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ESICM LIVES 2016: part three

Milan, Italy. 1–5 October 2016
  • T. Velasquez
  • G. Mackey
  • J. Lusk
  • U. G. Kyle
  • T. Fontenot
  • P. Marshall
  • L. S. Shekerdemian
  • J. A. Coss-Bu
  • A. Nishigaki
  • T. Yatabe
  • T. Tamura
  • K. Yamashita
  • M. Yokoyama
  • J. C. Ruiz-Rodriguez
  • B. Encina
  • R. Belmonte
  • I. Troncoso
  • P. Tormos
  • M. Riveiro
  • J. Baena
  • A. Sanchez
  • J. Bañeras
  • J. Cordón
  • N. Duran
  • A. Ruiz
  • J. Caballero
  • X. Nuvials
  • J. Riera
  • J. Serra
  • A. M. F. Rutten
  • S. N. M. van Ieperen
  • E. P. H. M. Der Kinderen
  • T. Van Logten
  • L. Kovacikova
  • P. Skrak
  • M. Zahorec
  • U. G. Kyle
  • A. Akcan-Arikan
  • J. C. Silva
  • G. Mackey
  • J. Lusk
  • M. Goldsworthy
  • L. S. Shekerdemian
  • J. A. Coss-Bu
  • D. Wood
  • D. Harrison
  • R. Parslow
  • P. Davis
  • J. Pappachan
  • S. Goodwin
  • P. Ramnarayan
  • S. Chernyshuk
  • H. Yemets
  • V. Zhovnir
  • S. M. Pulitano’
  • S. De Rosa
  • A. Mancino
  • G. Villa
  • F. Tosi
  • P. Franchi
  • G. Conti
  • B. Patel
  • H. Khine
  • A. Shah
  • D. Sung
  • L. Singer
  • S. Haghbin
  • S. Inaloo
  • Z. Serati
  • M. Idei
  • T. Nomura
  • N. Yamamoto
  • Y. Sakai
  • T. Yoshida
  • Y. Matsuda
  • Y. Yamaguchi
  • S. Takaki
  • O. Yamaguchi
  • T. Goto
  • N. Longani
  • S. Medar
  • I. R. Abdel-Aal
  • A. S. El Adawy
  • H. M. E. H. Mohammed
  • A. N. Mohamed
  • S. M. Parry
  • L. D. Knight
  • L. Denehy
  • N. De Morton
  • C. E. Baldwin
  • D. Sani
  • G. Kayambu
  • V. Z. M. da Silva
  • P. Phongpagdi
  • Z. A. Puthucheary
  • C. L. Granger
  • J. E. Rydingsward
  • C. M. Horkan
  • K. B. Christopher
  • D. McWilliams
  • C. Jones
  • E. Reeves
  • G. Atkins
  • C. Snelson
  • L. M. Aitken
  • J. Rattray
  • J. Kenardy
  • A. M. Hull
  • A. Ullman
  • R. Le Brocque
  • M. Mitchell
  • C. Davis
  • B. Macfarlane
  • J. C. Azevedo
  • L. L. Rocha
  • F. F. M. De Freitas
  • A. M. Cavalheiro
  • N. M. Lucinio
  • M. S. Lobato
  • G. Ebeling
  • A. Kraegpoeth
  • E. Laerkner
  • I. De Brito-Ashurst
  • C. White
  • S. Gregory
  • L. G. Forni
  • E. Flowers
  • A. Curtis
  • C. A. Wood
  • K. Siu
  • K. Venkatesan
  • J. B. H. Muhammad
  • L. Ng
  • E. Seet
  • N. Baptista
  • A. Escoval
  • E. Tomas
  • R. Agrawal
  • R. Mathew
  • A. Varma
  • E. Dima
  • E. Charitidou
  • E. Perivolioti
  • M. Pratikaki
  • C. Vrettou
  • A. Giannopoulos
  • S. Zakynthinos
  • C. Routsi
  • E. Atchade
  • S. Houzé
  • S. Jean-Baptiste
  • G. Thabut
  • C. Genève
  • S. Tanaka
  • B. Lortat-Jacob
  • P. Augustin
  • M. Desmard
  • P. Montravers
  • F. J. González de Molina
  • S. Barbadillo
  • R. Alejandro
  • F. Álvarez-Lerma
  • J. Vallés
  • R. M. Catalán
  • E. Palencia
  • A. Jareño
  • R. M. Granada
  • M. L. Ignacio
  • GETGAG Working Group
  • N. Cui
  • D. Liu
  • H. Wang
  • L. Su
  • H. Qiu
  • R. Li
  • K. Jaffal
  • A. Rouzé
  • J. Poissy
  • B. Sendid
  • S. Nseir
  • E. Paramythiotou
  • M. Rizos
  • F. Frantzeskaki
  • A. Antoniadou
  • S. Vourli
  • L. Zerva
  • A. Armaganidis
  • J. Riera
  • J. Gottlieb
  • M. Greer
  • O. Wiesner
  • M. Martínez
  • M. Acuña
  • J. Rello
  • T. Welte
  • E. Atchade
  • T. Mignot
  • S. Houzé
  • S. Jean-Baptiste
  • G. Thabut
  • B. Lortat-Jacob
  • S. Tanaka
  • P. Augustin
  • M. Desmard
  • P. Montravers
  • S. Soussi
  • E. Dudoignon
  • A. Ferry
  • M. Chaussard
  • M. Benyamina
  • A. Alanio
  • S. Touratier
  • M. Chaouat
  • M. Lafaurie
  • M. Mimoun
  • A. Mebazaa
  • M. Legrand
  • M. A. Sheils
  • C. Patel
  • L. Mohankumar
  • N. Akhtar
  • S. K. Pacheco Noriega
  • N. Navarrete Aldana
  • J. L. Ávila León
  • J. Durand Baquero
  • F. Fernández Bernal
  • E. Ahmadnia
  • J. S. Hadley
  • M. Millar
  • D. Hall
  • H. Hewitt
  • H. Yasuda
  • M. Sanui
  • T. Komuro
  • S. Kawano
  • K. Andoh
  • H. Yamamoto
  • E. Noda
  • J. Hatakeyama
  • N. Saitou
  • H. Okamoto
  • A. Kobayashi
  • T. Takei
  • S. Matsukubo
  • JSEPTIC (Japanese Society of Education for Physicians and Trainees in Intensive Care) Clinical Trial Group
  • H. B. Rotzel
  • A. Serrano Lázaro
  • D. Aguillón Prada
  • M. Rodriguez Gimillo
  • O. Diaz Barinas
  • M. L. Blasco Cortes
  • J. Ferreres Franco
  • J. M. Segura Roca
  • A. Carratalá
  • B. Gonçalves
  • R. Turon
  • A. Mendes
  • F. Miranda
  • P. J. Mata
  • D. Cavalcanti
  • N. Melo
  • P. Lacerda
  • P. Kurtz
  • C. Righy
  • L. E. de la Cruz Rosario
  • S. P. Gómez Lesmes
  • J. C. García Romero
  • A. N. García Herrera
  • E. D. Díaz Pertuz
  • M. J. Gómez Sánchez
  • E. Regidor Sanz
  • J. Barado Hualde
  • A. Ansotegui Hernández
  • J. M. Guergué Irazabal
  • V. Spatenkova
  • O. Bradac
  • P. Suchomel
  • T. Urli
  • E. Heusch Lazzeri
  • R. Aspide
  • M. Zanello
  • L. Perez-Borrero
  • J. M. Garcia-Alvarez
  • M. D. Arias-Verdu
  • E. Aguilar-Alonso
  • R. Rivera-Fernandez
  • J. Mora-Ordoñez
  • C. De La Fuente-Martos
  • E. Castillo-Lorente
  • F. Guerrero-Lopez
  • S. P. Gómez Lesmes
  • L. E. De la Cruz Rosario
  • E. D. Díaz Pertuz
  • A. Ansotegui Hernández
  • J. C. García Romero
  • M. J. Gómez Sánchez
  • A. N. García Herrera
  • J. Roldán Ramírez
  • E. Regidor Sanz
  • J. Barado Hualde
  • J. P. Tirapu León
  • L. Navarro-Guillamón
  • S. Cordovilla-Guardia
  • A. Iglesias-Santiago
  • F. Guerrero-López
  • E. Fernández-Mondéjar
  • A. Vidal
  • M. Perez
  • A. Juez
  • N. Arias
  • L. Colino
  • J. L. Perez
  • H. Pérez
  • P. Calpe
  • M. A. Alcala
  • D. Robaglia
  • C. Perez
  • S. K. Lan
  • M. M. Cunha
  • T. Moreira
  • F. Santos
  • E. Lafuente
  • M. J. Fernandes
  • J. G. Silva
  • L. E. de la Cruz Rosario
  • S. P. Gómez Lesmes
  • A. N. García Herrera
  • J. C. García Romero
  • E. D. Díaz Pertuz
  • M. J. Gómez Sánchez
  • E. Regidor Sanz
  • J. G. Armando Echeverría
  • A. Ansotegui Hernández
  • J. Barado Hualde
  • V. Podlepich
  • E. Sokolova
  • E. Alexandrova
  • K. Lapteva
  • P. Kurtz
  • C. Shuinotsuka
  • L. Rabello
  • G. Vianna
  • A. Reis
  • C. Cairus
  • J. Salluh
  • F. Bozza
  • J. C. Barrios Torres
  • N. J. Fernández Araujo
  • P. García-Olivares
  • E. Keough
  • M. Dalorzo
  • L. K. Tang
  • I. De Sousa
  • M. Díaz
  • L. J. Marcos-Zambrano
  • J. E. Guerrero
  • S. E. Zamora Gomez
  • G. D. Hernandez Lopez
  • A. I. Vazquez Cuellar
  • O. R. Perez Nieto
  • J. A. Castanon Gonzalez
  • D. Bhasin
  • S. Rai
  • H. Singh
  • O. Gupta
  • M. K. Bhattal
  • S. Sampley
  • K. Sekhri
  • R. Nandha
  • F. A. Aliaga
  • F. Olivares
  • F. Appiani
  • P. Farias
  • F. Alberto
  • A. Hernández
  • S. Pons
  • R. Sonneville
  • L. Bouadma
  • M. Neuville
  • E. Mariotte
  • A. Radjou
  • J. Lebut
  • S. Chemam
  • G. Voiriot
  • M. P. Dilly
  • B. Mourvillier
  • R. Dorent
  • P. Nataf
  • M. Wolff
  • J. F. Timsit
  • O. Ediboglu
  • S. Ataman
  • H. Ozkarakas
  • C. Kirakli
  • A. Vakalos
  • V. Avramidis
  • O. Obukhova
  • I. A. Kurmukov
  • S. Kashiya
  • E. Golovnya
  • V. N. Baikova
  • T. Ageeva
  • T. Haritydi
  • E. V. Kulaga
  • J. J. Rios-Toro
  • L. Perez-Borrero
  • E. Aguilar-Alonso
  • M. D. Arias-Verdu
  • J. M. Garcia-Alvarez
  • C. Lopez-Caler
  • C. De La Fuente-Martos
  • S. Rodriguez-Fernandez
  • M. Gomez Sanchez-Orézzoli
  • F. Martin-Gallardo
  • J. Nikhilesh
  • V. Joshi
  • E. Villarreal
  • J. Ruiz
  • M. Gordon
  • A. Quinza
  • J. Gimenez
  • M. Piñol
  • A. Castellanos
  • P. Ramirez
  • Y. D. Jeon
  • W. Y. Jeong
  • M. H. Kim
  • I. Y. Jeong
  • M. Y. Ahn
  • J. Y. Ahn
  • S. H. Han
  • J. Y. Choi
  • Y. G. Song
  • J. M. Kim
  • N. S. Ku
  • H. Shah
  • F. Kellner
  • F. Rezai
  • N. Mistry
  • P. Yodice
  • V. Ovnanian
  • K. Fless
  • E. Handler
  • R. Martínez Alejos
  • J. D. Martí Romeu
  • D. González Antón
  • A. Quinart
  • A. Torres Martí
  • M. Llaurado-Serra
  • A. Lobo-Civico
  • A. Ventura-Rosado
  • A. Piñol-Tena
  • M. Pi-Guerrero
  • C. Paños-Espinosa
  • M. Peralvo-Bernat
  • J. Marine-Vidal
  • R. Gonzalez-Engroba
  • N. Montesinos-Cerro
  • M. Treso-Geira
  • A. Valeiras-Valero
  • L. Martinez-Reyes
  • A. Sandiumenge
  • M. F. Jimenez-Herrera
  • CAPCRI Study
  • S. Helyar
  • P. Riozzi
  • A. Noon
  • G. Hallows
  • H. Cotton
  • J. Keep
  • P. A. Hopkins
  • A. Taggu
  • S. Renuka
  • S. Sampath
  • P. J. T. Rood
  • T. Frenzel
  • R. Verhage
  • M. Bonn
  • P. Pickkers
  • J. G. van der Hoeven
  • M. van den Boogaard
  • F. Corradi
  • L. Melnyk
  • F. Moggia
  • R. Pienovi
  • G. Adriano
  • C. Brusasco
  • L. Mariotti
  • M. Lattuada
  • M. J. Bloomer
  • M. Coombs
  • K. Ranse
  • R. Endacott
  • B. Maertens
  • K. Blot
  • S. Blot
  • M. P. van Nieuw Amerongen
  • E. S. van der Heiden
  • J. W. R. Twisk
  • A. R. J. Girbes
  • J. J. Spijkstra
  • P. Riozzi
  • S. Helyar
  • H. Cotton
  • G. Hallows
  • A. Noon
  • C. Bell
  • K. Peters
  • A. Feehan
  • J. Keep
  • P. A. Hopkins
  • K. Churchill
  • K. Hawkins
  • R. Brook
  • N. Paver
  • R. Endacott
  • N. Maistry
  • A. van Wijk
  • N. Rouw
  • T. van Galen
  • S. Evelein-Brugman
  • A. Taggu
  • B. Krishna
  • S. Sampath
  • A. Putzu
  • M. Fang
  • M. Boscolo Berto
  • A. Belletti
  • T. Cassina
  • L. Cabrini
  • M. Mistry
  • Y. Alhamdi
  • I. Welters
  • S. T. Abrams
  • C. H. Toh
  • H. S. Han
  • E. M. Gil
  • D. S. Lee
  • C. M. Park
  • S. Winder-Rhodes
  • R. Lotay
  • J. Doyle
  • M. W. Ke
  • W. C. Huang
  • C. H. Chiang
  • W. T. Hung
  • C. C. Cheng
  • K. C. Lin
  • S. C. Lin
  • K. R. Chiou
  • S. R. Wann
  • C. W. Shu
  • P. L. Kang
  • G. Y. Mar
  • C. P. Liu
  • S. Dubó
  • A. Aquevedo
  • M. Jibaja
  • D. Berrutti
  • C. Labra
  • R. Lagos
  • M. F. García
  • V. Ramirez
  • M. Tobar
  • F. Picoita
  • C. Peláez
  • D. Carpio
  • L. Alegría
  • C. Hidalgo
  • K. Godoy
  • J. Bakker
  • G. Hernández
  • Y. Sadamoto
  • K. Katabami
  • T. Wada
  • Y. Ono
  • K. Maekawa
  • M. Hayakawa
  • A. Sawamura
  • S. Gando
  • H. Marin-Mateos
  • J. L. Perez-Vela
  • R. Garcia-Gigorro
  • M. A. Corres Peiretti
  • M. J. Lopez-Gude
  • S. Chacon-Alves
  • E. Renes-Carreño
  • J. C. Montejo-González
  • K. L. Parlevliet
  • H. R. W. Touw
  • M. Beerepoot
  • C. Boer
  • P. W. G. Elbers
  • P. R. Tuinman
  • S. A. Abdelmonem
  • T. A. Helmy
  • I. El Sayed
  • S. Ghazal
  • S. H. Akhlagh
  • M. Masjedi
  • K. Hozhabri
  • E. Kamali
  • I. Zýková
  • B. Paldusová
  • P. Sedlák
  • D. Morman
  • A. M. Youn
  • Y. Ohta
  • M. Sakuma
  • D. Bates
  • T. Morimoto
  • P. L. Su
  • W. Y. Chang
  • W. C. Lin
  • C. W. Chen
  • F. Facchin
  • F. Zarantonello
  • G. Panciera
  • A. De Cassai
  • A. Venrdramin
  • A. Ballin
  • T. Tonetti
  • P. Persona
  • C. Ori
  • L. Del Sorbo
  • S. Rossi
  • G. Vergani
  • M. Cressoni
  • D. Chiumello
  • C. Chiurazzi
  • M. Brioni
  • I. Algieri
  • T. Tonetti
  • M. Guanziroli
  • A. Colombo
  • I. Tomic
  • A. Colombo
  • F. Crimella
  • E. Carlesso
  • V. Gasparovic
  • L. Gattinoni
  • A. Serpa Neto
  • M. Schmidt
  • T. Pham
  • A. Combes
  • M. Gama de Abreu
  • P. Pelosi
  • M. J. Schultz
  • for the ReVA Research Network and the PROVE Network Investigators
  • B. H. Katira
  • D. Engelberts
  • R. E. Giesinger
  • C. Ackerley
  • T. Yoshida
  • D. Zabini
  • G. Otulakowski
  • M. Post
  • W. M. Kuebler
  • P. J. McNamara
  • B. P. Kavanagh
  • R. Pirracchio
  • M. Resche Rigon
  • M. Carone
  • S. Chevret
  • D. Annane
  • S. Eladawy
  • M. El-Hamamsy
  • N. Bazan
  • M. Elgendy
  • G. De Pascale
  • M. S. Vallecoccia
  • S. L. Cutuli
  • V. Di Gravio
  • M. A. Pennisi
  • G. Conti
  • M. Antonelli
  • D. T. Andreis
  • W. Khaliq
  • M. Singer
  • J. Hartmann
  • S. Harm
  • S. Alcantara Carmona
  • P. Matia Almudevar
  • A. Naharro Abellán
  • J. Veganzones Ramos
  • L. Pérez Pérez
  • B. Lobo Valbuena
  • N. Martínez Sanz
  • I. Fernández Simón
  • M. Arrigo
  • E. Feliot
  • N. Deye
  • A. Cariou
  • B. Guidet
  • S. Jaber
  • M. Leone
  • M. Resche-Rigon
  • A. Vieillard Baron
  • M. Legrand
  • E. Gayat
  • A. Mebazaa
  • from the FROG ICU Investigators
  • M. Balik
  • I. Kolnikova
  • M. Maly
  • P. Waldauf
  • G. Tavazzi
  • J. Kristof
  • A. Herpain
  • F. Su
  • E. Post
  • F. Taccone
  • J. L. Vincent
  • J. Creteur
  • C. Lee
  • F. Hatib
  • Z. Jian
  • S. Buddi
  • M. Cannesson
  • S. Fileković
  • M. Turel
  • R. Knafelj
  • V. Gorjup
  • R. Stanić
  • P. Gradišek
  • O. Cerović
  • T. Mirković
  • M. Noč
  • J. Tirkkonen
  • H. Hellevuo
  • K. T. Olkkola
  • S. Hoppu
  • K. C. Lin
  • W. T. Hung
  • C. C. Chiang
  • W. C. Huang
  • W. C. Juan
  • S. C. Lin
  • C. C. Cheng
  • P. H. Lin
  • K. Y. Fong
  • D. S. Hou
  • P. L. Kang
  • S. R. Wann
  • Y. S. Chen
  • G. Y. Mar
  • C. P. Liu
  • M. Paul
  • W. Bougouin
  • G. Geri
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  • S. Legriel
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  • J. P. Mira
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  • E. Sullivan
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  • R. B. Brandon
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  • J. Revuelto Rey
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  • A. A. Tanaka Montoya
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  • V. Cordolcini
  • A. Agarossi
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  • F. Ortolano
  • N. Stocchetti
  • C. Mora Lourido
  • J. L. Santana Cabrera
  • J. D. Martín Santana
  • L. Melián Alzola
  • C. García del Rosario
  • H. Rodríguez Pérez
  • R. Lorenzo Torrent
  • S. Eslami
  • A. Dalhuisen
  • T. Fiks
  • M. J. Schultz
  • A. Abu Hanna
  • P. E. Spronk
  • M. Wood
  • D. Maslove
  • J. Muscedere
  • S. H. Scott
  • T. Saha
  • A. Hamilton
  • D. Petsikas
  • D. Payne
  • J. G. Boyd
  • Z. A. Puthucheary
  • A. S. McNelly
  • J. Rawal
  • B. Connolly
  • M. J. McPhail
  • P. Sidhu
  • A. Rowlerson
  • J. Moxham
  • S. D. Harridge
  • N. Hart
  • H. E. Montgomery
  • T. Jovaisa
  • B. Thomas
  • D. Gupta
  • D. S. Wijayatilake
  • H. P. Shum
  • H. S. King
  • K. C. Chan
  • K. B. Tang
  • W. W. Yan
  • C. Castro Arias
  • J. Latorre
  • A. Suárez De La Rica
  • E. Maseda Garrido
  • A. Montero Feijoo
  • C. Hernández Gancedo
  • A. López Tofiño
  • F. Gilsanz Rodríguez
  • L. K. Gemmell
  • R. Campbell
  • P. Doherty
  • A. MacKay
  • N. Singh
  • S. Vitaller
  • H. Nagib
  • J. Prieto
  • A. Del Arco
  • B. Zayas
  • C. Gomez
  • S. Tirumala
  • S. A. Pasha
  • B. K. Kumari
  • P. Martinez-Lopez
  • A. Puerto-Morlán
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  • L. Martinez Pujol
  • R. Algarte Dolset
  • B. Sánchez González
  • S. Quintana Riera
  • J. Trenado Álvarez
  • S. Quintana
  • L. Martínez
  • R. Algarte
  • B. Sánchez
  • J. Trenado
  • E. Tomas
  • N. Brock
  • E. Viegas
  • E. Filipe
  • D. Cottle
  • T. Traynor
  • M. V. Trasmonte Martínez
  • M. Pérez Márquez
  • L. Colino Gómez
  • N. Arias Martínez
  • J. M. Milicua Muñoz
  • B. Quesada Bellver
  • M. Muñoz Varea
  • M. Á. Alcalá Llorente
  • C. Pérez Calvo
  • S. D. Hillier
  • M. C. Faulds
  • H. Hendra
  • N. Lawrence
  • K. Maekawa
  • M. Hayakawa
  • Y. Ono
  • A. Kodate
  • Y. Sadamoto
  • N. Tominaga
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  • H. Murakami
  • T. Yoshida
  • K. Katabami
  • T. Wada
  • A. Sawamura
  • S. Gando
  • S. Silva
  • L. Kerhuel
  • B. Malagurski
  • G. Citerio
  • R. Chabanne
  • S. Laureys
  • L. Puybasset
  • L. Nobile
  • E. R. Pognuz
  • A. O. Rossetti
  • F. Verginella
  • N. Gaspard
  • J. Creteur
  • N. Ben-Hamouda
  • M. Oddo
  • F. S. Taccone
  • Y. Ono
  • M. Hayakawa
  • H. Iijima
  • K. Maekawa
  • A. Kodate
  • Y. Sadamoto
  • A. Mizugaki
  • H. Murakami
  • K. Katabami
  • T. Wada
  • A. Sawamura
  • S. Gando
  • A. Kodate
  • K. Katabami
  • T. Wada
  • Y. Ono
  • K. Maekawa
  • M. Hayakawa
  • A. Sawamura
  • S. Gando
  • L. W. Andersen
  • T. Raymond
  • R. Berg
  • V. Nadkarni
  • A. Grossestreuer
  • T. Kurth
  • M. Donnino
  • A. Krüger
  • P. Ostadal
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  • D. Vondrakova
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  • J. Cholkraisuwat
  • P. T. Pekkarinen
  • G. Ristagno
  • S. Masson
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  • T. Ala-Kokko
  • T. Varpula
  • J. Vaahersalo
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  • M. M. Mion
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  • K. S. Kim
  • G. J. Suh
  • W. Y. Kwon
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  • F. Zama Cavicchi
  • E. Iesu
  • L. Nobile
  • J. L. Vincent
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  • H. Tanaka
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  • S. Ishimatsu
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  • I. Romero
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  • P. Neuzil
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  • C. H. Huang
  • A. Chao
  • C. T. Lee
  • C. H. Lai
  • W. S. Chan
  • Y. J. Cheng
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  • M. Mourad
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  • Y. Cho
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  • Y. J. Cho
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  • L. Galarza Barrachina
  • J. H. Rodriguez Portillo
  • G. Pagés Aznar
  • L. Mateu Campos
  • M. D. Ferrándiz Sellés
  • M. Arlandis Tomás
  • A. Belenguer Muncharaz
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  • S. Monsalvo
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  • J. Park
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  • C. M. Park
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  • J. H. Yang
  • T. Witter
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  • M. B. Butler
  • M. Erdogan
  • P. C. Mac Dougall
  • R. S. Green
  • T. E. F. Abbott
  • H. D. T. Torrance
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  • N. Vaid
  • J. Emmanuel
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  • N. Prabu
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  • J. V. Divatia
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  • M. Hylander Møller
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  • P. Ramirez
  • M. R. Marqués-Miñana
  • E. Villarreal
  • M. Gordon
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  • A. Castellanos
  • R. Menendez
  • C. Sánchez Ramírez
  • M. Cabrera Santana
  • L. Caipe Balcázar
  • S. Hípola Escalada
  • M. A. Hernández Viera
  • C. F. Lübbe Vázquez
  • J. J. Díaz Díaz
  • F. Artiles Campelo
  • N. Sangil Monroy
  • P. Saavedra Santana
  • S. Ruiz Santana
  • A. Gutiérrez-Pizarraya
  • J. Garnacho-Montero
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  • K. Baumstarck
  • M. Leone
  • I. Martín-Loeches
  • R. Pirracchio
  • M. Legrand
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  • B. Cholley
  • A. Hubbard
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  • L. M. Claraco Vega
  • P. Ruiz de Gopegui Miguelena
  • M. C. Villuendas Usón
  • A. Rezusta López
  • E. Aurensanz Clemente
  • P. Gutiérrez Ibañes
  • A. L. Ruiz Aguilar
  • M. Palomar
  • P. Olaechea
  • S. Uriona
  • M. Vallverdu
  • M. Catalan
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  • F. Alvarez Lerma
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  • W. Y. Jeong
  • M. H. Kim
  • I. Y. Jeong
  • M. Y. Ahn
  • J. Y. Ahn
  • S. H. Han
  • J. Y. Choi
  • Y. G. Song
  • J. M. Kim
  • N. S. Ku
  • G. Li Bassi
  • E. Aguilera Xiol
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  • F. A. Idone
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  • C. Travierso
  • L. Fernández-Barat
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  • Q. Bobi
  • M. Rigol
  • A. Torres
  • I. Fuentes Fernández
  • E. Andreu Soler
  • A. Pareja Rodríguez de Vera
  • E. Escudero Pastor
  • V. Hernandis
  • J. Ros Martínez
  • R. Jara Rubio
  • M. Miralbés Torner
  • S. Carvalho Brugger
  • A. Aragones Eroles
  • S. Iglesias Moles
  • J. Trujillano Cabello
  • J. A. Schoenenberger
  • X. Nuvials Casals
  • M. Vallverdu Vidal
  • B. Balsera Garrido
  • M. Palomar Martinez
  • L. Mirabella
  • A. Cotoia
  • L. Tullo
  • A. Stella
  • F. Di Bello
  • A. Di Gregorio
  • M. Dambrosio
  • G. Cinnella
  • L. E. de la Cruz Rosario
  • S. P. Gómez Lesmes
  • J. C. García Romero
  • A. N. García Herrera
  • E. D. Díaz Pertuz
  • M. J. Gómez Sánchez
  • E. Regidor Sanz
  • J. Barado Hualde
  • A. Ansotegui Hernández
  • J. Roldán Ramirez
  • H. Takahashi
  • F. Kazutoshi
  • Y. Okada
  • W. Oobayashi
  • T. Naito
  • D. K. Baidya
  • S. Maitra
  • R. K. Anand
  • B. R. Ray
  • M. K. Arora
  • C. Ruffini
  • L. Rota
  • A. Corona
  • G. Sesana
  • S. Ravasi
  • E. Catena
  • D. N. Naumann
  • C. Mellis
  • S. L. Husheer
  • J. Bishop
  • M. J. Midwinter
  • S. Hutchings
  • F. Corradi
  • C. Brusasco
  • T. Manca
  • A. Ramelli
  • M. Lattuada
  • F. Nicolini
  • T. Gherli
  • A. Vezzani
  • A. Young
  • A. Fernández Carmona
  • A. Iglesias Santiago
  • L. Navarro Guillamon
  • M. J. García Delgado
  • M. Delgado-Amaya
  • E. Curiel-Balsera
  • L. Rivera-Romero
  • E. Castillo-Lorente
  • F. Carrero-Gómez
  • E. Aguayo-DeHoyos
  • ARIAM registry of adult cardiac surgery
  • A. J. Healey
  • C. Cameron
  • L.R. Jiao
  • R. Stümpfle
  • A. Pérez
  • S. Martin
  • O. Lopez del Moral
  • S. Toval
  • J. Rico
  • C. Aldecoa
  • K. Oguzhan
  • O. Demirkiran
  • M. Kirman
  • S. Bozbay
  • M. E. Kosuk
  • G. Asyralyyeva
  • M. Dilek
  • M. Duzgun
  • S. Telli
  • M. Aydin
  • F. Yilmazer
  • L. E. Hodgson
  • B. D. Dimitrov
  • C. Stubbs
  • L. G. Forni
  • R. Venn
  • D. Vedage
  • S. Shawaf
  • P. Naran
  • N. Sirisena
  • J. Kinnear
  • B. D. Dimitrov
  • L. E. Hodgson
  • C. Stubbs
  • L. G. Forni
  • R. Venn
  • J. Gonzalez Londoño
  • C. Lorencio Cardenas
  • A. Sánchez Ginés
  • C. Murcia Gubianas
  • E. Clapes Sánchez
  • J. M. Sirvent
  • V. Panafidina
  • I. Shlyk
  • V. Ilyina
  • S. Judickas
  • G. Kezyte
  • I. Urbanaviciute
  • M. Serpytis
  • E. Gaizauskas
  • J. Sipylaite
  • C. L. Sprung
  • G. Munteanu
  • R. C. Morales
  • H. Kasdan
  • T. Volker
  • A. Reiter
  • Y. Cohen
  • Y. Himmel
  • J. Meissonnier
  • M. E. Banderas-Bravo
  • C. Gómez-Jiménez
  • M. V. García-Martínez
  • J. F. Martínez-Carmona
  • J. F. Fernández-Ortega
  • M. J. O‘Dwyer
  • M. Starczewska
  • M. Wilks
  • J. L. Vincent
  • The Rapid Diagnosis of Infections in the Critically Ill Team
  • M. Torsvik
  • L. T. Gustad
  • I. L. Bangstad
  • L. J. Vinje
  • J. K. Damås
  • E. Solligård
  • A. Mehl
  • M. Tsunoda
  • M. Kang
  • M. Saito
  • N. Saito
  • N. Akizuki
  • M. Namiki
  • M. Takeda
  • J. Yuzawa
  • A. Yaguchi
  • Tokyo Womens Medical University
  • F. Frantzeskaki
  • P. Tsirigotis
  • S. Chondropoulos
  • E. Paramythiotou
  • M. Theodorakopoulou
  • M. Stamouli
  • K. Gkirkas
  • I. K. Dimopoulou
  • S. Makiko
  • M. Tsunoda
  • M. Kang
  • J. Yuzawa
  • N. Akiduki
  • M. Namiki
  • M. Takeda
  • A. Yaguchi
  • S. Preau
  • M. Ambler
  • A. Sigurta
  • S. Saeed
  • M. Singer
  • S. Jochmans
  • J. Chelly
  • L. V. P. Vong
  • O. Sy
  • J. Serbource-Goguel
  • N. Rolin
  • C. M. Weyer
  • R. I. Abdallah
  • C. Adrie
  • C. Vinsonneau
  • M. Monchi
  • U. Mayr
  • W. Huber
  • E. Karsten
  • T. Lahmer
  • P. Thies
  • B. Henschel
  • G. Fischer
  • R. M. Schmid
  • O. Ediboglu
  • S. Ataman
  • I. Naz
  • G. Yaman
  • C. Kirakli
  • P. L. Su
  • P. S. Kou
  • W. C. Lin
  • C. W. Chen
  • J. A. Benítez Lozano
  • P. Carmona Sánchez
  • J. E. Barrueco Francioni
  • F. Ruiz Ferrón
  • J. M. Serrano Simón
  • Z. Riad
  • M. Mezidi
  • M. Aublanc
  • S. Perinel
  • F. Lissonde
  • A. Louf-Durier
  • H. Yonis
  • R. Tapponnier
  • J. C. Richard
  • B. Louis
  • C. Guérin
  • PLUG working group
  • M. Mezidi
  • H. Yonis
  • M. Aublanc
  • F. Lissonde
  • A. Louf-Durier
  • S. Perinel
  • R. Tapponnier
  • J. C. Richard
  • C. Guérin
  • K. Marmanidou
  • M. Oikonomou
  • C. Nouris
  • C. Loizou
  • E. Soilemezi
  • D. Matamis
  • P. Somhorst
  • D. Gommers
  • K. Hayashi
  • T. Hirayama
  • T. Yumoto
  • K. Tsukahara
  • A. Iida
  • N. Nosaka
  • K. Sato
  • T. Ugawa
  • A. Nakao
  • Y. Ujike
  • S. Hirohata
  • F. Mojoli
  • F. Torriglia
  • M. Giannantonio
  • A. Orlando
  • S. Bianzina
  • G. Tavazzi
  • S. Mongodi
  • M. Pozzi
  • G. A. Iotti
  • A. Braschi
  • PLUG Working Group
  • D. Jansen
  • S. Gadgil
  • J. Doorduin
  • L. Roesthuis
  • J. G. van der Hoeven
  • L. M. A. Heunks
  • G. Q. Chen
  • X. M. Sun
  • X. He
  • Y. L. Yang
  • Z. H. Shi
  • M. Xu
  • J. X. Zhou
  • S. M. Pereira
  • M. R. Tucci
  • B. F. F. Tonelotto
  • C. M. Simoes
  • C. C. A. Morais
  • M. S. Pompeo
  • F. U. Kay
  • M. B. P. Amato
  • J. E. Vieira
  • S. Suzuki
  • Y. Mihara
  • Y. Hikasa
  • S. Okahara
  • H. Morimatsu
  • On behalf of Okayama Research Investigation Organizing Network (ORION)investigators
  • H. M. Kwon
  • Y. J. Moon
  • S. H. Lee
  • K. W. Jung
  • W. J. Shin
  • I. G. Jun
  • J. G. Song
  • G. S. Hwang
  • S. Lee
  • Y. J. Moon
  • H. M. Kwon
  • K. Jung
  • W. J. Shin
  • I. G. Jun
  • J. G. Song
  • G. S. Hwang
  • A. Ramelli
  • T. Manca
  • F. Corradi
  • C. Brusasco
  • F. Nicolini
  • T. Gherli
  • R. Brianti
  • P. Fanzaghi
  • A. Vezzani
  • B. A. Tudor
  • D. A. Klaus
  • D. Lebherz-Eichinger
  • C. Lechner
  • C. Schwarz
  • M. Bodingbauer
  • R. Seemann
  • K. Kaczirek
  • E. Fleischmann
  • G. A. Roth
  • C. G. Krenn
  • A. Malyshev
  • S. Sergey
  • Y. Yamaguchi
  • T. Nomura
  • E. Yoshitake
  • M. Idei
  • T. Yoshida
  • S. Takaki
  • O. Yamaguchi
  • M. Kaneko
  • T. Goto
  • N. Tencé
  • I. Zaien
  • M. Wolf
  • P. Trouiller
  • F. M. Jacobs
  • J. M. Kelly
  • P. Veigas
  • S. Hollands
  • A. Min
  • S. Rizoli
  • C. M. Coronado Robles
  • M. A. Montes de Oca Sandoval
  • O. Tarabrin
  • D. Gavrychenko
  • G. Mazurenko
  • P. Tarabrin
  • I. Palacios Garcia
  • A. Diaz Martin
  • M. Casado Mendez
  • V. Arellano orden
  • R. Leal Noval
  • C. McCue
  • L. Gemmell
  • A. MacKay
  • J. Luján
  • P. Villa
  • B. Llorente
  • R. Molina
  • L. Alcázar
  • C. Arenillas Juanas
  • S. Rogero
  • T. Pascual
  • J. A. Cambronero
  • P. Matía Almudévar
  • J. Palamidessi Domínguez
  • S. Alcántara Carmona
  • D. Palacios Castañeda
  • A. Naharro Abellán
  • A. Pérez Lucendo
  • L. Pérez Pérez
  • R. Fernández Rivas
  • N. Martínez Sanz
  • J. Veganzones Ramos
  • P. Rodríguez Villamizar
  • S. Javadpour
  • N. Kalani
  • T. Amininejad
  • S. Jamali
  • S. Sobhanian
  • A. Laurent
  • M. Bonnet
  • R. Rigal
  • P. Aslanian
  • P. Hebert
  • G. Capellier
  • PS-ICU Group
  • M. R. Diaz Contreras
  • C. Rodriguez Mejías
  • F. C. Santiago Ruiz
  • M. Duro Lombardo
  • J. Castaño Perez
  • E. Aguayo de Hoyos
  • A. Estella
  • R. Viciana
  • L. Perez Fontaiña
  • T. Rico
  • V. Perez Madueño
  • M. Recuerda
  • L. Fernández
  • A. Sandiumenge
  • S. Bonet
  • C. Mazo
  • M. Rubiera
  • J. C. Ruiz-Rodríguez
  • R. M. Gracia
  • E. Espinel
  • T. Pont
  • A. Kotsopoulos
  • N. Jansen
  • W. F. Abdo
  • A. Gopcevic
  • Z. Gavranovic
  • M. Vucic
  • M. Zlatic Glogoski
  • L. Videc Penavic
  • A. Horvat
  • L. Martin-Villen
  • J. J. Egea-Guerero
  • J. Revuelto-Rey
  • T. Aldabo-Pallas
  • E. Correa-Chamorro
  • A. I. Gallego-Corpa
  • P. Ruiz del Portal-Ruiz Granados
  • V. Faivre
  • L. Wildenberg
  • B. Huot
  • A. C. Lukaszewicz
  • M. Simsir
  • C. Mengelle
  • D. Payen
  • N. Martinez Sanz
  • B. Lobo Valbuena
  • M. Valdivia de la Fuente
  • P. Matía Almudena
  • L. Pérez Pérez
  • S. Alcántara Carmona
  • A. Navarro Abellán
  • I. Fernández Simón
  • J. J. Rubio Muñoz
  • J. Veganzones Ramos
  • S. Alcantara Carmona
  • P. Matia Almudevar
  • A. Naharro Abellan
  • M. A. Perez Lucendo
  • L. Perez Perez
  • J. Palamidessi Dominguez
  • R. Fernandez Rivas
  • P. Rodriguez Villamizar
  • S. Wee
  • C. Ong
  • Y. H. Lau
  • Y. Wong
  • M. E. Banderas-Bravo
  • V. Olea-Jiménez
  • J. M. Mora-Ordóñez
  • C. Gómez-Jiménez
  • J. L. Muñoz-Muñoz
  • J. Vallejo-Báez
  • D. Daga-Ruiz
  • M. Lebrón-Gallardo
  • G. Rialp
  • J. M. Raurich
  • I. Morán
  • M. C. Martín
  • G. Heras
  • A. Mas
  • I. Vallverdú
  • S. Hraiech
  • J. Bourenne
  • C. Guervilly
  • J. M. Forel
  • M. Adda
  • P. Sylla
  • A. Mouaci
  • M. Gainnier
  • L. Papazian
  • P. R. Bauer
  • A. Kumbamu
  • M. E. Wilson
  • J. K. Pannu
  • J. S. Egginton
  • R. Kashyap
  • O. Gajic
  • S. Yoshihiro
  • M. Sakuraya
  • M. Hayakawa
  • A. Hirata
  • N. Kawamura
  • T. Tsutui
  • K. Yoshida
  • Y. Hashimoto
  • Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study group
  • C. H. Chang
  • H. C. Hu
  • L. C. Chiu
  • C. Y. Hung
  • S. H. Li
  • K. C. Kao
  • S. Sibley
  • J. Drover
  • C. D’Arsigny
  • C. Parker
  • D. Howes
  • S. Moffatt
  • J. Erb
  • R. Ilan
  • D. Messenger
  • I. Ball
  • J. G. Boyd
  • M. Harrison
  • S. Ridi
  • J. Muscedere
  • A. H. Andrade
  • R. C. Costa
  • V. A. Souza
  • V. Gonzalez
  • V. Amorim
  • F. Rolla
  • C. A. C. Abreu Filho
  • R. Miranda
  • S. Atchasiri
  • P. Buranavanich
  • T. Wathanawatthu
  • S. Suwanpasu
  • C. Bureau
  • C. Rolland-Debord
  • T. Poitou
  • M. Clavel
  • S. Perbet
  • N. Terzi
  • A. Kouatchet
  • T. Similowski
  • A. Demoule
  • P. Diaz
  • J. Nunes
  • S. Escórcio
  • G. Silva
  • S. Chaves
  • M. Jardim
  • M. Câmara
  • N. Fernandes
  • R. Duarte
  • J. J. Jardim
  • C. A. Pereira
  • J. J. Nóbrega
  • C. M. Chen
  • C. C. Lai
  • K. C. Cheng
  • W. Chou
  • S. J. Lee
  • Y. S. Cha
  • W. Y. Lee
  • M. Onodera
  • E. Nakataki
  • J. Oto
  • H. Imanaka
  • M. Nishimura
  • A. Khadjibaev
  • D. Sabirov
  • A. Rosstalnaya
  • R. Akalaev
  • F. Parpibaev
  • E. Antonucci
  • P. Rossini
  • S. Gandolfi
  • E. Montini
  • S. Orlando
  • M. van Nes
  • F. Karachi
  • S. Hanekom
  • A. H. Andrade
  • U. V. Pereira
  • C. A. C. Abreu Filho
  • R. C. Costa
  • M. S. W. Parkin
  • M. Moore
  • A. H. Andrade
  • R. C. Costa
  • K. V. Silva Carvalho
  • C. A. C. Abreu Filho
  • H. J. Min
  • H. J. Kim
  • D. S. Lee
  • Y. Y. Choi
  • E. Y. Lee
  • I. Song
  • D. J. Kim
  • Y. Y. E
  • J. W. Kim
  • J. S. Park
  • Y. J. Cho
  • J. H. Lee
  • J. W. Suh
  • Y. H. Jo
  • K. S. Kim
  • Y. J. Lee
  • J. Ferrero-Calleja
  • D. Merino-Vega
  • A. I. González-Jiménez
  • M. Sigcha Sigcha
  • A. Hernández-Tejedor
  • A. Martin-Vivas
  • Á. Gabán-Díez
  • R. Ruiz-de Luna
  • N. De la Calle-Pedrosa
  • I. Temprano-Gómez
  • D. Afonso-Rivero
  • J. I. Pellin-Ariño
  • A. Algora-Weber
  • R. R. L. Fumis
  • A. B. Ferraz
  • J. M. Vieira Junior
  • H. Kirca
  • O. Cakin
  • M. Unal
  • H. Mutlu
  • A. Ramazanoglu
  • M. Cengiz
  • E. A. Nicolini
  • F. G. F. Pelisson
  • R. S. Nunes
  • S. L. da Silva
  • M. M. Carreira
  • F. Bellissimo-Rodrigues
  • M. A. Ferez
  • A. Basile-Filho
  • H. C. Chao
  • C. M. Chen
  • L. Chen
  • M. Hravnak
  • G. Clermont
  • M. Pinsky
  • A. Dubrawski
  • J. Luján Varas
  • R. Molina Montero
  • L. Alcázar Sánchez-Elvira
  • P. Villa Díaz
  • C. Pintado Delgado
  • B. Llorente Ruiz
  • A. Pardo Guerrero
  • J. A. Cambronero Galache
  • H. Sherif
  • H. Hassanin
  • R. El Hossainy
  • W. Samy
  • H. Ly
  • H. David
  • P. Burtin
  • C. Charpentier
  • M. Barral
  • P. Courant
  • E. Fournel
  • L. Gaide-Chevronnay
  • M. Durand
  • P. Albaladejo
  • J. F. Payen
  • O. Chavanon
  • A. Blandino Ortiz
  • S. Pozzebon
  • O. Lheureux
  • A. Brasseur
  • J. L. Vincent
  • J. Creteur
  • F. S. Taccone
  • F. Fumagalli
  • S. Scala
  • R. Affatato
  • M. De Maglie
  • D. Zani
  • D. Novelli
  • C. Marra
  • A. Luciani
  • D. De Zani
  • M. Luini
  • T. Letizia
  • D. Pravettoni
  • L. Staszewsky
  • S. Masson
  • A. Belloli
  • M. Di Giancamillo
  • E. Scanziani
  • R. Latini
  • G. Ristagno
  • Y. C. Kye
  • G. J. Suh
  • W. Y. Kwon
  • K. S. Kim
  • K. M. Yu
  • G. Babini
  • G. Ristagno
  • L. Grassi
  • F. Fumagalli
  • S. Bendel
  • M. De Maglie
  • R. Affatato
  • S. Masson
  • R. Latini
  • E. Scanziani
  • M. Reinikainen
  • M. Skrifvars
  • F. Kappler
  • M. Blobner
  • S. J. Schaller
  • A. Roasio
  • E. Costanzo
  • S. Cardellino
  • E. Iesu
  • F. Zama Cavicchi
  • V. Fontana
  • L. Nobile
  • J. L. Vincent
  • J. Creteur
  • F. S. Taccone
  • M. Park
  • K. M. You
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Open Access
Meeting abstracts

CHILDREN, TEENAGER AND FAMILIES IN THE ICU

A793 Malnutrition and clinical outcomes in critically ill children

T. Velasquez1, G. Mackey2,3, J. Lusk2,3, U.G. Kyle2,3, T. Fontenot2, P. Marshall2, L.S. Shekerdemian2,3, J.A. Coss-Bu2,3

1Texas Children's Hospital, Clinical Nutriiton, Houston, United States; 2Texas Children's Hospital, Intensive Care, Houston, United States; 3Baylor College of Medicine, Pediatrics, Houston, United States
Correspondence: J.A. Coss-Bu – Texas Children's Hospital, Intensive Care, Houston, United States

Introduction: Critically ill children in the pediatric intensive care unit (PICU) are at high risk for developing nutritional deficiencies and undernutrition is known to be a risk factor for morbidity and mortality. Malnutrition represents a continuous spectrum ranging from marginal nutrient status to severe metabolic and functional alterations and this in turn, affects clinical outcome.

Objectives: The aim of the study was to assess nutritional status of critically ill children admitted to the PICU and its association to clinical outcomes.

Methods: Critically ill children age 6 months to 18 years were prospectively enrolled on PICU admission. Nutritional status was assessed by weight for age (WFA: underweight), weight for height (WFH: wasting), height for age (HFA: stunting) z-scores and mid upper arm circumference (MUAC: wasting) according to the WHO. (1,2) Malnutrition was defined as mild, moderate, and severe if z-scores were > −1, > − 2, and > −3, respectively. Hospital and PICU length of stay (LOS), duration of mechanical ventilation (MV), and risk of mortality (ROM) by the Pediatric Index of Mortality 2 (PIM2) were obtained. Sensitivity and specificity of the MUAC to identify children with wasting (WFH) were calculated.

Results: Two hundred and fifty children (136 males), aged 81 months (23–167; median (25-75th IQR)), were prospectively included in the study. The hospital LOS was 8 (4–16) days; PICU LOS: 2 (1–4) days; duration of MV, 0 (0–1.5) days; PIM2 ROM 2.61 ± 0.25 %. WFA, WFH, and HFA z-scores of −0.48 ± 0.14; 0.19 ± 0.13; and −0.95 ± 0.13 respectively; MUAC, 16.3 ± 0.18 cm (6 to 59 months, n = 108); 24.2 ± 0.46 cm (5 to 18 years, n = 142). The prevalence of underweight, wasting and stunting was 26.4 %, 19.6 %, and 44.4 % respectively. The sensitivity and specificity for MUAC vs. WFH to identify wasting was: 34.5 % (20.3-50.6; 95 % CI) and 95.5 % (91.8-97.9), respectively. Values are mean ± SE.

Conclusions: Malnutrition in critically ill children is prevalent with half of the patients being stunted, reflecting the chronic nature of the disease process and its effects on the nutritional status. The performance of MUAC as a screening tool in this population was poor, but identified correctly almost all children with wasting. There was an association between nutritional status and length of stay and risk of mortality.

References

1 WHO: Technical Report Series, No. 854, 1995

2 Bulletin of the WHO, 1997, 75:11–18

Grant acknowledgement

Internal

FUNDING

Texas Children´s Hospital
Table 1 (abstract A793).

Malnutriiton and Outcomes

 

Underweight

Wasting

Stunting

 

Odds Ratio

95 % C.I.

p value

Odds Ratio

95 % C.I.

p value

Odds Ratio

95 % C.I.

p value

Hospital LOS

2.40

1.16–4.99

0.019

2.26

1.17–4.36

0.015

1.05

0.64–1.73

0.854

ICU LOS

2.17

1.05–4.49

0.037

2.28

1.05–4.95

0.037

2.33

1.14–4.79

0.021

PIM2 ROM

1.16

1.05–1.28

0.004

1.08

1.01–1.17

0.034

1.12

1.01–1.23

0.024

LOS length of stay, PIM2 pediatric index of mortality, ROM risk of mortality

A794 Retrospective analysis for predicting optimal tracheal tube size in pediatric patients

A. Nishigaki, T. Yatabe, T. Tamura, K. Yamashita, M. Yokoyama

Kochi Medical School, Department of Anesthesiology and Intensive Care Medicine, Nankoku, Japan
Correspondence: A. Nishigaki – Medical School, Department of Anesthesiology and Intensive Care Medicine, Nankoku, Japan

Introduction: There are several methods to estimate the optimal tracheal tube size in pediatric patients such as the Cole's formula (inner diameter (ID) = 4 + Age/4) [1]. However, these evaluation methods are made based on age in years (not months) and ID. Moreover, outer diameter (OD) may vary according to the type of the tracheal tube.

Objectives: We hypothesized that prediction of OD for determining the optimal tracheal tube size in pediatric patients based on age in months is better than Cole's formula. Therefore, we conducted a retrospective analysis to investigate our hypothesis.

Methods: The ethics committee of our hospital approved this retrospective study. We included consecutive patients aged < 6 years who underwent tracheal intubation under general anesthesia in our hospital from August 2013 to October 2015. We collected the following data from the anesthesia records: age in months, height, weight, type of a tracheal tube, and ID and OD of tracheal tube. Patients who were intubated using a cuffed tracheal tube or had incomplete data were excluded. We developed a regression formula for calculating ID and OD based on age in months and calculated the coefficient of determination R2 by using a regression analyses. A difference of 0.4 mm in the actual and predicted tube size was considered clinically permissible. Then, we compared the rate of a clinical permissible estimation of the Cole's formula and our new formulas used by multiple comparison analysis and a p value less than 0.05 was considered statistically significant.

Results: A total of 207 pediatric patients received general anesthesia during the study period. Of these, 67 patients were excluded because they did not meet the inclusion criteria. Finally, we included 140 patients for this analysis. The regression formula for predicting ID by based on age in months was ID = 0.019 × age in months + 3.48, and the coefficient of determination R2 was 0.54. The regression formula for predicting OD based on age in months was OD = 0.024 × age in months + 5.21, and coefficient of determination R2 was 0.558. The rate of a clinical permissible estimation of our ID and OD formulas were significantly higher than that of the Cole's formula (61 %, 69 % and 43 %, respectively; p < 0.01).

Conclusions: Our results showed that the prediction of ID based on age in months is more useful than that using Cole's formula. In addition, estimation of OD based on age in months might be more rational because OD varies according to the type of the tracheal tube used. These results should be confirmed in a future prospective study.

References

[1] Cole F. Pediatric formulas for the anesthesiologist. AMA J Dis Child. 1957;94:672–3.

A795 Teenagers perception towards cardiopulmonary resuscitation

J.-C. Ruiz-Rodriguez1, B. Encina1, R. Belmonte1, I. Troncoso1, P. Tormos2, M. Riveiro3, J. Baena3, A. Sanchez1, J. Bañeras4, J. Cordón1, N. Duran5, A. Ruiz1, J. Caballero1, X. Nuvials1, J. Riera1, J. Serra1

1Vall d' Hebron University Hospital, Critical Care Department, Barcelona, Spain; 2Vall d' Hebron University Hospital, Anesthesia & Reanimation Department, Barcelona, Spain; 3Vall d' Hebron University Hospital, Neurocritical Care Department, Barcelona, Spain; 4Vall d' Hebron University Hospital, Coronary Care Unit, Barcelona, Spain; 5Sagrat Cor University Hospital, Critical Care Department, Barcelona, Spain
Correspondence: J.-C. Ruiz-Rodriguez – Vall d' Hebron University Hospital, Critical Care Department, Barcelona, Spain

Introduction: Survival among out-of-hospital cardiac arrest (CA) relies primarily on bystanders and their knowledge of basic life support (BLS) manouvers [1]. Many medical societies and organizations recommend teaching BLS at schools as part of the educative program [2]; being this a reality in North European countries, but not yet an education standard issue in others including Spain. Moreover, less is written about the perception of CA and cardiopulmonary resuscitation (CPR) among the general population, and even less in school age.

Objectives: Describe the perception and knowledge about CA and CPR among a teenager school population in Barcelona, Spain.

Methods: Prospective, descriptive study carried out between 2007–2009 and 2012–2015 among teenagers school population, based on surveys before and after BLS - CPR classes. During this period , 17th classes were held, in 3 different schools in Barcelona. Before attending the class , each pupil was asked to answer a survey with questions related to previous knowledge of sudden death, CA, and CPR, and their attitude towards them. The class consisted on a three - hour theorical and practical instruction based on the European Resuscitation Council guidelines, adapted for laypersons. Practices were held with an instructor (ratio instructor:pupil 1:6–8), with the Little Anne mannequins (Laerdal®).

After the class, a new survey (post intervention) was distributed, with questions related to the new concepts and skills learnt, the attitude toward CA and CPR.

Results: We have instructed 561 pupils (14.02 (±0.79) years, 48.2 % female). The 87.8 % had heard about sudden death and CA before the class. Regarding starting CPR: 40 % said they were not capable of doing it, and 51.2 % suggested they would be able to do CPR but in a wrong manner. In a CA scene 58.9 % would contact the emergency service and start CPR, 27.4 % would call and wait, and 11.4 % would only do CPR. After attending the classes 98.6 % declared had understood the theorical concepts and practical skilles taught; 95.4 % would changed positively their attitude towards CPR; and 97.4 % would be prone to start maneuvers.

Conclusions: CPR and CA remain a well known issue among teenager population in Barcelona, as long as being an interesting topic. Nevertheless they do not feel capable of starting maneuvers. The concepts taught during the class were easy to learn , and after the intervention the majority were prone to start CPR. This population is adequate to teach CPR.

References

1. Hansen CM et al. The role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: Results from a statewide registry. Resuscitation 2015;96:303–9.

2. Böttiger BW et al. Kids save lives--Training school children in cardiopulmonary resuscitation worldwide is now endorsed by the World Health Organization (WHO). .Resuscitation. 2015;94:A5-7.

A796 Family = children included , guidance of visiting children at an adult intensive care

A.M.F. Rutten, S.N.M. van Ieperen, E.P.H.M. Der Kinderen, T. Van Logten

St Elisabeth Twee Steden Hospital, ICU, Tilburg, Netherlands
Correspondence: S.N.M. van Ieperen – St Elisabeth Twee Steden Hospital, ICU, Tilburg, Netherlands

Introduction: To meet the need of patients family members and staff we started to guide visiting children at our adult ICU in the St Elisabeth hospital (EZ) in Tilburg 3 years ago. To do so we developed a guidance leaflet for parents with practical instructions and information. Additionally, practical advice is given, such as what to say to the child and what to expect when visiting. The leaflet is subdivided in developmental stages. Furthermore we developed a book “mees op bezoek”, in which a child visits his father at the ICU. Pictures show what children can expect, which helps prepare the child for visiting at home. An instruction box is present at the ICU with ICU materials such as an iv catheter, a pulse oximetry or a tracheal tube. These materials give children a tactile experience of the ICU. The box is divided in two parts; the second part contains guidance materials for when a patient may die. Pedagogical staff are available to support parents, children and staff. If there are more profound problems a referral to our children's psychologist is possible. We made some improvements to our waiting area to make it more appealing to children. We instructed and educated our nurses and doctors on how to use these materials and how to guide children.

We recently merged with the Twee steden Hospital in Tilburg (TSZ), in this hospital there was no program to guide children. With the merger we also wanted to introduce our “Child as a visitor program” at the ICU on location TSZ. We wanted to know if there were differences of opinion between the nursing staff on guidance of children.

Methods: We held a survey among our nursing staff. In TSZ we handed out surveys on paper during an obligatory education. In EZ the same survey was sent by email.

Results: Response rate in EZ was 61 % (n = 127). Respons rate nursing staff in TSZ was 100 % (n = 33). Nearly all nurses share the view that children should be allowed to visit an ICU: EZ 97 % and TSZ 94 %. The appropriate age for children was deemed higher in TSZ with an average of 2,5 years, in EZ this was 0,74 years. 65 % of the nurse in EZ responded that children of all ages were welcome versus 33 % in TSZ. In EZ 44 % of the nurses didn't need any more support to guide children. In TSZ this was 3 %. 88 % of the nurses in TSZ wanted more education on the subject. In EZ there was still a great need: 56 % wanted this. More help from pedagogical staff was needed in 53 % of the nurses but in EZ this was 14 %. EZ 9 % needed more informational materials in TSZ this was 40 %.(see graph 1).

Conclusion: When you allow children to visit your ICU, nurses want to be educated on the subject, they need practical aids and help from pedagogical staff. The need for more pedagogical help and practical aids are less with the nurses who have more experience. A need for education on the subject will remain. We are introducing the “Child as a visitor program” at the ICU on location TSZ and will expand education in EZ.
Fig. 1 (abstract A796).

Do you need more support to guide children in our ICU?

A797 High-frequency chest wall oscillation therapy in pediatric cardiac intensive care unit

L. Kovacikova1, P. Skrak2, M. Zahorec3

1National Institute of Cardiovascular Diseases, PCICU, Bratislava, Slovakia; 2National Institute of Cardiovascular Diseases, Bratislava, Slovakia; 3National Institute of Cardiovascular Diseases, Pediatric Cardiac Intensive Care Unit, Bratislava, Slovakia
Correspondence: L. Kovacikova – National Institute of Cardiovascular Diseases, PCICU, Bratislava, Slovakia

Introduction: In critically ill children with cardiac diseases lung complications are frequently highlighting atelectasis and pneumonia. Physiotherapy has an important role in the treatment of these complications. High Frequency Chest Wall Oscillation (HFCWO) has been shown to be effective in helping to clear secretions from the lungs of patients with cystic fibrosis, primary ciliary dyskinesia, bronchiectasis and others. However, the role of HFCWO in children with cardiac diseases has not been established.

Objectives: This prospective observational study was conducted to determine if HFCWO treatment, as provided by The Vest™ Airway Clearance System (Hill-Rom, Saint Paul, MN), was safe and tolerated by these patients.

Methods: Eighty-five treatment courses were evaluated in 25 pediatric cardiac patients during the stay at intensive care unit. Median age of the patients was 2 months (range; 12 days - 7 years) and weight 4.2 kg (range; 2.4 - 54 kg). Twenty-three (92 %) patients were following cardiac surgery. Patients were receiving invasive or non-invasive mechanical ventilation (31 and 27 courses, respectively), or high-flow nasal cannula oxygen delivered by Vapotherm (27 courses). The main indication for HFCWO was atelectasis detected on a chest x-ray (84 % patients). Other indications included lack of cough reflex, arterial oxygen desaturations, and dyspnea. HFCWO was applied at 7 Hz (range; 5–15 Hz) and a pressure of 2 (range; 1–6 arbitrary units) for 10 minutes. Routine hemodynamic and pulse oximetry data, and qualitative data on patient tolerance were collected before, during, and after HFCWO.

Results: Heart rate, systolic and diastolic blood pressure, and respiratory rate increased significantly during HFCWO courses and decreased significantly following therapy. Oxygen saturations significantly decreased during HFCWO and significantly increased after discontinuation of treatment. The differences between pre- and post- HFCWO data were not significant. Patients remained calm during 80 HFCWO courses, and became agitated during 5 courses. No chest tubes, intracardiac lines, or catheters were dislodged in association with HFCWO. No premature discontinuation of therapy was required because of intolerance.

Conclusions: The study suggests that HFCWO therapy is safe and well tolerated in children with cardiac diseases in intensive care unit.

A798 Protein feeding in pediatric acute kidney injury does not delay renal recovery

U.G. Kyle1,2, A. Akcan-Arikan1,2,3, J.C. Silva1,2, G. Mackey1,2, J. Lusk1,2, M. Goldsworthy1,2, L.S. Shekerdemian1,2, J.A. Coss-Bu1,2

1Texas Children's Hospital, Intensive Care, Houston, United States; 2Baylor College of Medicine, Pediatrics, Houston, United States; 3Texas Children's Hospital, Renal Service, Houston, United States
Correspondence: J.A. Coss-Bu – Texas Children's Hospital, Intensive Care, Houston, United States

Introduction: Critically ill children are underfed early in their Pediatric Intensive Care Unit (PICU) stay and this may contribute to worse outcomes. Acute Kidney Injury (AKI) occurs in 10 % of all PICU admissions and the risk of acute and chronic malnutrition is high in these patients with AKI, and the presence of malnutrition in the context of AKI has been associated with more severe clinical deterioration and organ dysfunction. Critically ill children with AKI are at high risk of underfeeding.

Objectives: To evaluate the effects of protein feeding on the resolution of AKI.

Methods: This is a retrospective study of critically ill children admitted from 10/2012-12/2013 to the PICU. Patients with a diagnosis of end stage renal disease requiring renal replacement therapy or had received a kidney transplant were excluded. Nutritional status assessed by weight and height WHO z-scores after admission and caloric and protein intakes calculated from I.V. fluids and parenteral and enteral nutrition for the first 8 days of admission. Energy and protein needs estimated by Schofield and A.S.P.E.N., respectively. AKI was defined by pRIFLE (creatinine only) and persistent AKI was defined as patients who did not resolve their AKI during the first eight days of PICU stay.

Results: A total of 511 patients were included and 156 patients (30.5 %) had AKI. Patients with AKI vs. non-AKI had: age; 1.2 yrs (0.2-6) median (IQR) vs. 1.5 yrs. (0.4-6) (p = 0.10); height: 76 cm (58–110) vs. 81 cm (64–117) (p = 0.02), weight: 9.3 kg (5–21) vs. 11 kg (7–21) (p = 0.04) and mortality: 8.3 % vs. 4.2 % respectively. Forty-four (8.61 %) and 112 (21.9 %) patients had persistent and resolved AKI, respectively, and persistent AKI patients were more likely to have moderate/severe chronic malnutrition vs. non-AKI patients, odds ratio (95 % CI) 2.4 (1.2-4.6) (p = 0.014). Patients with no AKI, resolved AKI, and persistent AKI received in the first 8 days of PICU stay 73 %, 80 % and 80 % of recommended energy needs, and 39 %, 42 %, and 51 % of protein needs, respectively. Compared to 12 % of no-AKI patients, 17 % and 27 % of patients with resolved and persistent AKI, met ≥80 % of protein needs respectively, (p = 0.01) Although patients with persistent AKI received higher protein intake of ≥80 % of goal, was not independently associated with persistent AKI after adjustment for PRISM score (p = 0.13).

Conclusions: Protein prescription is improved in children with AKI in our PICU, largely due to ongoing educational efforts. Higher protein intake was not associated with a delay in renal recovery in patients with AKI after adjustment for severity of illness.

References:

1. Akcan-Arikan A, Kidney Int. 2007.

2. Schofield WN. Clin Nutr 1985.

3. Mehta NM. JPEN, 2009.

Grant acknowledgement

Internal Funding, Texas Children's Hospital

A799 Current intensive care management for adolescents in the United Kingdom: a retrospective cohort study

D. Wood1, D. Harrison2, R. Parslow3, P. Davis1, J. Pappachan4, S. Goodwin1, P. Ramnarayan5

1Bristol Royal Hospital for Children, Paediatric Intensive Care Unit, Bristol, United Kingdom; 2Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom; 3University of Leeds, Leeds, United Kingdom; 4Southampton University Hospitals NHS Trust, Southampton, United Kingdom; 5Great Ormond Street Hospital, London, United Kingdom
Correspondence: D. Wood – Bristol Royal Hospital for Children, Paediatric Intensive Care Unit, Bristol, United Kingdom

Introduction: The transition between childhood and adulthood is a time of rapid physical, psychological and behavioural change. Adolescents (aged 12–19 years) requiring intensive care differ from both the typical paediatric intensive care (PICU) population, mainly infants and pre-school children, and from the typical adult intensive care unit (AICU) population of much older adults. Critically ill adolescents are distinct from the majority of patients treated in either adult or paediatric intensive care units (ICU). Little data exist to describe how best to meet their needs or those of their families.

Objectives: We describe the case mix, resource use, and outcomes for adolescents admitted to AICU and PICU in the UK.

Methods: Analysis of national, prospectively collected data for adolescents (aged 12–19 years) admitted to ICUs in the UK between 2007 and 2014.

Results: 37320 adolescents were admitted during the study period. Excluding admissions following elective surgery, there were a total of 27442 admissions; in this group ICU mortality was 6.0 % and 5.4 % for those admitted to PICU and AICU respectively, a non-significant difference. The most common diagnostic categories for adolescents in AICU were trauma and drug/alcohol-related; those admitted to PICU most commonly had respiratory diagnoses.

Conclusions: ICU mortality was higher for those admitted to PICU than AICU, but this may represent a greater severity of acute illness or underlying burden of chronic illness for adolescents cared for in a PICU. There is increasing recognition that adolescents need special consideration when planning preventative health-care and access to health services. Identifying the appropriate setting for the provision of intensive care for this population may be equally important.

A800 Comparison of postoperative sedation and analgesia of neonates in cardiac surgery: dexmedetomidine vs standard regimen

S. Chernyshuk, H. Yemets, V. Zhovnir

UCCC, ICU, Kyiv, Ukraine
Correspondence: H. Yemets – UCCC, ICU, Kyiv, Ukraine

Introduction: Sedation and analgesia are important components of postoperative management of neonates who underwent cardiac surgery. Excessive or inadequate sedation may have a significant adverse effect on patient outcome.

Objectives. We aimed to determine which drug regimen would be most effective with less side-effect and better outcome.

Methods: From March 2012 till March 2014 we conducted a randomized controlled prospective study in 60 neonates with congenital heart disease who underwent Arterial Switch Operation in our clinic. Inclusion criteria: 1) gestational age more than 36 weeks, 2) birth weight over 2500 g, 3) age - up to 28 days, 4) absence of concomitant diseases and surgical complications.

Patients were randomized into 2 cohorts: 30 patients (50 %) were given infusion of dexmedetomidine with morphine boluses (study group) and 30 patients (50 %) were randomized to the standard regimen - infusion of morphine with diazepam boluses (control group).

Results: In both groups there were no differences in pre- and intraoperative indexes, duration of mechanical ventilation, sympathomimetic support, and time of infusion of dexmedetomidine/morphine. In study group time of ICU stay - 93.5 h - was significantly shorter than in control group -120 h (p-0.02). Onset of peristalsis and start of feeding in study group was earlier than in control group - 1-st vs 2-d day (p- 0.007) and 2-d vs 2.5-day (p-0.035), respectively. In the control group there were more patients who had complicated feeding (start after 3-d day, bloating or vomiting) - 11(37 %) vs 3(10 %) in the study group. We did not observe any decrease of mean blood pressure and heart rate in the study group as it could be expected.

Conclusion: Use of dexmedetomidine with morphine hydrochloride boluses for postoperative sedation and analgesia is effective and facilitates feeding process in neonates, leads to earlier onset of peristalsis and start of feeding, decreasing ICU stay.

A801 Impact of positive end expiratory pressure on cerebral hemodynamic in paediatric patients with post-traumatic brain swelling treated by surgical decompression

S.M. Pulitano’1, S. De Rosa1,2, A. Mancino1, G. Villa2,3, F. Tosi1, P. Franchi1, G. Conti1

1Catholic University, Department of Anesthesia and Intensive Care, Rome, Italy; 2International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy; 3University of Florence, Department of Health Science, Section of Anaesthesiology and Intensive Care, Florence, Italy
Correspondence: P. Franchi – Catholic University, Department of Anesthesia and Intensive Care, Rome, Italy

Introduction: Current Brain Trauma recommendations are based to early correction of hypoxemia and avoidance of hypocarbia after severe paediatric TBI. The use of positive end-expiratory pressure (PEEP) in this situation remains controversial. Positive end expiratory pressure (PEEP) may reduce ventilator-induced lung injury by avoiding cyclic recruitment/derecruitment and prevent lung collapse. The aim of this investigation is to evaluate the impact of different PEEP levels on cerebral hemodynamic, gas exchange and respiratory system mechanics in paediatric patients with a severe post-traumatic brain swelling treated with decompressive craniectomy (DC).

Objectives: The aim of this investigation is to evaluate the impact of different PEEP levels on cerebral hemodynamic, gas exchange and respiratory system mechanics in paediatric patients with a severe post-traumatic brain swelling treated with decompressive craniectomy (DC).

Methods: A prospective physiologic study was carried out on 14 paediatric patients presenting with severe traumatic brain swelling and treated with DC. Intracranial pressure (ICP), and cerebral perfusion pressure (CPP), central venous pressure (CVP), arterial oxygen saturation and the middle cerebral artery mean velocity (Vmed) was determined. After assessment at 0 PEEP (ZEEP), PEEP 4 and PEEP 8 were applied: all parameters were recorded at each level.

Results: The application of PEEP (from ZEEP to PEEP 8) significantly increased compliance of the respiratory system indexed to the weight of the patients (CrsI) (P = 0.02) without ICP modifications. No significant variations were observed in values of arterial pressure (MAP), CPP, Vmed, total resistance of the respiratory system indexed to the weight of the patients (RRSmaxI), and ohmic resistance of the respiratory system indexed to the weight of the patients (RRSminI). CVP significantly increased between ZEEP and PEEP 8 (P = 0.005), and between PEEP 4 and PEEP 8 (P = 0.05).

Conclusions: We describe cerebral hemodynamic responses to PEEP application in pediatrics. PEEP values up to 8 cm H2O seem to be safe in paediatric patients with a severe post-traumatic brain swelling treated with DC.

References:

1. Bein T, Kuhr LP, Bele S, Ploner F, Keyl C, Taeger K. Lung recruitment maneuver in patients with cerebral injury: effects on intracranial pressure and cerebral metabolism. Intensive Care Med 2002;28:554–8

2. Bor-Seng-Shu E, Hirsch R, Teixeira MJ, De Andrade AF, Marino R Jr (2006) Cerebral hemodynamic changes gauged by transcranial Dopp- ler ultrasonography in patients with posttraumatic brain swelling treated by surgical decompression. J Neurosurg 104:93–100

A802 Randomized clinical trial of high concentration oxygen versus titrated oxygen therapy in pediatric asthma exacerbation

B. Patel1, H. Khine2, A. Shah2, D. Sung2, L. Singer2

1The Children's Hospital at Montefiore, Pediatric Critical Care, Bronx, United States; 2The Children's Hospital at Montefiore, Bronx, United States
Correspondence: B. Patel – The Children's Hospital at Montefiore, Pediatric Critical Care, Bronx, United States

Introduction: Asthma exacerbation is one of the most common diagnoses seen in the pediatric ED. Several adult randomized controlled trials have shown that administration of high concentration oxygen leads to rise in carbon dioxide and increases admission rates. However, there are no studies in the pediatric population comparing the effects of high concentration oxygen versus titrated oxygen therapy in asthma exacerbation.

Objectives: We evaluated the effects of transcutaneous carbon dioxide (tPaCO2) in high concentration oxygen therapy versus titrated oxygen therapy to maintain saturation between 92 to 95 % in pediatric patients with acute asthma exacerbation in the ED.

Methods: Children 2 to 18 years with previously diagnosed asthma with moderate to severe asthma exacerbation (asthma score > 5) were randomized to high concentration oxygen therapy (100 % oxygen via face mask at >4 L/min.) or titrated oxygen therapy (titrated up from 21 % via a blender continuously) to maintain saturations between 92 to 95 % while receiving their nebulized treatments. Exclusion criteria included disorders with hypercapnic respiratory failure, unconscious patient, history of congenital heart disease, pregnancy, history of smoking or using sedatives and depressants. Asthma therapy was provided per the ED physician. Asthma score, tPaCO2, PEFR (age >7 years) were measured at the start of the study and every 20 minutes for the first hour then every 30 minutes until disposition decision. The primary outcome was increase in tPaCO2 with high concentration oxygen therapy. Secondary outcome included rate of admission to the hospital.

Results: 73 patients were enrolled with mean age of 8.6 years. 60 % were males and 72 % had poorly controlled asthma with mean asthma score of 7.6. There were 36 patients enrolled in the high concentration oxygen group (HCOT) and 37 patients in the titrated oxygen group (TOT). The 0 minute tPaCO2 were not statistically different(35.6 ± 3.8 HCOT v. 37.4 ± 4.4 TOT,p = 0.07); whereas, the 20 minutes tPaCO2 was statistically different(40 ± 3.8 HCOT v. 37.5 ± 5.1 TOT, p = 0.02). The 60 minutes tPaCO2 was 39.2 ± 4.6 HCOT v. 35.5 ± 4.3 TOT, p = 0.0009. At 20 minutes, 89 % of the patients had a rise in tPaCO2 in HCOT v. 30 % in the TOT(p = < 0.0001), and at 60 minutes 78 % had a rise in tPaCO2 in HCOT v. 16 % in the TOT(p = < 0.0001). The asthma score was similar in the two groups at 0 minute (7.8 ± 1.4 HCOT v. 7.4 ± 1.3 TOT, p = 0.23); whereas, the 60 minutes asthma score was lower in the TOT(4.7 ± 1.5 HCOT v. 3.7 ± 1.3 TOT, p = 0.002). The rate of admission to the hospital was 36.1 % in HCOT v. 24.3 % in the TOT.

Conclusions: High concentration oxygen therapy in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels. It also causes rise in carbon dioxide from the baseline which increases the asthma scores and rate of admission.

References:

1. Chien J.Uncontrolled oxygen administration and respiratory failure in acute asthma.Chest 2000;117(3):728–733.

A803 Treatment of refractory status epilepticus with thiopental versus propofol in children: a randomized trial

S. Haghbin1, S. Inaloo2, Z. Serati2

1Shiraz University of Medical Sciences, Pediatric intensive Care, Shiraz, Islamic Republic of Iran; 2Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
Correspondence: S. Haghbin – Shiraz University of Medical Sciences, Pediatric intensive Care, Shiraz, Islamic Republic of Iran

Introduction: Refractory status epilepticus (RSE) is a life-threatening condition in which seizures do not respond to first- and second-line anticonvulsant drug therapies and is associated with increased hospital length of stay, mortality and functional disability (1). Coma induction is advocated for its management by different agents (2).

Objectives: We aimed to assess the effectiveness (RSE control, adverse events) of propofol versus thiopental infusion in the treatment of RSE.

Methods: In this randomized, single blind studying children aged 2 months- 18 years with RSE not due to cerebral ischemia were included. Medications were increased toward the EEG burst-suppression or to maximum limit of medication, and then progressively weaned. The primary endpoint was the proportion of patients with RSE controlled after a first course of study medication; secondary endpoints included clinical outcomes measures.

Results: In this study, 40 patients were included, 18 received propofol and 22 thiopental. RSE was generalized in 32 patients and focal in 8.The primary endpoint was reached in 72 % with propofol versus 54 % with thiopental (P = 0.33). However, mean duration of treatment with propofol was 50 hrs (range 12–94), and with thiopental was 10 days. While mortality (44 % vs23% P = 0.18), infection and systemic hypotension were similar in both groups, thiopental use was associated with longer mechanical ventilator (P = 0.02). More patients returned to basic condition at discharge with propofol (P = 0.04). Treatment failure was seen in 7/8 patients with focal convulsion. Two patients died due to propofol infusion syndrome with dose of 8 and 7 mg/kg/hr, so the maximum dose of propofol decreased to 6 afterward. Five patients died due to complications of thiopental infusion.

Conclusions: Although this study showed no significant difference between two groups regarding effectiveness, adverse effects and mortality, patients on propofol obtained quicker convulsion control and better return to baseline condition. A previous study did not disclose any difference between these two agents (3). However, care must be taken when it is used in longer than 24 hours with higher dose than 6 mg/kg/hr .

Trial Registration: IRCT.IR IRCT138707231349N1

References

1. Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol. 2008,38(6): 37790.

2. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3.

3. Rossetti AO, Milligan TA, Vulliémoz S, Michaelides C, Bertschi M, Lee JW. A randomized trial for the treatment of refractory status epilepticus. Neurocrit Care. 2011 Feb;14(1):4–10.

A804 An evaluation and accuracy of new zero-heat-flux thermometer (3 M SpotOn) in pediatric intensive care patients

M. Idei1, T. Nomura2, N. Yamamoto1, Y. Sakai1, T. Yoshida1, Y. Matsuda1, Y. Yamaguchi1, S. Takaki1, O. Yamaguchi1, T. Goto2

1Yokohama City University Hospital, Intensive Care Unit, Yokohama, Japan; 2Yokohama City University Hospital, Department of Anesthesiology, Yokohama, Japan
Correspondence: M. Idei – Yokohama City University Hospital, Intensive Care Unit, Yokohama, Japan

Introduction: In critically ill patients, temperature measurement is a routine important care task and can lead to important decisions. Rectal temperature and bladder temperature are now used as a continuous body temperature measuring method in the pediatric intensive care, but these practices have several disadvantages including the patient´s discomfort, the risk of organ injury and the inaccurate measuring caused by the sensor position. A new temperature monitoring system 3MTM SpotOnTM (SpotOn) is a non-invasive zero-heat-flux thermometer designed to estimate core body temperature from the skin surface. Although the usefulness and accuracy of SpotOn system in adult patients have been demonstrated, there are no reports on pediatric intensive care patients.

Objectives: The aim of this study was to evaluate the effectiveness of a new temperature measurement system attached to the forehead, and compare it to rectal temperature sensors in terms of correlation and accuracy.

Methods: Pediatric patients weighing less than 10Kg, who were managed in our ICU during the period from February 2015 to March 2016, were enrolled in this study. Core temperature was measured and recorded at every minute from the both thermistor of a rectal thermal probe and with SpotOn in these patients. The data when the forehead sensor or rectal probe was taken out for nursing care was excluded from statistical analysis.

Results: 53495 sets of data of 26 children (Mean BW 5630 g) were examined retrospectively. In all patients, SpotOn showed higher than the rectal temperatures. The SpotOn temperature was analyzed to be 0.82 degrees (95 % limits of agreement of ± 0.51) higher temperature than the rectal one with a moderate correlation(r = 0.73).

Discussion and conclusion: Rectal temperature measurement is the gold standard method for pediatric patients in ICU despite several complications of rectal injury. Our children´s study demonstrated the slightly higher temperature in the SpotOn than rectal temperature with a substantial correlation. One possible explanation could be that the abundance of brain blood flow of children affected the results. Our study concluded that SpotOn system could be used as a highly reliable noninvasive core body temperature measurement for small pediatric patients.

References

1. Eshraghi Y, Nasr V, Parra-Sanchez I et al. An evaluation of a zero-heat-flux cutaneous thermometer in cardiac surgical patients. Anesth Analg. 2014 Sep;119(3):543–9.

2. Hebbar K, Fortenberry JD, Rogers K, et al. Comparison of temporal artery thermometer to standard temperature measurements in pediatric intensive care unit patients. Pediatr Crit Care Med. 2005; 6: 557–561.

Grant acknowledgement

None

A805 Viral bronchiolitis in pediatric acute respiratory distress syndrome

N. Longani, S. Medar

The Children's Hospital at Montefiore, Pediatric Critical Care, Bronx, United States
Correspondence: N. Longani – The Children's Hospital at Montefiore, Pediatric Critical Care, Bronx, United States

Introduction: Viral bronchiolitis (VB) remains one of the leading causes of hospitalization in early childhood. Despite the heavy burden of VB on the healthcare system, little is known about the incidence of Acute Respiratory Distress Syndrome (ARDS) in this cohort of patients. In 2015, the Pediatric Acute Lung Injury Consensus Conference (PALICC) published guidelines for the definition, management and research in pediatric ARDS (PARDS) (1).

Objectives: To study the incidence and prevalence of PARDS in VB and to study the association between PARDS and specific PICU outcomes such as incidence of mechanical ventilation, noninvasive ventilator settings length of PICU stay in this group of patients.

Methods: This is a retrospective single center observational cohort study that examined children 0–2 years of age admitted to the PICU with VB and respiratory failure (RF) from 2011–2014. PALICC criteria were applied to define PARDS. Clinical and demographic data was collected. Patients with a diagnosis of congenital heart disease or pre-existing chronic lung disease were excluded. Data was expressed as median with IQR ranges. Test of bivariate association were performed using Mann Whitney U test and chi square test. A two tailed p value of ≤ 0.05 was used to denote statistical significance.

Results: Out of 1700 patients with RF, 330 with VB met study criteria. Eighty of these 330 (24 %) patients admitted for VB met the criteria for PARDS or at risk for PARDS. Out of these 80 patients, 25 (31 %) met criteria for PARDS and 55 (69 %) met criteria for “at risk of PARDS”. Median age was 5 (2,11) months and the median weight was 6.9 (5.3, 9.5) kgs. Most common etiology for VB was respiratory syncytial virus (RSV) 68 % followed by Rhinovirus (20 %). There was no statistically significant difference in age, weight, and etiology of VB in patients with PARDS and those “at risk of PARDS.” Patients with PARDS had longer hospital and PICU length of stay (LOS) and more likely to receive diuretics compared to those “at risk for PARDS” (16 (10, 21) Vs 8 (6, 10.5), p = 0.0001; 10 (7, 13) Vs 3 (2, 4.5), p < 0.0001; and 66 % vs 33 %, p = 0.02 respectively). Nineteen (19/25, 76 %) patients with PARDS received invasive mechanical ventilation with a median duration of ventilation of 6 (1, 10) days.

Conclusions: Almost a quarter of children with VB developed PARDS or were at risk of PARDS. The presence of PARDS in children with VB was significantly associated with longer PICU and Hospital LOS compared to those “at risk of PARDS”. Children with VB are a high risk group for the development of PARDS.

References

1) Pediatric Acute Lung Injury Consensus Conference Group, et al.Pediatric acute respiratory distress syndrome:consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Crit Care Med 2015 Jun; 5: 428–439

2) Zorc J, Hall C. Bronchiolitis: recent evidence on diagnosis and management. Pediatrics 2010; 25:342–349

A806 Mean platelet volume dynamics and platelet count as prognostic indicators in pediatric surgical intensive care: a descriptive observational study

I.R. Abdel-Aal1, A.S. El Adawy2, H.M.E.-H. Mohammed2, A.N. Mohamed2

1Cairo University/Kasr Alainy Medical School, Anesthesia, Pain and Surgical ICU, Cairo, Egypt; 2Cairo University/Kasr Alainy Medical School, Cairo, Egypt
Correspondence: I.R. Abdel-Aal – Cairo University/Kasr Alainy Medical School, Anesthesia, Pain and Surgical ICU, Cairo, Egypt

Introduction: Mean platelet volume(MPV) seems to be a marker of platelet activation and may be related to severity of illness.1Changes in MPV and platelet count(PLC)could be used for disease prognosis and mortality in ICU patients.2We hypothesized that MPV changes and PLC could be used as prognostic tools in pediatric surgical intensive care units(PSICU).

Objectives: To study the association between MPV changes and mortality and morbidity in PSICU. Also to study the relation between PLC and PSICU mortality and morbidity.

Methods: This descriptive observational study was conducted on consecutive 100 pediatric surgical patients who admitted to PSICUs at Cairo University Hospitals starting from 1/6-1/12/2015.After approval by research ethics committee,informed consents were obtained from parents and pediatric cases aged from 1 month-18 years and stayed for > 48 h were enrolled.MPV and PLC were obtained and recorded at baseline(pre-operative values),on the day of ICU admission(day 0),1st,2nd,3rd,5th and 7th days.To measure daily MPV changes; (ΔMPV) was constructed and computed where ΔMPV = ([MPVday(X) − MPVday (0)]/MPVday(0) × 100 %. Pediatric Index of Mortality(PIM)score was calculated on day 0 and the Pediatric Logistic Organ Dysfunction(PELOD)Score was recorded daily.

Results: Patients who developed ICU complications (fever, sepsis, pneumonia, required mechanical ventilation, needed vasopressors or blood transfusion); showed higher ΔMPV compared to non complicated cases (Fig. 2). This association was statistically significant on days 2 (p value = 0.035),3(p value < 0.001), 5 (p value < 0.001) and 7(p value = 0.017) of ICU stay but it´s insignificant on day1(p value = 0.691).According to receiver operating characteristics(ROC) curve analysis, the sensitivity of ΔMPV to detect complications on day 2 was 57.2 % but its specificity on day 2 was 76.6 %.Patients who developed ICU complications showed lower PLC compared to non complicated cases(Fig. 3).This association was statistically significant on days1(p value < 0.001),2(p value <0.001 ) and 3(p value <0.001 ) but it was insignificant on day 0(p value = 0.237 ),5(p value = 0.861) and 7(p value = 0.247). On other hand, the sensitivity of PLC to detect complications day1 was 81.4 % but the specificity was 71.9 %, while the sensitivity of PLC to detect complications day 2 was 81.1 % but the specificity day 2 was 100 %.

Conclusions: MPV dynamics and PLC have prognostic roles and could be used in determining several complications in critically ill pediatric surgical patients. PLC is a more specific and sensitive tool to detect complications than mean MPV dynamics.

References

1- Cekmez F et al. Mean platelet volume in very preterm infants: a predictor of morbidities.Eur Rev Med Pharmacol Sci. 2013; 17: 134–137.

2- Cengizhan S, et al. Alterations in platelet count and mean platelet volume as predictors of patient outcome in the respiratory intensive care unit. Clin Respir J. 2014;5:35–40.
Fig. 2 (abstract A806).

Percentage changes in MPV (Delta MPV) among ICU co.

Fig. 3 (abstract A806).

Receiver operating characteristics (ROC) curve for

Fig. 4 (abstract A806).

Platelets count (PLC) among intensive care unit.

REHABILITATION & RECOVERY FROM ICU

A807 Physical function in critical care (Pacific): a multi-centre observational study

S.M. Parry1, L.D. Knight2, L. Denehy1, N. De Morton3, C.E. Baldwin4,5, D. Sani6, G. Kayambu6, V.Z.M. da Silva7,8, P. Phongpagdi1, Z.A. Puthucheary9,10,11, C.L. Granger1,2

1The University of Melbourne, Department of Physiotherapy, Melbourne, Australia; 2Royal Melbourne Hospital, Department of Physiotherapy, Melbourne, Australia; 3Peter MacCallum Cancer Centre, Department of Physiotherapy, Melbourne, Australia; 4Flinders Medical Centre, Department of Physiotherapy, Adelaide, Australia; 5University of South Australia, Member of the International Centre for Allied Health Evidence (iCAHE) and the Sansom Institute, Adelaide, Australia; 6National University Hospital, Department of Rehabilitation, Singapore, Singapore; 7Escola Superior da Saude, Health Sciences Program, Brasilia, Brazil; 8Hospital de Base do Distrito Federal, Brasilia, Brazil; 9University College London Hospitals, Division of Critical Care, London, United Kingdom; 10University College London Hospitals, Institute of Sports and Exercise Health, London, United Kingdom; 11National University Hospital, Division of Respiratory and Critical Care, Singapore, Singapore
Correspondence: S.M. Parry – The University of Melbourne, Department of Physiotherapy, Melbourne, Australia

Introduction: Impairment in physical function is a significant problem for survivors of critical illness [1,2]. There is growing urgency to develop a core set of outcome measures which can be adopted in clinical and research practice to evaluate efficacy in response to interventions such as rehabilitation. There is currently not a single outcome measure which can be used across the continuum from ICU admission to hospital discharge for individuals with critical illness [3].

Objectives: (1) To determine the clinical utility of two physical function measures: De Morton Mobility Index (DEMMI) and Physical Function in Intensive Care test-scored (PFIT-s) when used in isolation across the hospital admission; and (2) To transform the (15-item) DEMMI and (4-item) PFIT-s into a single measure to evaluate function in ICU survivors using rasch analytical principles.

Methods: Multi-centre prospective observational study conducted across four sites internationally. Consecutive eligible participants were recruited who met inclusion criteria; ; Adults > 18 years of age whom were mechanically ventilated > 48 hours and were ambulant at least 10 metres independently prior to their ICU admission. Physical function was evaluated at ICU awakening, and both ICU and hospital discharge using the PFIT-s and DEMMI, administered in a randomised sequence using concealed allocation on each measurement occasion to minimise bias in testing order.

Results: 128 participants have been recruited into the study to date across the four sites. 61 % were male (n = 78) with median age of 65 [53–73]; and moderate severity of illness (median [IQR] APACHE II: 22 [17–27]). Median [IQR] ICU and hospital LOS were 9 [5–14] and 21 [13–37] days respectively. The incidence of ICU-acquired weakness was 50 % (n = 67). Aim 1: On awakening mean ± SD PFIT-s was 4.9 ± 2.5 (out of 10) and DEMMI was 19 ± 21 (out of 100). In isolation the PFIT-s had a floor effect of 9 % (n = 11) at ICU awakening, and 1 % (n = 1) at both ICU and hospital discharge; and a large ceiling effect at hospital discharge of 42 % (n = 40). The DEMMI in isolation had a large floor effect in the ICU of 23 % at awakening, and a small ceiling effect at hospital discharge of 14 % (n = 14). Both the PFIT-s and DEMMI were demonstrated to be highly responsive to change in functional recovery over the acute hospitalisation period (p < 0.005). Aim 2: Preliminary exploration of a subgroup with complete data at hospital discharge (n = 73) was evaluated.The data fit the Rasch model Chi squared =10.4, df = 24, p = 0.99 with no item misfit or differential item functioning based on age, gender, BMI, severity of illness (APACHE II) or comorbidity. A new single measure (12-items) has been proposed combining the DEMMI and PFIT-s.

Conclusions: The PFIT-s and DEMMI have limitations when used in isolation. A new transformed scale based on rasch analytical principles is promising combining features of both tools for evaluation of functional recovery of critically ill.

A808 Functional status at ICU admission, physical therapy treatment and critical care outcomes

J.E. Rydingsward1, C.M. Horkan2, K.B. Christopher3,4

1Brigham and Women's Hospital, Department of Rehabilitation, Boston, United States; 2Brigham and Women's Hospital, Department of Medicine, Boston, United States; 3Brigham and Women's Hospital, Renal Division, Boston, United States; 4Brigham and Women's Hospital, Channing Division of Network Medicine, Boston, United States
Correspondence: J.E. Rydingsward – Brigham and Women's Hospital, Department of Rehabilitation, Boston, United States

Introduction: Limited information exists regarding the association between functional status at ICU admission at and outcomes.

Objectives: We hypothesized that initial functional status assessment as well the amount of physical therapy delivered would be associated with outcomes in ICU survivors.

Methods: We performed a retrospective cohort study in one Boston teaching hospital on 2,828 adults who received critical care from 1997 to 2011 and survived hospitalization. All patients had a formal evaluation by a physical therapist in the week prior to ICU admission and at hospital discharge. The exposure of interest was functional status determined by a licensed physical therapist based on the functional mobility sub scales of the Functional Independence Measure. All patients received physical therapy to improve functional performance. The primary outcome was 90-day all-cause mortality. We used logistic regression to describe how 90-day mortality differed with functional status at ICU admission. Negative binomial regression was utilized to describe how functional status at hospital discharge differed with functional status at ICU admission, the extent of physical therapy received and hospital length of stay.

Results: The cohort was 52 % male, 22 % non-white and had a mean age of 64.1 years. 10 % of the cohort had sepsis, 7 % had acute kidney injury, 32 % had respiratory failure and 53 % were surgical cases. The median [IQR] hospital length of stay was 8 [4, 14] days. The 90-day mortality rate was 14.6 %. Functional status at ICU admission was robustly associated with 90-day mortality. In a logistic regression model adjusted for age, gender, race, surgical patient type, Deyo-Charlson index, acute organ failure, sepsis, length of stay and the extent of physical therapy received, the second lowest and lowest quartiles of functional status at ICU admission was associated with a 1.8 and 2.3 fold increased odds of 90-day mortality respectively, compared to patients with the highest quartile of functional status [OR = 1.80(95%CI 1.26-2.57) and OR = 2.34(95%CI 1.63-3.36)]. Every 15 minute increment in physical therapy completed was associated with a decrease in the adjusted odds of 90-day mortality [OR = 0.60 (95%CI 0.53-0.68)]. Further, in survivors of hospitalization (n = 2,364), patients with the second lowest and lowest quartiles of functional status at ICU admission had a 2.7 and 3.4-fold lower functional status assessed at hospital discharge following adjustment, compared to patients with the highest quartile of functional status [IRR 2.74 (95%CI 2.50-3.01) and IRR 3.42 (95%CI 3.10-3.77)] respectively.

Conclusions: In critically ill patients, decreased functional status at ICU admission is associated with increased 90-day mortality. Increased intensity of physical therapy is associated with improved mortality outcomes. Both functional status at ICU admission and the intensity of physical therapy contribute to functional status determined at hospital discharge.

A809 Does enhanced physiotherapy and early mobilisation reduce the degree of muscle loss for patients admitted to critical care?

D. McWilliams, C. Jones, E. Reeves, G. Atkins, C. Snelson

Queen Elizabeth Hospital NHS FT, Birmingham, United Kingdom
Correspondence: D. McWilliams – Queen Elizabeth Hospital NHS FT, Birmingham, United Kingdom

Introduction: Patients admitted to critical care are shown to lose significant muscle mass, with the degree of muscle loss as high as 20 % in the first week for those in multi organ failure (Puthucheary, 2013). Early rehabilitation has been demonstrated as a safe and effective method of improving functional status at the point of critical care discharge and reducing both ICU and hospital length of stay (McWilliams et al., 2015), although the specific impact of this on muscle mass has not been reported.

Objectives: This study aimed to analyse the impact of enhanced physiotherapy incorporating early mobilisation on the rate of muscle decline for patients admitted to critical care.

Methods: Patients admitted to a large UK teaching hospital during the trial period and ventilated for ≥ 5 days were included in the study. Patients were randomised to either enhanced physiotherapy or standard care groups as part of a larger RCT. Baseline measurements were taken on the day of recruitment and then repeated at critical care discharge. Muscle mass was measured using ultrasound to calculate cross sectional area of quadriceps and biceps. To ensure validity , 2 measures were taken and the average of these taken as the final value. All scans were reviewed for agreement by 2 therapists trained in muscle ultrasound.

Results: 40 patients were included in the analysis. Patients in the enhanced physiotherapy group mobilised earlier and achieved a higher level of mobility at the point of critical care discharge (see Table 2.) All subjects demonstrated a reduction in muscle mass of both quadriceps and biceps over the course of their critical care stay. The extent of muscle loss was however lower in those receiving the enhanced physiotherapy, although this did not reach statistical significance (Quads 3 % vs 13 %. p = 0.14317; Biceps 6 % vs 13 %, p = 0.12033).
Table 2 (abstract A809).

Demongraphics

 

Enhanced (n = 20)

Control (n = 20)

Median Age (years)

62.5

60

Sex (male)

14 (70 %)

10 (50 %)

Median Time to Mobilise

8 days

9.5 days

Median MMS at critical care discharge

7

5.5

Median Critical care length of stay

16.5 days

18 days

Table 3 (abstract A809).

USS measurements

 

Baseline

Critical care discharge

Diff

Control Quads

2.65

2.30

−0.35 (13 %)

Enhanced Quads

2.55

2.48

−0.07 (3 %)

Control Biceps

2.66

2.32

−0.34 (13 %)

Enhanced Biceps

2.71

2.55

−0.16 (6 %)

Conclusions: A programme of enhanced physiotherapy appeared to be associated with a lower rate of muscle loss in both biceps and quadriceps in comparison to standard care. An appropriately powered RCT is required to assess these findings.

References

1. Puthucheary ZA, Rawal J, McPhail M et al. (2013) Acute Skeletal Muscle Wasting in Critical Illness. JAMA. 2013;310(15):1591–1600

2. McWilliams D, Weblin J, Atkins G et al. (2014) Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project. Journal of critical care. http://dx.doi.org/ 10.1016/j.jcrc.2014.09.18

A810 Similarities and differences in patients' and relatives' views of information provision after ICU

L.M. Aitken1,2,3, J. Rattray4, J. Kenardy5, A.M. Hull6, A. Ullman2, R. Le Brocque5, M. Mitchell2,3, C. Davis3, B. Macfarlane2,3

1City University London, School of Health Sciences, London, United Kingdom; 2Griffith University, NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Brisbane, Australia; 3Princess Alexandra Hospital, Intensive Care Unit, Brisbane, Australia; 4University of Dundee, Dundee, United Kingdom; 5University of Queensland, Brisbane, Australia, 6NHS Tayside, Dundee, United Kingdom
Correspondence: L.M. Aitken – City University London, School of Health Sciences, London, United Kingdom

Introduction: Survivors of critical illness experience a range of impairments after intensive care, including physical, cognitive and psychological compromise. The provision of information using a diary to describe the intensive care unit (ICU) experience is one strategy that has been proposed to improve psychological health.

Objectives: The purpose of this study was to explore similarities and differences in patients' and relatives' perceptions of information containing strategies, including ICU diaries, to assist recovery after critical illness.

Methods: An exploratory mixed-methods study was undertaken in an Australian tertiary hospital with general ICU patients admitted for ≥3 days and their relatives. Semi-structured interviews were conducted 3–5 months after ICU discharge. Transcripts were analysed using content analysis.

Results: Twenty-two patients and 19 relatives consented to participation and completed interviews prior to reaching data saturation. Patients were usually male (63 %) and aged 52 ± 14 years. Patients raised similar themes to relatives, although with diverse opinions. Themes of wanting to have a diary kept and considering they would find a diary helpful were consistent across a majority of participants, although with a minority expressing a desire to 'move on' and would not have liked a diary kept. Differences between patients and relatives arose in the areas of the purpose, content, ownership and timing of delivery of a diary. Patients viewed the diary as a therapeutic tool while relatives considered it as an information sharing mechanism, including as a mechanism to demonstrate to the patient 'how sick he really was' and 'what he put us through'. Possibly as a result of these differences, patients considered that ownership of the diary rested with them while some relatives envisaged shared ownership. Patients were more likely to note that the diary should not be provided to them until some weeks after ICU while relatives considered an early time point soon after ICU discharge to be appropriate. Patients were more likely to raise concerns about the potential negative impact of information sharing strategies including diaries and return visits to the ICU.

Conclusions: Patients and relatives expressed common themes related to information sharing strategies after ICU, but with some important differences. Differences in purpose, content, ownership and timing of delivery of a diary suggest there is a need to consider whether the same intervention meets the needs of both groups of stakeholders.

Grant acknowledgement: This project was funded by the NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Australia.

A811 PDCA for increasing effective use of CAM-ICU for delirium screening by critical care nurses

J.C. Azevedo, L.L. Rocha, F.F.M. De Freitas, A.M. Cavalheiro, N.M. Lucinio, M.S. Lobato

Hospital Israelita Albert Einstein, São Paulo, Brazil
Correspondence: M.S. Lobato – Hospital Israelita Albert Einstein, São Paulo, Brazil

Introduction: Confusion assessment method (CAM-ICU) is routinely used for delirium screening in ICU. In research environment, this tool has a very high sensitivity and specificity (1). However, in clinical settings, it may not be reproducible mainly because of inadequate training in CAM-ICU by bedside nurses (2).

Objectives: Develop a PDCA (plan-do-check-act) to train bedside critical care nurses in CAM-ICU application.

Methods: The study was conducted in a 600 bed tertiary private hospital in Sao Paulo, Brazil. A pre-training questionnaire to test bedside nurses about their knowledge of the correct application of CAM-ICU was applied. Later on, training sessions consisting of video lessons and practical mentored application of CAM-ICU were developed. Also, internal campaigns were developed to increase awareness about CAM-ICU between nurses. A post-training test was applied. Those who had a final test score higher than 90 % was approved. Those who had a final test score was ≤90 % were submitted to another round of training sections and another post-training test was applied until necessary score obtained. The instructors audited all in-training nurses CAM-ICU applications three months after training.

Results: A total of 50 nurses participated in the training, with a mean graduation time of seven years and mean hospital admission time of five years. In the pre-training questionnaire, about 83,3 % of bedside critical care nurses correctly answered questions about CAM-ICU. However when bedside application was checked, around 80 % of the nurses applied the tool correctly. The main identified causes for this were high patient turnover, demanding families, and lack of practice in CAM-ICU. After theoretical and practical training sections, all of the bedside nurses correctly answered the post-training test. In the audit period (three months after training), around 97 % of the nurses correctly applied the CAM-ICU.

Conclusions: An educational program enhances the correct application of CAM-ICU by bedside critical care nurses.

References

1. Ely EW et al. JAMA 2001;286:2703–10.

2. Van Eijik MM et al. Am J Resp Crit Care Med 2011;184:340–44.

Grant acknowledgement

None.

A812 Rocking chair mobilization therapy for critically ill patients in the intensive care unit

G. Ebeling1, A. Kraegpoeth1, E. Laerkner2

1Odense University Hospital, Anesthesiology and Intensive Care Medicine, Odense, Denmark; 2Odense University Hospital, University of Southern Denmark, Odense, Denmark
Correspondence: G. Ebeling – Odense University Hospital, Anesthesiology and Intensive Care Medicine, Odense, Denmark

Introduction: In the Intensive Care Unit (ICU) several patients are disturbed in their cerebral function due to their critical illness and medication, leading to discomfort, agitation, restlessness, pain and delirium.

Rocking Chair Mobilization Therapy (RCMT) is a chair with good seating comfort which gives rhythmic movements. Rocking chair studies have shown concrete results to improve patient satisfaction, balance and well-being in patients who suffered from dementia (1). However, no studies have evaluated the value and the effect of RCMT for critically ill patients in the ICU.

Objectives: The purpose of the study was to evaluate whether RCMT could be used in the rehabilitation of critically ill patients in the intensive care. The focus was to explore the impact of RCMT on critically ill patients comfort, pain, agitation and delirium.

Methods: The evaluation took place in a medical/surgical ICU in Denmark in the period from May to July 2015. Patients ≥ 18 years, who were physically stable and had the ability to be mobilized to chair could participate in the evaluation. The RCMT session lasted 20 minutes.Each session with RCMT was evaluated by registration of patient consciousness (Richmond Agitation and Sedation Scale (RASS)), pain (numeric rating scale (NRS) 0–10 or by Critical-Care Pain Observation Tool (CPOT)), delirium (CAM-ICU) before and after the session. Patient comfort was assessed by the patients as well as by the nurses during the session.

Results: 47 sessions with RCMT were evaluated. 24 males and 23 females, age between 49 and 88 years, participated in the evaluation. The results showed a decrease in patient agitation level and an increase in patient consiousness. Patients´ with RASS > 0 decreased from 18 before the session to 6 after the session. Patients with RASS ≤ −1 decreased from 5 before the session to 3 after the session. A decrease in delirium where 11 patients were assessed CAM-ICU positive before the session and 4 patients after the session. A decrease in pain where six patients scored NRS > 3 before the session compared to one patient after the session and 9 patients had CPOT scores > 2 before the session compared to 5 patients after the session. Assessment and evaluation of comfort by patients themselves and by the nurses, who cared for the particular patient, showed that RCMT was associated with a high degree of patient relaxation and comfort.

Conclusions: Promising results gives reason to recommend RCMT for critically ill patients in the ICU, as an alternative holistic non-pharmacological intervention to stimulate patients´ bodily awareness and enhance patient comfort and rehabilitation.

References:

1. Watson, Nancy M.; Wells, Thelma J.; Cox Christopher (1998) Rocking chair therapy for dementia patients: Its effect on psychosocial well -being and balance. American Journal of Alzheimer´s Disease. pp. 296–308

Grant acknowledgement

None

A814 Nutritional intake and physical functioning after ICU discharge

I. De Brito-Ashurst

Royal Brompton and Harefield NHS Foundation Trust, Rehabilitation and Therapies, London, United Kingdom

Introduction: Critical illness and immobility in the Intensive care unit (ICU) lead to a loss of muscle mass and reduced exercise capacity for many years following hospital discharge.[1] Nutritional management of the critically ill is challenging and most nutritional studies are focused in this period. Nutritional recommendations are for a high protein diet to minimise muscle breakdown and support protein synthesis during rehabilitation. Nevertheless, during the rehabilitation period little is known of patients' protein intake and physical functioning.

Objective: To investigate physical functioning, frailty and dietary protein intake after 6 months of ICU discharge.

Method: Our ICU is recognised as a therapy rehabilitation centre and the only ICU member of the UK Rehabilitation Outcomes (UK-ROC). Patients cognitive and physical functioning is assessed as part of their rehabilitation therapy with the Functional Independence Measure (FIM) score[2]. The FIM contains 18 items on motor (13) and cognitive (5) functions that are scored on a 7-point ordinal scale based on the amount of assistance a person requires to perform specific activities. The FIM scores on ICU discharge and also on return to the rehabilitation clinic after 6 months were assessed. In addition, frailty was assessed based on a scale ranging from very fit to very severely frail, terminally ill[3] and patients were asked to complete a protein food frequency questionnaire.

Results: Twenty patients were assessed. Data are reported as mean and (standard deviation). Patients were male 66 % and 53.4 years (33.5). Paired t tests of the changes in FIM scores from discharge showed significant increments; 9.7 ± 11.4 (P = 0.05) and 24.7 ± 23.4 (P < 0.04) for motor and cognitive scales respectively. Nevertheless, patients reported that they were “vulnerable to moderately frail” in the frailty scale. Dietary intake was also inadequate with a protein intake of 0.83 g/kg (1.15).

Conclusion: There was improvement in FIM score after discharge but that was mainly from cognitive function. A lower improvement was observed in motor functioning supporting the vulnerable to moderately frail scale and a reduced protein intake.

References

[1] Herridge, M.S., et al. 2011. Functional disability 5 years after acute respiratory distress syndrome. N.Engl.J.Med., 364(14) 1293–1304.

[2] Granger CV, Hamilton BB, Linacre JM, et al. Performance profiles of the functional independence measure. Am J Phys Med Rehabil. 1993; 72:84–89.

[3] McDermid RC, Stelfox HT, Bagshaw SM. Frailty in the critically ill: a novel concept. Critical Care. 2011; 15:301.

A815 ICU rehabilitation treatment time: outcomes and barriers

C. White1, S. Gregory2, L.G. Forni1

1Royal Surrey County Hospital, ICU and SPACeR research group, Guildford, United Kingdom; 2Royal Surrey County Hospital, Guildford, United Kingdom
Correspondence: S. Gregory – Royal Surrey County Hospital, Guildford, United Kingdom

Introduction: The Intensive Care Society in the UK has published core standards for the provision of physiotherapy and rehabilitation in ICU patients1. These state:'Patients receiving rehabilitation should be offered a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days a week of therapy per day, at a level which enables them to meet their goals for as long as they are continuing to benefit from the therapy and are able to tolerate it.'However these standards were adapted from the NICE Quality guidelines for stroke 20102 which targets 45 minutes per day over 5 days or 32 minutes per day over 7 days, rather than the direct needs of patients with Intensive Care Unit Acquired Weakness (ICUAW).

Objectives: We have examined our current rehabilitation service against the recommended 32 minute target for active therapy in the critical care unit to see if we achieve these core standards.

Methods: We recorded the therapy time provided per day to our emergency critical care patients on a documented Critical Illness Rehabilitation Pathway. Respiratory physiotherapy was excluded in the treatment times. We excluded patients on post-surgical Enhanced Recovery Pathways (ERP's). The study time run over 4 weeks with prospective data collection.

Results: A total of 53 patients were included with 417 physiotherapy contacts over the study period. Patients are offered two treatment sessions per day Monday to Friday and once at a weekend, standard practice in our critical care unit. Patients were described as one of 3 categories: self-ventilating, ventilated via tracheostomy and ventilated via Endotracheal Tube (ETT).

Conclusions: These results demonstrate that the major limiting factors in achieving the core standards are principally driven by factors unrelated to physiotherapy provision. In particular the most significant limiting factor of the self-ventilating and tracheostomy groups was fatigue/exercise tolerance, followed by medical limitation although self-ventilating patients are more likely to refuse treatment. The ventilated via ETT group, although receiving significant respiratory physiotherapy input receive less rehabilitation due to sedation. These data could be used to help inform any potential ESICM guidelines for ICUAW therapy.

References

1. The Intensive Care Society. Core standards for Intensive care units 2013. Available at: https://www.ficm.ac.uk/sites/default/files/Core%20Standards%20for%20ICUs%20Ed.1%20(2013).pdf

2. NICE quality standard (QS2) Stroke in Adults 2010. Available at: https://www.nice.org.uk/guidance/qs2

3. The Sentinel Stroke National Audit Programme (SSNAP). Available at: https://www.rcplondon.ac.uk/projects/outputs/sentinel-stroke-national-audit-programme-ssnap
Table 4 (abstract A815).

Treatment received (%)

Treatment Offered

Self-Ventilating

Ventilated via Tracheostomy

Ventilated via ETT

Bed Exercises

7.2

19.1

0

Chair Exercises

4

1.1

0

Stair practice

0.8

0

0

Balance and standing exercises

10.4

12.4

0

ROM/stretches

4.8

23.5

79

Mobility and gait re-education

45

41.5

0

Sit on edge of balance/sitting balance

7.2

10.1

0

Transfer practice

26.4

17.9

0

Positioning/UL exercises

8

11.1

31

Table 5 (abstract A815).

Limitations to Rehab (%)

Limitations to treatment

Self-ventilating

Ventilated via Tracheostomy

Ventilated via ETT

Fatigue and Exercise tolerance

41.6

39.3

3.57

Refusal/Confusion/Anxiety

24.8

5.6

0

Pain

14.4

1.1

7.14

Procedure/Unavailable

4

8.9

10.71

Acutely unwell/CVS/medical limitations/CVVHD

29.6

20.2

71.4

Sedated/Decreased GCS

1.6

12.4

7.14

Respiratory wean

0

5.6

0

Lack of equipment/Time

1.6

3.3

3.57

Other

16.8

6.7

0

Fig. 5 (abstract A815).

Results

A816 Exploring current rehabilitation on ITU: can we measure 'tolerance' and 'level' of rehabilitative physiotherapy?

E. Flowers, A. Curtis, C.-A. Wood

Guys and St Thomas NHS Foundation Trust, London, United Kingdom
Correspondence: E. Flowers – Guys and St Thomas NHS Foundation Trust, London, United Kingdom

Introduction: Rehabilitation in the Intensive Care Unit (ICU) aims to enhance health, wellbeing and recovery beyond survival of critical illness. Current rehabilitation practice requires description and measurement of effect to enhance exercise prescription1.

Objectives: Physiotherapy rehabilitation is a recognised component of ICU care. The Intensive Care Society - Core Standards2 recommends that rehabilitation is 'at a level that enables the patient to meet their rehabilitation goals for as long as they…are able to tolerate it'. In order to investigate and measure the terms 'tolerate' and 'level', physiological measurements and their relationship with self-perceived exertion and tolerance were analysed.

Methods: The project was registered with Guy's & St.Thomas' NHS Foundation Trust, Clinical Audit Group, (Project No. 4701). A convenience sample, of ICU patients undergoing active physiotherapy led rehabilitation, were observed between July and September 2014. A Modified Exertion Scale was used to measure patients' perceived effort. Patients also rated tolerance of the session using a Tolerability Scale, created based on the exertion scale. Sessions were timed, heart rate, blood pressure and oxygen saturation were monitored and the cardiovascular impact of the session measured using Heart Rate Reserve (HRR).

Results: Nine rehabilitation sessions were observed; mean length of 17 minutes (range 9–28). Minimum target HRR (>30 %) was achieved, but not sustained, by 3 patients, while 1 peaked within a normal target HRR (40-85 %). Of the 9 patients, 6 were able to use the tolerability scale and 7 the exertion scale. There did not appear to be a relationship between HRR and either perceived scale measurements. There did appear to be a link between perceived exertion and perceived tolerability with 5 of the 6 patients scoring within 3 points.

Conclusions: Reported perception of exertion and physiological markers could both indicate the 'level' patients are working at. We were able to measure effects of rehabilitation on heart rate. The majority of patients were able to use exertion and tolerance scales. However, the change in heart rate was not great enough to suggest a training effect, despite their exertion scores implying high effort levels. To fulfil the ICU society recommendations, a good understanding is needed of how hard patients are working during rehabilitation. Further research is needed to determine why there may be disparity between heart rate and patient-reported measures of exertion; and if either is a useful guide for exercise prescription with ICU patients.

References

1. Calvo-Ayala, E., Khan, B., O. Farber, M,. Ely, E., Boustani, M., (2013), 'Interventions to Improve the Physical Function of ICU Survivors', Chest, issue 144, no. 5, pp 1469–1480.

2. Core Standards for Intensive Care Units. Available online at [http://www.ficm.ac.uk/sites/default/files/CoreStandardsforICUsEd.1(2013).pdf] accessed on 23/12/2015

A817 Optimising mobilisation in the critically ill - translating knowledge into clinical practice

K. Siu1, K. Venkatesan2, J.B.H. Muhammad1, L. Ng1, E. Seet2

1Khoo Teck Puat Hospital, Rehabilitation Services, Singapore, Singapore; 2Khoo Teck Puat Hospital, Anaesthesia & Surgical Intensive Care, Singapore, Singapore
Correspondence: K. Siu – Khoo Teck Puat Hospital, Rehabilitation Services, Singapore, Singapore

Introduction: Critically ill patients are at risk of developing deconditioning, muscle atrophy and functional impairments long after hospital discharge. There is evidence demonstrating benefits of mobilization in critically ill patients - improved functional outcome and reduced ICU and hospital length of stay. However, there is limited information about how these advances are translated to clinical practice.

Objectives: To obtain a baseline data on patients who are eligible for mobilisation in ICU and how many of these patients are optimally mobilised in ICU. This would enable us to undertake a clinical practice improvement project (CPIP) using the Plan-Do-Study-Act (PDSA) implementation strategy to optimise mobilisation in at least 85 % of all eligible ICU patients.

Methods: Setting. 14-bedded intensivist led closed surgical ICU. The mobilisation team composed of physiotherapists, bedside nurses and respiratory therapists who worked along with an intensivist. Prospective audit conducted to collect data on the patients who met the eligibility criteria of mobilisation over a 3-month period. CPIP team

Results: Our audit revealed that at baseline, only 44 % of all eligible patients were optimally mobilised. RCA revealed a total of 21 barriers and through multi-voting and pareto-charting, we identified the top 3 barriers to change. Key barriers identified were: 1. Mobility not being a part of the daily review routine 2. Staff were unsure of the eligibility criteria 3. Lack of knowledge the benefits of optimal mobilisation in the critically ill. The team proposed following strategies to overcome the barriers: 1. Combined ICU multi-disciplinary handover rounds with the lead consultant asking the question “Can this patient be mobilised?” for every patient reviewed. 2. Providing a bedside decision-making algorithm on eligibility criteria, displayed within visibility of staff's work area. 3. Undertake sharing session with ground staff on the importance and benefits of optimising mobility of the critically ill.

Conclusions: Our audit revealed that less than half of eligible patients received early mobilisation. Our CPIP - a quality improvement initiative identified barriers in translating knowledge into clinical practice. Through various tools of CPIP, we identified the key barriers and strategies to overcome these barriers and thereby achieving the goal of optimising mobilisation in ICU patients.

References

1. Engel, Heidi J et al. (2013) ICU Early Mobilization: From Recommendation to Implementation at Three Medical Centres. Crit Care Med 41(9) S69-S80
Fig. 6 (abstract A817).

Comprised of multi-disciplinary stakeholders - frontline staff and patient representative. A brainstorming storming process identified various barriers to optimal mobilisation. Quality improvement tools such as Affinity diagram

Fig. 7 (abstract A817).

Root cause analysis (RCA)

Fig. 8 (abstract A817).

Run charts and Pareto charts were then utilized to form the prioritization matrices

A818 Impact of physiotherapy on the quality of assistance offered by an Angolan ICU

N. Baptista1, A. Escoval2, E. Tomas1

1Clinica Sagrada Esperança, Luanda, Angola; 2Escola Nacional de Saude Publica/UNL, Lisboa, Portugal
Correspondence: E. Tomas – Clinica Sagrada Esperança, Luanda, Angola

Introduction: Bed rest and immobility during critical illness may result in profound physical deconditioning. The multidisciplinary team in intensive care includes physiotherapists, who are responsible for performing diagnoses and procedures for critically ill patients, such as ventilation, respiratory monitoring and assessments of musculoskeletal, neurological, metabolic and cardiovascular diseases, and for the prevention and treatment of the effects of prolonged immobility.

Objectives: To evaluate the influence of physiotherapy on quality indicators in the intensive care unit of the Sagrada Esperança Clinic in Luanda, Angola.

Methods: A retrospective before-after study was designed to assess some quality indicators within the intensive care unit between July and September 2013, where there were no physiotherapists specially trained for respiratory care, and from January to March 2014, where the physiotherapists integrated a multidisciplinary team. The quality indicators analyzed were: the average duration of mechanical ventilation, prevalence of ventilator associated pneumonia and the rate of ventilated patients with non-invasive ventilation. The study population comprised 62 patients for 2013 and 71 for 2014. In this study the patients´ categorization was made by age, sex, pathology and also according with the patient classification systems SAPS 3 and SOFA. The statistical analysis used the systems SPSS version 22 for a 5 % significance level.

Results: The results obtained after analyzing the two homogeneous groups according to age, gender, type of admission and severity influencing the physiotherapy care in ICU quality indicators, in the Sagrada Esperança clinic, highlights the decrease of the average number of days with mechanical ventilation but it is not observed a significant relation between physical therapy and this indicator (p = 0:06).

Furthermore, it is also observed a decrease ventilator associated pneumonia, and a significant relation between this indicator and the respiratory physiotherapy. Last, there is a strong relation between the increase on the number of patients without invasive ventilation and physiotherapy (p = 0.017).

Conclusions: In this study it is demonstrated the respiratory therapy influences in some quality indicators, namely regarding the reduction of ventilation associated pneumonia and the promotion of non-invasive ventilation in the ICU of the CSE.

References

1) Pinto, W. A. M., Rossetti, H. B., Araújo, A., Spósito Júnior, J. J., Salomão, H., Mattos, S. S., Machado, F. R. (2014). Revista Brasileira de Terapia Intensiva, 26(1), 7–13.
Fig. 9 (abstract A818).

Baseline characteristics

Fig. 10 (abstract A818).

Outcome

FUNGAL INFECTION AND INFECTION PREVENTION

A820 Epidemiology, treatment pattern and outcomes of candida infection in non neutropenic patients in a medical icu of a developing country

R. Agrawal, R. Mathew, A. Varma

Fortis Escorts Heart Institute, Critical Care Medicine, New Delhi, India
Correspondence: R. Agrawal – Fortis Escorts Heart Institute, Critical Care Medicine, New Delhi, India

Introduction: The incidence of fungal infections has increased in Indian ICU`s over last few years1. The mortality due to unrecognized and untreated fungal infections is significantly higher.

Objectives: To study the incidence and epidemiology of fungal infections in a medical ICU in non neutropenic patients. We also studied the treatment pattern and patient outcomes in these critically ill patients.

Methods: The study was conducted from January 2015 to March 2016 over a period of fifteen months.Total patients admitted to the medical ICU were screened and patients with suspected candida infection were noted. The APACHE II score was calculated for assessing the severity of illness.Patients receiving emperical antifungal therapy and type of antifungal drugs used were also noted. The mortality rate in patients with cultures positive for candida was noted and compared to ICU mortality rate.

Results: There were total of 3700 patients who were admitted in the 50 bed medical ICU.Out of these 125 (3.3 %) patients were culture positive for candida. Candida tropicalis was the most common species followed by C. albicans (Table 6). The mean APACHE II score in patients with culture positive with candida was 19.2 whereas it was 17.5 in other patients (9.7 % higher in Candida group). Azoles were the most common antifungal used (58 %) followed by echinocandins (21.4 %). The crude mortality rate in patients with positive cultures for candida was 26.4 % (n = 33) which was significantly higher than ICU mortality rate of 5.5 %. (n = 197), (pvalue < 0.001).

Conclusions: Candida infections are a significant cause of mortality in ICU`s .C. tropicalis is more commonly isolated than C albicans. Azoles are the most common antifungals used though the usage of ecinocandins is rising. Early recognition and treatment of fungal infections is of critical importance. Avoiding overuse and promoting deescalation protocol of antibiotics can help in controlling fungal infections in the ICU.

References

1. Chakrabarti A. J Postgrad Med. 2005; 51(1): 16–20. 5. Dellinger et al. CCM. 2013;41:580–637

2. Pappas P, Et al. A Prospective Observational Study of Candidemia: Epidemiology, Therapy, and Influences on Mortality in Hospitalized Patients. Clin Infect Dis (2003) 37(5): 634–643.

Grant acknowledgement

None.
Table 6 (abstract A820).

Candida species isolated

FAMATA

2

1.9 %

GLABRATA

14

13.4 %

GUILLIERMONDII

1

1.0 %

HAEMULONII

2

1.9 %

KRUSEI

1

1.0 %

PARAPSILOSIS

3

2.8 %

RUGOSA

2

1.9 %

TROPICALIS

45

42.3 %

ALBICANS

37

35.2 %

A821 Candidemia in intensive care unit (ICU) patients: risk factors for non-albicans Candida species and for fluconazole resistance

E. Dima1, E. Charitidou2, E. Perivolioti3, M. Pratikaki3, C. Vrettou3, A. Giannopoulos3, S. Zakynthinos3, C. Routsi3

1University of Athens, Medical School, Evangelismos Hospital, Athens, Greece; 2National Technical University of Athens, Athens, Greece; 3Evangelismos Hospital, Athens, Greece
Correspondence: E. Dima – University of Athens, Medical School, Evangelismos Hospital, Athens, Greece

Introduction: The incidence of candidemia has increased in ICU patients (1). In addition, there are differences in epidemiology among different countries. We have previously shown an increased proportion of non-albicans Candida species in our ICU (2).

Objectives: To identify the variables associated with candidemia due to non- albicans Candida species, as well as with fluconazole-resistant strains in a multidisciplinary ICU.

Methods: All ICU patients with candidemia were prospectively studied over two time periods (2005–2008 and 2012–2015). Demographics, illness severity, clinical and laboratory variables were recorded. SOFA score value on ICU admission subtracted from the value on the day of candidemia occurrence was defined as Delta SOFA. Patients with C. albicans candidemia were compared to those with non-albicans candidemia. Also, patients with fluconazole-resistant candidemia were compared to those without fluconazole resistance.

Results: Among 143 patients with ICU-acquired candidemia, in 55 patients candidemia was due to C. albicans and in 88 patients to non-albicans species. C. parapsilosis was the most common (46 %) followed by C. albicans (38 %). The median time from ICU admission to candidemia onset was 12 and 23 days for C. albicans and non-albicans respectively, p = 0.02. Similarly, the median time for candidemia due to fluconazole sensitive isolate was 14 days and 32 days for fluconazole resistant, p < 0.001. Resistance to fluconazole was 9 % and 51 % in C. albicans and in non-albicans species respectively, p < 0.001).Presence of shock on candidemia day (OR 6.85; CI: 2.2-25, p = 0.001) and the Delta SOFA score (OR 0.74; CI: 0.60-0.89, p = 0.002) were independently associated with candidemia due to C. albicans. Independent risk factors for fluconazole resistant isolates were the length of ICU stay before the development of candidemia (OR 1.03; CI: 1.01-1.05, p = 0.003) and the presence of shock on candidemia day (OR 0.23; CI: 0.07-0.64, p = 0.006). Previous fluconazole exposure (10 patients) was not associated with fluconazole resistance.

Conclusions: This study confirms the predominance of non-albicans Candida species, in our ICU patients with candidemia, with high prevalence of fluconazole resistance. Early onset of candidemia and the presence of shock were most likely due to C. albicans whereas late onset was associated with fluconazole-resistant non- albicans species. These findings may be of value for empiric antifungal treatment selection.

References

(1) Intensive Care Med 2014;40:1303

(2) Mycoses 2011;54:154

A822 Early fungal infections after lung transplantation

E. Atchade, S. Houzé, S. Jean-Baptiste, G. Thabut, C. Genève, S. Tanaka, B. Lortat-Jacob, P. Augustin, M. Desmard, P. Montravers

Hopital Bichat Claude Bernard, Paris, France
Correspondence: E. Atchade – Hopital Bichat Claude Bernard, Paris, France

Introduction: Fungal infections (FI) after lung transplantation (LT) are common and associated with high mortality and morbidity rates (1). Published studies report late invasive infections caused by Aspergillus sp, but the early post-transplant period in intensive care unit (ICU) patients is rarely assessed.

Objectives: The primary goal of the study was to describe the epidemiology of early FI in ICU after LT. Secondary aims were to evaluate its impact on the outcome on ICU stay and to determine the risk factors for fungal colonisation.

Methods: This observational, retrospective, monocentric study analysed microbiologic results, clinical evolution and outcome of 176 LT, in ICU, during a 6-year period. Fungal positive respiratory sample was considered as colonisation when no clinical, radiological or histological criteria for invasive infection were present. Results are expressed as median and interquartile range. Statistical analyses were performed using Chi square, Mann-Whitney and Kruskal Wallis tests. The level of statistical significance was set at 5 %. The local Ethic Committee approval was obtained for the study.

Results: During the pre-transplantation period, Candida sp colonisation was reported in 17 % of the patients (87 % C. albicans), while Aspergillus sp colonisation was observed in 4 % of them. In the post-transplantation period, 69 % of patients were colonised with fungi, mainly C.albicans (33 % of cases), rarely Aspergillus spp (7 %). Median time to onset of Candida colonisation was 4 days [1–8] and 5 days [3–14] for Aspergillus colonisation. Fungi were significantly associated with the presence of Enterobacteriaceae (OR = 2.61, 95%CI [1.36-5]; p = 0.003) and enterococci (OR = 5.09, 95%CI [1.14, 22.75]; p = 0.02). Risk factors for fungal post-operative colonisation were bi-pulmonary transplantation (OR = 2.49, 95%CI [1.15-5.45], p = 0.02) and COPD (OR = 2.71, 95%CI [1.39-5.32], p = 0.003). Among the patients developing candida colonisation in the post-transplantation period, 57 % received an antifungal treatment during their ICU stay (10 % echinocandins, 97 % azoles). A significant association between pre-transplant Candida sp colonisation and mortality rate in ICU was observed (OR = 2.35, 95%CI [1.14-4.9], p = 0.03). Post-operative fungal colonisation was not associated with increased death rate in ICU (OR = 1.32, 95%CI [0.62, 2.82], p = 0.57) or duration of mechanical ventilation ≥3 days (OR = 1.65, 95%CI [0.87-3.12]) while post-operative Candida sp colonisation was associated with prolonged ICU stay (p < 0.001) and increased duration of mechanical ventilation (p = 0.002).

Conclusions: Prevalence of fungal colonisation is high after LT, most commonly caused by Candida sp. The lack of association between post-transplant fungal colonisation and mortality and morbidity suggests to avoid antifungal therapy when no clinical signs of fungal infection are observed.

References

(1) Solé A, Transplant Rev Orlando Fla, 2008; 22(2): 89–104

Grant acknowledgement: None.

A823 Clinical significance of Aspergillus isolation in critically ill H1 N1 patients

F.J. González de Molina1,2, S. Barbadillo3,4, R. Alejandro5, F. Álvarez-Lerma6, J. Vallés7, R.M. Catalán8, E. Palencia9, A. Jareño10, R.M. Granada11, M.-L. Ignacio12, GETGAG Working Group

1Hospital Universitari Mútua de Terrassa, Intensive Care Department, Terrassa, Spain; 2AGAUR, Grup Recerca Emergent, Terrassa, Spain; 3Hospital General de Catalunya, Intensive Care Department, Sant Cugat del Vallés, Spain; 4Universidad Autónoma de Barcelona, Departament de Medicina, Barcelona, Spain; 5Hospital Universitari de Tarragona Joan XXIII, Intensive Care Department, Tarragona, Spain; 6Hospital del Mar, Intensive Care Department, Barcelona, Spain; 7Hospital Parc Taulí, Intensive Care Department, Sabadell, Spain; 8Hospital General de Vic, Intensive Care Department, Vic, Spain; 9Hospital Infanta Leonor, Intensive Care Department, Madrid, Spain; 10Hospital del SAS de Jerez, Intensive Care Department, Jerez de la Frontera, Spain; 11Hospital de Bellvitge, Intensive Care Department, Barcelona, Spain; 12St James's University Hospital, Dublin, Ireland
Correspondence: F.J. González de Molina – Hospital Universitari Mútua de Terrassa, Intensive Care Department, Terrassa, Spain

Introduction: Invasive Aspergillus infections are well-known complications of immunocompromised states, chronic obstructive pulmonary disease and haematopoietic stem cell transplant. Bacterial coinfection is well described in influenza literature but there is scarce data on invasive aspergillosis complicated severe influenza infection.

Objectives: The aim of this study is to describe the clinical and demographic characteristics of patients with Aspergillus isolation in severe influenza A(H1 N1) pneumonia.

Methods: Prospective, observational, multicenter study conducted in 148 Spanish ICUs from 2009 to 2015. All individuals with severe primary influenza A(H1 N1) pneumonia requiring invasive mechanical ventilation were included in the study. Influenza A(H1 N1) patients without coinfection were compared with those with Aspergillus isolation in respiratory samples. All serotypes were confirmed using RT-PCR at ICU admission. Patients´ demographic, clinical, radiologic features, laboratory values, ICU and hospital length of stay (LOS) and outcomes were recorded. Discrete variables are expressed as counts (percentage) and continuous variables as medians with 25th to 75th interquartile range (IQR). Differences between groups were assessed using the x2 test and the Fisher exact test for categoric variables and Mann-Whitney U test for continuous variables.

Results: Of 1594 intubated patients with confirmed influenza A (H1 N1) pneumonia at ICU admission, 385 were excluded due to other microorganism coinfection. At all, 1185 patients with H1 N1 pneumonia were compared to 24 patients with H1 N1 pneumonia and Aspegillus isolation (AI) in respiratory samples. Patients with AI were older (64 [54–71] vs 49 [38–60], P < 0.001), presented a higher proportion of COPD (39.1 % vs 17.8 %, P =0.024), chronic renal failure (21.7 % vs 7.1 %, P = < 0.023), and immunodeficiency (34.8 % vs 10.8 %, P =0.002). Patients with AI developed more acute kidney injury (47.6 % vs 28.0 %, P =0.048) and were treated more frecuently with corticosteroids (71.4 % vs 47.1 %, P = < 0.044). Overall mortality was much higher in those patients with AI (65.2 % vs 29.6 %, P < 0.001).

Conclusions: The mortality rate was significantly higher in H1 N1 patients with Aspergillus isolation in respiratory samples. Diagnosis of invasive aspergillosis in critically ill patients in the post-influenza era must be re-evaluated. Clinical studies should be conducted in order to know the clinical significance of Aspergillus isolation in respiratory samples in intubated patients with primary influenza A(H1 N1) pneumonia.

References

1.- Wauters J, et al. Invasive pulmonary aspergillosis is a frequent complication of critically ill H1 N1 patients: a retrospective study. Intensive Care Med. 2012;38(11):1761–8.

2.- Adalja AA, et al. Isolation of Aspergillus in three 2009 H1 N1 influenza patients. Influenza Other Respir Viruses. 2011;5(4):225–9.

A824 Initial Therapeutic Strategy Of Invasive Candidiasis For Intensive Care Unit Patients: An Analysis From The China-Scan Study

N. Cui1, D. Liu1, H. Wang1, L. Su1, H. Qiu2, R. Li3

1Peking Union Medical College Hospital, Critical Care Medicine, Beijing, China; 2Nanjing Zhongda Hospital, Southeast University School of Medicine, Critical Care Medicine, Nanjing, China; 3Peking University First Hospital, Peking University, Research Center for Medical Mycology, Beijing, China
Correspondence: N. Cui – Peking Union Medical College Hospital, Critical Care Medicine, Beijing, China

Introduction: The empiric or pre-emptive approach can be used as a better target therapy in antifungal treatment and affect mortality.

Objectives: To investigate the impact of initial antifungal therapeutic strategies on the prognosis of invasive Candida infections (ICIs) in intensive care units (ICUs) in China.

Methods: A total of 306 patients with proven ICIs in the China Survey of Candidiasis study were analyzed. Empiric, pre-emptive, and targeted therapy were adopted based on starting criteria including clinical, microbiological, and other conventional prediction rules. The primary outcome was ICU/hospital mortality.

Results: Compared with the empirical initial antifungal therapy and targeted initial antifungal therapy, patients with pre-emptive initial antifungal therapy had significantly less clinical remission [11/53 (21.2 %) vs. 61/142 (43.3 %) vs. 22/73 (30.1 %), p = 0.009], higher ICU [26/53 (57.8 %) vs. 42/142 (32.2 %) vs. 27/73 (43.5 %), p = 0.008] and hospital mortality [27/53 (60.0 %) vs. 43/142 (32.8 %) vs. 29/73 (46.8 %), p = 0.004] and more microbiological persistence [9/53 (17.0 %) vs. 6/142 (4.2 %) vs. 9/73 (12.3 %), p = 0.011]. Kaplan-Meier survival analysis revealed that ICI patients with pre-emptive initial antifungal therapy and targeted initial antifungal therapy were associated with reduced hospital duration compared with patients with empirical initial antifungal therapy after confirmation of fungal infection (log-rank test: p = 0.021).Multivariate regression analysis provided evidence that initial empirical antifungal therapy was an independent predictor for hospital mortality in ICI patients[odds ratio 0.349(95 % confidence interval 0.168-0.724); p = 0.005).

Conclusions: The initial therapeutic strategy for invasive candidiasis was independently associated with hospital mortality. Prompt empirical antifungal therapy could be critical to decrease early hospital mortality.

Acknowledgement

This study was supported by Merck Sharp & Dohme China. We would like to thank the patients and investigators who participated in this study. We also acknowledge the investigators at each study site, without whom this study would not have been possible.

A825 De-escalation of antifungal treatment in critically ill patients: incidence, associated factors and safety

K. Jaffal1, A. Rouzé1, J. Poissy1, B. Sendid2, S. Nseir1

1Lille University Hospital, ICU, Lille, France; 2Lille University Hospital, Mycology and Parasitology Lab, Lille, France
Correspondence: S. Nseir – Lille University Hospital, ICU, Lille, France

Introduction: Although antifungal treatment is common in critically ill patients, only a small proportion of patients receiving antifungal treatment have confirmed fungal infection. Side effects of this treatment include toxicity, resistance and unnecessary high costs. In addition, recent studies suggested no benefit of empirical antifungal treatment in these patients.

Objectives: The aim of this study was to identify the incidence, associated factors, and safety of de-escalation of antifungal treatment.

Methods: Retrospective study, conducted in a 30-bed mixed ICU, during a 1-year period. All patients hospitalized for >5d and treated with antifungals for first suspected or proven fungal infection were included. Patients receiving prophylactic antifungals were excluded. De-escalation was defined as switch from initial systemic antifungal therapy drugs (except fluconazole) to triazoles, or stopping initial drugs within 6 days following their initiation. Patients with de-escalation were compared with those with no de-escalation using univariate and multivariate analysis.

Results: Among the 234 patients who received systemic antifungals, 44 % received empirical, 23 % preemptive, and 33 % targeted treatment. Caspofungin (51 %), fluconazole (34 %), voriconazole (11 %), and liposomal amphotericin B (2 %) were the most frequently used antifungals. Antifungal treatment was de-escalated in 48 (20.5 %) patients.

Factors associated with higher rate of de-escalation in univariate analysis were: sterile repeated mycological samples, empirical treatment, preemp