socio-economic level. 12% of parents are separated. Admission is in 66% during the night accompanied by the whole family in 77% of the cases. 38% of children have a medical history. The main reasons for admission to resuscitation are respiratory distress in 26%, septic shock 20%, neurological in 14% and traumatic 13%. Of the socio-professional consequences on parents, 62% admit having abandoned the family and 75% of disturbances in the work Brutal and painful hospitalization of children in pediatric intensive care is an extremely painful experience for parents with social and professional consequences.
  • Pediatric mortality and morbidity at the Intensive Care Unit (ICU) of the Centre Hospitalier Universitaire de Libreville: a retrospective study over 4 years.
    Orateur(s) :
    • Laurence Essola-Rerambiah (Libreville / GABON)
    14h24 / 14h31
    Abstract : severe medical affections or major surgical interventions in children may necessitate admission in the pediatric intensive care unit. The aim of this work was to evaluate the pediatric mortality and morbidity in the Intensive Care Unit.This was a retrospective, descriptive and analytical study done over 4 years, from January 2012 to December 2015. Included were children from one month to 16 years who were hospitalized for 24 hours or more. Studied variables included social and demographic data, clinical, paraclinical, and prognostic data.during the studied period, 229 children were admitted to the ICU, that is 16.1% of admissions. 218 children (15.4%) fitted our criteria for inclusion. Female population presented 52.1% of total. Mean age of patients was 90.6 ± 68.1 months.13 patients (5.9%) were homozygotes SS and had multiple transfusions. Motives for admission included altered consciousness with fever or without and severe respiratory distress in 25.6% and post-operative care (23.7%). Main pathologies recorded were severe malaria (10.1%), bronchopneumopathies (7.8%) and meningitis and meningo-encephalitis (7.8%). Severe maternal pathologies represented 10.6% of admissions. The mean duration of hospitalization was 5.2 days with extremes of 1 and 46 days. Mortality was 27.5%. Factors for bad prognosis were mechanical ventilation (p=0.00), meningitis and meningo-encephalitis.The infectious pathologies form the main causes of admission of pediatric patients to the ICU. The knowledge of the main causes of referral and of deaths should allow us a better orientation of preventive strategies and a better management of our patients in our ICU.
  • Impact of early drainage of primary spontaneus pneumothorax (PSP) in Young adults
    Orateur(s) :
    • Myriam Jugie (Paris / FRANCE)
    • Olivier Bustarret (Paris / FRANCE)
    • Guillaume Geslain (Paris / FRANCE)
    • Julien Grassias (Paris / FRANCE)
    • Maxime Eloi (Paris / FRANCE)
    • Nadege Salvi (Paris / FRANCE)
    • Gilles Orliaguet (Paris / FRANCE)
    14h31 / 14h38
    Abstract : The primary spontaneous pneumothorax (PSP) Is an idiopathic pneumothorax without pulmonary pathology. The PSP ´s impact Is rare : 2.68 in 1997 and 3.41 for 10 000 children in 2006 in United States of America. There is no international consensus for the treatment of PSP. The aim of our study was to retrospectively analyzed The initial treatment of this PSP in Young adults. Between 2010 and 2017 , all the children with a PSP who came from home to our hospital in emergency were eligible. Âge, sex, kind of pneumothorax, needle ponction, thoracic CT scan realization, Time limit between PSP diagnosis and thoracic drainage, type of drain used, duration of drainage according to The type of drain and eventual recurrences were studied. Fifteen children âged from 9.5 to 15 years ( median 14 years) boys mostly (93%) had had a PSP du ring this period. Among The 15 children , 13 needed a thoracic drain, 2 were simply observed. All The 4 patients who had a complete PSP and had a needle exsufflation needed a thoracic drain. Among The 15 children , 6 had emphysema bubbles on the Thoracic CT scan. ( 40%). The Time limit between PSP diagnosis and the drainage was between 1 and 7 days. ( CI 95% 0-7) . The duration of drainage according to The type of drain was 4.1 days for a Furhman's drain and 9.4 days for a Monod's drain. Among The 5 PSP treated with a Monod's drain, there was 4 recurrences. Among The 8 other PSP drained with a furhman's system, there was 4 recurrences. Our study shown clearly that exsufflation of large PSP in pediatric intensive care without vital Life issue Is useless and delayed The treatment. Thoracic CT scan in a large PSP or after recurrency Is strongly recommended because of emphysema bubbles diagnosis . Furhman's drain Is mainly used in intensiv care instead of Monod's drain mostly used by the surgeons. We must now confirm all this by a prospective study with other national or international pediatric intensive care center.
  • Monitoring of Procalcitonin plasma levels evolution could be useful for safely shortening duration of antibiotic treatment in pediatric ventilator-associated pneumonia
    Orateur(s) :
    • Olivier Lintz (Strasbourg / FRANCE)
    14h38 / 14h45
    Abstract : Ventilator associated pneumonia (VAP) is a common infection in Pediatric Intensive Care Units (PICUs) and is associated with significant morbidity and mortality. Previous studies suggest that Procalcitonin (PCT) follow-up in VAP may be helpful for reducing duration of antibiotic therapy in adults intensive care patients in order to lower the risk for selection of antibiotic (ATB)-resistant bacteria. Our main objective was to study the impact of monitoring the PCT plasma levels at day 0 (D0) and day 3 (D3) on the duration of antibiotic treatment in cases of VAP in the Strasbourg University Hospital PICU (France). We prospectively (2016-2018) included hospitalized patients in our unit that developped VAP ccording to the 2005 and 2016 Infectious Diseases Society of Amarica / American Thoracic Society guidelines. Duration of PCT-guided antibiotic treatment was compared to retrospectively collected data in patients treated for VAP between 2014 and 2016. Five patients were included prospectively with a mean duration of ATB of 4.8 days [3-8], compared with 8.7 days [4-15] in the control group (n = 10). The différence was found to be statistically significant (p=0,002). There was no treatment failure or death attributable to VAP in both groups. These results tend to show that the PCT follow-up between D0 and D3 of VAP diagnosis could favor short-term antibiotic duration in PICUs.
  • Use of biomarkers to improve the diagnostic accuracy of concomitant bacterial infections in critically ill infants with viral bronchiolitis : a pilot study
    Orateur(s) :
    • Patricia Fontela (Montreal / CANADA)
    • Patricia Papenburg (Montreal / CANADA)
    • Guillaume Emeriaud (Montreal / CANADA)
    14h45 / 14h52
    Abstract : Bronchiolitis is the most common lower respiratory tract infection in children <12 months of age, with 2-12% of patients requiring admission to a pediatric intensive care unit (PICU). Despite its predominantly viral etiology, the use of antimicrobials in PICUs for bronchiolitis is widespread. This pilot prospective cohort study aims to compare the levels of infection markers in critically ill infants with bronchiolitis with and without concomitant bacterial pneumonia.This is a pilot prospective cohort study including 37 patients <2 years old diagnosed with a first episode of viral bronchiolitis and admitted to 3 Canadian PICUs between November 1st 2017 and April 30th 2018. We collected data on patient demographics, severity scores , diagnostic criteria for viral bronchiolitis and concomitant bacterial infections, and bacterial culture results. We gathered data on the following infection biomarkers during the first day of PICU admission: temperature, procalcitonin, CRP, and white blood cell count (WBC). We analyzed our preliminary results using descriptive statistics.Our preliminary results include the analysis of data collected for 37 patients. Participants mean age was 1.5±2.3 months. Fifteen (40%) patients were positive for respiratory syncytial virus. Three (8.1%) patients had bacterial pneumonias confirmed by culture results; no other bacterial infections were observed. Twenty (57%) patients received antimicrobials (mean duration 1.9±2.9 days). Regarding infection biomarkers on study day 1, 8 (12%) patients presented fever and 1 (0.3%) hypothermia; the mean levels for procalcitonin and CRP were 1.0±1.7 ng/mL and 32±39 mg/L, respectively; mean WBC was 9.4±3.6 109 cells/L. The mean levels of procalcitonin (1.25 ng/mL vs. 1.37 ng/mL) and WBC (9.52 109 cells/L vs. 8.4 109 cells/L) were similar between patients with bronchiolitis and patients with bronchiolitis and concomitant bacterial pneumonia. The mean level of CRP was higher in patients with with bronchiolitis and concomitant bacterial pneumonia (34.12 mg/L vs. 81.70 mg/L).CRP may be a suitable biomarker for the diagnosis of concomitant bacterial pneumonia in critically ill infants with bronchiolitis
  • Population pharmacokinetics of meropenem in critically ill children with different renal function
    Orateur(s) :
    • Mélanie Rapp (Paris / FRANCE)
    • Saïk Urien (Paris / FRANCE)
    • Sihem Benaboud (Paris / FRANCE)
    • Emmanuelle Bille (Paris / FRANCE)
    • Naïm Bouazza (Paris / FRANCE)
    • Déborah Hirt (Paris / FRANCE)
    • Inès Gana (Paris / FRANCE)
    • Yi Zheng (Paris / FRANCE)
    • Fabrice Lesage (Paris / FRANCE)
    • Agathe Béranger (Paris / FRANCE)
    • Sylvain Renolleau (Paris / FRANCE)
    • Jean-Marc Treluyer (Paris / FRANCE)
    • Medhi Oualha (Paris / FRANCE)
    14h52 / 14h59
    Abstract : Usual dosing regimens of meropenem could lead to the suboptimal exposure since the pharmacokinetic (PK) between subject variability (BSV) is particularly high in critically ill children with sepsis. We aimed to develop a population PK model then simulate dosing regimens to optimize patient exposure. This prospective study was conducted in a bed pediatric intensive care unit (PICU) center at the Necker Hospital. All children aged < 18 years and weighing > 3.5 Kg were enrolled. Meropenem plasma concentration was quantified by high performance liquid chromatography. Meropenem PK model was developed using non linear mixed-effect modeling software (MONOLIX version 2018R1). Estimated glomerular filtration rate (eGFR) was estimated by the Schwartz formula.Forty patients (median age of 16.8 months (1.4-187.2), median weight of 9.1 kg (3.8-59) and median eGFR of 151 mL/min/1.73m2 (19-440)) were included. Eleven patients (27 %) received continuous replacement renal therapy (CRRT). Data were best described with a two compartment and first order elimination model. Bodyweight (BW) with the allometric relationship, eGFR and CRRT were significant covariates explaining the BSV on clearance (CL), inter compartment clearance (Q) and central/peripheral volume of distribution (V1/V2): V1i= V1pop x (BW/70)1, Qi = Qpopx (BW/70)0.75, V2i = V2pop x(BW/70)1 , CLi= (CLpop x (BW/70)0.75) x (eGFR/151)0.355) and for patients with CRRT; CLi = (CLpop x (BW/70)0.75) x 0.8; were population CL, V1, Q, and V2 are: 7.93 L.h-1, 37.9 L, 1 L.h-1 and 9.66 L. Monte Carlo simulations were performed to provide the highest probability of reaching the target of 50 % fT > MIC and 100 % fT > MIC depending on renal function. Continuous infusion (both 60 and 120 mg/kg per day) seemed to be the best dosing regimen for high MIC value (> 4 mg/L) without risk of accumulation except in children with severe renal failure without CRRT. Usual dosing regimens (20 mg/kg/8h over 20 min) are adequate for only patients with a severe renal failure regardless of the MIC value. Continuous infusion allows to reach the targets of fT > MIC (for bacteria with a high MIC value) with safety for children with normal or augmented renal clearance and who received CRRT. Usual dosing regimens should be kept for children with severe renal failure regardless of MIC value.
  • Development of a French-Speaking Pediatric Intensive Care Unit Registry: PICURe
    Orateur(s) :
    • Stéphane Leteurtre (Lille / FRANCE)
    • Aurélie Aldebert (Lille / FRANCE)
    • Jean-Benoît Baudelet (Lille / FRANCE)
    • Francis Leclerc (Lille / FRANCE)
    • Jean-Marie Renard (Lille / FRANCE)
    • Stéphane Dauger (Paris / FRANCE)
    • François Dubos (Lille / FRANCE)
    • Morgan Recher (Lille / FRANCE)
    • Hervé Hubert (Lille / FRANCE)
    • Gfrup (Lille / FRANCE)
    14h59 / 15h06
    Abstract : Medical databases and patient registries have expanded considerably, particularly in pediatric critical care medicine (PICANet –UK-, ANZPIC Registry Australia and VPS –USA-). Such a registry is not yet available in French-Speaking countries. The aim of this study was to develop a French-speaking Registry for Pediatric and Pediatric&Neonatal PICU/P&NICUs in France 1/ to determine structure, personnel and outcome 2/ to propose an actualized common email directory. The 34 potential French Pediatric and Pediatric/Neonatal ICU identified by the GFRUP were solicited. Previously, the necessary variables that ought to be included in a French pediatric critical care registry were identified (Recher, J Eval Clin Pract 2018). Collected variables: hospital and service characteristics (Pediatric, neonatal, Middle Care unit –MCU-, ICU activity characteristic, number of beds, personnel (medical, paramedical -nurse-, number and full-time equivalent –FTE-), patients (number of patients in 2017 and outcome -survivors/non survivors-). A secured web site was created. Each head of PICU P&NICU can complete the online data in a secured common email directory.29 French PICU or P/NPICU were included (incomplete data:n=3). 14 PICU and 15 N&PICU were identified with 23 MCU associated. Pediatric Number of bed varied from 2 to 16 (total pediatric beds = 235 in 29 PCIU or N&PICU) and Neonatal number of beds varied from 8 to 18 (total neonatal beds=154 in 15 N&PICU). In PICU or N&PICU, median nurse ratio “FTE /number of beds” was 2.7 (range:2.02-3.91). In 2017, 11481 pediatric patients were admitted in 26 PICU or N&PICU (mean 393, range : 51-841) with non survivors patients (n=513, range:3-50) ie mean mortality rate of 4.5% (range: 1.3 – 11.2). In 2017, 3146 neonates were admitted in 12 N&PICU (mean 262, range: 136-458) with non survivors neonates (n=260, range:3-38) ie mean mortality rate of 8.7% (range: 1.4 – 16). ). Mail directory was completed by 240 physicians (n=26PICU/N&PICU).In 2018, the development of a French-speaking Pediatric Intensive Care Unit Registry named PICURe provide 1/a large description of almost French PICUs and N&PICUs, in term of structure and mortality 2/a updated and secure mail directory. The next stage will be the implementation of the collection of the patients' data.
E-Poster
14h10 - 15h10
Espace poster 2
Médecin : Bactérie multi résistante - Hygiène
Modérateur(s) : François Barbier (Orléans / FRANCE), Saad Nseir (Lille / FRANCE)
  • A positive Multi-drug resistant bacteria at admission as a predictive factor of mortality in critically ill patients
    Orateur(s) :
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Ines Fathalah (Ben Arous / TUNISIE)
    • Ghada Sboui (Ben Arous / TUNISIE)
    • Sahar Hbacha (Ben Arous / TUNISIE)
    • Ameni Sgahier (Ben Arous / TUNISIE)
    • Asma Mahdi (Ben Arous / TUNISIE)
    • Emna Nouri (Ben Arous / TUNISIE)
    • Haifa Fazeni (Ben Arous / TUNISIE)
    • Nadia Kouraichi (Ben Arous / TUNISIE)
    14h10 / 14h17
    Abstract : The pandemic spread of multidrug-resistant bacteria (MDRB) pose a threat to healthcare Worldwide especially in intensive care unit (ICU). The aim of our study was to investigate the relation between a positive MDRB at admission with infection as well as prognosis among patients admitted in medical ICU.We conducted a retrospective cohort study included 224 patients admitted to the medical intensive care unit of YASMINET hospital between 1 th september 2016 and 15 th september 2018. We collected the demographic characteristics of patients (Sex,age, IGSII, SOFA, comorbidities…) and the characteristics of infection (number of episods, site, germs, screening MDRB at admission), we also analyzed the length of stay and mortality rate.We enrolled 224 critically ill patients. The mean age of our population was 55,1±20,54 years. The sex ratio was M/F=1.8. The mean IGSII and SOFA scores were respectively: 13±9,23 and 5±4,07. Seventy-three patients (33%) required machanical ventilation. The average of duration of mechanical ventilation was 7, 78±14, 81 days. The screening of MDRB at admission was done in 87,1% (195 cases). Fourty-four patients (19, 6%) had positive MDRB at admission. After univariate analysis, a positive MDRB at admission was significantly associated with: a frequent incidence of infection (30/44cases), a prolonged length of stay (29±23,75 days versus 9,4±10 days) and a higher rate of mortality (18/46 cases) with respectively p<10-3, p<10-3and p=0,002. With multivariate analysis, only prolonged length of stay was significantly associated with positive MDRB at admission.Our data concluded that, a positive MDRB at admission can be a predictor factor of infection, length of stay and mortality in critically ill patients.
  • Establishment of monitoring of colonization by BGN carbapenemases in burn victims in Tunisia
    Orateur(s) :
    • Lamia Thabet (Tunis / TUNISIE)
    • Yosra Bourbiaa (Tunis / TUNISIE)
    • Beya Maamer (Tunis / TUNISIE)
    • Khalil Jmal (Tunis / TUNISIE)
    • Imen Rahmani (Tunis / TUNISIE)
    • Amen Allah Messadi (Tunis / TUNISIE)
    14h17 / 14h24
    Abstract : Burn patients are at risk for multi-drug resistant (MDR) infections, burdened with a high mortality rate. The aim of this work was to establish the follow-up of digestive colonization by carbapenemase-producing Gram negative bacilli (BGN-PC) in patients admitted to the Burn intensive care unit.Our study was conducted over a period of 18 months (02/2017 - 07/18). It focused on rectal samples taken from burns in search of BGN-PC. GeneXpert multiplex real-time PCR (Cepheid) was performed directly on the rectal swabs by Cepheid's Gene Xpert Carba-R allowing detection of the 5 most prevalent carbapenemase gene families: blaVIM, blaNDM, blaIMP, blaOXA-48 and blaKPC.During the study period, 150 patients underwent rectal swab carbapenemase screening on admission. 95 PCRs (63.3% of the cases) were positive. Among the patients who had a positive PCR on admission, 114 were transferred from another hospital (76%), mainly hospitals in the south of the country. The study of the molecular profile of isolated carbapenemases showed the predominance of a positive result for 3 blaVIM + blaNDM + blaOxa48 genes in 41 cases (ie 43.2%), 12 cases were positive for the blaNDM gene (12.6%), 11 cases were positive for the blaVIM gene (11.6%), 9 cases with both blaVIM + blaNDM genes (9.5%), 9 blaOxa48 gene-positive cases (9.5%), 7 blaVIM + blaoxa48 genes (7.4%), and 5 blaNDM genes + blaoxa48. Parallel BMR research using conventional bacteriology confirmed the presence of carbapenem-resistant BGNs in PCR-positive specimens.63.3% of the patients explored are carriers of carbapenemases. 76% of these patients were transferred from another hospital in Tunisia. This highlights, on one hand, the need of an isolation policy during the care of transferred patients and, on the other hand, the need to set up a control strategy for the spread of these MDRs.
  • Screening of multi-drug resistant bacteria among critically ill patients : two sites versus five sites
    Orateur(s) :
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Ines Fathalah (Ben Arous / TUNISIE)
    • Ghada Sboui (Ben Arous / TUNISIE)
    • Sahar Hbacha (Ben Arous / TUNISIE)
    • Ameni Sgahier (Ben Arous / TUNISIE)
    • Asma Mahdi (Ben Arous / TUNISIE)
    • Haifa Fazeni (Ben Arous / TUNISIE)
    • Nadia Kouraichi (Ben Arous / TUNISIE)
    14h24 / 14h31
    Abstract : Use, overuse and misuse of antibiotics led to emergence of multidrug-resistant bacteria (MDRB) witch is a real problem of public health. To fight against this real scourge, screening is the best tool. We conducted a study to evaluate the efficency of two MDRB screening ways.Our study was retrospective, it included 224 patients admitted in a medical intensive care unit (ICU) during the periode between 1 th September 2016 and 15 th September 2018. We collected patients demographic characteristics (Sex, age, IGSII, SOFA, comorbidities…) and infection characteristics ( episods, site, germs…). We used two ways of MDRB screening : taking samples from two sites (nasal and rectal) ( Janury 2018 – September 2018) versus five sites (nasal, buccal, axillary, inguinal and rectal) (October 2016- December 2017).We enrolled 224 critically ill patients. The average age was 55,1± 20,54 years. The sex ratio was of 1.8. The median IGSII and SOFA scores were respectively 35 [23 ; 49] and 4 [2 ; 7]. Seventy-three patients (33%) required mechanical ventilation. Its median duration was of one [1 ;9] day. The 2 sites method of screening MDRB was realised in 36,2% (81 cases) while the 5 sites method was practiced in 53,1% (119 cases). Ninety-five episods of infection were detected. The most frequent sites of infection were : pulmonary (13,8%), vascular (12,6) and urinary (11%). Multivariate study reaveled that the two sites method led to adapted antibiotherapy in 68% of cases versus only 36 % in the five sites method (p =0.008).We concluded that two sites MDRB screening method was efficient to detect nosocomial infections and to adapt emperic antibiotherapy. It helped to reduce management costs.
  • The « threatening » water: a potential source for an outbreak of Stenotrophomonas maltophilia in a French intensive care unit.
    Orateur(s) :
    • Flora Delamaire (Rennes / FRANCE)
    • Antoine Caubel (Lorient / FRANCE)
    • Nathalie Prades (Lorient / FRANCE)
    • Liliane Grolier-Bois (Lorient / FRANCE)
    • Pierre-Yves Donnio (Rennes / FRANCE)
    14h31 / 14h38
    Abstract : Stenotrophomonas maltophilia (SM), a non-fermenting gram-negative bacterium (NF-GNB), causes serious opportunistic infections and represents a major threat on intensive care unit (ICU) due to its multidrug resistance (MDR). An outbreak of SM occurred between September 2016 and January 2017 in the ICU of a general hospital. An outbreak control team was convened to investigate, at the same time as an epidemiological survey was conducted and corrective measures were initiated.The outbreak was investigated by a combination of clinical and environmental samplings and molecular typing using pulse-field gel electrophoresis (PFGE). All patients infected or colonized with SM during this period were included and clinical data were analyzed.Sixteen patients contaminated with SM were included. Among them, 13 had pulmonary contaminations and one bacteraemia. Two deaths probably related to SM infections were reported. Admission screening showed that the outbreak strains were acquired on ICU. The median time to SM contamination was 19.5 days (range: 2-43 days). Thirteen patients (81.2%) were intubated, with a median length of 29 days of intubation (range: 2-120 days). All patients received multi-antibiotic treatments including broad-spectrum antibiotics [Table]. SM clinical strains genotyping found the same SM genotype for only 3 patients. Environmental sampling revealed contamination of almost all sinks in the ICU: 24 of the 28 sinks in the ICU were contaminated with SM (85.7%), including 15 sinks among the 16 patient rooms (93.7%). Further environmental screening showed an early recontamination after siphons and plugholes had been replaced. Infection control measures, including the eviction of tap water for patients' cares and a strengthening of preventive hygiene measures, made it possible to control the outbreak by January 2017.PFGE results suggest that this outbreak was not related to a unique clone of SM but to a polyclonal colonization of the ICU water system. SM causes severe infections in debilitated patients and is a source of inappropriate antibiotherapy. Should an anti-SM antibiotic be integrated in the probabilistic antibiotherapy within an ICU contaminated with SM?This outbreak report highlights the risk from MDR gram-negative bacterium contaminated water system for ICU patients. Although the complete eviction of the environmental pathogen was impossible, a discontinuation of the outbreak was obtained with infection control procedures, pedagogy and reasoned evictions.
  • Usefulness of repeating routine screening of faecal carriage of multi-drug resistant bacteria in ICU patients
    Orateur(s) :
    • Ahmed El Kalioubie (Lille / FRANCE)
    • Aurelien Donze (Lille / FRANCE)
    • Ludivine Wozniak (Lille / FRANCE)
    • Frédéric Wallet (Lille / FRANCE)
    • Saad Nseir (Lille / FRANCE)
    14h38 / 14h45
    Abstract : To reduce the incidence of ICU infections with extended-spectrum beta-lactamase-producing (ESBL) and extensively drug resistant (XDR) bacteria, a routine screening for faecal carriage is recommended for all patients and specific contact precautions are applied in colonized patients. The aim of this study is to assess the usefulness of repeating routine screening of these bacteria in ICU patients. Retrospectively, we studied all patients admitted to our 5 mixed 10-beds ICU units, between January 2014 and December 2016. Systematically, screening was done by anal swab at admission and weekly thereafter, targeting ESBL Enterobacteriaceae and XDR bacteria: Carbapenemase-producing Enterobacteriaceae and Carbapenem-resistant Acinetobacter Baumanii/Pseudomonas Aeruginosa. The incidence was assessed and compared over the 3 study years (trend chi2 test). Among the 3684 study patients, 971 (26,4%) were screened positive for multi-drug resistant bacteria (19,8/1000 ICU days). Incidence was 23% in 2014 (17,3/1000 ICU days), 28% in 2015 (20/1000 ICU days), and 28% in 2016 (22/1000 ICU days) (p=NS). This positive carriage was acquired in ICU for 540 patients (14,7%; 11/1000 ICU days): 158 patients in 2014 (13%; 9,7/1000 ICU days), 169 patients in 2015 (14,5%; 10,5/1000 ICU days), 213 patients in 2016 (16,4%; 13/1000 ICU days). Over the 3 study years, 61% of these patients were male with a mean age of 61(49;69). Table 1 describes the distribution of multi-drug resistant bacterial faecal carriage over the 3 study years. Acinetobacter baumannii was found as a lone entity in 13 patients, Pseudomonas aeruginosa in 23 patients. Among the 848 ESBL positive patients, further XDR carriage was diagnosed simultaneously in 46(1,2%) patients, and later in 37(1%) patients. Faecal carriage became positive within 2(1;3) weeks of ICU admission. None of the positive patients became bacteria-free in subsequent anal swabs analysis. After diagnosis of faecal carriage, we pursued weekly anal swabs with a median of 1(0;3) swabs and a total of 1907 swabs over the 3 study years. With an average 120 euros per anal swab analysis, this represents an additional cost of 228840 euros. Multidrug resistant bacterial faecal carriage is common in our ICU. Once diagnosed, further screening may not be pursued and contact precautions should only be applied. This would probably result in significant cost reductions, with no side effects.
  • Identification of fungi isolated from intensive care unit surfaces
    Orateur(s) :
    • Wahiba Imene Ghomari (Sidi-Bel-Abbes / ALGÉRIE)
    • Yassine Merad (Sidi-Bel-Abbes / ALGÉRIE)
    14h45 / 14h52
    Abstract : Nosocomial fungal infections could arise from exposure to spores or filamentous fungi existing in the hospital environment. The present study aimed to investigate the quality of surfaces in an intensive care unit, to ascertain their potential contribution to fungal infection rate in the hospital. During one morning (28/05/2017) punctual samples were taken from surfaces by moistened sterile swabs and were inoculated on Sabouraud dextrose and Malt extract agar. Qualitative evaluation of moulds was based on the microscopic view and morphological features of colonies; identification of yeasts was based on routine biochemical tests (Auxacolor-Bio-Rad). Out of 100 samples taken from surfaces, 24 were positive for fungal presence, divided into moulds (75%) and yeasts (25%), the identified strains belonged to 9 genera, most frequently to Aspergillus, Candida, Mucor, Cladosporium, Penicillium and Trichosporon, the most predominant fungi encountered is Aspergillusniger (25%).To achieve our professional service and provide a safe environment for patients, punctual fungal monitoring needs to be done consistently.
  • Identifying risk factors for multidrug resistance Gram-negative bacilli pneumonia in intensive care units
    Orateur(s) :
    • Wafa Ibn Saied (Paris / FRANCE)
    • Bertrand Souweine (Clermont-Ferrand / FRANCE)
    • Claire Dupuis (Paris / FRANCE)
    • Benoit Misset (Rouen / FRANCE)
    • Shidasp Siami (Paris / FRANCE)
    • Carole Schwebel (Grenoble / FRANCE)
    • Jean-Marie Forel (Marseille / FRANCE)
    • Stéphane Ruckly (Paris / FRANCE)
    • Michel Darmon (Saint-Etienne / FRANCE)
    14h52 / 14h59
    Abstract : Risk factors of multidrug resistant (MDR) gram negative VAP (GN VAP) are not fully known. In particular the ICU-resistance rate that increases this risk is not known and postulated to be 10 to 25% according to recent published guidelines. Objective: To investigate the risk factors of MDR in GN-VAPAdult patients admitted between January 1997 and February 2016 in 17 French ICUs contributing to the OUTCOMEREA prospective database were included. Diagnosis required positive culture of quantitative tracheal aspirate (>106 cfu/ml), plugged telescoping catheters (>103 cfu/ml) or bronchoalveolar lavage (>104 cfu/ml). The rate of MDR-GN / GN infections was calculated for each ICU and used as an ICU-variable. Patient-based variables included severity, procedure use, previous antimicrobial use (as % of days with use), and previous colonization with MDR. A generalized mixed model with binomial distribution was built to assess the risk factors of MDRGN-VAP. A total of 1,335 VAP episodes were studied including 935 GN-VAP episodes. Among them, 634(67.8%) MDR-GN organisms and 301 (32.2%) only susceptible GN organisms. Treatment was more frequently adequate within 24 h in susceptible GN-VAP (229(76%) vs 395 (62%), p<0.01). Risk factors of MDR-GN VAP are on Table. A rate of 15% or more of MDR-GN infections in the ICU was independently associated with MDR-GN-VAP.In this large cohort of GN-VAP patients, chronic respiratory diseases, previous colonization with MDR GNB and previous antimicrobial use were independent risk factor of MDR-GN-VAP. A rate of MDR GN infections of more than 15% in the ICU is also independently associated with this risk.
  • Fatal micro outbreak due to NDM-producing Klebsiella Pneumonia in a tertiary belgian ICU
    Orateur(s) :
    • David Grimaldi (Bruxelles / BELGIQUE)
    • Martin Vandeputte (Bruxelles / BELGIQUE)
    • Leda Nobile (Bruxelles / BELGIQUE)
    • Alexandre Brasseur (Bruxelles / BELGIQUE)
    • Delphine Martiny (Bruxelles / BELGIQUE)
    • Maya Hites (Bruxelles / BELGIQUE)
    • Baudouin Byl (Bruxelles / BELGIQUE)
    • Jacques Creteur (Bruxelles / BELGIQUE)
    • Frédérique Jacobs (Bruxelles / BELGIQUE)
    14h59 / 15h06
    Abstract : Carbapenemase-producing Enterobacteriaceae (CPE) represent a growing problem worldwide. These pathogens are resistant to most of available antibiotic, therefore challenging to treat. New Delhi metallo-β-lactamase (NDM) can hydrolyze penicillins, cephalosporins, and carbapenems1. First isolated from a patient travelling in India in 20082, it has now been described all around the world. In our intensive care unit (Erasme Hospital, Brussels, Belgium), an epidemic of 5 cases in 4months occured. The aim of this study is to describe characteristics and evolution of colonized/infected patientsWe screened all patients with colonization/infection with CPE-producing Klebsiella Pneumoniae (KP) within a range of 6 months around identification of the first case. We included the patients with confirmed NDM-KP (by genotyping). We described patient's profile, previous antibiotic use, infection type, treatment and outcomeFive patients had at least one sample positive with NDM-KP in our ICU between November 2017 and March 2018. Strains were susceptible to fosfomycin, some also to colistin and chloramphenicol. We didn't perform genotyping. Detailed features are listed in table 1. Patients were young (mean age: 55years), but suffered from severe medical conditions. 4 out of the 5 patients had stayed in the same ICU subunit. 4 out of the 5 patients presented an infection related to the NDM-KP. Median-time between colonization and infection was 9days (4-63). All patients had received previous broad-spectrum antibiotherapy. Infections were treated with rarely used antibiotics, highly toxic. We observed microbiological success in 3 patients, relapse in 2. The 4 infected patients died. Cause of death was untracktable infection in 3, comorbidities in 1. The colonized patient survived (mortality rate: 80%)NDM-producing Enterobacteriaceae is emerging in Europe.3 To our knowledge, our series is the first describing locally-acquired cases in Belgium. 4 It is worrying for few reasons. First, the colonization/infection ratio was high, attesting the high pathogenic power of these pathogens (and/or host frailty). Second, 100% of infected patients died, despite early targeted antimicrobial therapy. It is well known that genes encoding CPE are usually plasmid-transmitted. The fact that all patients had previous broad-spectrum antibiotic therapy supports this statement. However, the only species found was K.P, all the patients had been staying in the same unit and time proximity was clear. This pleads for a “contact” component of transmission. Hygiene rules, in addition to antibiotic stewardship, are therefore crucial.
  • Risk factors for central line–associated bloodstream infection in pediatric intensive care unit: a monocentric case-control retrospective study
    Orateur(s) :
    • Eric Thebault (Paris / FRANCE)
    • Catherine Doit (Paris / FRANCE)
    • Michael Levy (Paris / FRANCE)
    • Jérôme Naudin (Paris / FRANCE)
    • Géraldine Poncelet (Paris / FRANCE)
    • Camille Ducrocq (Paris / FRANCE)
    • Stéphane Bonacorsi (Paris / FRANCE)
    • Stéphane Dauger (Paris / FRANCE)
    15h06 / 15h10
    Abstract : Central line-associated bloodstream infections (CLABSI) remain a significant source of morbidity, cost, and mortality in pediatric intensive care unit (PICU). Pediatric international recommendations are extrapolation of adults'guidelines. We sought to determine risk factors (RF) for CLABSI, to describe CLABSI incidence, and to compare evolution of patients with and without central venous catheter (CVC) removal.Monocentric retrospective case-control study, matched by sex, age, and ICU admission date, in a tertiary 20-bed-PICU from the 01/01/2009 to the 31/12/2017. CLABSI were defined according to the CDC criteria, identified through a prospective data collection of positive hemoculture in the PICU. Premature and patients over 18-years-old on admission were excluded. Control subjects were patients with a CVC without any infection. A list of potential RF was developed by literature review. Comparisons of characteristics between case patients and control subjects were made using the Wilcoxon rank sum test, the Khi-2 test, or the Fisher exact test, as appropriate. Univariate and multivariate conditional logistic regression models were used to identify independent RF for CLABSI. Two-sided P values of less than .05 were considered to be significant.79 case patients were matched with 158 control subjects. Independent RF for CLASBI were: vein of insertion: jugular (OR=4.59, IC95%=[1.34 – 15.74], p=0.015), and subclavian (OR=4.97, IC95%=[1.15 – 21.43], p=0.031); congenital metabolic disease (OR=24.54, IC95%=[2.21 – 272.34], p=0.009); parenteral nutrition (OR=6.08, IC95%=[2.23 – 16.56], p=0.00041); blood transfusion (OR=3.30, IC95%=[1.58 – 6.86], p=0.0014); duration of CVC (OR=1.03, IC95%=[1.005 – 1.055], p=0.0188). CVC type, number of lumens, gastrostomy tube, rate of white cells, were not independent RF for CLABSI. 3 case patients went under a guidewire exchange catheterization, and none of the control subjects. The incidence of CLABSI was 4.04/1000 days of CVC [2.74 – 5.34]. 8 CLABSI were due to extended-spectrum ß-lactamase producing Enterobacteriaceae (10.1%), and 2 were due to methicillin-resistant Staphylococcus aureus (2.5%), all occurring in previously identified carriers.Insertion vein, congenital metabolic disorders, parenteral nutrition, blood transfusion, duration of ICU CVC, were independent RF for CLABSI. These results must be confirmed by a prospective multicenter study.
E-Poster
14h10 - 15h10
Espace poster 3
Médecin : Biomarqueurs
Modérateur(s) : Patrick Ray (Dijon / FRANCE), Fabio Taccone (Bruxelles / BELGIQUE)
  • Procalcitonin to reduce exposure to antibiotics during acute chest syndrome in sickle cell disease. PROSTA study
    Orateur(s) :
    • Keyvan Razazi (Créteil / FRANCE)
    • Ségolène Gendeau (CrÉteil / FRANCE)
    • Elise Cuquemelle (CrÉteil / FRANCE)
    • Mehdi Khellaf (CrÉteil / FRANCE)
    • Constance Guillaud (CrÉteil / FRANCE)
    • Bertrand Godeau (Créteil / FRANCE)
    • Giovanna Melica (CrÉteil / FRANCE)
    • Stéphane Moutereau (CrÉteil / FRANCE)
    • Camille Gomar (CrÉteil / FRANCE)
    • Slim Fourati (CrÉteil / FRANCE)
    • Nicolas de Prost (Créteil / FRANCE)
    • Christian Brun Buisson (CrÉteil / FRANCE)
    • Pablo Bartolucci (CrÉteil / FRANCE)
    • Anoosha Habibi (CrÉteil / FRANCE)
    14h10 / 14h17
    Abstract : Acute chest syndrome (ACS) is a major complication of sickle cell disease and the main cause for mortality in adult patients. Current guidelines recommend the use of antibiotics for the treatment of ACS, but bacterial infection is documented in only a minority of cases. The use of procalcitonin (PCT) may allow shortening the exposure to antibiotics during ACS. Prospective before-after study in a university hospital. Patients received antibiotics according to current French guidelines for ACS. During the control (before) period, clinicians were blinded to PCT concentrations. At the end of this period, these measurements were used to build an algorithm to fasten antibiotic cessation after three days of treatment if bacterial infection was not documented and serial PCT concentrations were <0.5 μg/L. During the intervention (after) period, the PCT algorithm was used, with the final decision to start or stop antibiotics at the discretion of the physician. The primary endpoint was the number of days alive without antibiotics at day-21. The control and intervention periods included 43 and 60 ACS episodes occurring in 41 and 59 patients, respectively. A total of 46 (45%) episodes required ICU admission. A microbiologically documented infection was found in only 7 (7%) episodes. The number of days alive without antibiotics at day-21 was longer during the intervention than the control period (15 [14-18] vs. 13 [13-14] days, p=0.001). More patients had a short (≤ 3 days) course of antibiotics during the intervention as compared to the control period: 18 (31%) vs 5 (12%), p<0.01. There was no infection relapse nor pulmonary reinfection. Hospital length of stay was not different between the two groups (control group: 7 [6-11] vs. intervention group: 8.0 [6.0-12.0] days, p=0.315)A PCT-guided strategy was able to shorten the duration of antibiotic therapy with no apparent adverse outcomes.
  • SVEGFR2: A New Triage biomarker for patient with suspected SEPSIS at Emergency Department admission
    Orateur(s) :
    • Thomas Lafon (Limoges / FRANCE)
    • Christine Vallejo (Limoges / FRANCE)
    • Marion Douplat (Lyon / FRANCE)
    • Franck Verschuren (Bruxelles / BELGIQUE)
    • Saïd Laribi (Tours / FRANCE)
    • Thibault Desmettre (Besançon / FRANCE)
    • Anaïs Colonna (Montauban / FRANCE)
    • Maxime Maignan (La Tronche / FRANCE)
    • Mustapha Sebbane (Montpellier / FRANCE)
    • Jacques Remize (Brive / FRANCE)
    • Olivier Dupeux (Angoulême / FRANCE)
    • Marie-Angélique Cazalis (Marcy-L'étoile / FRANCE)
    • Laurence Barbier (Marcy-L'étoile / FRANCE)
    • Bruno François (Limoges / FRANCE)
    14h17 / 14h24
    Abstract : An accurate assessment of septic patients at risk for poor clinical outcomes is challenging for emergency physicians. Patients experiencing sepsis can develop organ dysfunctions whose intensity and duration have been linked with deleterious outcomes. As early management of sepsis has been proven successful, accurate triage of these patient is key. In this study, we investigated whether biomarkers could predict the deterioration in patients admitted at ED with a suspected infection and help emergency physicians to better triage/manage.TRIAGE was a prospective, multicentre (14 sites in France and Belgium) observational study. Adult patients admitted in the ED with a suspected infection and at least 2 SIRS criteria were included. Blood samples were collected at 0, 6 and 24 hours after admission. Main outcome was subsequent deterioration (death, intensive care admission, increase of SOFA score) within 72 h. This primary endpoint was assessed by an independent adjudication committee of sepsis experts. Biomarkers association with primary endpoint and prognostic performances were assessed on clinical variables (age, sex, Charlson score, SOFA score, qSOFA, lactates). AUC under the ROC curve and their 95% confidence interval were computed using DeLong's method. Predictive performances were assessed using classification threshold optimized for high sensitivity.sVEGFR2 and sUPAR protein levels were measured in 462 ED patients at 3 time points: H0 (patient's admission), H6 and H24. Of these 462 patients, 124 (27%) worsened within the 72-hour study period. Compared with other biomarkers, the sVEGFR2/sUPAR protein combination was the most differentially expressed between worsening and non-worsening patients at H0 and H6 (p-value < 0.01, Mann-Whitney test). Interestingly, 233 patients were no considered as sepsis patients at enrolment (SOFA<2). Of these, 48 (21%) developed organ dysfunction within the 72-hour study period. Again, the combination of sVEGFR2 and sUPAR protein levels was, at inclusion (H0), the best predictor of worsening (AUC=0.73, sensitivity= 0.92, NPV=0.95), compared with other biomarkers: CRP (AUC=0.57), lactates (AUC=0.48), qSOFA (AUC=0.54) and PCT (AUC=0.61). Moreover, this performance was increased at H6 (AUC=0.79, sensitivity=0.94, NPV=0.98).The expression of the sVEGFR2/sUPAR protein significantly predicts the worsening of septic patient within 72 hours after their admission to the ED. Such biomarker(s) could enhance early identification of severe patients for an appropriate and rapid management able to decrease risks of poor outcome.
  • TRIAGE Study protocol: Assessment of biomarkers to predict clinical worsening of patients with sepsis admitted in the Emergency Department
    Orateur(s) :
    • Thomas Lafon (Limoges / FRANCE)
    • Christine Vallejo (Limoges / FRANCE)
    • Laurence Barbier (Marcy-L'étoile / FRANCE)
    • Marie-Angélique Cazalis (Marcy-L'étoile / FRANCE)
    • Thomas Daix (Limoges / FRANCE)
    • Arnaud Desachy (Limoges / FRANCE)
    • Valérie Gissot (Tours / FRANCE)
    • Pierre-François Laterre (Bruxelles / BELGIQUE)
    • Karim Tazarourte (Lyon / FRANCE)
    • Bruno François (Limoges / FRANCE)
    14h24 / 14h31
    Abstract : Sepsis is a frequent reason for admission in the Emergency Department (ED) and assessment of septic patients at risk for poor clinical outcomes is challenging for clinicians. Currently, no validated prognostic tool is available. Therefore, identification of patients at high risk of worsening in the ED is key. The TRIAGE objective was to assess the prognostic value of a blood marker panel to predict early clinical worsening of patients admitted in the ED with suspected sepsis. TRIAGE was a prospective, multicenter (14 sites in France and Belgium) study on biological samples. Adults patients admitted in the ED with suspected or confirmed community-acquired infection and at least 2 SIRS criteria were included. The protocol included 5 clinical and biological time points (H0, H6, H24, H72, D28). Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission, increase of SOFA score) within 72 h. Patients were divided into 2 groups depending on worsening or not. The evolution criteria were centrally evaluated by an independent adjudication committee of sepsis experts (emergency physicians and intensivists). Accuracy and prognostic performances of biomarkers were assessed. Patients were followed up to day 28 for mortality. The study duration was 3 years, 602 patients were included (wrongly included, n = 38; secondary excluded, n = 112) so 462 patients were analyzed (mean age 62.6 ± 20.5 y, Charlson score: 3.1± 2.6). After adjudication, 124 patients have been classified as worsening and 338 patients without deterioration. At admission there was no difference between the 2 groups on SIRS criteria count, WBC, CRP and lactates (cf table). The centralized analysis is in progress to select the combination of biomarkers with the best prognostic performance.While no vital signs nor biological markers or parameters can predict worsening of patients, the prognostic value of a panel of blood markers in EDs could help identification of septic patient at risk of worsening at time of admission and develop specific management.
  • The role of biomarkers as predictors of mortality in septic shock
    Orateur(s) :
    • Sabrine Bradai (Sfax / TUNISIE)
    • Mariem Dlela (Sfax / TUNISIE)
    • Karama Bouchala (Sfax / TUNISIE)
    • Hela Kallel (Sfax / TUNISIE)
    • Olfa Turki (Sfax / TUNISIE)
    • Mabrouk Bahloul (Sfax / TUNISIE)
    • Mounir Bouaziz (Sfax / TUNISIE)
    14h31 / 14h38
    Abstract : Septic shock is one of the leading causes of mortality among critically ill patients. Biomarkers offer a tool in facilitating early diagnosis, identifying patients at high risk of complications and monitoring progression of the disease. In this study, we aim to explore the value of procalcitonin (PCT), C-reactive protein (CRP), and cholinesterase activity (SChEA) kinetics, as useful predictors of mortality in patients with septic shock admitted in intensive care unit (ICU).We conducted a prospective single-blinded study at the ICU of Habib Bourguiba university hospital, Sfax, Tunisia, between January 01, 2017, and December 31, 2017. Were included all patients with 18 years of age, or older, with confirmed septic shock. For all included patients, blood samples of septic biomarkers (PCT, SChEA and CRP) were obtained. Serum was collected at the day of ICU admission (D0), the day of septic shock (D1), then 3 and 5 days after the septic shock development (D3 and D5).During the study period, 60 patients were included. The mean age (± SD) was 47.7 ± 19 years. There were 46 male (74%) and 14 female (26%) patients. Mean SAPSII on ICU admission was 40.7 ± 16 (median: 40) and mean SOFA score on ICU admission was 16 ± 4 (median: 7). Out of the 60 included patients, 37 patients died (The mortality rate was 61%). On the day when septic shock was settled (D1), there were no differences between the two groups in the mean plasma concentrations, neither in those of SChEA, nor in those of PCT and CRP. However, the comparison of mean plasma concentrations of SChEA, PCT and CRP on D3 and D5, showed a significant difference between survivors and non-survivors. (Table1) Our study suggests that in a group of critically ill patients with severe septic shock, a fall in procalcitonin and/or CRP levels; and/or a rise in SChEA were associated with a favorable outcome. Further studies are needed on this subject.
  • Procalcitonin fail to distinguish between bacterial and viral infection in severe AECOPD
    Orateur(s) :
    • Cédric Daubin (Caen / FRANCE)
    • François Fournel (Caen / FRANCE)
    • Stephane Allouche (Caen / FRANCE)
    • Fabrice Thiolliere (Lyon / FRANCE)
    • Fabrice Daviaud (Paris / FRANCE)
    • Michel Ramakers (Saint Lo / FRANCE)
    • Andrea Polito (Garches / FRANCE)
    • Damien Du Cheyron (Caen / FRANCE)
    • Jean-Jacques Parienti (Caen / FRANCE)
    14h38 / 14h45
    Abstract : Recently in a randomised clinical trial, we failed to demonstrate the non inferiority of a procalcitonin (PCT) guided antibiotic therapy with respect to 3 month mortality among patients with severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who needed mechanical ventilation [1]. To explain this result we assessed the capacity of PCT to distinguish between infectious and non infectious causes of severe AECOPD.The PCT levels of all patients at time of inclusion (H0), 6 hours after and at day 1 were measured using a sensitive immunoassay. Regarding all the cohort (n=302), at any time, the PCT levels were higher in patients with bacterial infection (n=66) and viral infection (n=69) than in patients without documented infection (Fig.1). Interestingly, whether the PCT levels tended to be higher in patients with bacterial infection (n=33) than in patients with viral infection (n=37) in the pneumonic group patients, PCT failed to distinguish between bacterial infection (n=33) and viral infection (n=32) in non pneumonic group patients. These results underline the interest of PCT as biomarker to distinguish between infectious and non infectious causes of severe AECOPD. However, PCT could fail to distinguish between bacterial and viral infection in this setting.
  • Severe eosinopenia as a predictive factor of ICU admission in infected patients admitted in an Emergency Department
    Orateur(s) :
    • Jérémy Rosman (Charleville-Mézières / FRANCE)
    • Simon Hainguerlot (Charleville-Mézières / FRANCE)
    • Aurélien Cordonnier (Charleville-Mézières / FRANCE)
    • Karelle Staffe (Charleville-Mézières / FRANCE)
    • Olivier Gallon (Charleville-Mézières / FRANCE)
    • Thomas Beuvelet (Charleville-Mézières / FRANCE)
    • Xavier Fontaine (Charleville-Mézières / FRANCE)
    • Philippe Mateu (Charleville-Mézières / FRANCE)
    14h45 / 14h52
    Abstract : Infectious diseases represent a frequent cause of consultation in the Emergency Department (ED). Biomarkers may help clinicians to assess severity and address them more promptly to the intensive care unit (ICU). Severe eosinopenia may reflect level of systemic inflammation. The aim of our study was to evaluate severe eosinopenia, as defined a value <0.01 G/L (<10/mm3), in infected patients to predict evolution towards an admission in ICU. Infected patients admitted in the ED with at least one complete blood count were included. Factors explaining admission in ICU within 7 days following ED admission were evaluated by multivariable logistic regression. Among 15.639 patients screened, 1.643 infected patients were finally included. Nearly half of them had severe eosinopenia at admission in the ED. By multivariable analysis, severe eosinopenia [aOR 2.5 (95% IC 1.2 - 4.3)], history of chronic renal failure [aOR 2.8 (95% IC 1.4 - 5.6)], C-reactive protein ≥70 mg/L [aOR 2.0 (95% IC 1.4 - 3.5)] and pulmonary infection [aOR 1.8 (95% IC 1.1 - 2.9)] were independent factors associated with ICU admission within the following week. All other elements in differential count were eliminated in the model. Severe eosinopenia was also significantly associated with longer length of stay, more bacteremia (17% vs 6%), septic shock within 7 days (2% vs 0.5%), 28-days mortality (5% vs 2%) (p ≤0.002 for all outcomes).Severe eosinopenia, a reflect of systemic inflammation, was an independent factor associated with ICU admission within 7 days and was also associated with longer length of stay, bacteremia, septic shock and mortality.
  • Is severe lymphopenia a predictive marker of infection in the Emergency Department ?
    Orateur(s) :
    • Thomas Lafon (Limoges / FRANCE)
    • Arthur Baisse (Limoges / FRANCE)
    • Thomas Daix (Limoges / FRANCE)
    • Olivier Barraud (Limoges / FRANCE)
    • Christine Vallejo (Limoges / FRANCE)
    • Bruno François (Limoges / FRANCE)
    • Philippe Vignon (Limoges / FRANCE)
    14h52 / 14h59
    Abstract : In the Emergency Department (ED), early and appropriate recognition of infection is crucial to start antibiotic treatment in a timely fashion. Traditional biomarkers remain not specific enough in infected patients. Lymphopenia, known to be associated with sepsis in the ICU, has not yet been evaluated as a potential infection biomarker in the ED. On the contrary, white blood cell (WBC) count is routinely and widely performed as part of admission assessment. We investigated whether isolated or clinically associated severe lymphopenia in ED could be a marker of infection.We conducted a retrospective single-center study over a 1 year-period. Adult patients admitted in the ED with severe lymphopenia (lymphocyte count < 0.5 G/L) were analyzed. Patients with hematological or oncological diseases, HIV infection, hepato-cellular deficiency, immunosuppression and over 85 years old were excluded. Diagnosis of infection was confirmed by an independent adjudication committee. Correlation between lymphopenia and infection was assessed using a univariate analysis and a multivariate logistic regression.From January to December 2017, 953 patients were admitted in ED with severe lymphopenia and 245 were eligible (148 men; mean age 63±19 years). Infection was confirmed in 159 patients (65%) (bacterial: 60%, viral: 30%, other: 10%). Initially, only 61 patients (25%) were referred to ED for suspected infection. Among biological markers, only CRP was different between infected and uninfected groups (109±133 vs 46±62, p<0.01). The depth of lymphopenia was associated with a higher prevalence of infection, bacteremia, and microbiological identification (Figure). In multivariate analysis, only clinical criteria were independently associated with infection (SIRS criteria: OR = 2.4, p < 0.01; fever: OR = 3.35, p = 0.02). On the contrary, classical biological biomarkers did not appear associated with infection (WBC count: OR = 0.93, p=0.07; CRP: OR = 1.01, p = 0.07).Prevalence of infection is high in patients with severe lymphopenia regardless the reason of admission to the ED and traditional biomarkers results. This easy measurable marker could be used routinely by emergency physicians to assist in the early diagnosis of infection.
  • Contribution of neutrophil to lymphocyte and platelet to lymphocyte ratios in diagnostic of infection during decompensated cirrhosis.
    Orateur(s) :
    • Ameni Khaled (Ariana / TUNISIE)
    • Sana Khedher (Tunis / TUNISIE)
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Cyrine Abdennabi (Ariana / TUNISIE)
    • Nasreddine Foudhailin (Ariana / TUNISIE)
    • Mohamed Salem (Ariana / TUNISIE)
    • Radhwan Debbesh (Ariana / TUNISIE)
    14h59 / 15h06
    Abstract : The prognosis of infection in Acute on chronic liver failure (AoCLF) depends on the rapidity of diagnosis which may be difficult, because of the absence of classical signs as fever.. It has been found that Neutrophil-lymphocyte ratio (NLR) and Platelet-lymphocyte ratio( PLR) are regarded as cheap, simple and promising parameters to predict sepsis severity in several diseases. We aim to Evaluate the role of NLR and PLR in the diagnosis of infection in AoCLF.This was a retrospective follow-up study of 92 cases with the diagnosis of decompensated cirrhosis from January to December 2016.A total of 92 cases of decompensated cirrhosis were enrolled in our study. The mean age was 62 ± 13,4 years. The gender was 0,95. The diagnosis of sepsis was identified in 46% of cases. Multivariate logistic regression analyses showed that there is a significant positive correlation between C-reactive protein (CRP) (p=0,00), Procalcitonin (p=0,004), PLR (p=0,006) and NLR (p=0,02) with infection. To evaluate the ability of NLR, CRP, Procalcitonin and PLR to predict infection , ROC curves were obtained Of all the evaluated parameters, NLR showed a strong, statistically significant correlation, a high concordance correlation coefficient.Infection is one of the leading causes of hospitalization of patients with decompensated cirrhosis and is associated with considerable mortality, for which clinicians are seeking useful and easily obtained biomarkers. Our study had shown that Both PLR and NLR were good markers to predict infection in AoCLF.
E-Poster
14h10 - 15h10
Espace poster 5
Médecin : Evaluation, organisation
Modérateur(s) : René Robert (Poitiers / FRANCE), Jean-Damien Ricard (Colombes / FRANCE)
  • Anxiety, depression and post-traumatic stress disorder after intensive care unit discharge: prevalence and predictors
    Orateur(s) :
    • Ornella Caruso (Lille / FRANCE)
    14h10 / 14h17
    Abstract : Evaluate anxiety, depression and post-traumatic stress disorder prevalence (PTSD) in intensive care unit (ICU) survivors. Determine risk factors of post intensive care unit psychologic comorbidity and evaluate professional practices' evolution.The study included adult patients, with length of stay ≥ 48 hours in ICU, whom came to the 3-month follow-up's consultation with the filled form: Post-Traumatic Stress Symptom scale (PTSS-10) and Hospital Anxiety and Depression Scale (HADS), received a month earlier. Potential risk factors of pre, per and post intensive care unit were collected. Prevalences of psychiatric comorbidities were determined by year.Among 120 patients studied, 48.33% (CI 95% (39.12; 57.63)) had anxiety, 36.67% (CI 95% (28.06; 45.95)) had depressive symptoms and 8.33% (95% CI (4.07; 14.79)) had PTSD. Anxiety, depression and PTSD was defined by HADS score ≥ 8 and PTSS-10 > 35. The only predictive factor was age for anxiety (p = 0.001). Any other risk factors of psychiatric comorbidity were no significant. Memory disorder seemed to favor PTSD, as well as sepsis' presence favors anxiety and non-invasive ventilation favors anxiety and depression. There was no significant change in prevalence due to professional practices' evolution.Anxiety, depression and PTSD after critical illness are common. The detection of predictors allows an early multidisciplinary management of the patient in order to reduce their prevalence.
  • Clinical and epidemiological aspects of a low income country MICU patients
    Orateur(s) :
    • Mohamed Ahmed Boujelben (Sousse / TUNISIE)
    • Hela Kallel (Sfax / TUNISIE)
    • Ines Fathalah (Ben Arous / TUNISIE)
    • Sahar Habacha (Ben Arous / TUNISIE)
    • Dora Sakis (Ben Arous / TUNISIE)
    • Mariem Tobich (Ben Arous / TUNISIE)
    • Nadia Kouraichi (Ben Arous / TUNISIE)
    14h17 / 14h24
    Abstract : During the last thirty years, our society has undergone several socio-economic and demographic changes, which implies new challenges in public health and the different aspect of critical care management. The aim was to describe the characteristics and mortality risk factors of patients admitted to a low income country MICU.A retrospective analysis of chart reviews of all patients admitted to a 6-bed tertiary MICU from October 17th, 2016 to July 17th, 2017. Were collected Patients´ characteristics, evolution and outcomes. Univariate and multivariate regression analyses were performed to identify factors independently associated to mortality.97 patients w ere admitted during the study period. Their main characteristics were : mean age, 55.9±20.6 years ; male gender, 68(70.1%) ; mean SAPS II, 41.7±20.4 with a predicted mortality of 28%, median length of stay, 8[4-15.5] days. The common causes for admission were acute respiratory failure (42.2%, n=41), from which 42.8%(n=18) were on chronic one; and multi-organ dysfunction (15.4%, n=15). Upon admission the most occurring diagnoses were : community acquired pneumonia, 15(15.5%) ; septic shock, 11(11.3%) and voluntary poisoning, 11(11.3%). 82.5%(n = 80) of the patients were admitted from our local emergency room. The rate of acute renal failure was 45.5%(n=44). 6(6.2%) patients had chronic kidney disease at admission and 9(9.2%) patients required renal replacement therapy. Non-invasive ventilation (NIV) and invasive mechanical ventilation (MV) were indicated for 37.1%(n=36) and 50.5% (n=49) of the patients respectively. The median duration of NIV and MV were 3.5 days [2-7] and of 5 days [3-17]. 9(18.4%) patients were tracheostomized due to difficult weaning. The ICU acquired complications are detailed in Table 1. The mortality rate was 28.9%(n=28). Multivariate analysis identified two independent risk factors for mortality: SAPSII >= 55.5 (OR=8.03, CI95[2.52; 25.6], p<10-3 ) and acute renal failure (OR=6.13, CI95[1.84; 20.37], p=0.03).This study described the trends of MICU admissions in our district. The high incidence of ICU acquired complications remains a major problem in Tunisia and requires the implementation of several reforms. The independent risk factors for mortality were SAPSII and acute renal failure at admission.
  • Critically ill elderly patients: what about long term caregiver's burden?
    Orateur(s) :
    • Bertrand Guidet (Paris / FRANCE)
    • Hélène Vallet (Paris / FRANCE)
    • Ariane Boumendil (Paris / FRANCE)
    • Laura Moïsi (Paris / FRANCE)
    • Caroline Thomas (Paris / FRANCE)
    14h24 / 14h31
    Abstract : In intensive care unit, the elderly patient's admission is growing last years. The mortality rate is high and the loss of autonomy is common among survivors. However, data regarding the impact of critical illness on caregiver's are lacking. Objectives of this study were to evaluate the caregiver's burden in a critically ill elderly population and to assess factors associated with high burden level.All patients were included in ICE-CUB 2 clinical trial (clinical trial gouv NCT 01508819). Inclusion criteria were an age≥75, at least on critical condition, a preserved functional status defined as an Activities of Daily Living (ADL) score ≥4, a preserved nutritional status and the absence of known active cancer. Patients, for which the Zarit Burden Interview (ZBI) at 6 months was available, were selected. The primary endpoint was a ZBI ≥ 21 (mild to severe burden) at 6 months.One hundred ninety one patients (median age 86 [81-89] years) were included. The median caregiver's ZBI at 6 months was 13 [5-27] and ≥21 for 71 patients (37%). In multivariate analysis, factors significantly associated with moderate to severe burden were the 6-month ADL decrease (OR: 1.3 [1-1.68], p = 0.049) and the mental component of the quality of life (QoL) score (SF- 12) at 6 months (OR: 0.94 [0.89-0.98], p = 0.0009). In contrast, age, ICU admission and length of hospital stay were not associated with moderate to severe load (OR 0.84 [0.41-1.73], p=0.64; OR 0.99 [0.93-1.06], p=0.85 and OR: 1.02 [0.99-1.06], p=0.12 respectively). Functional autonomy and QoL at 6 months are associated with mild to severe caregiver's burden, contrary to age, ICU admission and length of hospital stay. Advanced age shouldn't be an obstacle to the care of critically ill elderly patient. However, improving their long term autonomy and QoL remains important, that means higher implication of geriatricians in their medical care.
  • Post Intensive Care Syndrome : an observational study
    Orateur(s) :
    • Julien Le Marec (Tours / FRANCE)
    • Youenn Jouan (Tours / FRANCE)
    • Maud Vaudour (Tours / FRANCE)
    • Stephan Ehrmann (Tours / FRANCE)
    • Charlotte Salmon (Tours / FRANCE)
    14h31 / 14h38
    Abstract : « Post-intensive care syndrome » is the sum of all the cognitive, psychiatric and physical sequelae after a hospitalization in intensive care unit. These frequent sequelae can have a serious impact on the quality of life, autonomy, morbidity and mortality of such patients, and can last for several years after the initial hospitalization. Although it is not consensual, intensive care unit teams more and more frequently schedule visits to assess the physical and mental status of these patients after their discharge of the ward. The clinical interest of such a practice has not been evidenced yet. Since 2015, a follow-up visit after intensive care unit discharge has been set in the Médecine Intensive – Réanimation ward of Tours University Hospital Centre, in order to detect the potential occurrence of a post-intensive care syndrome in our patients. Patients admitted for acute respiratory distress syndrome and / or septic shock were eligible. We conducted a descriptive study of this cohort to assess their evolution. Patients were informed about the study and could decline participation.Thirty-eight patients (on 41 summoned) were reevaluated at a follow-up visit 1 month after discharge. Among them, 16 (39%) had been admitted to ICU for an acute respiratory distress syndrome, 2 (5%) for a septic shock, 3 (7%) for both acute respiratory distress syndrome and septic shock, and 14 (34%) for another diagnosis, such as acute respiratory failure or severe intoxication. Thirteen patients (34%) were still hospitalized in rehabilitation on the follow-up visit day. Among the remaining 25 patient, 10 (40%) had not consulted their general practitioner yet. Fourteen patients (37%) presented with a cognitive alteration, 10 patients (26%) had psychiatric troubles and 32 patients (84%) had physical sequelae (respiratory, neurological….). One patient out of two had sequelae in at least 2 of the 3 domains of post intensive care syndrome. Only 1 patient (3%) had no sequelae at all (Figure 1). Fifteen patients were reevaluated 3 months after discharge, showing a global improvement in their status but with persistent deficiencies. Overall, 84% were referred to a specialist and/or had a modification in their treatment after the follow-up visit. Our observational study confirmed the frailty of the patients discharged of intensive care unit, with 97% of our patients presenting with troubles belonging to the field of post intensive care syndrome; this highlights the potential interest of an early reevaluation.
  • Predictive factors of prolonged length of stay of icu elderly patients
    Orateur(s) :
    • Dhouha Ben Braiek (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Rafla Ben Dabebiss (Sousse / TUNISIE)
    • Said Kortli (Sousse / TUNISIE)
    • Mohamed Ben Rejeb (Sousse / TUNISIE)
    • Houssem Hmouda (Sousse / TUNISIE)
    14h38 / 14h45
    Abstract : Prolonged LOS of ICU patients, especially elderly is a well-defined problem, associated with increased health care costs, resource utilization, delayed ICU admissions from the emergency departments, and may have an impact on morbidity and mortality. Prediction of ICU LOS may contribute to more efficient resources' allocation and better planning of care. The aim was to determine the incidence and predictive factors of prolonged ICU-LOS in elderly patients admitted to a tunisian medical ICU. It is a retrospective analytic study conducted in a 4 bedded MICU of a university hospital during a-4 year period including elderly patients (more than 65 years old). ICU stay was considered prolonged when exceeded 15 days. Variables found to be statistically significant in univariate analysis were included into a multivariate regression model to identify factors independently associated with prolonged ICU stay.During the review period, 97 patients were included. Patients' characteristics were : mean age, 75±7 ; mean SAPSII, 40±11 ; mean APACHE II, 22±10 ; mean SOFA, 7±4; respiratory disorder on admission, 76(78.4%); invasive mechanical ventilation, 51(52.6%) and vasopressors use, 56(57.7%). The median length of ICU stay was 8[5-14]days. Twenty-three patients (23.7%) had prolonged ICU stay. Univariate analysis identified several factors associated with prolonged ICU stay: past history of chronic respiratory failure (CRF) (p=0.026), admission for exacerbation of CRF (p=0.026), intubation before ICU admission (p=0.038), hyponatremia at admission (p=0.019), invasive mechanical ventilation (p=0.05), sedation (p=0.002), nosocomial infections (p=0.003), shock (p=0.035), ICU-acquired weakness (p=10-3), dyskalemia (p=0.026), anemia (p=0.011). In multivariate analysis, three predictors were independently associated with prolonged ICU stay: exacerbation of chronic respiratory failure (OR, 4.85 ; 95%CI, [1.44-16.35] ; p=0.011), hyponatremia at admission (OR, 5.44 ; 95%CI, [1.70-17.43] ; p=0.008) and nosocomial infections (OR, 4.72 ; 95%CI, [1.51-14.77] ; p=0.004).Exacerbation of chronic respiratory failure, hyponatremia on admission and nosocomial infections were the only independent predictors of prolonged ICU stay. Further research is needed for better identification of patients with prolonged ICU stay to ensure optimal use of ICU resources.
  • Trends in use of radiological procedures in medical ICU.
    Orateur(s) :
    • Ines Fathalah (Ben Arous / TUNISIE)
    • Asma Mehdi (Ben Arous / TUNISIE)
    • Sahar Habacha (Ben Arous / TUNISIE)
    • Eya Seghir (Ben Arous / TUNISIE)
    • Ghada Sboui (Ben Arous / TUNISIE)
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Ameni Sgahier (Ben Arous / TUNISIE)
    • Nadia Kouraichi (Ben Arous / TUNISIE)
    14h45 / 14h52
    Abstract : The place of chest film radiography in management of critical care patients is well known. However since advances in imaging technology in last decades, many other tools have been added to the diagnostic arsenal. Few studies investigate the use of other radiological procedures in intensive care unit (ICU). We aimed to determine use frequency, conditions of realization, diagnostic and therapeutic impact ,specificity and costs of different radiological procedures in the ICU.Retrospective study conducted in a medical ICU. All consecutive radiological procedure realized between July 2017 and July 2018 were included .data were collected from medical files.One hundred five radiological investigations were realized. Among which 41(41%) Computed Tomography-scan (CT scan), five(5%) Magnetic resonance imaging (MRI) and 57 (54%) echography which includes 21 trans-thoracic echography(TTE), 2 trans-esophageal echography(TEO), 28 abdominal echography and 6 lower limb venous sonography. Forty one (39%) were realized in patients' bed, 55(52%) were realized in our hospital and 9 (10%) required medical transportation to others centers. Sixty-one (58%) examinations were realized to patient under mechanical ventilation, 69( 66%) to patient under sedation and 74(70.5%) to patient under vasopressors. Radiological procedures was compromised in 2%, and complications after realization occurred in 4% (n=4). Suspected diagnosis was confirmed in 30% (n=34)of exams. Five (5%) exams was inconclusive. CT scan allowed to confirm 16(37%) suspected diagnosis and echography allowed to confirm 17 (30%). Forty-five percent of suspected pulmonary embolism (PE) were confirmed by pulmonary computed tomography angiography. Forty –four (42%) radiological examinations has a direct therapeutic impact. Mean cost of a radiological exam was 44,7 euro with a global cost of 5004.1 euro. The contribution of Imaging in diagnosis and managements of ICU patients is considerable given an important therapeutic impact . Examinations conditions shouldn't dissuade clinicians for the realization of radiological investigations given the low rate of incidents (2%) and complications (4%).
  • Characteristics and outcomes of elderly patients admitted to a Tunisian intensive care unit (ICU)
    Orateur(s) :
    • Hend Zorgati (Sousse / TUNISIE)
    • Imen Ben Saida (Sousse / TUNISIE)
    • Said Kortli (Sousse / TUNISIE)
    • Nesrine Fraj (Sousse / TUNISIE)
    • Mohamed Ahmed Boujelben (Sousse / TUNISIE)
    • Wafa Zarrougui (Sousse / TUNISIE)
    • Khaoula Meddeb (Sousse / TUNISIE)
    • Mohamed Boussarsar (Sousse / TUNISIE)
    14h52 / 14h59
    Abstract : The aging of the population has increased the demand for critical care resources for elderly worldwide. There are few data on the characteristics and outcomes of those patients in ICU. The aim was to assess characteristics and to identify predictors of ICU mortality in elderly patients.A retrospective study conducted in a medical ICU between January 2016 and December 2017 and included patients aged more than 65 years. Medical patients' records were reviewed to compile demographic characteristics, severity and diagnosis at admission, management and outcomes. Univariate and multivariate analysis were used to identify predictors of ICU mortality.During the study period, 486 patients were admitted to ICU. 178 (36.6%) were aged more than 65 years. Patients' characteristics were : median age, 74 years [ 68-79] ; male, 109(61,2%) ; median Charlson score, 4 [4-5] ; Knauss C or D, 129(72,5%) ; MacCabe≥2, 85(47,8%) ; median SAPSII, 34[28-44]; median APACHE, 16 [11,75-20] ; median SOFA, 4[3-7] ; invasive mechanical ventilation (IMV), 80(44,9%) with a median duration at 8 days [3,25-19,75] ; vasopressors use, 65(36,5%) ; renal replacement therapy, 9(5,1%). The main reasons for admission were : respiratory disorders, 141(79,2%) ; shock, 24(13,5%) ; neurological disorders, 7(3,9%) and miscellaneous, 6(3,4%). The median length of stay was 8[5-17] days. Mortality rate was 47,2%. The univariate analysis identified respectively for deaths and survivals : Apache II (17.6 ±6.8 vs 14.9±5.9, p=0.006) ; SOFA (5.89 ±3.4 vs 3.98±2.3, p=0.000) ; Shock on admission (47.6% vs 26.6%, p=0.004) ; IMV use on admission (42.9 % vs 20.2%, p=0,01) ; acute kidney injury ( 85.7% vs 37.2 %, p=0.00) ; Arrythmia ( 27.4% vs 6.4%, p= 0.000) and nosocomial infection (66.7% vs 12.8%, p=0.000). Multivariate regression model identified the following factors as independently associated to mortality : nosocomial infection (OR, 7.78 ;95%CI, [3.34- 18.09] ; p=0.000), acute kidney injury (OR, 12.18 ;95%CI, [4.5- 32.8] ; p=0.000) and IMV use on admission (OR, 5.95 ; 95%CI, [2.39-14.8] ; p=0.000). IMV use on admission, nosocomial infection and acute kidney injury were independently associated to fatal outcome in elderly critical ill patients.
  • How and why do intensivists finance their congresses ?
    Orateur(s) :
    • Michael Thy (Paris / FRANCE)
    • Salam Abbara (Paris / FRANCE)
    • Redwan Maatoug (Paris / FRANCE)
    • Nathan Peiffer-Smadja (Paris / FRANCE)
    14h59 / 15h06
    Abstract : Congresses are a place of exchange and update of medical knowledge. However, their cost is not negligible and their profitability on the training of participants remains unclear and not studied. The purpose of this study was to identify how and why young intensivits are funding their participation in congresses.A self-questionnaire in French has been sent to young doctors of any specialty through mailing lists to the interns. People are surveyed about their characteristics, their attendance at a conference, the funding of staff and the total of these and the contribution. The relative data was anonymous. The questionnaire was registered at the CNIL.In total, from August 2017 to November 2017, 1759 people including 185 (10.5%) intensivists responded to a questionnaire, of which 156 (84.3%) internal with an equivalent proportion of each year of internship and 29 (15.7%) ) young seniors (clinical leaders and specialist assistants). The last congresses that hosted intensivists were in France for 93.5% of them. The participation of each participant in conferences (75.1% or 139), 15.1% (n = 28) received an invitation, 8.1% (n = 15) received funding and 3.2% ( n = 6) had a scholarship. The average amount of personal financing amounted to € 256.7 (SD = 190.3) for an average total amount of € 332.5 (SD = 256.9) (Figure 1). The reasons for their participation were for a simple presence for 77.9% (n = 141) of them and for a presentation at the congresses for 22.1% (n = 40) of them. 90.8% (n = 168) of participants thought that the main interest of conventions was 85.4% (n = 158) thought the price to pay had already been a barrier.Intensivists - self-financed to a significant participation for their participation in congresses while this is organized in a training objective. Better funding opportunities and promotion of fellowships for congresses about intensive care.
E-Poster
14h10 - 15h10
Espace poster 6
Médecin : Hemodynamique 1
Modérateur(s) : Julien Maizel (Amiens / FRANCE), Armand Mékontso-Dessap (Créteil / FRANCE)
  • Midline catheter: an alternative to central venous catheter?
    Orateur(s) :
    • Naïke Bigé (Paris / FRANCE)
    • Shobanya Selvarathnam (Paris / FRANCE)
    • Jean-Rémi Lavillegrand (Paris / FRANCE)
    • Guillaume Dumas (Paris / FRANCE)
    • Constance Chateauvieux (Paris / FRANCE)
    • Jean-Luc Baudel (Paris / FRANCE)
    • Bertrand Guidet (Paris / FRANCE)
    • Hafid Ait-Oufella (Paris / FRANCE)
    14h17 / 14h24
    Abstract : A midline catheter (MC) is a peripheral venous catheter inserted in a deep-arm vein with extended lifespan up to 30 days. MC could represent an alternative to central venous catheter for patients with poor venous access and/or requiring prolonged intravenous treatment such as antibiotics. We seek to determine. The objective of this study was to determine dwell time and safety of MC.We performed a prospective observational study including consecutive MC insertions in an academic hospital between March and September 2018. Fully integrated PowerGlide ProTM (Bard) device was used. All MCs were inserted using a sterile technique by senior intensivists with experience of ultrasound-guided catheter placement. Before MCs utilization period, nurses and physicians received a training for MCs management. A MCs team (1 pharmacy resident and 1 senior intensivist) followed patients from MC insertion to removal. Ultrasound examination was performed once weekly. MC tips were systematically cultured at removal.Fifty-seven MCs were inserted in 50 patients (men 58%, age 58 years [range 22–96]) representing a total of 691 MC-days. A median of 1 [range 1- 5] catheter was used per insertion. Indications for MC placement were not exclusively: extended antibiotherapy (n=29), poor venous access (n=46), iterative blood sampling (n=12), hydration (n=11). Median dwell time was 11 days [range -26]. Twenty-nine (47%) MCs were removed without complication. Four patients were lost to follow-up. Twenty-three (40%) MCs were retrieved because of the following complications: accidental removal (n=4), suspected infection (n=7) of whom 5 were confirmed by a positive tip-culture, MC dysfunction without vein thrombosis (n=2), vein thrombosis (n=10) responsible for MC dysfunction (n=6) and clinical symptoms (n=4). No MC-related bloodstream infection (BSI) occurred. The overall incidence of MC-related complications was 33,3/1000 MC-days. MC-infection could have been overestimated because 4 of the 5 observed infections occurred in the same patients in whom 4 MC were inserted. Insufficient diameter of the vein (basilic or brachial) in which MC tip was located could be responsible for high rate of vein thrombosis.Despite nurses training and close monitoring of patients, we observed a shorter dwell time than expected and a high rate of MC-associated thrombosis. These results question definite utilization of the MC device we tested. However, longer device with axillary tip could be safer and more durable.
  • Variation of fluid balance as indicator of early clinical outcome in burn patients
    Orateur(s) :
    • Achref Laajili (Tunis / TUNISIE)
    • Alaa Zammit (Tunis / TUNISIE)
    • Hana Fraj (Tunis / TUNISIE)
    • Imen Rahmani (Tunis / TUNISIE)
    • Sarra Ben Zarrouk (Tunis / TUNISIE)
    • Nejla Ben Slimene (Tunis / TUNISIE)
    • Mehdi Somai (Sfax / TUNISIE)
    • Bahija Gasri (Tunis / TUNISIE)
    • Lotfi Rebai (Tunis / TUNISIE)
    • Amel Mokline (Tunis / TUNISIE)
    • Amen Allah Messadi (Tunis / TUNISIE)
    14h31 / 14h38
    Abstract : Early and adequate fluid rescuscitation in burns contributes to improve outcomes of severly burned patients, leading to less tissue oedema fluid accumulation and reduces both organ and system dysfunction. The aim of our study was to evaluate the impact of this approach in early burn outcome. A pospective study was conducted in Intensive Burn Care Department of Tunisia during 5 months (January 2017 and May 2017). Were included patients aged > 18 years, with a total body surface area > 20%, admitted within 24H post burn injury and hospitalized for a duration > 72 hours. Patients were resuscitated according to Parkland Formula. Goals of ressuscitation were: Mean arterial pressure (MAP)≥ 65 mm Hg and Hourly urine output (HUO) ≥ 0.5 ml/kg/h. Body weight was measured at admission and daily using a bed scale. Early clinical outcome in burn patients designed the first week post burninjury.During the period study, 141 patients were admitted in the burn ICU. 34 patients were included. The mean age was 38±15 years with a ratio sex of 4.7. The average TBSA was 44±20%. Early ICU mortality was 26.5% (n=9). Patients were assigned into 2 groups: G1: survivors (n=25) and G2: non survivors (n=9). Comparative study of 2 groups was as follows (Table 1): Table1: Comparative study of 2 groups Optimal initial fluid resuscitation in burn patients is associated with lower fluids overload during the first 48 hours and improves early outcome with a lower early mortality. .
  • Norepinephrine synergistically increases the efficacy of volume expansion on venous return in septic shock
    Orateur(s) :
    • Imane Adda (Le Kremlin-Bicêtre / FRANCE)
    • Christopher Lai (Le Kremlin-BicÊtre / FRANCE)
    • Jean-Louis Teboul (Le Kremlin-Bicêtre / FRANCE)
    • Laurent Guerin (Le Kremlin-Bicêtre / FRANCE)
    • Francesco Gavelli (Le Kremlin-Bicêtre / FRANCE)
    • Christian Richard (Le Kremlin-Bicêtre / FRANCE)
    • Xavier Monnet (Le Kremlin-Bicêtre / FRANCE)
    14h38 / 14h45
    Abstract : Through reduction in venous capacitance, norepinephrine increases the mean systemic pressure (Pms) and increases cardiac preload. This effect may be added to the ones of fluids when both are administered in septic shock. Nevertheless, it could be imagined that norepinephrine potentiates in a synergic way the efficacy of volume expansion on venous return by reducing venous capacitance, reducing the distribution volume of fluids and enhancing the induced increase in stressed blood volume. The purpose of this study was to test if the increase in Psm induced by a preload challenge were enhanced by norepinephrine (NE).This prospective and comparative study had included 25 septic shock adults. To reversibly reproduce a volume expansion and preload increase at different doses of norepinephrine, we mimicked fluid infusion through a passive leg raising (PLR). In patients in which the decrease of NE was planned, we estimated Psm (heart-lung interactions method, using end-inspiratory and end-expiratory occlusions) at baseline and during a PLR test (PLRHigh). The dose of NE was then decreased and Psm was estimated again before and during a second PLR (PLRLow).NE dose decreased from 0.58[0.33-1.1] to 0.44[0.24-0.94] µg/kg/min (p<0.0001). The increase in Psm induced by PLRHigh (ΔPsmHigh) at the highest dose of NE was significantly greater than the ΔPsm induced by PLRLow (37[15-48]% vs 12[7.0-32]%, p<0.001). The increase in cardiac index induced by PLRLow was significantly greater than that induced by PLRHigh (p=0.0001). ΔPsmHigh - ΔPsmLow was moderately correlated with the diastolic arterial pressure at BaselineHigh (p=0.014, r=0.50) and with the NE-induced change in mean arterial pressure (p=0.0044, r=0.57).Norepinephrine enhances the increase in Psm induced by a PLR, which mimics a fluid infusion. This suggests that it may potentiate the effects of fluid in a synergetic way in septic shock patients. This may decrease the amount of administered fluids and contribute to decrease the cumulative fluid balance.
  • Transthoracic echocardiography cannot reliably estimate or track changes in central venous pressure in critically-ill patients
    Orateur(s) :
    • Mathieu Jozwiak (Le Kremlin-Bicêtre / FRANCE)
    • Alice Boilève (Le Kremlin-Bicêtre / FRANCE)
    • Jean-Louis Teboul (Le Kremlin-Bicêtre / FRANCE)
    • Christian Richard (Le Kremlin-Bicêtre / FRANCE)
    • Xavier Monnet (Le Kremlin-Bicêtre / FRANCE)
    14h52 / 14h59
    Abstract : As a static marker of cardiac preload, the central venous pressure (CVP) remains a helpful variable at the bedside to guide the hemodynamic management of critically-ill patients. Since transthoracic echocardiography (TTE) is currently the first-line tool for evaluating the hemodynamic conditions in critically-ill patients, we aimed at assessing the ability of TTE to estimate and to track changes in CVPIn 31 patients (25 mechanically ventilated and four with atrial fibrillation), concomitant CVP measurement (internal jugular catheter) and TTE examination were performed before and after a passive leg raising test or the infusion of 500-mL of saline. We calculated the tricuspid E/A waves ratio, the tricuspid E/e' waves ratio, the right ventricular isovolumic time (IVRT), the E/IVRT ratio, the S/D waves ratio of the supra-hepatic vein flow, the VTI-systolic filling fraction and the peak velocities-systolic filling fraction of the supra-hepatic vein flow, the end-expiratory diameter of the inferior vena cava (IVC) and the respiratory variations of the IVC diameter. For the statistical analysis, we considered that a CVP threshold value of 10 mmHg was clinically relevant.Changes in CVP were induced by a passive leg raising test in 10 patients and by fluid administration in 21 patients. After pooling all values, only the end-expiratory IVC diameter and the respiratory variations of the IVC diameter were correlated to CVP (r=0.40 and r=-0.26, respectively, p<0.05 for both). At baseline, an end-expiratory IVC diameter =<14 mm predicted a CVP = or <10 mmHg with a specificity of 100% (95%CI: 81-100%) but with a sensitivity of 29% (95%CI: 8-58%). An end-expiratory IVC diameter>26 mm predicted a CVP >10 mmHg with a specificity of 100% (95%CI: 77-100%) but with a sensitivity of 0% (95%CI: 0-20%). At baseline, the respiratory variations of the IVC diameter could predict neither a CVP = or <10 mmHg nor a CVP>10 mmHg (AUC=0.683, p=0.08). Only relative changes in the S/D ratio and in VTI-systolic filling fraction correlated with relative changes in CVP (r=0.44 and r=0.43, respectively, p<0.05). The concordance rate between changes in S/D ratio and CVP was 48% and the concordance rate between changes in VTI-systolic filling fraction and CVP was 55%.In critically-ill patients, TTE cannot reliably estimate CVP or track changes in CVP induced by changes in cardiac preload. Nevertheless, an end-expiratory IVC diameter = ou < 14 mm or >26 mm can detect a CVP = ou <10 mmHg or >10 mmHg respectively with a specificity of 100%.
  • Large arteries in septic shock – a feasibility study for using Speckle Tracking Echocardiography to examine elastance in large arteries
    Orateur(s) :
    • Sebastian Knudsen (Perth / AUSTRALIE)
    • Sam Orde (Sydney / AUSTRALIE)
    • Yoann Zerbib (Amiens / FRANCE)
    • Elie Zogheib (Amiens / FRANCE)
    • Julien Maizel (Amiens / FRANCE)
    • Michel Slama (Amiens / FRANCE)
    14h59 / 15h06
    Abstract : Arterial elastance (Ea) and ventricular end systolic elastance (Ees) have been shown to be linked in a way that may optimize efficiency for converting left ventricular power into forward flow. This relationship may be disrupted in sepsis. We devised a pilot study to investigate the feasibility of using Speckle Tracking Echocardiography (STE) to examine Ea as a surrogate for conventional equations based on blood pressure and stroke volumes in ICU patients. We then chose a group of septic patients and a group of non-septic patients in an attempt to demonstrate a “de-coupling” of Ea and Ees when using conventional equations, and when using STE.19 septic and 23 non-septic patients underwent echocardiographic and carotid artery examination. Invasive blood pressure measurements and echocardiographic measurements of stroke volumes and ejection fractions were used to calculate Ea and Ees by conventional means. Carotid STE was performed to analyze circumferential strain and strain-rate.Studying Ea was feasible using STE in all patients. Ea was correlated with circumferential strain (r=-0.37; p=0.04) and strain-rate (r=0.46; p=0.008). When using conventional methods, we demonstrated a relationship between Ea and Ees (r=0.77, p<0.0001), and between Ees and (1) circumferential strain (r=0.28, p>0.05); (2) circumferential strain rate (-0.36, p=0.08). There was no difference between septic and non-septic patients regarding STE, Ea or Ea/Ees.Speckle Tracking Echocardiography (STE) is a feasible way of examining the elastance of the great arteries in ICU patients. No difference was observed between septic and non-septic patients regarding arterial elastance assessed using conventional method or STE.
  • Association between fluid overload and sofa score kinetic from admission to day 5 during septic shock: results of EpiGOAL study
    Orateur(s) :
    • Xavier Chapalain (Brest / FRANCE)
    • Véronique Vermeersch (Brest / FRANCE)
    • Pierre-Yves Egreteau (Morlaix / FRANCE)
    • Gwenaël Prat (Brest / FRANCE)
    • Eric Vicaut (Paris / FRANCE)
    • Olivier Huet (Brest / FRANCE)
    15h06 / 15h10
    Abstract : Fluid infusion is one of the cornerstones of sepsis resuscitation therapies. However, a paradigm shift is currently occurring as concerns have been raised about the potential adverse effects of fluid therapy. One of the major adverse effects reported is fluid overload (FO). FO is defined as a fluid accumulation > 10% of baseline body weight. The objective of this study was to assess influence of FO on SOFA score changes from day 0 to day 5. This study is a retrospective, multicenter, epidemiologic data analysis. All adult patients admitted for septic shock, caused by peritonitis or pneumonia and mechanically ventilated, were enrolled in the study. Delta SOFA score was defined as the SOFA score measured on admission minus SOFA score measured on day 5. Bivariate analysis was performed with parametric tests or non-parametric tests. A multivariate analysis was performed to study the association between FO and Delta SOFA score.129 patients met the inclusion criteria of the study. Cumulative fluid balance at day 5 was greater in the FO group, with a between-group difference of 5.977 ml (p-value < 0.001). Delta SOFA score was more than two-fold higher in the no FO group than in the FO group with a difference of 2.37 between the two groups (p-value = 0.001). Patients without FO were more rapidly discharge from ICU compared to patients with FO and had one week less of mechanical ventilation compare to FO patients (p-value < 0.05). There was a stepwise decrease of delta SOFA score when duration of fluid overload was greater (p-value = 0.001). In linear modelling, the association between fluid overload status and delta SOFA score was confirmed with an adjusted relative-risk of 0.15 (p-value = 0.009). In this study, we report that: 1) Exposition to fluid overload is a frequent event which occurs in about 40% of the patients of our cohort; 2) Fluid overload patients had more prolonged multi-organ failure during septic shock.
E-Poster
14h10 - 15h10
Espace poster 7
Médecin : Neurologie - Analgésie
Modérateur(s) : Nicolas Weiss (Paris / FRANCE), Romain Sonneville (Paris / FRANCE)
  • Safety and comfort of broncho-alveolar lavage with hypnosis and HFNC in critically ill immunosuppressed patients- preliminary data.
    Orateur(s) :
    • Virginie Lemiale (Paris / FRANCE)
    • Laure Calvet (Paris / FRANCE)
    • Michael Darmon (Paris / FRANCE)
    • Sandrine Valade (Paris / FRANCE)
    • Lionel Kerhuel (Paris / FRANCE)
    • Elie Azoulay (Paris / FRANCE)
    14h10 / 14h17
    Abstract : Patient with acute respiratory failure (ARF), broncho-alveolar lavage (BAL) are at high risk of intubation. Oxygenation procedure could improve safety in that setting. However those procedures are usually associated with discomfort, some patients need sedation which is also associated with a risk of intubation. Hypnosis has been suggested as useful in improving comfort.Observational feasibility study performed in 9 patients with ARF requiring 11 BAL. Hypnosis was induced by trained physician with technique described by Milton Erickson while fiberoptic bronchoscopies was performed by a pulmonologist after local anesthesia. All patients were highly hypoxemic. Intubation or need of non-invasive ventilation, within 24 hours after bronchoscopy was recorded. After bronchoscopy, comfort was assessed. Physician who performed the hypnosis recorded the achievement of hypnosis during bronchoscopy. Nine patients were admitted to ICU for ARF and need BAL. Median age was 52 [40-66] years old, 4/9 (44%) patients were male. Underlying immune defect was related to HIV (2 patients), steroids treatment (1 patient), allogeneic stem cell transplant (2 patients), hematological malignancy (4 patients). Suspected diagnosis of ARF was mainly pneumocystis pneumonia in 7 patients. Mean oxygen level before bronchoscopy was 5 [3.5-6] l/min and respiratory rate was 30 [25.5-32.5]/ min. No patient needed vasopressor before bronchoscopy. During BAL, HFNC was mainly used (9/11 (82%)) (table 1). No patient required cessation of bronchoscopy for intolerance. Only 4/11 (36%) had cough during BAL. Mechanical invasive ventilation was required within the 24 hours after bronchoscopy for one (9%) patient. Comfort was described very good by 4/11 (36%) patients, quite good for 1/11 (9%) patients, bearable for 5/11 (45%) and difficult for 1 (9%). Two patients did not reach hypnosis state during bronchoscopy and they described bronchoscopy as a bearable (1 patient) and difficult (1 patient). In other patients, hypnosis state was achieved (n= 6) or almost achieved (n=3). One patient who experiment 3 BAL asked for hypnosis for the 2 last bronchoscopies. Pulmonologist reported they felt bronchoscopy was easier than usually with hypnosis. Hypnosis seems feasible and safe for patient with ARF requiring BAL. It seems associated with an increase satisfaction rate for patient and pulmonologist. Additional comparative studies are needed to confirm these results.
  • Resuscitation residents' knowledge, attitudes and practices regarding the modalities of administration of antiepileptic drugs by nasogastric tube in comatose patients
    Orateur(s) :
    • Ramla Mizouri (Tunis / TUNISIE)
    • Rim Charfi (Tunis / TUNISIE)
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Emna Gaies (Tunis / TUNISIE)
    • Anis Klouz (Tunis / TUNISIE)
    • Sameh Trabelsi (Tunis / TUNISIE)
    14h17 / 14h24
    Abstract : In comatose patients, antiepileptic drugs (AED) are usually administered by nasogastric tube (NGT). This population often has residual plasma concentrations of AED outside the therapeutic range. The objective of our study was to estimate the modalities of administration of the AED by NGT in the various intensive care units in Tunis. Our study consisted on investigating the modalities of administration of AED's with NGT by residents in intensive care during four months. We prepared 10 questions including demographic informations. Participation was voluntary and anonymous. The questionnary was distributed in seven intensive care departments after authorization of each head of the departement. So 40 residents were included.Residents sex-ratio was 0.37 and mean age was 28 ± 2 years. For the period after which the NGT replacement is performed, the average of the responses was 6 ± 3 days. Residents who thought that AED were administered at the same time as food accounted for 42% of the total population. According to 90% of residents, the dosage form administered by NGT the most used in the intensive care unit was the tablets of which 95% think that it should be crushed before administration. Before introducing the drug into the NGT, 58% of residents thought it was mixed with tap water. No resident responded that treatment is introduced dry in NGT. According to residents, the most used AED in resuscitation services were phenobarbital (75%). All residents responded that to detect a possible under or overdose, the therapeutic drug monitoring is the best way in AED adjustment in this particular population. Among the residents, 62 % expressed the need for a training on the modalities of administration of the treatment by NGT to improve their knowledge.The management of the comatose under AED requires a control of the methods of administration by NGT. Thus, an action strategy should be put in place to improve the knowledge of the medical sector on this subject.
  • Upper airway viral infection and myasthenia gravis exacerbation
    Orateur(s) :
    • Rania Bounab (Garchess / FRANCE)
    • Nicholas Heming (Garchess / FRANCE)
    • Diane Friedmann (Garchess / FRANCE)
    • Bernard Clair (Garchess / FRANCE)
    • Pierre Moine (Garchess / FRANCE)
    • Elyanne Gault (Boulogne Billancourt / FRANCE)
    • Djillali Annane (Garchess / FRANCE)
    14h24 / 14h31
    Abstract : Myasthenia gravis (MG) is an autoimmune disorder characterized by generalized weakness (Gilhus NE. NEJM. 2016). Treatment of MG is based on immunosuppressants, mainly corticosteroids. The annual incidence of MG ranges between 0.8 to 1 cases per 100 000 (Carr AS et al. BMC Neurol. 2010). Acute exacerbations of MG are characterized by worsening muscle weakness, which may result in acute respiratory failure requiring invasive mechanical ventilation. Upper airway viral infections may induce acute exacerbations. Our aim was to describe the characteristics of myasthenia gravis exacerbations caused by upper airway viral infections, as well as their outcome. Retrospective cohort study undertaken in the medical ICU of a tertiary care hospital. All adult patients hospitalized for myasthenia gravis exacerbation due to a respiratory viral episode (positive multiplex PCR assay) between July 2009 and December 2017 were included.Upper airway viral infections caused 35 out of a total of 427 hospitalizations for MG exacerbation (8%) over an 8 year period. Affected patients were mainly female (n=23; 66%), IGS II: 43 ± 17, age 56 ± 18years, all patients were treated by immunosuppressors (systemic glucocorticoids and immunosuppressants for >3 months). Six patients (17%) required invasive mechanical ventilation. Vasopressors were required for 5 patients (14%). ICU-mortality was 11 % (n=4). Bacterial co-infection occurred in 4 patients (11%). Detected viruses were influenza (n=24; 69%), parainfluenza (n=2; 6%) and Respiratory syncytial virus (RSV) (n=9; 26%). Upper respiratory airway infection is not a frequent cause of myasthenia gravis exacerbation despite our population being immunosuppressed.
  • Predictive ability of Early PREdiction of DELIRium for Intensive Care (E-PRE-DELIRIC) to diagnose delirium in a low nurse-to-patient ratio Belgian ICU cohort.
    Orateur(s) :
    • Olivier Carelli (Maurage / BELGIQUE)
    • Karl Brousmiche (Etterbeek / BELGIQUE)
    • Jean-Charles Preiser (Bruxelles / BELGIQUE)
    • Pascal Sacre (Gilly / BELGIQUE)
    14h31 / 14h38
    Abstract : The PREdiction of DELIRium for Intensive Care (E-PRE-DELIRIC) model was developed in 2012(1) and was recalibrated for Early PREdiction (E-PRE-DELIRIC model) in 2015(2). This test has been proved to be feasible and fast to do in university hospitals or university affiliated teaching hospitals. It would be of high value to confirm this in a non-university ICU. The main outcome of this study was the predictive ability of E-PRE-DELIRIC to diagnose delirium. Therefore, a correlation between a positive E-PRE-DELIRIC score (> or =50%) (3) and an ICDSC score < or =4(4) (Intensive Care Delirium Screening Checklist) was searched. In a subsequent analysis, the performance of E-PRE-DELERIC was used in the cardiac surgery vs other patients. We also compared the abilities of E-PRE-DELERIC and APACHE II score to predict delirium.This study was approved by the medical ethical committee and all patients signed an informed consent. Data of all patients were collected in a secured electronic system. All consecutive patients aged > or =18y were included during a 6-week period. Patients were excluded if they had a cognitive dysfunction known at the admission or if chronic alcoholism. The E-PRE-DELERIC score was calculated by the physician 24 h after admission. The presence of delirium was screened by the nurses during a period of five days with ICDSC scale and NICS (Nursing Instrument for Communication of Sedation) score.80 patients were eligible for analysis. The overall incidence of delirium was 20% with the highest incidence of new-onset delirium on day 2. The results of the ROC analysis (Figure 1.) show that the E-PRE-DELIRIC score is highly discriminant (AUC: 0.881, 95% CI: 0.796-0.966). As seen in other studies (5-6), a higher incidence of delirium in the post cardiac surgery group (38 patients), with three times more delirium in this group compared to the general population. For the E PRE-DELERIC score, the threshold of 50% was the one that combined the maximal sensitivity and specificity (maximum Youden index =0.703) and for the APACHE II score, the threshold would be 15 but the E-PRE-DELIRIC score has more discriminative power than the APACHE II score (AUC : 0.747, 95% CI: 0.5983-0.8948).The E-PRE-DELIRIC delirium prediction model is reliable and remains fast and easy to do in a general non-university ICU, characterized by a great turnover of patients and of caregivers, and a rather low nurse-to-patient ratio (1:3 to 1:4), allowing early preventive measures aimed to reduce delirium incidence in those high risk patients (7).
  • Myoclonus after cardiac arrest: incidence, characteristics and outcome
    Orateur(s) :
    • Omar Ben Hadj Salem (Poissy / FRANCE)
    • Matthieu Jamme (Paris / FRANCE)
    • Marine Paul (Paris / FRANCE)
    • Lucie Guillemet (Paris / FRANCE)
    • Jean-Francois Llitjos (Paris / FRANCE)
    • Florence Dumas (Paris / FRANCE)
    • Julien Charpentier (Paris / FRANCE)
    • Jean-Daniel Chiche (Paris / FRANCE)
    • Jean-Paul Mira (Paris / FRANCE)
    • Hervé Outin (Paris / FRANCE)
    • Alain Cariou (Paris / FRANCE)
    14h38 / 14h45
    Abstract : Post cardiac arrest myoclonus (PCAM) can occur in patients admitted after cardiac arrest (CA) and their association with the outcome is debated. We aimed to identify incidence, risk factors and outcome of PCAM in this setting. We also described clinical characteristics and EEG patterns.Using the Cochin CA registry (PROCAT), we retrospectively included all consecutive CA patients admitted between January and December 2016 in the ICU. All patients were treated with targeted temperature management. Main outcome was prevalence of PCAM and survival at ICU discharge. Risk factors for PCAM, clinical characteristics and EEG patterns were also assessed.Among the 132 patients (73.5% male, median age 66 years) included in the analysis, 37 (28%) developed PCAM during their ICU stay. PCAM were associated with an initial non-shockable rhythm (p= 0.03) and with hypoxic cause (p=0.009). Only two patients with PCAM survived (5.4%) and only one PCAM patient had a good outcome (CPC 1), whereas 44 patients without PCAM (46.3%) survived at ICU discharge. Irreversible brain damages were the leading cause of death among patients with PCAM. We observed a strong association between myoclonus during ICU stay and mortality at ICU discharge (odds ratio 17.5 [4.2-123.2]). Clinical characteristics and EEG patterns were also reported. PCAM were observed in nearly one third of CA patients admitted in ICU. Myoclonus were independently but not invariably associated with ICU mortality. A syndromic approach combining semiology and electrophysiology could help to use myoclonus as a tool for prognostication after CA.
  • Therapeutic monitoring of antiepileptic drugs in comatose patients
    Orateur(s) :
    • Ramla Mizouri (Tunis / TUNISIE)
    • Rim Charfi (Tunis / TUNISIE)
    • Emna Gaies (Tunis / TUNISIE)
    • Anis Klouz (Tunis / TUNISIE)
    • Sameh Trabelsi (Tunis / TUNISIE)
    14h45 / 14h52
    Abstract : If the AED are administered by nasogastric tubes (NGT) in comatose patients, evaluation of AED efficacy and toxicity may be difficult. So, the therapeutic drug monitoring (TDM) may be useful in AED adjustment in this particular population. In this study, we aimed to analyze the trough plasmatic levels (C0) of AED administered by NGT in comatose patients. We conducted a retrospective study on comatose patients addressed over seven years (2009-2015) for a C0 measurement of AED administered by NGT. It included 105 samples from 44 patients. AED C0 were measured by an automated chimiluminescence technique (ARCHITECT®-ABBOTT®). We used the pharmacokinetic parameter C0/Dp (dose per weight) to assess the AED bioavailability in the included patients.In this study, the sex-ratio was 2.38. The patients' median age was 24 years. There was 14 % of children (≤16 years). Among the 105 samples, C0 measurement concerned valproic acid (VPA) in 56 %, phenobarbital (PNB) in 28 %, carbamazepine (CBZ) in 14 % and phenytoin in 2 %. Two AED or more were associated in 42 % of patients. AED were associated to other drugs in 85 % of cases. Polymedication (≥ 5 drugs) was noted in 21 % of cases. The AED C0 were subtherapeutic in 71 % of cases. The VPA C0 were subtherapeutic in 88 % of cases. Among the samples, 65 % corresponded to a value of C0/Dp lower than the recommanded one. In these samples, 55% presented at least one drug association with the concerned AED. In 45 % of the cases, there was no drug association but a non-respect of NGT modality of AED administration in patients.TDM is a useful tool to assess drug-drug interactions and to control modalities of AED administration in comatose patients.
  • Early in-hospital management of cardiac arrest from neurological cause: diagnostic pitfalls and treatment issues
    Orateur(s) :
    • Stéphane Legriel (Le Chesnay / FRANCE)
    • Wulfran Bougouin (Paris / FRANCE)
    • Richard Chocron (Paris / FRANCE)
    • Frankie Beganton (Paris / FRANCE)
    • Lionel Lamhaut (Paris / FRANCE)
    • Nicolas Deye (Paris / FRANCE)
    • Daniel Jost (Paris / FRANCE)
    • Antoine Vieillard-Baron (Boulogne / FRANCE)
    • Eloi Marijon (Paris / FRANCE)
    • Xavier Jouven (Paris / FRANCE)
    • Florence Dumas (Paris / FRANCE)
    • Alain Cariou (Paris / FRANCE)
    14h52 / 14h59
    Abstract : Out-of-hospital cardiac arrest (OHCA) is associated with poor short and long term outcomes. Determinants of outcome are related not only to the initial resuscitation process but also to the cause of the cardiac arrest itself. Cardiac causes of OHCA have been extensively studied in the recent decades; conversely, little is known on non-cardiac causes. In the present study, we aimed at reporting the diagnostic pitfalls and treatment issues in a large series of patients selected from a prospective population-based registry with a final diagnosis of OHCA from neurological cause (OHCA-NC). Furthermore, we also aimed to identify factors that were associated with the use of iCAG as first line investigation during the initial diagnostic check-up.Retrospective analysis of all consecutive patients from the Paris Sudden Death Expertise Centre (France) registry from May 2011 to September 2015 presenting with a sustained return of spontaneous circulation (ROSC) at hospital admission and a final diagnosis of OHCA-NC. Description of the early diagnostic check-up performed to identify the cause of cardiac arrest. Logistic multivariate regression to identify factors associated with immediate coronary angiography (iCAG) in OHCA-NC patientsAmong 3542 patients with ROSC, a final diagnosis of OHCA-NC was established in 247 (7 %). The early diagnostic check-up consisted in a total of 207 (84%) immediate cranial CT-scan, 66 (27%) iCAG and 25 (10%) chest CT-scan. The brain CT-scan allowed identifying a neurovascular cause in 116 (47%) patients. An iCAG was performed as the first line exam in 57 (23%) patients, in whom a final diagnosis of neurovascular cause for OHCA-NC was later identified in 41 patients. By multivariate analysis, decision for iCAG was independently associated with ST-segment elevation on post-ROSC electrocardiogram (OR, 5.94; 95%CI, 2.14-18.28; P=0.0009), whereas an obvious cause of cardiac arrest on scene was negatively associated with iCAG (OR, 0.14; 95%CI, 0.02-0.51; P=0.01). OHCA-NC is a rare event that is mainly related to neurovascular causes. The initial ECG pattern may be a confounder regarding triage for early diagnostic check-up. Further studies are required to explore the potential harmfulness associated with decision to perform an iCAG in this population.
  • Mood disorders in a Tunisian intensive care unit (ICU) survivors
    Orateur(s) :
    • Marwa Zghidi (Sousse / TUNISIE)
    • Imen Ben Saida (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Nesrine Fraj (Sousse / TUNISIE)
    • Mohamed Ahmed Boujelben (Sousse / TUNISIE)
    • Wafa Zarrougui (Sousse / TUNISIE)
    • Badii Amamou (Monastir / TUNISIE)
    • Mohamed Boussarsar (Sousse / TUNISIE)
    14h59 / 15h06
    Abstract : Anxiety and Depression are unpleasant emotions that many ICU survivors experience. Those psychiatric disorders can impact negatively their quality of life. Little is known about the factors associated with anxiety and depression after critical illness. The aim was to evaluate the incidence of anxiety and depression among critical care survivors and identify their risk factors.It is a mixed method study conducted in a medical ICU from January 2017 to January 2018 including all ICU survivors beyond 3 months after discharge.. Data were obtained from medical records. At 3 months post-ICU discharge, patients were contacted by phone to complete the Hospital Anxiety and Depression Scale (HADS). Univariate and logistic regression analyses were used. 393 patients were admitted during the study period. 191 (48.6%) were discharged alive, 56(29.3%) were never successfully contacted and 21(11%) died within the 3 months' period. 114 patients were enrolled in the study. Patients' characteristics were : mean age 56.29±17.88 years ; male, 66(57.9%) ; mean SAPSII, 25.04±12.1 ; invasive mechanical ventilation (IMV), 47(41.2%) vasopressors use, 30(26.3%). Anxiety and depressive symptoms were found respectively in 24(21.1%) and 11(9.6%) ICU survivors. Median HADS-A and HADS-D scores were respectively 4 [3-10] and 5 [4-6]. In univariate analysis, factors associated with anxiety were: age (44±20 vs 59.56±15, p=0.001), female sex (62.5% vs 36.7%, p=0.023), IMV (75% vs 32.2%, p=0.000) and sedative use (57% vs 32.2%, p=0.000). On multivariable logistic regression, sedative use (OR, 6.1 ; 95%CI, [1.9 -19] ; p=0.002), female sex (OR, 3.08 ; 95%CI, [1.03 -9.2] ; p=0.044) and age (OR, 0.96 ; 95%CI, [0.94-0.99] ; p=0.024) were independently associated with anxiety. Only age (41.9±19 vs 57.83±17, p=0.005) was associated to depression in univariate analysis. On multivariable logistic regression, sedative use (OR, 5.26 ; 95%CI, [1.25 -22] ; p=0.023) and female sex (OR, 5.07 ; 95%CI, [1.2 -21.24] ; p=0.026) were independently associated to depression. Mood disorders are rather common in ICU survivors. Female sex, young age and sedative use were independently associated with anxiety and depression after ICU discharge.
E-Poster
14h10 - 15h10
Espace poster 8
Médecin : Insuffisance Respiratoire 1
Modérateur(s) : Guillaume Carteaux (Créteil / FRANCE), Jean-Pierre Frat (Poitiers / FRANCE)
  • Influence of the noninvasive ventilation protocol on intubations rates in patients with de novo acute respiratory failure: a systematic review of randomized trials.
    Orateur(s) :
    • Rémi Coudroy (Poitiers / FRANCE)
    • Marie Anne Hoppe (Poitiers / FRANCE)
    • Jean-Pierre Frat (Poitiers / FRANCE)
    • Arnaud Thille (Poitiers / FRANCE)
    14h10 / 14h17
    Abstract : Continuous application of noninvasive ventilation (NIV), using a dedicated ventilator, with high levels of positive end-expiratory pressure (PEEP), and in an expert center could be more efficient to reverse respiratory failure. We performed a systematic review of randomized controlled trials to assess whether the protocol to carry out NIV may influence intubation rates in patients admitted to ICU for de novo acute respiratory failure. All randomized trials were identified from PubMed and Embase from inception to April 2018. Pediatric studies, performed outside the ICU, including patients treated for another reason than de novo respiratory failure, and in which NIV protocol was not specified were excluded. Two authors independently extracted intubation rates and the NIV protocol especially continuous application or by intermittent sessions, the type of ventilator, set PEEP levels and centers' experience (single versus multicenter studies). Fourteen studies including 750 ICU-patients treated by NIV for de novo respiratory failure were identified. Overall intubation rate was 39% [33-46] and was not influenced by continuous application of NIV, the type of ventilator, or the expertise of centers. Intubation rates were lower in studies using higher PEEP levels (> 6 cm H2O) than the others (25% [15-37] vs. 35% [33-54], p=0.025). Inclusion criteria were heterogeneous and numerous critical data on NIV were lacking. Except high PEEP levels that might be associated with lower intubation rates, the protocol to carry out NIV does not seem influence outcomes in patients with de novo respiratory failure.
  • High-flow nasal oxygen therapy: Clinical practice in French north-west intensive care units
    Orateur(s) :
    • Emmanuel Besnier (Rouen / FRANCE)
    • Sinad Hobeika (Rouen / FRANCE)
    • Fabien Lambiotte (Valenciennes / FRANCE)
    • Damien Du Cheyron (Caen / FRANCE)
    • Bertrand Sauneuf (Cherbourg / FRANCE)
    • Benoit Misset (Rouen / FRANCE)
    • Fabienne Tamion (Rouen / FRANCE)
    • Guillaume Schnell (Le Havre / FRANCE)
    • Jack Richecoeur (Beauvais / FRANCE)
    • Christophe Girault (Rouen / FRANCE)
    14h17 / 14h24
    Abstract : Despite an extensive use of High-Flow Nasal Oxygen therapy (HFNO) for acute respiratory failure (ARF), daily clinical practice has not been assessed yet. We therefore designed a regional survey to evaluate the physician's clinical experience.We performed an observational survey (Surveymonkey online software) to senior physicians belonging to the north-west ICU Boreal Study group, during a 3 months period in 2016-2017. Thirty-four ICU were solicited. The survey included questions regarding the effective use of HFNC, indications and expected efficiency, practical aspects of use (initiation, weaning). Results are presented as medians with first and third quartiles or percentage of responses.137 ICU physicians over 235 answered (58.3%). All regularly use HFNO. Admissions for ARF were 20.4/ICU bed. Indications and expected results of HFNO are presented in table 1. Hypoxemic ARF was considered as the best indication (100%) with pneumonia and thoracic trauma as favorite. Nevertheless, physicians considered HFNO efficient (i.e avoiding intubation in at least 60% of cases) for hypoxemic ARF in only 28.6% of cases. Hypercapnic ARF was considered as a good indication for only 32.5% of physicians with an expected success rate of 1.5%. 40.2% of physicians estimated that HFNO was indicated for conventional oxygen needs >6L/min, 39.1% for >9L/min, 11.8% for >12L/min and 8.8% for >15L/min. HFNO was mainly used via a specific device (91.1%) or a ventilator (65.2%). 58% of physicians initiate HFNO with 50-100% FiO2 and progressive increase in flow. 92.8% regularly use HFNO continuously and 54.1% intermittently with NIV. Practices for HFNO weaning were heterogeneous depending on situations, but FiO2<30% was considered as necessary to stop HFNO for 47.8% , whereas such a FiO2 and a flow < 20 L/min was required for 29.7%. Criteria for HFNO failure (i.e. need for intubation) were ventilatory pauses or arrest (93.6%), persistent hypoxemia (94.5%), respiratory acidosis (80.9%), respiratory worsening (94.5%) and bronchial congestion occurrence (78.2%).HFNO can be considered by ICU physicians in many situations of ARF despite a relatively low expected success rate, especially in cases of hypercapnia. Clinical practices appear very heterogeneous regarding administration and weaning modalities. Despite the physiological benefit of HFNO, these results may reflect some discrepancies between current clinical studies. Further prospective observational studies are needed on HFNO daily practices.
  • Teaching Mechanical Ventilation for Residents in Intensive Care A randomized Trial Using Traditional Lectures VS Computer-Based Simulation (SimVA©)
    Orateur(s) :
    • Hadrien Rozé (Bordeaux / FRANCE)
    • Etienne Rivière (Bordeaux / FRANCE)
    • Remi Dubois (Bordeaux / FRANCE)
    • Alexandre Ouattara (Bordeaux / FRANCE)
    14h24 / 14h31
    Abstract : During educational process, trainees apply their knowledge to treat patient in intensive care before achieving full clinical competency. Moreover, advances in knowledge regarding mechanical ventilation in particular lung protective ventilation and asynchronies have been shown to be associated with mortality. For these reasons we developed a simulator of controlled and spontaneous artificial ventilation (SimVA) and virtual breathing patients. Mathematical model resolved differential equations of chest and lung movements according to inspiratory effort or not in order to match with a clinical database. The aim of this study was to compare two teaching modalities on mechanical ventilation: traditional lectures versus virtual simulation.This randomized controlled study involved 54 residents. One group of 22 participants attended the same didactic lecture on mechanical ventilation (3 hours) whereas the other 22 were in the simulator group (3 hours). Performance was measured using a pre and post-test evaluation of knowledge on respiratory settings and pressure flow time curves monitoring. A retention test was done at 3 months (The same questioner was used for pre, post and retention test). Comparison was individual in each group (ANOVA, multiple comparison) and between groups (Mann-Whitney), p<0,05 was considered significant. Baseline knowledge was not different between groups; post-test was significantly improved in both groups (figure) but was significantly higher in the simulator group. Retention test was only significantly different from the pre-test in the simulator group.A computer-based simulation with a modelisation of controlled and spontaneous mechanical ventilation has the potential to improve knowledge and skills in ventilator settings in comparison to traditional didactic lectures.
  • Pressure support titration to personalize assistance: preliminary results
    Orateur(s) :
    • Francois Perier (Créteil / FRANCE)
    • Tommaso Maraffi (Créteil / FRANCE)
    • Bruno Louis (Créteil / FRANCE)
    • Keyvan Razazi (Créteil / FRANCE)
    • Nicolas de Prost (Créteil / FRANCE)
    • Guillaume Carteaux (Créteil / FRANCE)
    14h31 / 14h38
    Abstract : Usually, clinicians do not measure the respiratory effort under mechanical ventilation, as it requires the use of an esophageal catheter. Keeping patient's respiratory effort within a normal range during pressure support ventilation (PSV) is therefore difficult to achieve. The main aims of this study were: 1 to describe the relation between the respiratory pattern and respiratory effort indices over a wide titration of pressure support level (PSL) in PSV, 2 to assess new calculated indices of respiratory effort that do not require an esophageal catheter. Patients were eligible during the first 48 hours after the switch from controlled ventilation to PSV. The PSL was decreased by steps of 2 cmH2O from 20 to 6 cmH2O. Flow, airway and esophageal pressures, and electrical impedance tomography (EIT) signals were continuously recorded during the titration. P0.1 was measured at each step. Indices of respiratory effort, including muscle pressure (Pmus) and esophageal pressure-time product (PTPes) were derived from recorded signals. The calculated Pmus (Pmuscalc) and PTPes were computed using the equation of motion of the respiratory system and respiratory mechanics previously collected while patients were under controlled ventilation. These preliminary results involve the first five patients. Tidal volume (Vt) variations over the PSL titration depended on the basal level of respiratory effort. Vt values remained relatively stable during normal or underassisted efforts (PTPes above 50 cmH2O.s.min-1) and increased dramatically in case of overassistance (PTPes below 50 cmH2O.s.min-1) (Figure 1). The Pmuscalcl calculated at peak inspiratory flow correlated with the actual peak of Pmus (r=0,34; p<0,0001). In addition, P0.1 seemed better correlated with Pmus (r=0,76 ; p<0,0001) than Pmuscalcl. Definitive results, including EIT assessment, will be presented at the meeting.These preliminary data suggest the potential interest of analyzing Vt values evolution over a PSL titration. Furthermore, new calculated tools, as Pmuscalc may help clinicians assessing respiratory effort at the bedsides and personalizing the level of assistance.
  • Body mass index and outcome of immunocompromised ICU patients
    Orateur(s) :
    • Audrey de Jong (Montpellier / FRANCE)
    • Peter Pickkers (Nijmegen / PAYS-BAS)
    • Marcio Soares (Rio de Janeiro / BRÉSIL)
    • Anders Perner (Copenaghe / DANEMARK)
    • Philippe Bauer (Rochester / ETATS-UNIS)
    • Jordi Rello (Barcelone / ESPAGNE)
    • Andry Van de Louw (Hershey / ETATS-UNIS)
    • Pleun Hemelaar (Amsterdam / PAYS-BAS)
    • Ignacio Martin-Loeches (Dublin / IRLANDE)
    • Tine Sylvest Meyhoff (Copenaghe / DANEMARK)
    • Jorge Salluh (Rio de Janeiro / BRÉSIL)
    • Peter Schellongowski (Vienne / AUTRICHE)
    • Katerina Rusinova (Prague / RÉPUBLIQUE TCHÈQUE)
    • Sangeeta Mehta (Toronto / CANADA)
    • Massimo Antonelli (Rome / ITALIE)
    • Achille Kouatchet (Angers / FRANCE)
    • Andreas Barrat Due (Oslo / NORVÈGE)
    • Miia Valkonen (Helsinki / FINLANDE)
    • Pearl Landburg (Groningen / PAYS-BAS)
    • Fabrice Bruneel (Versailles / FRANCE)
    • Ramin Brandt Bukan (Herley / DANEMARK)
    • Anne-Sophie Moreau (Lille / FRANCE)
    • Virginie Souppart (Paris / FRANCE)
    • Gaston Burghi (Montevideo / URUGUAY)
    • Christophe Girault (Rouen / FRANCE)
    • Ulysse V A Silva (Barretos / BRÉSIL)
    • Luca Montini (Rome / ITALIE)
    • Lene Nielsen (Odense / DANEMARK)
    • Benjamin Gaborit (Nantes / FRANCE)
    • Samir Jaber (Montpellier / FRANCE)
    • Elie Azoulay (Paris / FRANCE)
    14h38 / 14h45
    Abstract : In the immunocompromised intensive care unit (ICU) population, the association of prognosis and body mass index (BMI) has never been assessed. The objectives of this study were to determine: 1) the influence of BMI on ICU immunocompromised patient's mortality. 2) the risk factors of ICU mortality according to the BMI.A post-hoc analysis of a prospective, multinational cohort study, performed in 16 countries in immunocompromised acute-respiratory-failure (ARF) patients, was conducted. The primary endpoint was ICU-mortality rate. Impact of BMI on ICU-mortality and risk factors according to BMI were analysed using multivariate Cox analysis. The best threshold for separating dead from alive patients was determined using the Youden index.In the 1483 patients with BMI available, the overall ICU-mortality rate was 32% (470/1483). Ninety-one (6%) patients were underweight (32% ICU-mortality), 646 (44%) normal weight (32% ICU-mortality), 457 (31%) overweight (31% ICU-mortality), 172 (12%) obese grade 1 (33% ICU-mortality), 80 (5%) obese grade 2 (29% ICU-mortality) and 37 (2%) obese grade 3 (24% ICU-mortality). After multivariate Cox analysis including initial oxygenation strategy, Sequential Organ Failure Assessment (SOFA) score without respiratory item, PaO2/FiO2 ratio < 100 at ICU admission, invasive mechanical ventilation, pattern of chest X ray and etiology of ARF, higher BMI was significantly associated with lower mortality rate (Adjusted HR (aHR) = 0.98(0.97-1.00), P=0.02). No centre effect was observed. Two BMI groups were separated: low (<28kg/m²) and high (BMI≥28 kg/m²), the adjusted risk of dying being lower in the high BMI (≥28 kg/m²) group compared to the low BMI (< 28 kg/m²) group: (aHR=0.81(0.65-1.00), P=0.05). After multivariate Cox analysis, some risk factors of mortality were common to both groups: SOFA score without respiratory item, NIV use and invasive mechanical ventilation, other found only in the low BMI group: PaO2/FiO2 ratio <100mmHg and alveolar-interstitial radiologic pattern (Figure 1).In immunocompromised ARF patients, higher BMI was associated with lower mortality. Contrary to the low BMI group, PaO2/FiO2 ratio and radiological pattern were not associated with mortality in the high BMI group. These results, suggesting that PaO2/FiO2 ratio and radiological pattern are not reliable to predict prognosis of obese ARF patients, might be one explanation to the inverse adjusted association observed between ICU mortality and BMI.
  • Airway pressures and difficult weaning prediction in mechanically ventilated patients
    Orateur(s) :
    • Wafa Zarrougui (Sousse / TUNISIE)
    • Nesrine Fraj (Sousse / TUNISIE)
    • Mohamed Ahmed Boujelben (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Marwa Zghidi (Sousse / TUNISIE)
    • Ahmed Khedher (Sousse / TUNISIE)
    • Imen Ben Saida (Sousse / TUNISIE)
    • Abdelbaki Azouzi (Sousse / TUNISIE)
    • Khaoula Meddeb (Sousse / TUNISIE)
    • Mohamed Boussarsar (Sousse / TUNISIE)
    14h45 / 14h52
    Abstract : Mechanical Ventilation (MV) is intended to improve gas exchange and offset the work of breathing. Newtonian equation of motion clearly illustrates the respective restrictive and/or elastic components that could impede ventilation. Static and dynamic airway pressures (Paw) may be of valuable assistance to weaning process. The aim was to identify the discriminative properties of Paw to predict difficult weaning.A chart reviews of consecutive MV patients admitted to our MICU from November 2015 to February 2018 was performed. Patients' characteristics at admission, Paw (at admission and at day 4), high pressure ratio (HPR= number of days spent with high pressures: peak >=40 cmH2O and/or plateau >=30 cmH2O; and/or driving >=14 cmH2O; and/or auto-PEEP >=6 cmH2O; divided by LOS) and outcomes were recorded. Difficult weaning was expressed by prolonged duration of MV >= 7 days, null ventilator-free days at day 28 (VFDs), and a composite outcome : death and/or LOS >= 14 days. Univariate and multivariate regression analyses were performed to identify factors independently associated to difficult weaning.Were included 304 MV patients. Their main characteristics were : mean age, 56±18years ; mean SAPSII, 35±14 ; pH, 7.3±0.1 ; pCO2, 50±23mmHg ; PaO2/FiO2, 204±101mmHg ; AE/COPD, 105(34.5%) ; ARDS, 25(8.2%) ; median MV duration, 6[3;14] days ; LOS, 13[6; 21] days ; tracheostomy, 44(14.5%) and mortality, 173(56.9%). Mean Paw were respectively for peak, plateau, driving and auto-PEEP at admission: 32.3±9.2, 20.4±6, 13.4±5, 4.4±4.2 cmH2O and at day 4: 32.6±10, 20.9±6.6, 13.8±5.3, 6.5±4.4 cmH2O. Median HPR was 0.15[0-0.6]. Multivariate analysis yielded the following variables as independently associated to the studied endpoints: 1) VFDs: plateau at day 4 (OR, 1.06 ; 95%CI, [1.01-1.12] ; p=0.019) and HPR (OR, 1.07 ; 95%CI, [1.01- 1.14] ; p=0.03); 2) prolonged duration of MV : HPR (OR, 3.4 ; 95%CI, [2.2- 5.7] ; p=0.000); 3) composite outcome: plateau at day 4 (OR, 1.13 ; 95%CI, [1.05- 1.22] ; p=0.01) and HPR (HR, 1.97 ; 95%CI, [1.04-1.37] ; p=0.01). High plateau pressure and the number of days spent with high Paw seem to alter significantly the weaning.
  • Reproducibility of real-time shear wave ultrasound elastography, a new tool for the evaluation of diaphragm and limb muscles stiffness in critically ill patients: preliminary results of the ULTRAMUSCLE Study
    Orateur(s) :
    • Yassir Aarab (Montpellier / FRANCE)
    • Aurélien Flatres (Montpellier / FRANCE)
    • Stefan Matecki (Montpellier / FRANCE)
    • Mathieu Amalric (Montpellier / FRANCE)
    • Jean-Jacques Tudesq (Montpellier / FRANCE)
    • David Chapeau (Montpellier / FRANCE)
    • Samir Jaber (Montpellier / FRANCE)
    • Kada Klouche (Montpellier / FRANCE)
    • Boris Jung (Montpellier / FRANCE)
    14h52 / 14h59
    Abstract : In critically ill patients, Intensive care unit (ICU)-acquired weakness is a complication commonly observed and is associated with poor outcomes and increased length of stay. The assessment of skeletal muscle and diaphragm ICU-associated morphological changes is usually appreciated by ultrasonography. Shear wave elastography (Swe) is a novel technique which allows to measure the absolute elasticity value (kPa) of soft tissues and to quantify their mechanical properties. We therefore aimed to determine the reliability and reproducibility of ultrasonographic Swe measurements in critically ill patients. In a first phase, two operators tested, in 16 healthy subjects, various probe positions in order to select the most reproducible. Among them, the best 3 probe positions were used to examine their intra and inter-operator reliability in 15 other healthy subjects. In the second phase, intra and inter-operator reliability of elastography was evaluated in 12 critically ill patients. Each operator was blinded to the measurements of the other one. IRB was obtained (2017-CLER-MTP-09-16 Reliability was calculated using the intra-class correlation coefficient (ICC) and a bootstrap sampling method assessed their consistency. The measurements of elastic modulus of diaphragm, biceps brachii, and rectus femoris on 31 healthy subjects and 12 critically ill patients leaded to the record of 622 Swe elastograms. In the first group of healthy subjects, inter-operator reliability favored longitudinal view rather than the transverse one except for diaphragm. (Respective ICC: 0.29 vs 0.83, 0.88 vs 0.39, and 0.86 vs 0.7). In the second group of healthy subjects, no significant differences were found in the 3 muscles stiffness measurements between the 2 operators results. A very satisfactory inter-operator and intra-operator reliability was observed for all measurements with an ICC values ranging from 0.76 to 0.96 (table 1). In critically ill patients, within-operator and between-operator reliability of Swe measurements was also satisfactory (ICC = 0.83 – 0.98) (table 1). The probability to reach inter-rater ICCs greater than 0.8 in a 10.000 bootstrap sampling was respectively 98%, 100% and 72%. In critically ill patients, the feasibility, reproducibility and reliability of ultrasonographic SWe measurements of limb muscles and the diaphragm assessed herein were fair. Though our results may encourage the promotion of this technique in ICU settings, its application to the understanding and management of ICU-acquired weakness needs to be further studied.
  • Acquired von Willebrand syndrome in patients with extracorporeal CO2 removal
    Orateur(s) :
    • Amélie Couteau (Paris / FRANCE)
    • Nadia Rivet (Paris / FRANCE)
    • Jean-Loup Augy (Paris / FRANCE)
    • Damien Vimpere (Paris / FRANCE)
    • Aymeric Lancelot (Paris / FRANCE)
    • Morgane Commereuc (Paris / FRANCE)
    • Clotilde Bailleul (Paris / FRANCE)
    • Etienne Puymirat (Paris / FRANCE)
    • Emmanuel Guerot (Paris / FRANCE)
    • Ana Novara (Paris / FRANCE)
    • David Smadja (Paris / FRANCE)
    • Pascale Gaussem (Paris / FRANCE)
    • Jean-Luc Diehl (Paris / FRANCE)
    14h59 / 15h06
    Abstract : Acquired von Willebrand syndrome (AVWS) is a hemostasis disorder widely described with different extracorporeal circulatory assistances. Conversely, very few data are available in the field of extracorporeal CO2 removal (ECCO2R). We report the results of a prospective monocentric study focusing on von Willebrand disorders induced by ECCO2R devices.Prospective study performed in 20 consecutive patients treated with ECCO2R (either Hemolung® or iLA activve® device). Biological testing included: platelet function analyzer–adenosine diphosphate (PFA-ADP) and –epinephrine (PFA-EPI), von Willebrand factor antigen (VWF :Ag) and activity (VWF :RCo), and multimeric profile (Hydrasys 2 system). Measurements were performed prior to ECCO2R initiation, then at 5, 30, 60 and 180 minutes, daily during ECCO2R from D1 to D7, and 24 hours after stopping ECCO2R. Bleeding and thrombotic events were recorded.Hemolung® was used in 8 patients, and iLA activve® in 12 between January 2017 and July 2018. The indications for ECCO2R were acute exacerbation of chronic obstructive pulmonary disease (n = 16), acute respiratory distress syndrome (n = 3), and severe acute asthma (n = 1). Significant prolonged PFA-ADP (151s of median time at D1 versus 82s at D0, p = 0,0001) and PFA-EPI (214s at D1 versus 106 at D0, p = 0,0017) were observed in 19 patients (one patient with missing data) during ECCO2R, and normalized in respectively 11 and 10 among the 14 patients tested 24 hours after stopping ECCO2R. The VWF :RCo/VWF :Ag ratio decreased for all patients between 60 minutes and D1 (0,65 of median ratio at D1 versus 0,93 at D0, Figure 1A, 1B). The ratio was normalized 24 hours after ECCO2R cessation in 8 of the 10 patients tested. Loss of high molecular weight multimers occured in all patients tested (n = 14) as early as 60 minutes (0,48 of median ratio at D1, versus 1,05 at D0) and was associated with an increase in low molecular weight multimers (Figure 1C, 1D). Fourteen bleeding events were reported. Nine thrombotic events were reported (6 at the right internal jugular cannulation site, 3 device's thrombosis). There was a trend to a more pronounced decrease in high molecular weight multimers in patients with bleeding events.Von Willebrand disorders were observed in all ECCO2R patients. They may contribute at least in part to the frequency and severity of bleeding complications observed in this population.
E-Poster
14h10 - 15h10
Espace poster 9
Médecin : BPCO : insuffisance respiratoire chronique hypercapnique
Modérateur(s) : Nicolas Terzi (Grenoble / FRANCE), Muriel Fartoukh (Paris / FRANCE)
  • Acute exacerbation of chronic obstructive pulmonary desease : prognostic and patients's characteristics
    Orateur(s) :
    • Hela Kallel (Sfax / TUNISIE)
    • Karama Bouchala (Sfax / TUNISIE)
    • Sabrine Bradai (Sfax / TUNISIE)
    • Amal Triki (Sfax / TUNISIE)
    • Olfa Turki (Sfax / TUNISIE)
    • Mabrouk Bahloul (Sfax / TUNISIE)
    • Mounir Bouaziz (Sfax / TUNISIE)
    14h10 / 14h17
    Abstract : We aimed to identify the characteristics of patients with severe acute exacerbation of chronic obstructive pulmonary disease (COPD) and evaluate the prognostic of COPD patients. This is a retrospective study performed during a 10-year period in the ICU of Habib Bourguiba University Hospital (Sfax, Tunisia). All patients with severe acute exacerbation of COPD were included. During the study period,169  patients with acute exacerbation of COPD were admitted in our ICU, 65(38,5%) were emphysema patients. The mean age (±SD) was 67,99 ± 9.8 years,the sex ratio was at 7.04. The most common comorbidities were hypertension in 54(32%) patients,cardiac failure in 36(21,3%)situations and diabetes in 32(18,9%) cases. The mean SAPSII score was 38,34(±13,29). On ICU admission 94 of patients have acute circulatory failure and 124(73,4%) patients required mechanical ventilation. Mortality rate in this study was around 49,1%,length of stay (LOS) was at 8 [1;69] and length of invasive ventilation medians was 8[1;39]. During their ICU stay evolution was marked by death of 83(49,1%) patients mortality was significantly higher in patients with cardiac failure (63.88% vs 44,71%; P = 0.043) and those who necessitate the introduction of catecholamines in admission (60% vs 23% P=0,000) .A high plasma urea and plasma creatinine concentration were significantly associated with mortality P=0,000 ; P=0,003 respectively . Copd exacerbation is a frequent cause of hospitalization in ICU ,severe form requiring mechanical ventilation were associated with a poor outcomes. Development of Shock and acute kidney injury were significantly associated with mortality.
  • Predictors of invasive ventilation requirement in acute exacerbations of chronic obstructive pulmonary disease
    Orateur(s) :
    • Jihene Guissouma (Bizerte / TUNISIE)
    • Sourour Belhaj Youssef (Bizerte / TUNISIE)
    • Hatem Ghadhoune (Bizerte / TUNISIE)
    • Hana Benali (Tunis / TUNISIE)
    • Habib Brahmi (Bizerte / TUNISIE)
    • Sana Karrat (Bizerte / TUNISIE)
    14h17 / 14h24
    Abstract : Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are the most important events characterizing respiratory illness progression. Their management often needs intensive care unit hospitalization and ventilator support either noninvasive ventilation (NIV) or invasive ventilation (IV). The objective of our study was to describe the epidemiologic and clinical characteristics of patients admitted for AECOPD, the treatment and the evolution in ICU in order to deduce the factors predicting IV. A 4-year retrospective analytic observational single-center study including patients with AECOPD. Statistical analyses were performed with SPSS 23. Eighty nine patients were enrolled. Mean age was 67±9 years and male/female ratio was 3.9. Seventy nine percent were smokers and 50 % were classified GOLD stage 3. History of noninvasive ventilation (NIV) and invasive ventilation (IV) were found in 64 % and 34 % of all cases respectively. Mean progression of COPD was 9±5 years and mean exacerbations frequency was 1.89±0.9 per year. Mean duration of symptoms before hospitalization (DSBH) was 5±4 days. Mean SAPS II and APACHE II were 38±15 and 20±8 respectively. Mean pH, paCO2 and paO2/fiO2 were 7.28±0.2, 80±28 mmHg and 221±105 respectively. Mean GCS was 11±4 and it was less than 9 in 25% of all cases. The predominant precipitating factor for acute exacerbation (AE) was respiratory tract infection (69% of all cases). Thirty two percent of our patients had a septic choc at admission. Symptomatic treatment was based on inhaled bronchodilators, corticosteroids and mechanical ventilation: NIV in 70 % and IV in 61 % of all cases. Twenty two patients were intubated immediately after hospitalization and 32 after NIV failure. Mortality was 40 %. The duration of COPD progression (p= 0.039), exacerbations frequency per year (p=0.013), prior IV (p= 0.04), DSBH (p= 0.002), SAPS II (p= 0.003), GCS (p<10-3), pH (p=0.01) and septic choc at admission (p=0.004) were all predictive of IV in univariate analysis but only GCS (p=0.002) was significant in multivariate analysis. Requirement of IV in AECOPD depends on the severity of the underlying respiratory illness, the gravity of the AE and the quality of an early management. Thus, basic treatment improvement and an early appropriate treatment of the AE might reduce its severity and the need of IV.
  • CORE- REA preliminary study : COPD Right hEart and REspiratory Acidosis
    Orateur(s) :
    • Jean-Loup Augy (Paris / FRANCE)
    • Aymeric Lancelot (Paris / FRANCE)
    • Clotilde Bailleul (Paris / FRANCE)
    • Damien Vimpere (Paris / FRANCE)
    • Amélie Couteau (Paris / FRANCE)
    • Ana Novara (Paris / FRANCE)
    • Emmanuel Guerot (Paris / FRANCE)
    14h24 / 14h31
    Abstract : Influence of respiratory acidosis on right ventricular(RV) function in severe exacerbation of chronic obstructive pulmonary disease(COPD) patients placed under invasive mechanical ventilation (IMV) remains unclear. Few previous studies reported conflicting results and respiratory acidosis might decrease contractile function in cardiomyocytes. Veno-venous extracorporeal CO2 removal (ECCO2R), increasingly used in the setting of COPD allows acute modifications of PaCO2 and pH. We aimed to detect the influence of PaCO2 decreased with ECCO2R on the RV systolic function assessed by variation of the systolic velocity wave at tricuspid annulus(St). This was a monocentric observational ancillary study of the REXECOR study(NCT02965079). All patients presenting with severe exacerbation of COPD and implanted by ECCO2R [Hemolung(Alung Technologies, Pittsburgh, USA)] were assessed by transthoracic echocardiography(TTE) at baseline and one hour after starting ECCO2R. IMV ventilation parameters were kept unmodified two hours before and one hour after the beginning of ECCO2R. TTE data, IMV parameters and arterial blood gas were simultaneous collected. Seven patients[(5 women, median age 63 years(56-73), median body mass index 39.5kg/m2 (24.1-47.0)] were included from November 2017 to February 2018. Median SAPS2 at admission was 32(29-40) and respiratory SOFA was 3(2-3). Regarding TTE findings, the 7 patients had RV hypertrophy with RV free wall superior to 5 mm (6.9mm±0,9) and no RV dysfunction was reported (Mean St=20.1±5.1cm/s and mean TAPSE=21.8±5.7mm). The ECCO2R induced a significant variation of PaCO2 from 68mmHg(67-75) to 57mmHg (52-59),P<0.009 and of pH from 7.24(7.23-7.28) to 7.37(7.27-7.37),P=0.025 Figure 1 shows evolution of echo parameters and PaCO2 after ECCO2Rimplantation. There was no difference between S' wave value after significant reduction of PaCO2 by ECCO2R (p=0.16) whereas systolic pulmonary arterial pressures (sPAP) decreased significantly from 45.2mmHg(±5.4) to 38.0mmHg(±7.6), P=0.01. Pulmonary vascular resistance(PVR) was also not significantly decreased[2.24UW(±0.41) vs. 1.80UW(±0.39), P=0.07]. Of note, parameters assessing the LV function did not change during the ECCO2R flow variations. In the physiological study, the decreased of PaCO2 induced by the ECCO2r flow variations lead to a decreased of sPAP without modifying the systolic RV function parameters.
  • Do comorbidity phenotypes in COPD impact the outcome of ICU admission following COPD exacerbation
    Orateur(s) :
    • Redwan Maatoug (Paris / FRANCE)
    • Wiem Nouira (Monastir / TUNISIE)
    • Zeineb Hammouda (Monastir / TUNISIE)
    • Manel Lahmar (Monastir / TUNISIE)
    • Nacef Ben Mrad (Monastir / TUNISIE)
    • Islem Ouanes (Monastir / TUNISIE)
    • Fahmi Dachraoui (Monastir / TUNISIE)
    • Lamia Besbes (Monastir / TUNISIE)
    14h31 / 14h38
    Abstract : “Comorbidomes” correspond to comorbidities that are frequently associated in COPD (such as cardiovascular disease, diabetes, oetoporosis, sarcopenia) carrying a significant impact on mortality. The distribution and the type of comorbidities vary between studies but agreement exists on five phenotypes of comorbidities: The current study was conducted to determine the association between specific comorbidities and ICU survival of acute exacerbation of COPD . : Consecutive patients admitted to the ICU for hypercapnic exacerbation of COPD were classified according to associated comorbidities in five clusters: cluster 1 included cardiac profile; cluster 2 included less comorbidities; cluster 3 included metabolic syndrome, apnea and anxiety-depression; cluster 4 included denutrition and sarcopenia, and cluster 5 included bronchiectasis. Patients had standard ventilatory (NIV or standard MV), and pharmacologic (nebulized ß2 agonists, steroids, and anticholinergics) management . The discharge status (dead or alive) was compared between the 5 identified comorbid clusters. During the study period, 81 patients (mean age=67±9 years, 72% male) were consecutively admitted to the ICU for a definitive diagnosis of AECOPD. NIV was used as the primary ventilator modality in 83% while the remaining had conventional invasive ventilation. ICU mortality occurred in 25% following a mean ICU and ventilatory support duration of 17±10days and 10±7 days, respectively. The figure depicts relative mortality in each comorbidities cluster. The difference in observed mortality rates between clusters was statistically significant. Conclusion: The current study shows that comorbidity phenotypes of COPD is associated with short term outcome and ICU mortality following exacerbation.
  • What does hypercapnic respiratory failure hide? A prospective ICU-based study.
    Orateur(s) :
    • Wiem Nouira (Monastir / TUNISIE)
    • Redwan Maatoug (Paris / FRANCE)
    • Zeineb Hammouda (Monastir / TUNISIE)
    • Manel Lahmar (Monastir / TUNISIE)
    • Nacef Ben Mrad (Monastir / TUNISIE)
    • Islem Ouanes (Monastir / TUNISIE)
    • Fahmi Dachraoui (Monastir / TUNISIE)
    • Lamia Besbes (Monastir / TUNISIE)
    14h38 / 14h45
    Abstract : Hypercapnic respiratory failure is a frequent cause of admission in the ICU. Several kinds of lung diseases are designated under this nosological framework. Most of these carry prognostic information with a potential impact on the clinical decisions that could be made during the management of these patients. The aim of the study is to assess the frequency of patients admitted for hypercapnic respiratory failure without prior pulmonary diagnosis, and assign a final diagnosis with emphasis on morbid overlaps.: in consecutive patients admitted in the ICU for hypercapnic respiratory failure demographic and clinical data pertaining to current and prior hospitalisations were recorded. Patients were managed for the acute episode, and when they were considered for ICU discharge, the following was performed: pulmonary CT scan with particular emphasis on emphysema and fibrosis patterns, spirometry for the diagnosis of obstructive lung disease, transthoracic cardiac echography, and nocturnal polygraphy for the diagnosis of sleep apnea syndrome (AHI≥5). During the study period, 107 patients (mean age 66±6 years, 63% male) were consecutively admitted for severe hypercapnic respiratory failure requiring ventilatory support. NIV was started in 83% patients with a failure rate 20%. Table 1 reports the pulmonary diseases eventually adjudicated at admission, and at ICU discharge.Reliable information on actual lung diseases of patients admitted for hypercapnic respiratory failure is often lacking at ICU admission. Our study highlights the frequency of COPD, bronchiectasis, and obesity-hypoventilation syndrome in these patients. Overlaps are frequently present in these patients with a need for characterization of their evolutionary genius in the short and long term.
  • Home mechanical ventilation compliance: experience of a low income country MICU
    Orateur(s) :
    • Dhouha Ben Braiek (Sousse / TUNISIE)
    • Said Kortli (Sousse / TUNISIE)
    14h45 / 14h52
    Abstract : Despite the wide spread use of home mechanical ventilation (HMV) to treat chronic hypercapnic respiratory failure, compliance with HMV among patients has seldom been systematically studied. Evaluating outcomes for ICU survivors requiring home mechanical ventilation is also interesting. The aim was to determine patients' compliance to home mechanical ventilation indicated at discharge and to determine patients' outcomes and quality of life within three months after discharge.It is a retros pective observational study conducted in a 9-bed medical ICU. All consecutive patients discharged from ICU with home mechanical ventilation between January,1st 2015 and of December, 31st 2017 were included. Data collected involved patients' demographics, past history and underlying diseases, functional state, clinical, paraclinical, therapeutic and ICU stay course characteristics. At discharge, data on types, modes and indications of home mechanical ventilation, were gathered. Compliance reports were obtained from providers after one to three months of use. Vital status and quality of life as assessed by the St. Georges Hospital on Respiratory Problems (SGRQ), were estimated via phone calls at three months after discharge.Among a to tal of 717 ICU admitted patients, 635 required mechanical ventilation. 66(10.4%) patients were discharged with HMV, 38(57.6%) via non-invasive ventilation and 28(42.4%) on tracheostomy (TPPV). They were 61,5±14,4 mean age. They had predominantly chronic respiratory failure, 60(91%); 45(68.2%), COPD; 35(58.3%), mMRC score at III and IV; 18(27,3%), already on HMV, 34(51.5%) patients had at least two comorbidities with Charlson comorbidity index at 2[1-4]. On admission, mean SAPSII, 26±11 with a median ICU stay at 15[10-27] days. After discharge, compliance reports were obtained, only for 20(26%) patients. Respectively, mean percentage daily use of home NIV and TPPV (≥4h per day) were respectively, 92±11% and 96±6%. Twelve patients (18.2%) were readmitted. Mortality at three months was estimated at 19(28.8%). Health related quality of life assessed by SGQR showed a significant impairment, mean total score, 47±7; (symptoms score, 27±16; activities score, 44±18; impacts score, 52±8) compared to population norms (total score, 12; symptoms score, 16; activity score, 16; impacts score, 8).The present study shows rather poor vital and functional outcomes at three months after discharge with HMV albeit a satisfying HMV compliance.
  • Incidence of pulmonary embolism and its impact on the outcomes of chronic obstructive pulmonary disease
    Orateur(s) :
    • Hela Kallel (Sfax / TUNISIE)
    • Karama Bouchala (Sfax / TUNISIE)
    • Amal Triki (Sfax / TUNISIE)
    • Sabrine Bradai (Sfax / TUNISIE)
    • Olfa Turki (Sfax / TUNISIE)
    • Mabrouk Bahloul (Sfax / TUNISIE)
    • Mounir Bouaziz (Sfax / TUNISIE)
    14h52 / 14h59
    Abstract : We aimed to determine the incidence and the prognostic impact [mortality and length of intensive care unit (ICU) stay (LOS)] of pulmonary embolism (PE) in critically ill patients with severe acute exacerbation of chronic obstructive pulmonary disease (COPD).This is a retrospective study performed during a 10-year period in the ICU of Habib Bourguiba University Hospital (Sfax, Tunisia). All patients with severe acute exacerbation of COPD were included. The diagnosis of PE is confirmed by spiral computed tomography scan showing one or more filling defects or obstruction in the pulmonary artery or its branches.During the study period, 169 patients with acute exacerbation of COPD were admitted in our ICU. The mean age (±standard deviation) was 67,99 ± 9.2 years. During their ICU stay, 28 patients (17%) developed PE. The diagnosis was confirmed within 48 h from ICU admission in all cases. The comparison between the two groups (with and without PE) showed that they had the same baseline characteristics. However, most of patients on PE group developed shock (71,4%) on ICU admission or during ICU stay. ICU mortality was significantly higher in the PE group (67.9% vs 44,5%; P = 0.024). In addition, the ICU LOS was significantly higher in the PE group than the PE-free group (P = 0.005).Our study showed that PE is common in patients with severe COPD exacerbation requiring ICU admission. Moreover, PE was significantly associated with higher mortality and ICU LOS in critically ill patients with severe COPD exacerbation.
  • Asynchronies using a simulator of artificial ventilation (SimVA) in virtual COPD patients, effects of reducing pressure support or increasing expiratory trigger.
    Orateur(s) :
    • Hadrien Rozé (Bordeaux / FRANCE)
    • Remi Dubois (Bordeaux / FRANCE)
    14h59 / 15h06
    Abstract : Simulation in intensive care is an innovative method for teaching. Respiratory settings can be responsible for some asynchronies, which may increase mortality of our patients (1). For this reason we develop a simulator of spontaneous artificial ventilation (SimVA) and virtual breathing patients. Mathematical model resolved differential equations of chest and lung movements according to inspiratory effort in order to match with a clinical database. The goal of this study was to evaluate asynchrony index (AI) in virtual COPD patients according to pressure support (PS) level and Inspiratory time (Ti) and to compare the results to the study of Thille et al (2).Virtual case were COPD, defined by thoracic and pulmonar compliance, total resistance, lung volumes, and inspiratory adaptive muscle pressure. Asynchrony Index was patient ineffective efforts (IE)/ (IE +Ventilator Respiratory Rate). Ventilatory protocols were Baseline-PS, Optimal-PS and Optimal-Ti (Optimal meant decreasing PS or Ti in order to reduce AI) as described by Thille et al (2). Each virtual case was titrated with each protocol. AI was recorded and compared to the results of Thille et al.The optimal protocols titrated PS or Ti in order to reduce AI, the software simulates the corresponding values of tidal volume and respiratory frequency and its effect on intrinsic PEEP and gas trapping. The difference in settings and respiratory mechanic between virtual cases and patients were not significant (Table and Figure 1). AI was able to change according to PS or Ti settings within the same range as the study from Thille et al. Simulation with the software SimVA is realistic and may help to teach interactively ventilatory settings and asynchronies in COPD patients under Pressure Support Ventilation anywhere without any risk for the patient. Ref: 1. Intensive Care Med. 2015;41:633-41. 2. Intensive Care Med. 2008;34:14773-1486.
  • Long-term survival of ICU patients surviving hypercapnic respiratory failure: impact of home ventilation.
    Orateur(s) :
    • Redwan Maatoug (Paris / FRANCE)
    • Manel Lahmar (Monastir / TUNISIE)
    • Zeineb Hammouda (Monastir / TUNISIE)
    • Islem Ouanes (Monastir / TUNISIE)
    • Fahmi Dachraoui (Monastir / TUNISIE)
    • Wiem Nouira (Monastir / TUNISIE)
    • Lamia Besbes (Monastir / TUNISIE)
    15h06 / 15h10
    Abstract : The impact of home ventilation on survival of patients with chronic respiratory failure is still debated. Most studies that included patients with chronic hypercapnia away from hospitalisation, showed a positive effect on the frequency of exacerbation. The impact of home ventilation on survival in patients discharged from the ICU is not well proven. The current study reports long term survival according to the use of home ventilation. All patients surviving their ICU stay for hypercapnic respiratory failure were considered for home ventilation on the following basis: frequent exacerbators under long-term oxygenotherapy in obstructive lung disease, and signs of nocturnal hypoventilation in restrictive lung disease. Vital status was checked in January 2018 and Kaplan-Meier survival curve was drawn (with Log Rank statistical test). During the study-period 229 patients fulfilled the inclusion criteria and were included in the study. The mean age was 67±11 years and 70% were male the majority (74%) had COPD. Home ventilation was administered to 176 patients while the remaining 53 did not. At a mean follow-up of 50±24 months, patients under home ventilation had significantly longer survival than patients without home ventilation (Log Rank <0.05, Figure Home ventilation is associated with prolonged survival in ICU patients surviving hypercapnic respiratory failure.
Flash Com
14h10 - 15h10
Forum 1
Médecin : Organisation, Evaluation
Modérateur(s) : Jean Reignier (Nantes / FRANCE), Nadia Aissaoui (Paris / FRANCE)
  • Efficiency of a combined geriatric and intensivist evaluation to identify clusters of elderly patients admitted to the intensive care unit : the SENIOREA study.
    Orateur(s) :
    • Julien Demiselle (Angers / FRANCE)
    • Guillaume Duval (Angers / FRANCE)
    • Jean François Hamel (Angers / FRANCE)
    • Anne Renault (Brest / FRANCE)
    • Dominique Perrotin (Tours / FRANCE)
    • Laurent Martin-Lefèvre (La Roche Sur Yon / FRANCE)
    • Dominique Vivier (Le Mans / FRANCE)
    • Daniel Villers (Nantes / FRANCE)
    • Montaine Lefèvre (Morlaix / FRANCE)
    • Philippe Markowicz (Cholet / FRANCE)
    • Sylvain Lavoué (Rennes / FRANCE)
    • Anne Courte (Saint-Brieuc / FRANCE)
    • Eddy Lebas (Vannes / FRANCE)
    • Stéphanie Chevalier (Saint Malo / FRANCE)
    • Cédric Annweiler (Angers / FRANCE)
    14h10 / 14h18
    Abstract : Improving the care for older patients in the ICU is a challenge both in terms of survival and of quality of life (QoL). We set up a prospective observational to assess the effectiveness of a combined geriatric and intensivist initial evaluation in determining clusters of older patients and the one-year outcome of these clusters.Patients aged 75 years and older admitted to 13 ICUs in Western France and requiring mechanical ventilation from September 2012 to December 2013 were included. Proxy members were consulted at ICU admission using a predefined comprehensive geriatric assessment. Survival was assessed at one year and comprehensive geriatric assessment was performed on place of living in survivors. Clustering was performed based on baseline characteristics and ICU admission parameters using Jaccard similarity measure.Five hundred and one patients were included in the analysis. Age was 80±4 years, 53.5% were male. Ninety-two percent of patients were living at home before ICU admission, mean comorbidity burden assessed with CIRS-G score was 8.3±4.3, 78,9% of patients had ADL score ≥5 and SOFA at ICU admission was 7±3.7. Clustering resulted in three groups. Group 1 (n=166) was characterized by older age, lower comorbidity burden and intermediate acute severity. Group 2 (n=111) was characterized by lower age, intermediate comorbidity, and higher acute severity. Group 3 (n=98) had higher age, higher comorbidity, and lower acute severity. 126 patients could not be clustered due to incomplete data. Clusters experienced different trajectories throughout ICU stay with higher ICU mortality for group 2, and the highest amount of organ support. Moreover, clusters evolution was different after hospital discharge. Overall, one-year survival was 53.8%, mortality was higher in group 2 and 3 when compared to group 1 (p=0.03, see figure). 163 patients (62% of survivors) underwent one-year at-home evaluation. If a moderate decrease in independency was observed, perceived QoL remains satisfactory with 88% of patients indicated that they were happy or very happy. No difference in one-year geriatric evaluation was observed between clusters. Comprehensive geriatric assessment and acute severity parameters are useful to identify three different patterns of patients with different outcomes. Such patterns may be useful for design future interventional studies. Long term survival of older patients after an ICU stay has improved compared to previous studies.
  • Unique blood culture in ICU is associated with a dramatic reduction of blood culture contamination rates: an interrupted time-series study
    Orateur(s) :
    • Rafael Mahieu (Angers / FRANCE)
    • Matthieu Eveillard (Angers / FRANCE)
    • Valérie Seegers (Angers / FRANCE)
    • Carole Lemarié (Angers / FRANCE)
    • Vincent Dubée (Angers / FRANCE)
    • Alain Mercat (Angers / FRANCE)
    • Achille Kouatchet (Angers / FRANCE)
    14h18 / 14h26
    Abstract : Blood cultures (BC) remain the first-line tool for identification of the causative agent in patients with severe infection. However, several parameters affect diagnostic performances of BC. Sensibility depends on volume of collected blood; false-positive BC may arise from blood contamination during venipuncture. Our objective was to assess the effect of a unique high-volume blood culture (UBC) strategy on the rate of BC contamination and pathogen detection.An interrupted time-series study was conducted in a medical 24-bed ICU from January 2013 to December 2016. After the UBC protocol was implemented on January 2015, all patients with suspected bacterial infection had 40 mL of blood collected by a single phlebotomy. Ten milliliters of blood were inoculated into two BacT/Alert FA aerobic bottles and two BacT/Alert FN anaerobic bottles. Performing additional blood culture within 48 hours was strongly discouraged unless a new bloodstream infection was suspected. Nurses' and physicians' knowledge on BC collection and practice skills were reinforced through an educational program on December 2014. Protocol adherence was evaluated at 2 and 12 months through monitoring of BC volume.During the study period, there were 3497 ICU stays with at least one BC. No difference was observed between the two periods regarding severity (IGS2 and SOFA at admission) or in-ICU death. After the educational program, the median volume of blood culture per bottle increased from 3.2 mL [95% confidence interval (CI) 3 – 3.5] to 9.1 mL [95% CI: 8.7 - 9.5] at 2 months and decreased to 7.1 mL [95% CI: 6.3 - 8] at 12 months (p<0.001). During the UBC period, the rate of bloodstream infection per patient (bacteremia with a true pathogen) was 14.3%, as compared with 14,7% before (p=0.1). The rate of BC contamination amongst positive BC decreased by 55.8% (from 43% before protocol implementation to 19% after; p<0.001). The median number of BC bottles collected per week decreased by 58.5% (from 188 [interquartile range 149 - 235] before UBC to 78 [64 - 90] after protocol implementation), corresponding to a saving of 37,000 € per year. Implementation of a UBC protocol was associated with an important decrease in rate of BC contamination and BC-associated costs, without affecting pathogen detection rate.
  • Risk factors of post-traumatic stress disorder (PTSD) among ICU survivors
    Orateur(s) :
    • Marwa Zghidi (Sousse / TUNISIE)
    • Imen Ben Saida (Sousse / TUNISIE)
    • Said Kortli (Sousse / TUNISIE)
    • Hend Zorgati (Sousse / TUNISIE)
    • Abdelbaki Azouzi (Sousse / TUNISIE)
    • Khaoula Meddeb (Sousse / TUNISIE)
    • Ahmed Khedher (Sousse / TUNISIE)
    • Mohamed Boussarsar (Sousse / TUNISIE)
    14h26 / 14h34
    Abstract : Extended follow-up of ICU survivors has shown that many patients suffer from long-term physical and psychological sequalae. PTSD is an increasingly psychiatric disorder reported in ICU survivors. The aim was to determine the frequency of PTSD and its predictors.It is a mixed method study conducted in a medical ICU from January 2017 to January 2018. Data were obtained from medical records. At 3 months post-ICU discharge, patients were contacted by phone to complete the Impact Event Scale- Revised questionnaire (IES-R). Univariate and logistic regression analyses were used to identify variables independently associated with IES-R (≥33). 393 patients were admitted during the study period. 191 (48.6%) were discharged alive, 56(29.3%) were never successfully contacted and 21(11%) died within the 3 months' period. 114 patients fulfilled the inclusion criteria. Patients' characteristics were : mean age 56.29±17.88 years ; male, 66(57.9%) ; median Charlson comorbidity index, 1 [1-2] ; mean SAPSII, 25.04±12.1 ; invasive mechanical ventilation (IMV), 47(41.2%) and vasopressors use, 30(26.3%). The median duration of IMV and length of stay were respectively 0 days [0-4] and 6 days [4-10]. 25 (21.9%) patients met diagnostic criteria for PTSD. In univariate analysis, risk factors of PTSD were respectively for PTSD group and controls : age (42.7±19 vs 60.1±15.6, p=0.000) , female sex (64% vs 36% , p=0.012) ; Alcoholism ( 24% vs 7.9 % , p=0.035) ; IMV (76% vs 31.5%, p=0.000) ; Sedative use (76% vs 31.5%, p=0.000) ; polyneuromyopathy (28 % vs 2.2%, p= 0.000) ; delirium (16.7% vs 1.1%, p=0.008) ; catheterization (56 % vs 21.6%, p=0.001) ; duration of IMV (6.58±7 vs 2.32 ±6.3, p=0.005) and physical restraint (72 % vs 23.6 %, p=0.000). On multivariable logistic regression, age (OR, 0.95 ; 95%CI, [0.92 -0.98] ; p=0.001) , female sex (OR, 3.88 ; 95%CI, [1.08 -13.9] ; p=0.038) , physical restraint (OR, 6.27 ; 95%CI, [1.66 -23.67] ; p=0.007) and polyneuromythy (OR, 11.15 ; 95%CI, [1.5-80.1] ; p=0.01) were identified as risk factors independently associated to PTSD. PTSD is common in ICU survivors. Physical restraint, female sex, polyneuromyopathy and younger age were the only factors independently associated to PTSD.
  • Help, my hospital is burning : Experience return on fire in the Guadeloupe University Hospital (GUH)
    Orateur(s) :
    • Frédéric Martino (Pointe-À-Pitre / FRANCE)
    • Pascale Piednoir (Pointe-À-Pitre / FRANCE)
    • Bertrand Pons (Pointe-À-Pitre / FRANCE)
    • Benjamin Madeux (Pointe-À-Pitre / FRANCE)
    • Khalid Elkoun (Pointe-À-Pitre / FRANCE)
    • Elain Elie (Pointe-À-Pitre / FRANCE)
    • Roland Lawson (Pointe-À-Pitre / FRANCE)
    • Rémi Lazdunski (Pointe-À-Pitre / FRANCE)
    • Rémi Malhomme (Pointe-À-Pitre / FRANCE)
    • Cyril Marimoutou (Abymes / FRANCE)
    • Juliette Masse (Pointe-À-Pitre / FRANCE)
    • Alessia Napoleone (Pointe-À-Pitre / FRANCE)
    • Eric Paris (Pointe-À-Pitre / FRANCE)
    • Jean-Baptiste Putegnat (Pointe-À-Pitre / FRANCE)
    • Asma Benguerrah (Pointe-À-Pitre / FRANCE)
    • Morgane de Oliveira (Pointe-À-Pitre / FRANCE)
    • David Fedida (Pointe-À-Pitre / FRANCE)
    • Philippe Le Noach (Pointe-À-Pitre / FRANCE)
    • Zakaria Mahi (Pointe-À-Pitre / FRANCE)
    • Mathilde Pibarot (Pointe-À-Pitre / FRANCE)
    • Mathieu Tournay (Pointe-À-Pitre / FRANCE)
    • Killian Yao (Pointe-À-Pitre / FRANCE)
    • Mohamed Zidani (Pointe-À-Pitre / FRANCE)
    • Raphael Blanc (Fort-De-France / FRANCE)
    • Ji Soo Kim (Pointe-À-Pitre / FRANCE)
    • Fanny Ardisson (Abymes / FRANCE)
    • Bernard Leaute (Pointe-À-Pitre / FRANCE)
    • Anthony Veyron (Abymes / FRANCE)
    • Harold Willem (Abymes / FRANCE)
    • Hossein Mehdaoui (Fort-De-France / FRANCE)
    • Serge Ferracci (Abymes / FRANCE)
    • Patrick Portecop (Abymes / FRANCE)
    • Amélie Rolle (Abymes / FRANCE)
    • Michel Carles (Pointe-à-Pitre / FRANCE)
    14h34 / 14h42
    Abstract : The GUH fire causing its total evacuation is an unprecedented event in France. We report factual elements of the first days after the disaster involving intensive care unit (ICU) activities with specific proposed/imposed responses, as it is the sole ICU of Guadeloupe island (near half million people).Data are extracted from ICU medical files, experience reports, and Emergency department softwares.The fire started on 28/11/2017 around 13:45 on the 2nd floor of the building, between the ICU (1st floor) and operating room (3rd floor). At 14:00, the ICU (25 occupied beds over 26, including 12 ventilated patients) was invaded by a thick smoke, not triggering the fire alarm. The evacuation of the ICU was decided by doctors before the activation of the official evacuation plan (> 1 hour) in absence of any administrative instructions. The 12 ventilated patients were relocated at the radiology level (access to medical gases), 8 non-ventilated patients evacuated to the outdoor car park, 5 patients to other services. At 17:00 all patients were extracted from the ICU. Patients were then evacuated to other centers: 3 ventilated patients to the Basse Terre public hospital (Post Anesthesia Care Unit), 9 ventilated patients and 8 non-ventilated patients to a private hospital located at 11km, into a unit of 12 ambulatory surgery beds, thus the same day re-affected as ICU with 2 to 3 patients per room. At 22:53, all ICU patients were evacuated from the GUH. On 29/11/2017, 11 patients were prioritized for medical evacuation to the Martinique University Hospital (MUH) thanks to military vectors : 8 patients simultaneously (CASA military aircraft), and 3 by medical helicopter (SAMU). No worse initial progression was noted, except for 1 patient (septic shock needing intubation and norepinephrine) at the radiology level. ICU activities were heavily impacted during this period by difficulties related to emergency services, medico-surgical services and support structures (laboratories, radiology, pharmacy) rearrangement. This disastrous never experienced situation had a limited immediate impact (no deaths) due to the fast management of patient's transfer, related to ICU doctors initiatives. Regional support (MUH and military vector) helped to propose an immediate response for the most severe ICU patients. Mid- and long-term consequences are significant for evacuated patients as well as for the Guadeloupe care provision, in term of ICU and other hospital components, related to the distance away from France.
  • Evaluation and description of alarms in an Intensive Care Unit, Improvement of professional practices: optimizing monitoring and reducing noise pollution
    Orateur(s) :
    • Pierre-Yves Delannoy (Marcq En Baroeul / FRANCE)
    • Lydie Martel (Tourcoing / FRANCE)
    • Nicolas Boussekey (Tourcoing / FRANCE)
    • Damien Thellier (Tourcoing / FRANCE)
    • Hugues Georges (Tourcoing / FRANCE)
    • Olivier Robineau (Tourcoing / FRANCE)
    • Olivier Leroy (Tourcoing / FRANCE)
    14h42 / 14h50
    Abstract : The excess of alarms in intensive care has multiple consequences: the noise generated alterate the quality of patient's stay and participate in the genesis of the phenomenon called "alarm fatigue". This, by altering the quality of surveillance, directly impacts patient safety in a pejorative term. The objective of this project is to improve the quality of care and working conditions in intensive care unit in Tourcoing by optimizing the monitoring of our patients through a collaboration between the medical team and the company providing the monitoring products. An analysis of alarms from Philips Intelivue monitors for one month is performed, then corrective measures to reduce their number are implemented through a collaborative DMAIC approach (Define, Measure, Analyze, Improve, Control). These corrective measures include a personalization of the monitoring with a medical reflection on the alarm's thresholds and creation of specific profile patient, training of caregivers on the good use of the monitoring, creation of an alarm culture via these trainings and the creation of communication tools. To these actions are added technical interventions on intensive care ventilators and monitors. The impact of alarms on caregivers and patients present during the analysis period are evaluated using questionnaires. A second alarm analysis assess an evaluation of the effectiveness of the implemented measures. 127.927 alarms (equivalent to 243 alarms / day / patient) including 40.118 vital alarms, 58.647 critical and 29.162 techniques are found in the first period. The analysis of the patient questionnaire is not very contributive with 20 usable questionnaires. Among the responders, the majority did not feel any significant discomfort during their stay. The health questionnaire has a response rate of 91% (n = 51). Responders believe that there is a decrease in attention and an increase in reaction time due to false alarms. They also believe that irrelevant alarms disrupt the quality of the patient's stay and that better alarm management could prevent incidents. Nearly 86% of caregivers say that alarms could not be heard and were missed. In the second period, a 30% reduction in the total number of alarms (90,096 alarms, equivalent to 202 alarms / day / patient, p = 0.002) is obtained.By creating and implementing targeted corrective measures with DMAIC approach, a reduction in the number of alarms is achieved. This reduction probably enhance patient safety and improve healthcare environement for patients and caregivers.
  • Can we routinely use electronic medical data management systems to drive the prescription of red blood cell transfusion in Canadian and British pediatric intensive care units?
    Orateur(s) :
    • Camille Jutras (Montreal / CANADA)
    • Geneviève Du Pont-Thibodeau (Montreal / CANADA)
    • Marisa Tucci (Montreal / CANADA)
    • Simon Stanworth (Oxford / ROYAUME UNI)
    • Samiran Ray (Londres / ROYAUME UNI)
    • Barney Scholefield (Birmingham / ROYAUME UNI)
    • Samuel Kadoury (Montreal / CANADA)
    • Philippe Jouvet (Montreal / CANADA)
    • Jacques Lacroix (Montreal / CANADA)
    14h50 / 14h58
    Abstract : There is evidence that electronic medical data management systems (eMDMS) may help practitioners to improve the appropriateness of red blood cell (RBC) transfusion in hospitalised adults, but there is a lack of data supporting this in children. It is unclear if eMDMS are used in paediatric intensive care units (PICUs). This survey aims to document the availability of eMDMS in British and Canadian PICUs and characteristics of the data recorded. An electronic self-administered questionnaire was sent out thrice, using Survey Monkey, from November 2017 to February 2018, to the director of 16 Canadian and 27 British PICUs. Respondents were asked to describe their PICU and to indicate what eMDMS was used in their institution.Among the 43 units studied, 12 Canadian and 25 British PICUs (37/43 = 86%) answered to the survey; three of them were excluded because they exclusively took care of premature infants and newborns. Some eMDMS were used in 24 out of the 34 remaining PICUs (71%); the table below details the data collected by these eMDMS in PICUs. Seventeen PICUs (71%) used Windows as their eMDMS operating system. Two types of Electronic Medical Records (EMR) were used to document patient care: IntelliSpace Critical Care and Anesthesia (ICCA, Philips, 9 PICUs) and Allscripts Professional (1 PICU) (total: 42%); EMR name was unknown in 14 instances. Electronic medical data were known to be stored in a Structured Query Language (SQL) server in seven PICUs (29.17%%).Data management by eMDMS is common in British and Canadian PICUs. Computerized physician order for RBC transfusion is reported to be available in 79.17% of these PICUs. Using eMDMS to enable an electronic medical decision support tool for RBC transfusion should be feasible in most PICUs, and may facilitate efficient data collection for clinical trials.
  • Short and long term outcome of patients with systemic rheumatic disease related interstitial lung disease admitted to intensive care unit: a multicentre retrospective study
    Orateur(s) :
    • Romaric Larcher (Montpellier / FRANCE)
    • Lorrain Banuls (Montpellier / FRANCE)
    • Fanny Garnier (Montpellier / FRANCE)
    • Mathieu Amalric (Montpellier / FRANCE)
    • Laura Platon (Montpellier / FRANCE)
    • Jonathan Charbit (Montpellier / FRANCE)
    • Kevin Chalard (Montpellier / FRANCE)
    • Samir Jaber (Montpellier / FRANCE)
    • Boris Jung (Montpellier / FRANCE)
    • Kada Klouche (Montpellier / FRANCE)
    14h58 / 15h06
    Abstract : Owing their high mortality rate, admission to the intensive care unit (ICU) of patients with interstitial lung disease (ILD) is questioning. Systemic rheumatic diseases related ILD (SRD-ILD) seem to be associated with a better outcome but data are still lacking. We aimed therefore to evaluate short and long-term outcome and prognostic factors for SRD patients admitted to the ICU.This multicenter retrospective study was conducted, between 2006 and 2016, in five French ICUs and included patients with SRD-ILD admitted for acute respiratory failure. In-hospital and one-year crude mortalities were assessed and potential prognostic factors were identified using logistic regression.Seventy-one patients (female: 55%, mean age: 65 years [58-74], median SAPS2 43 [32-59], median SOFA Score 7 [4-9]) entered the study. ILD was related to connective tissue disease (43%), vasculitis (28%), myositis (13%), sarcoidosis (13%), and ankylosing spondylitis (3%). Causes of acute respiratory failure were sepsis (48%), pulmonary flare-up (28%) and miscellaneous (24%). Fifty-five patients (77%) required mechanical ventilation, 38 patients (53%) vasoactive drugs and 24 (34%) renal replacement therapy. One patient had a extracorporeal membrane oxygenation. Occurrence of severe, moderate and mild ARDS was 39%, 21%, 28% respectively. Thirty-seven survived at hospital discharge and 24 one year later. By univariate analysis, the following factors were significantly associated with mortality: ICU admission SAPS II (p=0,009), PaO2/FiO2 ratio (p = 0,007), vasoactive drugs (p=0,01) and mechanical ventilation requirement (p = 0.02). Among these factors, multivariate analysis showed that only low PaO2/FiO2 ratio (OR 3.63, CI95% [3.59-298.74]) was associated with one year- mortality.In our study, SRD-ILD patients admitted to the ICU have an in-hospital and one-year crude mortality rate at 48% and 66% respectively. Though this mortality rate remains high, it should not discourage intensivists to admit these patients. We found also that a low PaO2/FiO2 ratio during ICU stay was associated with one-year mortality. Further studies are however needed to best help physicians in the ICU management of ILD patients.
Flash Com
14h10 - 15h10
Forum 2
Médecin : Fin de vie
Modérateur(s) : Alexandra Laurent (Besançon / FRANCE), Thierry Boulain (Orléans / FRANCE)
  • Impact of Advance Directives on the decision-making in Intensive Care Unit
    Orateur(s) :
    • Margot Smirdec (Clermont-Ferrand / FRANCE)
    • Bruno Pereira (Clermont-Ferrand / FRANCE)
    • Alexandre Lautrette (Clermont-Ferrand / FRANCE)
    14h10 / 14h18
    Abstract : Physicians do not know how to follow the patients' wishes when they are unable to express themselves. We assessed the impact of Advances Directives (AD) and how they have been written on the physician's decisions.A multicentre, prospective, interventional, simulation study was carried out. Height patients were recruited and wrote AD after receiving clear and complete information by video and interview with one ICU physician. Two simulation scenarios including ten questions about ICU admission and situations of withholding/withdrawing therapies using the patients' characteristics were submitted to ICU physicians from 28 French ICU, in three rounds (R): simulation without knowledge of the patient's AD (R1), with these AD (R2) and with these AD and the knowledge of how they were carried out (R3).The qualitative analysis of these 8 AD highlights a form of living will or end-of-life will and not formal guidelines on medical care. The results were performed on complete data of 102 physicians [Figure 1]. The variability between physicians themselves was high: among the 80 questions of R1, there were 37, 26 and 17 questions with an agreement > 80%, 80-60% and <60% respectively. The AD significantly decreased the number of questions with an agreement > 80%, and increased the number of questions with an agreement <60% (p=0.02). There was no difference between the rounds 2 and 3 (p=0.84). Few physicians' characteristics were associated with the inter-individual variability. The intra-individual variability between R1 and R2 was very high (52 questions on 80 with kappa coefficient k<0,4) and the AD were significantly associated with this variability after adjustment on characteristics of the physicians and the patients (p<0,001). It is relevant to notice that the knowledge of how AD were carried out has a very low impact on the physicians' decisions.We were expecting find some help in the AD of patients to diminish this variability among physicians and respect the patients' autonomy. But the variability between the physicians themselves was increased in our study. We assume that this variability reflects a difference in the interpretation of these AD among physicians themselves. The AD have a major impact on the physicians' decisions for admission, withholding and withdrawing therapies decisions and increase the inter-individual variability but not the knowledge of how these AD have been written. It might be a limit of the autonomous model.
  • End of life decisions in acute respiratory failure immunocompromised patients
    Orateur(s) :
    • Gaston Burghi (Montevideo / URUGUAY)
    • Victoria Metaxa (Londres / ROYAUME UNI)
    • Peter Pickkers (Nijmegen / PAYS-BAS)
    • Marcio Soares (Rio de Janeiro / BRÉSIL)
    • Anders Perner (Copenaghe / DANEMARK)
    • Jordi Rello (Barcelone / ESPAGNE)
    • Philippe Bauer (Rochester / ETATS-UNIS)
    • Andry Van de Louw (Hershey / ETATS-UNIS)
    • Pleun Hemelaar (Amsterdam / PAYS-BAS)
    • Virginie Lemiale (Paris / FRANCE)
    • Ignacio Martin-Loeches (Dublin / IRLANDE)
    • Tine Sylvest Meyhoff (Copenaghe / DANEMARK)
    • Jorge Salluh (Rio de Janeiro / BRÉSIL)
    • Peter Schellongowski (Vienne / AUTRICHE)
    • Katerina Rusinova (Prague / RÉPUBLIQUE TCHÈQUE)
    • Sangeeta Mehta (Toronto / CANADA)
    • Massimo Antonelli (Rome / ITALIE)
    • Andreas Barrat Due (Oslo / NORVÈGE)
    • Miia Valkonen (Helsinki / FINLANDE)
    • Pearl Landburg (Groningen / PAYS-BAS)
    • Fabrice Bruneel (Versailles / FRANCE)
    • Ramin Brandt Bukan (Herley / DANEMARK)
    • Anne-Sophie Moreau (Lille / FRANCE)
    • Virginie Souppart (Paris / FRANCE)
    • Christophe Girault (Rouen / FRANCE)
    • Ulysse V A Silva (Barretos / BRÉSIL)
    • Luca Montini (Rome / ITALIE)
    • Lene Nielsen (Odense / DANEMARK)
    • Benjamin Gaborit (Nantes / FRANCE)
    • Samir Jaber (Montpellier / FRANCE)
    • Elie Azoulay (Paris / FRANCE)
    • Audrey de Jong (Montpellier / FRANCE)
    14h18 / 14h26
    Abstract : In recent years, there has been an increase in immunocompromised patients admitted to the intensive care unit (ICU). End-of life decisions are challenging in these severe patients with often life-threatening underlying disease. The main aim of this study was to identify patient and organizational factors associated to decisions to forgo life-sustaining therapies (DFLSTs) among immunocompromised ICU patients. A secondary analysis of the EFRAIM study including 1611 immunocompromised patients with acute respiratory failure enrolled in 68 ICUs from 16 countries between October 2015 and June 2016 was performed. A multivariate logistic analysis was performed to identify independent predictors of DFLSTs.In the 1382 patients with data about DFLSTs available, 485 (35%) had a DFLST. Figure 1 presents the code status on ICU admission and the final decision about DFLSTs for each code status. The following variables were independently associated with increased incidence of DFLST: age (OR 1.024 per one year increase, IC 95% 1.012-1.035; p<0.0001), SOFA at ICU admission (OR 1.065, IC 95% 1.025-1.107, p=0.0013), need for orotracheal intubation (OR 1.478, IC 95% 1.068-2.004, p=0.0183), and performance status measured by the Eastern Cooperative Oncology Group scale (ECOG) (OR 1.7 per point, IC 95% 1.504-2.028, p<0.0001), units without protocoled admission criteria (OR 1.701, IC 95% 1.176-2.462, p=0.0022), palliative care involvement (OR 1.688, IC 95% 1.216-2.343, p=0.0018) and units with frequent admission of transplant patients (OR 1.662, IC 95% 1.200-2.302, p=0.0022). Two variables were independently associated with a decreased incidence of DFLST, namely: acute respiratory failure with an easy aetiology identification (OR 0.913, IC 95% 0.860-0.968, p=0.0025) and the use of checklists for global ICU care (OR 0.531, IC 95% 0.387-0.728, p<0.0001). Centre effect was not significant after multivariate analysis. The current study suggests that, in addition to patient-related factors, ICU characteristics and critical-care organization also influence decisions to forgo life sustaining therapies. Palliative care involvement, frequent admission of transplant patients, protocoled admission criteria at admission and the use of checklists are organizational variables associated with DFLSTs.
  • Practices assessment ten years after setting up a procedure of collegial decision for
    Orateur(s) :
    • Marc Amouretti (Longjumeau / FRANCE)
    • Martha Gomis (Longjumeau / FRANCE)
    • Fabien Merrina (Longjumeau / FRANCE)
    • Sarah Benhamida (Longjumeau / FRANCE)
    • Nicolas Lau (Longjumeau / FRANCE)
    • Matthieu Le Meur (Longjumeau / FRANCE)
    • Remy Paulet (Longjumeau / FRANCE)
    • Nicolas Roucaud (Longjumeau / FRANCE)
    • Jordane Lebut (Paris / FRANCE)
    • Martial Thyrault (Longjumeau / FRANCE)
    14h26 / 14h34
    Abstract : Since the 2002 “Kouchner law” and the 2016 “Leonetti Claeys law”, WWT decisions have become essential in discussions within intensive care units. Our Intensive Care Unit (ICU) has conducted a work on this topic in 2008, leading to the implementation of WWT procedural forms and follow-ups. We assessed our practices 10 years after having implemented this traceability. Patient Limitation Records (PLR) are initiated and reassessed during weekly ICU meetings bringing together medical and paramedical staff. They can also be initiated at any other time during exceptional meetings. PLR are initiated at the request of any member of the paramedical team, medical team or patient's entourage as soon as the meaningfulness of continuing care is contested. They include advanced medical instructions, an estimation of the patient's quality of life before and after the ICU stay, patient's wellbeing during the stay, interviews with the patient, his relatives and his practitioners. They also mention the conditions and time of application for the limitation. Analyzed records extend over a period of 18 months ending in June 2018. In 2008, the analysis period lasted 10 months from September to June. 106 PLR were established over the 2017-2018 period compared to 32 in 2008. 70% of patients are limited during the first ethical meeting during the 2017-2018 period. 18% have no limitation of life sustaining treatments. Patient's will is unknown in 72% of cases. Among patients whose will is known, 21% express their opposition to therapeutic relentlessness. Patient's general practitioner interview before the meeting is made for 42% of the patients. The most frequent therapeutic limitations are cardiac arrest resuscitation (70%) and renal replacement therapy (57%). Invasive mechanical ventilation is limited in 35% of cases. Nutrition and hydration are never limited. Ten years after setting up a WWT procedure in our ICU, limitations are more frequent, appear earlier, concern younger patients, and are more often at the paramedic initiative, which reflects a stronger involvement of caregivers in end of life issues.
  • Assessment of the psychological consequences of hospitalization in intensive care unit: Patients and their relatives are both concerne.
    Orateur(s) :
    • Ghada Sbouii (Kairouan / TUNISIE)
    • Nesrine Baili (Sousse / TUNISIE)
    • Rabia Atig (Sousse / TUNISIE)
    • Olfa Beji (Sousse / TUNISIE)
    • Houssem Hmouda (Sousse / TUNISIE)
    14h34 / 14h42
    Abstract : The aim of our study was to evaluate the psychological impact of critical illness on patients and their relatives in a Tunisian medical ICU (MICU). In this study, included the patients who were admitted in our MICU from January 2015 and December 2016. We used the Impact of Events Scale (IES) 22-items for patients. Scores above 30 on the IES indicate severe psychological trauma symptoms, and individuals scoring in the range between 24 and 35 are likely to meet diagnostic criteria for PTSD. The Burden (Mini-Zarit) 7-items was used for relatives. All patients and relatives were interviewed by telephone.We contacted 46 families, 18 patients (39%) died, 28 patients (60.9%) participated with their relatives to this study, sex ratio was F/M= 1,09, mean age was 75 years [65 to 90 years], average length of stay (LOS) was 11.89 days [1 to 60 days], 45.7% of patients had mechanical ventilation with a mean duration of 4.84 days, 8.7% of the patients had a tracheostomy, dementia was diagnosed in 6.5% of patients, 78.3% of the patients were autonomous, and the main reason of ICU admission was respiratory distress in 30.4%. The average of IES on patients was 22.7 [6 to 35], the IES was significantly correlated with male gender (p=0.039), LOS in the ICU (p=0.043), oro-tracheal intubation (OTI) (p=0.03), tracheostomy (p=0.013), and use of vasopressor agents (p=0.045) The average of Mini-Zarit on relatives was 3.35 [1.5 to 5.5], the Mini-Zarit was significantly correlated with LOS (p‹0.001), OTI (p=0.001), duration of OTI (p=0.045), tracheostomy (p=0.012), duration of tracheostomy (p=0.024), use of vasopressor agents (p=0.034) and the APACHE II score (p=0.047). Patients recovering from critical illness can be left with significant physical and cognitive problems that can deeply affect quality of life of both patients and relatives. Understanding the nature of the relationship between critical illness and PTSD is a challenge that demands attention, particularly in an era when mental health professionals are beginning to recognize the profound costs associated with this psychiatric syndrome.
  • Impact of frailty on elderly patients (≥80 years) admitted in French Intensive Care Units: a post-hoc analysis from the international VIP study
    Orateur(s) :
    • Jérémy Rosman (Charleville-Mézières / FRANCE)
    • Aurélien Cordonnier (Charleville-Mézières / FRANCE)
    • Xavier Forceville (Meaux / FRANCE)
    • Guillaume Besch (Besançon / FRANCE)
    • Hervé Mentec (Argenteuil / FRANCE)
    • Philippe Michel (Saint-Martin-Du-Tertre / FRANCE)
    • Philippe Michel (Pontoise / FRANCE)
    • Lucie Vettoretti (Besançon / FRANCE)
    • Jeremie Bourenne (Marseille / FRANCE)
    • Nathalie Marin (Paris / FRANCE)
    • Max Guillot (Strasbourg / FRANCE)
    • Cyril Goulenok (Massy / FRANCE)
    • Nathalie Thieulot-Rolin (Melun / FRANCE)
    • Jonathan Messika (Colombes / FRANCE)
    • Lionel Lamhaut (Paris / FRANCE)
    • Cyril Charron (Boulogne / FRANCE)
    • Bertrand Guidet (Paris / FRANCE)
    • Philippe Mateu (Charleville-Mézières / FRANCE)
    14h42 / 14h50
    Abstract : Very elderly Intensive care Patients (VIP1) is an international multicentric prospective study endorsed by the European Society of Intensive Care Medicine assessing prognosis of elderly patients (≥80 years) admitted in the intensive care unit (ICU). Our study is a subgroup analysis of French patients. All elderly patients (≥80 years) admitted in 18 French ICUs and included in VIP1 study from October 2016 to May 2017 were analyzed in a post-hoc subgroup study. Frailty was defined as a Clinical Frailty Scale ≥5/9. Multivariable analysis [with adjusted odd ratio (aOR) and 95% confidence interval (IC 95%)] was performed to determine factors associated with in-ICU and 30-days mortality. Among 368 patients admitted in French ICUs, 38% were frail (44% in the entire cohort). Compared to non-frail patients, frailty was associated with the similar in-ICU (34% vs 35%, p = 0.93) and 30-days mortality (51% vs 44%, p = 0.22) , despite a lower severity (SAPS2 46 vs 54, p = 0.04), lower use of mechanical ventilation (46% vs 62%, p = 0.003), and lower use of vasoactive drugs (39% vs 55%, p = 0.004). However, withholding was more frequent (57% vs 35%, p<0.001), but not withdrawing (20% vs 21%, p = 0.76). In multivariable analysis, frailty was not an independent risk factor for mortality, contrary to withdrawing [aOR 18.8 (IC95% 8.1 – 43.8)], withholding [aOR 3.9 (IC95% 2.0 – 7.4)], use of mechanical ventilation [aOR 2.3 (IC95% 1.1 - 5.0)] and SOFA at admission (per one point increase) [aOR 1.2 (IC95% 1.1 – 1.3)]. In elderly patients admitted in French ICUs, frail patients have the same mortality than non-frail patients, despite a lower initial severity and higher frequency of withholding decisions.
  • Evaluation of patients refused admission to intensive care unit
    Orateur(s) :
    • Alix Leurent (Poissy / FRANCE)
    • Matthieu Jamme (Paris / FRANCE)
    • Claire Pichereau (Poissy / FRANCE)
    • Siu-Ming Au (Poissy / FRANCE)
    • Christophe Barbier (Poissy / FRANCE)
    • Yann Loubieres (Poissy / FRANCE)
    • Jan Hayon (Poissy / FRANCE)
    • Renaud Getti (Poissy / FRANCE)
    • Hervé Outin (Paris / FRANCE)
    • Omar Ben Hadj Salem (Poissy / FRANCE)
    14h50 / 14h58
    Abstract : Some patients referred to intensive care unit (ICU) are refused by intensivist because they are considered to be too well or too ill to benefit from intensive care treatment. This study aims to evaluate factors associated with decision to refuse ICU admission and to assess the outcome of excluded patients.All inpatients referred to our ICU between February and August 2018 were included in the analysis. All patients were evaluated in emergency unit or in hospitalization areas by a senior intensivist. Refused patients were considered to be too well (inappropriate referral (IR)) or too ill (futility) for ICU admission. The main outcome was survival 28 days after first referral to ICU. Patient characteristics, number of beds available at the time of referral, quality of life 28 days after ICU referral were also assessed.Out of 379 patients, 267 were admitted and 112 were refused (29.6%). Reasons for refusal were futility (“too ill”) (n=68 (60.7%)) and IR (“too well”) (n=44 (39.3%)). The median mortality probability model (MPMII) score for IR group and for futility group at day 0 was -1.65 and -0.4. Admission request came from emergency unit (65.2% (n=73)), medical department (24% (n=27)) or surgery department (10.8% (n=12)). The main outcome for futility and IR groups were 52.9% and 4.5% respectively. In the futility group, modified Rankin score increased from 3.52 to 4.15 between inclusion and final evaluation. Lack of autonomy, elderly people and dementia were the main causes for refusal in the futility group (n=57, 42 and 31 respectively).Refusal of ICU admission occurs in 29.6% of cases. Refusal for futility is strongly but not invariably associated with deaths whereas patients considered to be too well for intensive care treatment rarely died. Strategy should be developed to create admission criteria for patients.
Session Thématique
14h10 - 15h10
S02
Infirmier(e) : Abdomen post-opératoire
Modérateur(s) : Sandrine Monot (Levallois-Perret / FRANCE), Nathalie Baugé (Aulnay-Sous-Bois / FRANCE)
  • Rééquilibration hydroélectrolytique
    Orateur(s) :
    • Gaël Piton (Besançon / FRANCE)
    14h10 / 14h30
  • Gestion des stomies au quotidien
    Orateur(s) :
    • Anick Rippon (Paris / FRANCE)
    14h30 / 14h50
  • Optimiser la nutrition
    Orateur(s) :
    • Amélie Toussaint (Paris / FRANCE)
    14h50 / 15h10
Flash Com
14h10 - 15h10
Forum 3
Médecin : Infection nosocomiale
Modérateur(s) : Lila Bouadma (Paris / FRANCE), Jean-Ralph Zahar (Bobigny / FRANCE)
  • Carbapenem- sparing regimens for infections caused by ESBL-producing Enterobacteriaceae in ICU patients
    Orateur(s) :
    • Matthieu Bosset (Suresnes / FRANCE)
    • Anne-Gaelle Si Larbi (Suresnes / FRANCE)
    • Solen Kerneis (Paris / FRANCE)
    • Julien Charpentier (Paris / FRANCE)
    • Mathilde Phillips Houlbracq (Suresnes / FRANCE)
    • François Parquin (Suresnes / FRANCE)
    • Jean-Paul Mira (Paris / FRANCE)
    • Charles Cerf (Suresnes / FRANCE)
    • Rémi Gauzit (Paris / FRANCE)
    • Philippe Lesprit (Suresnes / FRANCE)
    14h10 / 14h18
    Abstract : The objectives of this study were, in ICU patients with an ESBL-producing Enterobacteriaceae infection: (i) to identify predictors of de-escalation of the empirical treatment with a carbapenem (CP) to a CP-sparing regimen (CPS) and (ii) to compare outcomes of patients de-escalated to those maintained on CP (CPM).Retrospective study performed in ICUs from 2 hospitals in which all CP prescriptions were reviewed within 72 hours by the antimicrobial stewardship team and the ICU physicians. Demographics, clinical and therapeutic data were compared between CPS and CPM patients. Unfavorable clinical outcome (defined as mortality or relapse) was evaluated at day 60 of follow-up. Results are presented as median (IQR) or n (%).Ninety patients were included (54 CPM and 36 CPS), mainly treated for pneumonia (n=35) or urinary tract infection (UTI, n=30). Septic shock was found in 20 CPM (37%) and 19 CPS (53%), p=0.14. The main CP-sparing antibiotics were piperacillin/tazobactam (n = 11), cefoxitin (n = 11) and temocillin (n = 7). Median CP duration was 3 days (2-5]) in CPS patients. Cohort patients received a total of 1263 days of antibiotic (CP 827 days, CPS 436 days). Therefore, 35% of CP daily doses were saved. Factors associated with the use of a CPS were: older age (CPS 71 years [66-77], CPM 64 years [51-76]; p= 0.02), UTI (CPS: n=24 (69%), including 19 male UTI; CPM: n=6 (11%); p<0.001), absence of immunosuppressive therapy (CPS: n=6 (21%), CPM: n=17 (39%), p=0.002) and total duration of antibiotic therapy (CPS 14 d [9-21], CPM: 9 d [7-15], p=0.014). An unfavorable outcome was observed in 9 CPS (25%) and 22 CPM (41%), respectively (p=0.5). Factors associated with unfavorable outcome were UTI (Hazard ratio [HR] 0.4, p=0.045), respiratory tract infection (HR 2.76, p=0.01) and immunosuppressive therapy (HR 3.5, p<0.001). Use of a CPS had no effect (HR 0.6, p=0.20). CP de-escalation was performed in 40% of the patients, mainly those who were immunocompetent and treated for an UTI. This strategy seemed not to be associated with a worse outcome and reduced CP exposure. However, total duration of antibiotic therapy was longer with the CPS, because of the high rate of male IU treated.
  • Influence of the intervention of an infectiologist on the strategy of antibiotic therapy in a intensive care unit.
    Orateur(s) :
    • Marie Bénistand (Nimes / FRANCE)
    • Arnaud Salmon Rousseau (Dijon / FRANCE)
    • Stéphanie Honoré (Auxerre / FRANCE)
    • Thomas Rogier (Dijon / FRANCE)
    • Mylène Herrera (Dijon / FRANCE)
    • René-Gilles Patrigeon (Auxerre / FRANCE)
    14h18 / 14h26
    Abstract : Impact of the discussion with bacteriologists and an infectiologist on antibiotic therapy in the 14-bed intensive care unit of the Auxerre hospital. Observational and retrospective study was conducted from 01/01/2014 to 31/12/2017. It was a before/after study. First period : a weekly infectiology meeting of one hour composed of intensive care pratician, bacteriologist and pharmacist. Second period : intervention of an infectiologist. The primary outcome was the change in antibiotic consumption in daily doses per 1,000 days of hospitalization (DDJ / 1000J). The secondary outcome was the change in the number of multi-resistant bacteria (BMR) isolated by weekly screenings after 72 hours of hospitalization. The various proportions were compared using a Chi2 test. 1712 patients were hospitalized in intensive care unit (833 in 2014/15 vs 879 in 2016/17). Populations were comparable in age, sex, average length of stay, simplified seriousness index, and mortality. Antibiotic consumption differs between two periods. There is a statistically significant impact in antibiotic consumption. Fluoroquinolones and Amoxicillin-clanulanic acid which are known to induce resistance have decreased during the second period. Prescriptions of some antibiotics have improved such as Cefepime for Enterobacter, Ceftazidime and Ciprofloxacin for Pseudomonas thus saving Colimycin and Imipenem Cilastatin. There is a non-significant trend to lower multi-resistant broad-spectrum betalactamase-producing bacteria, cephalosorinases and carbapenemases in screening tests. The intervention of an infectiologist in our service allowed an effective adaptation of the strategy of the antibiotic therapy in the hope that, in the coming years, the selection of BMR will decrease.
  • Appropriateness of empiric antimicrobial therapy with imipenem/colistin in severe septic patients: An observational cohort study
    Orateur(s) :
    • Ahlem Trifi (Tunis / TUNISIE)
    • Cyrine Abdennabi (Ariana / TUNISIE)
    • Sami Abdellatif (Tunis / TUNISIE)
    • Foued Daly (Tunis / TUNISIE)
    • Yosr Touil (Tunis / TUNISIE)
    • Rochdi Nasri (Tunis / TUNISIE)
    • Salah Ben Lakhal (Tunis / TUNISIE)
    14h26 / 14h34
    Abstract : empiric antimicrobial therapy (EAMT) using imipenem/colistin is commonly prescribed as a first line therapy in critically ill patients with severe sepsis. We aimed to assess the appropriateness of prescribing imipenem/colistin as EAMT in ICU patients.a 3-years observational prospective study including ICU patients that required imipenem/colistin as EAMT. EAMT was assessed according to microbiological and clinical outcome. Outcomes were: delay to apyrexia, delay to decrease biological inflammatory parameters (BIP), requirement for vasoactive agents, bacteriological eradication, length of stay (LOS), ventilator days and 30-day mortality. 79 administrations of EAMT in 70 patients were studied. EAMT was appropriate in 52% of studied cases. An ICU stay > 6 days was related to inappropriateness and chronic respiratory failure was associated to appropriateness. In the appropriate EAMT group, we showed: earlier apyrexia , shorter delay to decrease biological inflammatory parameters (BIP) and less significant vasopressors requirement (attached fig). Furthermore, EAMT improved survival with a median gain of 4 days. Inappropriate EAMT increased the mortality risk by six. Acquisition of NI in ICU was also an independent factor of mortality. EAMT using imipenem-colistin was appropriate in half of cases and inappropriateness was associated with increased ICU mortality risk.
  • Treatment of infections with extended spectrum beta-lactamase producing Enterobacteriaceae in ICU patients
    Orateur(s) :
    • Lev Volkov (Nancy / FRANCE)
    • Elisabeth Baux (Vandoeuvre-Les-Nancy / FRANCE)
    • Sandrine Henard (Vandoeuvre-Les-Nancy / FRANCE)
    • Bruno Lévy (Nancy / FRANCE)
    • Sebastien Gibot (Nancy / FRANCE)
    • Pierre-Edouard Bollaert (Nancy / FRANCE)
    14h34 / 14h42
    Abstract : The incidence of extended-spectrum beta-lactamase producing-enterobacteriaceae (ESBL-PE) is growing, with an emerging worldwide distribution. The aim of this study was to describe the outcome of patients hospitalized in an ICU with an extended spectrum beta-lactamase producing Enterobacteria (ESBL-PE) infection treated with carbapenems and alternative carbapenem-sparing therapy.We performed a retrospective, descriptive, monocentric study in a Public University Hospital. Patients over 18 years, hospitalized in one of the ICUs of the hospital and presenting at the admission or during the stay an infection with an ESBL-PE between January 1st 2016 and March 31st 2018 were included. Patients colonized but not infected by ESBL-PE were not included. Primary study outcome was patient's vital status at discharge of the ICU. Secondary outcomes were vital status at discharge of the ICU in patients treated with carbapenems and in patients treated with an alternative therapy, relapse and antibiotic change after reception of the antibiotic susceptibility test results.In our study, 109 patients were included. Among them, 93.6% had at least one risk factor of ESBL-PE acquisition, mostly a recent hospitalization within 3 months and a use of antibiotics within 3 months. Overall, 32 patients (29.4%) died during the ICU stay. The mean SAPS II score at admission was 49.8 ± 22.1. Invasive mechanical ventilation was required for 66% of the patients. Catecholamine use was required for 64% of patients. Escherichia coli was the most frequent bacteria identified (41%), followed by Enterobacter cloacae complex (33%) and Klebsiella pneumonia (19%). Distribution of the infection sites is summarized in Figure 1. Relapse occurred in 13 (12.1%) patients. In our study 84 of 109 patients (77.1%) received an empirical antimicrobial treatment, of which 22 (26.2%) received a carbapenem and 62 (73.8%) a non-carbapenem treatment. Among the 95 patients with documented treatment, carbapenems were used in 55 (57,9%) patients and non-carbapenems in 40 (42.1%) patients. Piperacillin/tazobactam was the most used non-carbapenem treatment. There was no statistically significant difference in mortality between patients treated with a carbapenem and patients treated with a non-carbapenem therapy.Infections with ESBL-PE in critically ill patients are associated with a great mortality. Because of the sample size of this retrospective study, no difference between the groups is observed. Therefore, a larger study should be drawn.
  • Risk factors in intravascular catheter-related infections
    Orateur(s) :
    • Haifa Fazeni (Ben Arous / TUNISIE)
    • Sahar Habacha (Ben Arous / TUNISIE)
    • Ameni Sgahier (Ben Arous / TUNISIE)
    • Ines Fathalah (Ben Arous / TUNISIE)
    • Eya Seghir (Ben Arous / TUNISIE)
    • Asma Mehdi (Ben Arous / TUNISIE)
    • Ghada Sboui (Ben Arous / TUNISIE)
    • Khaoula Ben Ismail (Ben Arous / TUNISIE)
    • Nadia Kouraichi (Ben Arous / TUNISIE)
    14h42 / 14h50
    Abstract : Catheter-related infection (CRI) is common in critically ill patients. Different factors are incriminated in developing CRI. Our study aimed to identify CRI risk factors.We conducted retrospective study including all patients admitted in our intensive care unit (ICU) during the period from October 2016 to August 2018. Catheter related infections were identified using the criteria of Infectious Diseases Society of America of 2009. Only patients with valid bacteriological data were included.During the study period, 164 patients were collected with a mean age of 55 ± 20 years and a sex ratio of 1.92. Median SOFA score was 4 [2;7] The most frequent causes of admission in ICU were acute respiratory failure (48.2%) , coma (15.1%) and septic shock (7.9%). Diabetes mellitus was the main medical antecedent (34.1%). The median length of stay was 14 days [1;117] . The overall mortality rate was 29.9% (49 cases). Among the 96 central venous catheters inserted, only twenty-two catheter related infections were diagnosed. SOFA score superior to 5 on admission was related to a higher risk of developing a CRI (OR, 1.75 ; 95%CI , [0.44-4.66] ; p=0.033). In addition , time delay to develop a ventilator-associated pneumonia ( VAP) was an independent risk factor for developing a CRI , for patients who developed a CRI median time to develop a VAP was 6 days versus 14 days for patients who did not develop a CRI (p=0.04). SOFA score at admission superior to five was a predictive factor of developing a catheter-related infection.
  • Cannula-related infection (Ca-RI) and insertion site colonization in patients supported by peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) managed with a standardized dressing procedure
    Orateur(s) :
    • Faiza Sayagh (Clichy / FRANCE)
    14h50 / 14h58
    Abstract : VA-ECMO is a life support technique used in patients with cardiac failure. High rates of Ca-RI have been reported in patients supported by ECMO. Based on evidences from Ca-RI prevention, we developed a standardized procedure: maximal sterile barrier precautions, antiseptic skin preparation using with 2% chlorhexidine-70% isopropyl alcohol solution, semi-permeable transparent and highly adhesive chlorhexidine dressing. Dressings were changed 24 hours after catheter insertion and then every 7 days, but leaking or soiled dressings were changed immediately.Study design : We retrospectively review charts of all consecutive patients who underwent VA-ECMO support for > 48 hours from January 2015 to December 2017. Peripheral blood samples were collected for culturing each VA-ECMO day and the insertion site was sample at each dressing by pressing a nutritive trypticase-soy agar plate (Count-tact; Biomerieux, France) on the skin for 5 seconds, centering the plate on the insertion site. Evaluation criteria were cannula-related bloodstream infection (Ca-RBSI) (defined as a combination of 1 or more positive peripheral blood cultures without any other infection explaining the positive blood culture result), Ca-RI (defined as local infections signs with or without Ca-RBSI), and skin colonization defined as neither Ca-RBSI nor Ca-RI but a positive insertion-site skin culture at catheter dressing. Over the study period, 131 patients were supported by 133 VA-ECMO (femoro-femoral VA-ECMO: n= 47, femoro-axillary: n = 86): age: 56.4 ± 13.8; male: 97(73.6%); SAPS II: 56.7 ± 19.3; SOFA at cannulation: 9 ± 3.7; ECMO duration: 9 ± 8,8, corresponding to 1524 ECMO-days. Primary ECMO indications were post-cardiac surgery: 32 (24.1%), myocardial infarction: 30 (22.5%), primary graft dysfunction: 26 (19.5%), cardiac arrest: 20 (15%). Ca-RBSI and Ca-RI occurred in 13 (9.8%) and 31 (23.3%) patients respectively corresponding to an incidence rate of 8.5/1000 ECMO-days and 20.3/1000ECMO-days. Colonization of insertion site was frequent and mainly related to Coagulase-negative staphylococci, however, we found no Ca-RBSI and no Ca-RI related to this microorganism. Skin colonization was more frequent for cannulas in femoral position than for cannulas in axillary position. Cannula-related infection and insertion site colonization were frequent despite a standardized procedure including semi-permeable transparent and highly adhesive Chlorhexidine dressing in patients supported by VA-ECMO
  • Impact of the implementation of a multimodal and multidisciplinary care bundle for necrotizing skin and soft tissue infections
    Orateur(s) :
    • Tomas Urbina (Paris / FRANCE)
    • Camille Hua (Créteil / FRANCE)
    • Emilie Sbidian (Créteil / FRANCE)
    • Romain Bosc (Créteil / FRANCE)
    • Françoise Tomberli (Créteil / FRANCE)
    • Raphael Lepeule (Créteil / FRANCE)
    • Jean-Winoc Decousser (Créteil / FRANCE)
    • Olivier Chosidow (Créteil / FRANCE)
    • Nicolas de Prost (Créteil / FRANCE)
    14h58 / 15h06
    Abstract : Prompt antibiotic administration and surgical debridement of infected tissues are the main modifiable prognostic factors for necrotizing skin and soft tissue infections (NSTI). A multidisciplinary and multimodal care bundle was implemented in our center in order to standardize patient management. The aim of this work was to evaluate its impact on patient recruitment, management, and outcomes.This retrospective cohort study included all NSTI cases admitted in our center between 2006 to 2017. A multimodal care bundle was progressively implemented through 2012 to 2013. It consisted mainly in (1) the creation of an NSTI multidisciplinary team involving intensive care and infectious diseases physicians, dermatologists available 24/7 for patient referral, plastic surgeons and microbiologists; (2) the use of a triage algorithm including a multidisciplinary bedside assessment to accelerate access to the operating room; (3) the prospective identification of all NSTI cases ; (4) and an active communication policy towards the medical community about the existing bundle. We compared patients from the pre-implementation period (2006-2011) to patients from the post-implementation period (2014-2017) regarding clinical features, management and outcomes. The primary endpoint was 60-day survival.Overall, 224 patients were admitted during the study period (pre-implementation, n=60; per-implementation, n=35, and post-implementation, n=129). The number of yearly NSTI cases increased significantly between the pre- and the post-implementation periods (median [IQR] 9 [8-13] vs 30 [24-42]); p=0.014). There was no significant difference between these periods regarding age, comorbidities, NSTI location or potentially modifiable prognostic factors, including time to surgery (0 [0-1] vs 0 [0-1] days; p=0.281), the proportion of patients undergoing surgery within 24h of admission (79% vs 78%; p>0.99), antibiotic administration within 48h (98% vs 100%; p=0.683) and the adequation of antibiotherapy to guidelines (93% vs 94%; p=0.960). Inclusion during the post-implementation period was associated with an increase in 60-day survival in univariable analysis (70% vs 85%; p=0.020 by log-rank analysis) (Figure 1). Yet, this association was not statistically significant after adjustment for patient comorbidities and severity in a multivariable Cox model (adjusted hazard ratio=0.88; 95% CI [0.41-1.87]; p=0.741).The implementation of a multidisciplinary and multimodal care bundle for NSTI was associated with higher patient recruitment and better 60-day censored survival in univariable but not multivariable analysis.
Flash Com
14h10 - 15h10
Forum 4
Médecin : Détresse respiratoire aiguë
Modérateur(s) : Alexandre Demoule (Paris / FRANCE), Fekri Abroug (Monastir / TUNISIE)
  • Does prior home ventilation positively impact the outcome of ICU-conducted Non Invasive ventilation?
    Orateur(s) :
    • Redwan Maatoug (Paris / FRANCE)
    • Manel Lahmar (Monastir / TUNISIE)
    • Zeineb Hammouda (Monastir / TUNISIE)
    • Islem Ouanes (Monastir / TUNISIE)
    • Fahmi Dachraoui (Monastir / TUNISIE)
    • Wiem Nouira (Monastir / TUNISIE)
    • Fekri Abroug (Monastir / TUNISIE)
    • Lamia Besbes (Monastir / TUNISIE)
    14h10 / 14h18
    Abstract : NIV failure is associated with increased morbi-mortality in the ICU. NIV failure prediction could help improving overall outcome by prompting earlier intubation, and paying more attention to the management of patients at risk. In addition to the type of disease leading to acute respiratory failure, technical considerations might account for NIV failure. The aim of the current study is test the hypothesis that patients who are under home ventilation do experience a lower rate of failure when ventilated non-invasively in the ICU.This retrospective study with prospective data collection included all patients admitted between January 2011 and December 2017 to the ICU of CHU F.Bourguiba Monastir, for acute hypercapnic respiratory failure. In included patients we collected demographic and clinical data, details of diagnosis workup, ventilatory support, and its outcome (success vs failure). Variables usually considered with impact on ventilatory outcome were compared between patients with successful NIV course and those with NIV failure. Continuous variables are presented as means±SD, and p<0.05 was considered statistically significant. During the study period, 355 patients were admitted in the ICU for hypercapnic respiratory failure. Of these 341 (96%) had NIV as the primary mode of ventilatory support. 94/341 had home ventilation, and the main cause of decompensation overall, was cardiac dysfunction (54%) . ICU-conducted NIV failed in 50 patients (14.6%) with similar rates in patients with prior home ventilation (n=16/94, 17%) compared to patients without prior home ventilation (n= 34/247, 14%). Table 1 depicts the risk factors of NIV failure disclosed by statistical analysisPrior home ventilation is not associated with a lower rate of NIV failure suggesting that failure from technical reasons was not highly prevalent in our series. NIV failure risk-factors disclosed pertain to clinical severity of the decompensation and its cause.
  • Physiological study of minimally invasive ECCO2R in exacerbation of COPD requiring invasive mechanical ventilation (EPHEBE study)
    Orateur(s) :
    • Jean-Luc Diehl (Paris / FRANCE)
    • Lise Piquilloud (Lausanne / SUISSE)
    • Damien Vimpere (Paris / FRANCE)
    • Emmanuel Guerot (Paris / FRANCE)
    • Marc Pierrot (Angers / FRANCE)
    • Delphine Hourton (Paris / FRANCE)
    • Armelle Arnoux (Paris / FRANCE)
    • Christian Richard (Le Kremlin-Bicêtre / FRANCE)
    • Jordi Mancebo (Barcelone / ESPAGNE)
    • Alain Mercat (Angers / FRANCE)
    14h18 / 14h26
    Abstract : Mechanical ventilation for exacerbations of COPD (AE-COPD) aims to provide adequate gas exchanges and to reduce the work of breathing (WOB). Extracorporeal CO2 removal (ECCO2R) can be a valuable additional modality for AE-COPD patients requiring invasive mechanical ventilation (IMV), by improving gas exchanges without deleterious consequences in terms of dynamic hyperinflation. However, little is known about the quantification of such ECCO2R-induced benefits.Open phase II-III prospective crossover (fixed order) study performed in 12 deeply sedated IMV AE-COPD patients. Dynamic hyperinflation and gas exchanges were compared without and with ECCO2R(Hemolung, Alung, Pittsburgh, USA) and adjustment of the respiratory rate (Carescape R860, GE Healthcare). The adjustment algorithm (either positive or negative) aimed to normalize arterial pH value and was based mainly on native lungs VCO2 values. When possible, WOB (Campbell's method) with and without ECCO2R was measured at the end of the weaning process. Results are expressed in median [IQR]. Non-parametric tests were used.Patients (SAPS2: 33[28.5-38.5] were included in 2 centers during an 18-months period. Table indicates the main results obtained without and with ECCO2R (using the higher permitted value of sweep gas flow) and adjustments of respiratory rate. WOB measurements (Joules/min. and Joules/L) were possible in 5 patients, indicating near-significant higher values when stopping the sweep gas flow for a 1 hr. period: 11.7[7.5;15.0] versus 22.6[13.9;34.7] J/min., p= 0.0625 and 1.1[0.8;1.4] versus 1.5[0.9;2.8] J/L, p=0.0625. Three patients died in-ICU. The other patients were successfully hospital-discharged. The total duration (days) of tracheal intubation was 8 [6-18]. The duration of tracheal intubation after ECCO2R initiation was 6 [4;16.5]. The duration of ICU stay was 14.5 [8;22.5]. There were 4 VAP episodes, 3 hemorrhagic and 3 thrombotic complications. Significant PaCO2, pH and SatHbO2 improvements were observed. The algorithm for pH normalization performed rather well, but without reduction in respiratory rate in the whole group and accordingly improvements in dynamic hyperinflation. This can be due to (i) mixed respiratory-metabolic acidosis in some patients and to (ii) intrinsic Hemolung properties (low to middle extracorporeal blood flow and membrane surface area). Results in terms of WOB are in line with previous publications.
  • Hyperoxia is toxic in patients with septic shock according to the Sepsis-3 criteria
    Orateur(s) :
    • Julien Demiselle (Angers / FRANCE)
    • Martin Wepler (Ulm / ALLEMAGNE)
    • Clair Hartmann (Ulm / ALLEMAGNE)
    • Peter Radermacher (Ulm / ALLEMAGNE)
    • Ferhat Meziani (Strasbourg / FRANCE)
    • Mervyn Singer (London / ROYAUME UNI)
    • Valérie Seegers (Angers / FRANCE)
    • Pierre Asfar (Angers / FRANCE)
    14h26 / 14h34
    Abstract : The Sepsis-3 definition of septic shock includes vasopressor treatment to maintain a mean arterial pressure over 65 mmHg and a lactate concentration over 2 mmol/L. The impact of hyperoxia in patients fulfilling these criteria is unknown.We conducted a post hoc analysis of the HYPER2S trial, including patients requiring vasopressor therapy with an available plasma lactate value at study inclusion. We compared the effect of hyperoxia and normoxia treatment on mortality of patients with hyperlactatemia (>2mmol/L) and of patients requiring vasopressor for hypotension without hyperlactatemia.397 patients were enrolled in this analysis, in whom 230 had lactate over 2 mmol/L and 167 had lactate lower or equal to 2 mmol/L. Among patients with lactate > 2 mmol/L, 108 and 122 were “hyperoxia”- and “normoxia”-treated, respectively. Patients with lactate > 2mmol/L had significantly less coronary artery disease, more cirrhosis and required surgery more frequently. They also had higher illness severity (SOFA 10.6±2.8 vs 9.5±2.5, p=0.0001), required more renal replacement therapy (RRT), and received vasopressor and mechanical ventilation for longer time. Mortality rate at day 28 was higher in the “hyperoxia”-treated patients with lactate > 2mmol/L as compared to “normoxia”-treated patients (57.4% vs 44.3%, p 0.054), despite similar RRT requirements as well as vasopressor and mechanical ventilation-free days. A multivariate analysis showed an independent association between hyperoxia and mortality at day 28 and 90. In patients with lactate ≤ 2 mmol/L, hyperoxia had no effect on mortality, nor on other outcomes. This study suggests that hyperoxia may be associated with a higher mortality rate in patients with septic shock using the Sepsis-3 criteria, but not in patients with hypotension requiring vasopressor without hyperlactatemia.
  • Acute respiratory failure in obesity-hypoventilation syndrome managed in the intensive care unit
    Orateur(s) :
    • Nader Chebib (Lyon / FRANCE)
    • Pascale Nesme (Lyon / FRANCE)
    • Nathalie Freymond (Pierre-Bénite / FRANCE)
    • Laurent Argaud (Lyon / FRANCE)
    • Thomas Rimmele (Lyon / FRANCE)
    • Julien Bohé (Lyon / FRANCE)
    • Gilles Devouassoux (Lyon / FRANCE)
    • Pierre Jean Souquet (Pierre-Bénite / FRANCE)
    14h34 / 14h42
    Abstract : Obesity-hypoventilation syndrome (OHS) is an increasing cause of acute hypercapnic respiratory failure (AHRF) in intensive care unit (ICU). Our objective was to describe the epidemiology, the ventilatory management and the outcome of patients with OHS admitted to the ICU for AHRF.We retrospectively built a cohort of OHS patients staying in 2 pneumology wards and admitted for AHRF in the 4 ICUs taking part of the tertiary University teaching hospital in Lyon, France, between January 1st 2013 and September 30th 2017. Clinical, functional and biological characteristics of patients at the time of OHS diagnosis were used as covariates. The main end-point was the rate of success of noninvasive ventilation (NIV) in the ICU. The secondary end-points were patient survival from OHS diagnosis to last follow-up, risk factors for ICU admission and for long-term survival including the role of ICU stay. Data were expressed as median (1st-3rd quartiles) and counts (percentage) and compared with nonparametric tests. Survival was measured by the Kaplan-Meier method and the difference in restricted mean survival time (RMST). Multivariate logistic regression analysis was used to assess risk factors of ICU admission. Cox proportional hazard model and multistate model were used to determine the risk factors of long-term survival.One-hundred and fifteen prevalent patients with OHS were included. Over a median follow-up period of 3.5 (1.4-6) years, 37 patients (32.1%) were admitted to the ICU for AHRF. The most frequent cause of AHRF was congestive heart failure (54%). Fourteen patients (37.8%) were treated for OHS with continuous or bilevel positive airway pressure prior to ICU admission. NIV was used as a first-line ventilatory support in 36 patients (97.2%) and was successful in 33 patients (89.2%). ICU mortality was low (2.7%). Patients admitted to ICU had significantly higher age, lower forced expiratory volume in 1 second and lower vital capacity (VC) at the time of OHS diagnosis. Difference in RMST was significant with a gain in survival of 663 days for patients not admitted to ICU. Multivariate analysis showed that lower VC at OHS diagnosis was significantly associated with higher risk of ICU admission. No factor was independently associated with long-term overall mortality in multivariate analysis.AHRF is frequent in OHS diagnosis and is generally responsive to NIV. Lower VC is associated with a higher risk of ICU admission.
  • Critical Illness-Related Corticosteroid Insufficiency during difficult weaning from mechanical ventilation.
    Orateur(s) :
    • François Bagate (CrÉteil / FRANCE)
    • Alexandre Bedet (CrÉteil / FRANCE)
    • Françoise Tomberli (Créteil / FRANCE)
    • Keyvan Razazi (Créteil / FRANCE)
    • Nicolas de Prost (Créteil / FRANCE)
    14h42 / 14h50
    Abstract : Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO.Prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 hours, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (T0) 0.25 mg iv of tetracosactrin and 30 and 60 minutes afterward. Δmax was defined as the difference between the maximal value after the test and T0. CIRCI was defined as T0<10μg/dL (276nmol/L) and/or Δmax<9μg/dL (248nmol/L) and inadequate adrenal reserve as Δmax<9μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation.Seventy-six consecutive patients (63+/-14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation (alive was significantly decreased in patients with CIRCI or inadequate adrenal reserve (Figure 1A and 1B), as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI or with inadequate adrenal reserve, and did not influence weaning outcome, whatever the definition used.CIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO.
  • Bedside predictors of successful weaning from high-flow nasal cannula in ICU
    Orateur(s) :
    • Rémi Coudroy (Poitiers / FRANCE)
    • Maeva Rodriguez (Poitiers / FRANCE)
    • Arnaud Thille (Poitiers / FRANCE)
    14h50 / 14h58
    Abstract : High-flow nasal cannula oxygen therapy (HFNC) is a recent technique that can provide high FiO2, decrease the work of breathing, and recruit lungs. Despite promising clinical results, its weaning has never been investigated. Our objective is to describe factors associated with successful weaning of HFNC.In a retrospective monocenter study over a 2-year period, all patients admitted to ICU and treated with HFNC for acute respiratory failure were included. Patients who were never weaned from HFNC during ICU stay, those who were treated with HFNC associated to NIV, and those who received preventive post-extubation HFNC were excluded. Our primary outcome was to compare patients according to the outcome of the first HFNC weaning attempt. Our secondary outcome was to compare the evolution of patients who failed HFNC weaning at first attempt, and then who were successfully weaned from HFNC.From the 190 patients included, 168 (88%) were successfully weaned from HFNC at the first attempt. At time of the first attempt, those who were successfully weaned had lower FiO2 (39 vs. 48%, p=0.02), were more likely to have a SpO2/FiO2 > 235 (corresponding to a PaO2/FiO2 > 200 mm Hg) (74% vs. 41%, p=0.005), and had a higher ROx index (SpO2/FiO2 /RR) than those who failed (p=0.002). The 19 patients who failed the first attempt significantly increased the ROx index at time of successful weaning (p=0.04).If confirmed in further studies, SpO2/FiO2 and ROx index could be 2 useful noninvasive predictors of success of HFNC weaning available at bedside.
  • Is immunosuppression status a risk factor for noninvasive ventilation failure in acute hypoxemic respiratory failure?
    Orateur(s) :
    • Rémi Coudroy (Poitiers / FRANCE)
    • Tai Pham (Toronto / CANADA)
    • Arnaud Thille (Poitiers / FRANCE)
    14h58 / 15h06
    Abstract : Recent European/American clinical practice guidelines recommend first-line noninvasive ventilation (NIV) to manage acute hypoxemic respiratory failure in immunocompromised patients. In contrast, in non-immunocompromised patients, the experts were unable to offer a recommendation given the uncertainty of evidence. Immunocompromised patients have particularly high mortality rates when they require invasive ventilation. However, it is not clear whether immunosuppression status is a risk factor for NIV failure. We aimed to assess the influence of immunosuppression status on outcomes of patients treated with NIV for acute respiratory failure.We performed a post-hoc analysis pooling 2 prospective studies on acute hypoxemic respiratory failure. Patients treated by NIV were included. Those with cardiogenic pulmonary edema, acute-on-chronic respiratory failure or hypercapnia were excluded. Among the 208 patients analyzed, 71 (34%) were immunocompromised whose main reason was cancer (n=37, 52%). Immunocompromised patients had higher severity scores upon ICU admission, were more likely to have bilateral lung infiltrates and received higher pressure-support levels under NIV than non-immunocompromised patients. Intubation and in-ICU mortality rates were higher in immunocompromised patients than in the others: 61% (43 out of 71 patients) vs. 43% (p=0.02), and 38% (27 patients) vs. 15% (p<0.001), respectively. Using multivariate analysis, immunosuppression was independently associated to intubation with an adjusted OR of 2.18 (95% CI 1.18-4.14, p=0.01) and to ICU mortality (OR 3.44,95%CI 1.73-7.03, p<0.001).Immunosuppression status influences outcomes in patients with acute hypoxemic respiratory failure treated with NIV. Studies in this specific population are mandatory.