key: cord-335975-m6lkrehi
authors: nan
title: Proceedings of Réanimation 2018, the French Intensive Care Society International Congress
date: 2018-02-05
journal: Ann Intensive Care
DOI: 10.1186/s13613-017-0345-7
sha: 
doc_id: 335975
cord_uid: m6lkrehi

nan

Introduction: Veno-venous extracorporeal CO 2 removal (ECCO2R) is a promising new therapeutic option in the critical care setting. We conducted a prospective observational study of the use of ECCO2R in selected voluntary centers during 2 years aiming to assess the prevalence of the ECCO2R use mainly among COPD and ARDS patients. Patients and methods: Two medical devices: Hemolung (Alung Technologies, Pittsburgh, USA) and iLA Activve (Xenios Novalung, Heilbronn, Germany) were selected after literature and medico-economic evaluations. A specific medical and nurses training was provided in Table 1 Characteristics of 130 patients with known or de novo SVV (small-vessel vasculitis) admitted to the intensive care unit for Acute Respiratory Failure (ARF) All ARF (n = 130) Immune ARF (n = 67) Non immune ARF (n = 63) p

Age , Introduction: Ineffective triggering is frequent during pressure support ventilation (PSV). Its occurrence is favored by dynamic hyperinflation that may arise when increasing the pressure support level (PSL). Decreasing the PSL however fails to suppress ineffective triggering in a subgroup of patients that are therefore exposed to refractory ineffective triggering. Proportional assist ventilation with load-adjustable gain factors (PAV +) decreases the incidence of ineffective triggering in unselected patients but its effect on refractory asynchrony during PSV is unknown. The main aim of our study was to assess the effect . The median gain during PAV + was 70% [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] . The asynchrony index was significantly lower with PAV + than PSV (3% [2] [3] [4] [5] [6] [7] [8] vs. 24% respectively, p = 0.02). Moreover, the asynchrony index decreased in every patient with PAV + (Fig. 1) . Noticeably, the tidal volume was already protective in PSV and decreased even more during PAV + (5.71 mL kg [4.6-9.3] vs. 5.71 mL [1.8-7 .1] respectively, p = 0.03); and the neural respiratory rate was high in both modes (41 cycles min in PSV vs. 40 [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] in PAV + , p = 0.61). Total esophageal Pressure-Time Product (PTPes) did not significantly differ between the two modes but the PTPes proportion that was wasted in ineffective efforts decreased with PAV + (1% [1] [2] vs. 18% , p = 0.03). Conclusion: Our preliminary data suggest that: (1) PAV + reduces the incidence of refractory ineffective triggering; (2) patients exposed to refractory ineffective triggering during PSV seem characterized by rapid shallow breathing despite high ventilatory support, questioning the tolerance of both ventilatory modes. Results with further inclusions will be presented. Introduction: The use of alternatives to carbapenems to treat patients with extended-spectrum beta lactamase-producing Gram negative bacilli (ESBL-GNB) infections remains controversial. Their use in patients with severe infections in the ICU has been poorly studied. The aim of this study was to compare the outcome of ICU patients having received carbapenems to those having received a carbapenem-sparing agent (CSA).

The charts of patients with ESBL-GNB infection hospitalized in our ICU between 2015 and 2017 were retrospectively reviewed. Patients treated with betalactam betalactam inhibitor (BL BLI), cefepime or quinolones were considered has having received an alternative to carbapenems (CSA). Patients having received such a CSA were compared to those having received a carbapenems. Primary outcome was treatment failure at day 28, defined as ESBL-GNB infection recurrence (relapse with same pathogen) or death, whichever first occurred.

Results: 66 patients with ESBL-GNB infection were included. Source of infection was the lung for most of them. Characteristics of patients are displayed on Table 1 . Their median SAPS II and SOFA scores were 59 and 12 [7] [8] [9] [10] [11] [12] [13] [14] [15] , respectively, and 38 (58%) were on septic shock. 40 patients received a carbapenem empirically, among whom 18 were switched to a CSA agent when antibiogram was available (CSA-definite group), whereas carbapenems were pursued in the 22 others (carbapenem-only group), mainly because pathogens were resistant to others antibiotics. Among the 26 patients having received a non-carbapenem agent as empirical treatment, pathogen was susceptible to this agent in 9 and they pursued the same treatment (CSA-only group), whereas 17 were switched to a carbapenem (pathogens resistant to empirical treatment, carbapenem-definite group). Treatment failure were not different among these 4 groups (Table 1) . Globally, 27 patients received a CSA as their definite treatment (CSAdefinite and CSA-only groups), whereas 39 received a carbapenems (carbapenems-only and carbapenems-definite groups). Whereas duration of antimicrobial treatment was similar (8 [6-10] days vs. 9 [7-10] days, respectively, p = NS), treatment failure rate was not higher in the former, as compared to those having received a carbapenems (29 vs. 71%, respectively, p = 0.049). Conclusion: Treatment of patients with ESBL-GNB severe infection in the ICU with a CSA seems to be safe when the pathogen is susceptible to this CSA. However, MIC should be first determined before de-escalating to a CSA. Larger studies are needed. 1 Percentages of samplings which attained the PK PD targets for various CrCL with potential suboptimal beta-lactam concentration in critically-ill patients with AKI treated either with an early or a delayed RRT strategy. Patients and methods: Ancillary study in a subset of patients with severe AKI (KDIGO3), receiving a beta-lactam antibiotic, in a trial comparing two RRT initiation strategies. In this trial, patients from 31 intensive care units were randomly assigned to either an early (immediate RRT) or a delayed (late or no RRT) RRT initiation strategy. Beta-lactam residual concentrations were sampled at 24 and 48 h after inclusion.

The appropriate concentration was defined as a trough of at least 4 times the minimal inhibitory concentration (clinical breakpoint of EUCAST). The primary outcome was an adequate plasma concentration of the beta-lactam during the first 2 days. Results: Among the 233 patients included in the 11 centers participating to this ancillary study, a beta-lactam trough concentration was evaluated in 112 subjects, 53 in the early and 59 in the delayed groups. Ninety patients (80.4%) had an adequate beta-lactam dosage. RRT initiation strategy had no impact on beta-lactam concentration (p = 0.78). Among the 83 septic shock patients (74% of the sampled patients), 73 (88%) had a correct antibiotic concentration. In contrast, only 10 of the 16 patients without definite sepsis (62.5%) had a correct dosage. Factors associated with an adequate beta-lactam trough concentration in univariate analysis were admission for a septic shock (p = 0.002), a higher plasma creatinine level (p = 0.024), a higher mean arterial pressure (p = 0.018) and a lower serum bicarbonate level (p = 0.045) at randomization. A higher SOFA score was associated with an adequate beta-lactam concentration near to statistical significance (p = 0.053). Multivariate analysis will be presented.

In the context of severe AKI, beta-lactam concentration reached a sufficient level in 88% of septic shock patients. Interestingly, RRT initiation strategy was not associated with beta-lactam trough concentration. Early RRT did not affect trough concentration of betalactam. We may hypothesize that physicians were highly vigilant and adapted antibiotic administration adequately in these patients. Introduction: Amikacin infusion requires to target a peak serum concentration (C max ) 8-10 times the minimal inhibitory concentration,

corresponding to a C max at 60-80 mg L −1 for the least susceptible bacteria. Recent study reported that 33% of critically ill patients do not attain this target with a 25 mg kg dose (1) . Membrane sequestration, alteration of the volume of distribution and lack of data in this population make drugs pharmacokinetics (PK) on ECMO challenging. Our study aimed to assess the prevalence of insufficient Amikacin C max in critically ill patients on ECMO and to identify relative risk factors. Patients and methods: Prospective, observational, monocentric study of adult patients on venoarterial (VA) or venovenous (VV) ECMO receiving a loading dose of Amikacin for suspected Gramnegative infections. Intravenous Amikacin was administered with a loading dose of 25 mg kg of total body weight and C max was measured 30 min after the end of the infusion. Independent predicators of C max < 60 mg L −1 after the first Amikacin infusion were identified by mixed model multivariate analysis. Results: From January 2015 to February 2016, 106 patients (median SAPS 2 (interquartile range) 68(47-81); age 55(45-62) years) under VA-ECMO (68%) or VV-ECMO (32%) were included. At inclusion, the SOFA score was 15 (12-18) and 54 (51%) patients were on renal replacement therapy. Overall ICU mortality was 54%. C max was < 60 mg L −1 in 41 (39%) of the patients. Independent risk factors of amikacin under-dosing were body mass index (BMI) < 22 kg m −2 (Odds Ratio (OR) 6.38, 95% confidence interval 95%CI 1.8-22.8, p = 0.043) and a positive 24 h fluid balance (OR per 500 mL increment: 1.28, 95%CI 1.05-1.65, p = 0.041) (Fig. 1 ). Our results were comparable to those observed in patients treated with Amikacin without ECMO (1) .

Conclusion: This large prospective study suggests that the prevalence and associated risk factors of Amikacin under-dosing are similar in critically-ill patients with or without ECMO. The use of a 30 mg kg dose in low BMI patients and in those with a positive 24-h fluid balance on ECMO is strongly encouraged to obtain adequate therapeutic targets and prevent therapeutic failure.

Results: Fifty patients were included (29 with delirium, 21 controls), at day 4 for controls and day 5 for patients with confusion. Delirium patients were more severely ill SOFA 5 [3; 9] versus 3 [1; 5] (p = 0.05); with higher RASS 1[0; 2] versus 0[0; 0] (p = 0.05). They presented with 41% BL overdosing versus 19% in controls (p = 0.09); with 41% of BL in therapeutic index: 71% in controls (p = 0.04). Obesity and renal failure were not associated with BL overdosing but there was a trend with hypoalbuminemia (p = 0.09). Discussion: Trend in association of BL overdosing with delirium corresponds to previous studies, and would need a larger scale study to be confirmed. Severity differences in groups would need changes in inclusion criteria to obtain homogeneous groups. A possible association of BL underdosing with poor evolution of infection and organ failures would need more precise evaluation. Hypoalbuminemia could have an impact on BL overdosing. Conclusion: Delirium was not associated with BL overdosing but with therapeutic index. A high variability of BL concentrations warrants therapeutic drug monitoring. A larger scale study should include changes in design.

Feasibility and safety of low-flow extracorporeal CO 2 removal with a renal replacement platform to enhance lung protective ventilation in patients with mild to moderate ARDS Schmidt Matthieu 1 , Jaber Samir 1 , Constantin Introduction: Extracorporeal carbon dioxide removal (ECCO2R) might allow ultraprotective mechanical ventilation with lower tidal volume (VT) (< 6 mL kg ideal body weight), plateau pressure (Pplat) (< 30 cm H 2 O), driving pressure, and respiratory rate (RR) to reduce ventilator induced lung injury (VILI). The aim of this study was to assess the feasibility and safety of ECCO2R with a renal replacement platform (RRT) to permit ultra-protective ventilation in patients with mild to moderate acute respiratory distress syndrome (ARDS). Patients and methods: Twenty patients with mild (n = 8) or moderate ARDS were included. VT was gradually reduced from 6 to 5, 4.5 and 4 mL kg −1 and PEEP adjusted to reach 23 > Pplat > 25 cm H 2 O. Standalone ECCO2R (no hemofilter associated on the RRT platform) was initiated when arterial PaCO2 increased by more than 20%. Ventilation parameters (VT, RR, PEEP), respiratory compliance, driving pressure, arterial blood gases, and ECCO2R system operational characteristics (blood flow, sweep gas flow, and CO 2 removal rate) were collected during a minimum of 24 h of ultra-protective ventilation. Complications, mortality at day 28, need for adjuvant therapies and data on weaning from both mechanical ventilation and ECCO2R were also collected. Results: While VT was reduced from 6 to 4 mL kg −1 and Pplat kept below 25 cm H 2 O, PEEP was significantly increased from 13.4 ± 3.6 at baseline to 15.0 ± 3.4 cm H 2 O at VT = 4 mL kg −1 . As a result, the driving pressure was significantly reduced to 7.9 ± 3.2 cm H 2 O at VT = 4 mL kg −1 (p < 0.05) (Fig. 1) . No significant differences in RR, PaO2 FiO2 ratio, respiratory system compliance were observed after Vt reduction. Mean extracorporeal blood, sweep gas flow and CO 2 removal were 421 ± 40 mL min −1 , 10 ± 0.3 L min −1 and 51 mL min −1 , respectively. Mean treatment duration was 31 ± 22 h. Main side effects related to ECCO2R were membrane clotting which occurred in 7 patients after 19 ± 9 h. Conclusion: A low-flow ECCO2R device driven by a RRT platform efficiently removed CO2 while allowing ultra-protective mechanical ventilation settings in patients with mild to moderate ARDS (ClinicalTrials. gov identifier: NCT02606240).

Morimont Philippe 1 , Habran Simon 1 , Desaive Thomas 1 , Janssen Nathalie 1 , Amand Theophile 1 , Blaffart Francine 1 , Dauby Pierre 1 , Kolh Philippe 1 , Defraigne Jean-Olivier 1 , Lambermont Bernard 1 Introduction: Protective lung ventilation (PLV) is recommended in patients with acute respiratory distress syndrome (ARDS) to minimize additional injuries to the lung. However, increased right ventricular (RV) afterload resulting from ARDS could be enhanced by hypercapnic acidosis resulting from ventilation at lower tidal volume. Relative contribution of these factors (ARDS and PLV) in RV afterload is not clearly established. The aim of this study was to compare RV afterload in ARDS combined with PLV to RV afterload in PLV alone. Patients and methods: This study was performed in an experimental model of severe hypercapnic acidosis performed in 2 series of 6 pigs. In both groups, respiratory tidal volume was decreased by 60%. In the first group (ARDS group), an ARDS (obtained by repeated bronchoalveolar lavage) was performed before reducing ventilation, while in the second group (control group), hypercapnic acidosis was resulting from low tidal volume ventilation alone. Results: In both groups, systolic pulmonary artery pressure (PAPs) significantly increased during PLV. This increase was significantly higher in ARDS group than in control group (Fig. 1) . Severe hypercapnic acidosis occurred in both groups: PaCO2 increased from 41.7 ± 3.6 to 78.6 ± 8.1 (p < 0.01) and arterial pH decreased from 7.44 ± 0.05 to 7.13 ± 0.04 (p < 0.01) in ARDS group while PaCO2 increased from 37.7 ± 9.4 to 93.6 ± 6.4 (p < 0.01) and arterial pH decreased from 7.48 ± 0.05 to 7.11 ± 0.04 (p < 0.01) in control group. PaO2 significantly decreased in ARDS group (178 ± 42 to 54 ± 12.3 mmHg, p < 0.01) but did not significantly changed in control group. Conclusion: Isolated hypercapnic acidosis resulting from PLV was clearly responsible for increased RV afterload and this effect was significantly enhanced in ARDS. Pulmonary vasoconstriction resulting from hypercapnic acidosis is strongly enhanced by factors like hypoxia, endothelial injuries or inflammatory mediators in ARDS. Extracorporeal CO 2 removal could be the solution to limit afterload burden on the right ventricle when PLV is achieved during ARDS. Introduction: Prone positioning has been shown to improve mortality in acute respiratory distress syndrome (ARDS) patients. The respiratory system driving-pressure (DPRS) and the transpulmonary driving-pressure (DPL), measured with esophageal manometry, have been shown to be strongly correlated with mortality. The aim of this study was to investigate the evolution of the DPL during prone positioning and its relationship with evolution of oxygenation in ARDS patients. Patients and methods: Ten patients with ARDS equipped with esophageal manometry were enrolled. DPRS, DPL and chest wall driving-pressure (DPCW) were measured before and 1 h after prone positioning. Respiratory system, pulmonary and chest wall elastance (ERS, EL, ECW) were calculated at the same time. Finally, we studied the correlation between these respiratory variables and oxygenation indicators. Patients were classified as responders to prone positioning if the change in the ratio of arterial oxygen partial pressure oxygen inspired fraction (Delta.PaO2/FiO2) induced by the manoeuvre was larger than the median value observed in the group. Results: In the whole population, median value of Delta.PaO2/FiO2 was 53.5 mmHg, and 5 patients were classified as responders and 5 as non-responders. In responders, DPL significantly decreased from 8.8 ± 4.1 cm H 2 O to 5.9 ± 5.4 cm H 2 O (p = 0.02) and EL decreased from 21.9 ± 5.1 cm H 2 O L to 14.9 ± 6.5 cm H 2 O L (p = 0.02) after prone positioning. Other respiratory variables did not change. In non-responders, respiratory variables did not change. Between responders and nonresponders, there was no significant difference between baseline respiratory variables. After prone positioning, Delta.PaO2/FiO2 was not related to baseline respiratory parameters. On the contrary Delta.

PaO2/FiO2 induced by prone positioning was strongly correlated with changes in DPL (r = − 0.70, p = 0.02) and changes in EL (r = − 0.69, p = 0.03). We did not find any correlation between Delta.PaO2/FiO2 and changes in DPCW or changes in ECW. The correlation between Delta.PaO2/FiO2 and changes in DPRS (r = − 0.56, p = 0.09) and changes in ERS (r = − 0.55, p = 0.10) did not reach significance. Conclusion: In patients who respond to prone positioning by the highest improvement in oxygenation, DPL significantly decrease after prone positioning. The changes in DPL and the changes in EL play a major role in the improvement in oxygenation induced by prone positioning whereas the changes in DPCW and ECW do not.

Introduction: Whereas prone positioning (PP) has been shown to improve patient survival in moderate to severe ARDS patients, its rate of use was 7.4% in Lung Safe study. However, Lung Safe study was not specifically focused on PP. Therefore, present study aimed to determine prevalence of use of PP in ARDS patients (primary endpoint), physiologic effects of and reasons for not using PP (secondary end-points).

The APRONET study was a prospective international one-day prevalence study performed 4 times in April, July, October 2016 and January 2017. At each study day, investigators had to screen every patient staying in ICU from 0 to 24 h and to fill electronic CRF. For patients with ARDS (defined from the Berlin definition criteria) at each study day oxygenation and ventilator settings were recorded. For those receiving PP these variables were recorded before and at the end of PP session. The reasons for not proning were also collected. Values are presented as median (1st-3rd quartiles). Prevalence rates of PP were compared by using Chi square for trend and groups were compared with nonparametric tests. Introduction: Although acute respiratory distress syndrome (ARDS) has been largely focused on, few data are available concerning hypoxemia independently of its cause in intensive care unit (ICU) patients. A recent prevalence-point-day (PPD) evaluated the patterns and outcomes of hypoxemia in French speaking ICUs. Here, we describe the main etiologies, management and outcomes of the patients of this cohort presenting with severe hypoxemia. Patients and methods: A PPD was conducted among 117 French speaking ICUs during spring 2016. Hypoxemia was defined by a PaO2 FiO2 ratio below 300. We analyzed the data from patients with severe hypoxemia (i.e. with a PaO2 FiO2 ratio < 100) and compared their characteristics (causes of hypoxemia, ventilatory and non-ventilatory management) and outcomes to the patients with mild or moderate hypoxemia. Results: Among the 859 hypoxemic patients the day of the study, 74 (9%) had severe hypoxemia. The main cause of hypoxemia was pneumonia and this diagnosis was more frequent than in mild and moderate hypoxemia. Whereas bilateral radiologic infiltrates were present in 56 (84.9%) patients, ARDS was diagnosed by physicians in only 30 (40.5%) of them. Invasive mechanical ventilation (MV) was used in 55 (74.3%) patients. High flow oxygen was administered in 11 (14.9%) of them and 8 (10.8%) were under non-invasive ventilation (NIV) the day of the study. Median Vt was 6.1 (4.8-6.6) ml kg of IBW. Positive end-expiratory pressure (PEEP) was higher than in mild and moderate hypoxemic patients (10 (8-12) vs. 5 (5-8) and 7 (5-10) cm H 2 O respectively, p < 0.001). Median plateau pressure was 25.5 (23-29.5) and was higher than in mild and moderate groups. Median driving pressure was 13 (10-19) cm H 2 O with no difference when compared to other groups. Neuromuscular blocking agents were administered in 28 (51.9%) patients, inhaled nitric oxide (iNO) in 7 (13%) patients and only 6 patients (11.1%) were on prone positioning. Fourteen (18.9%) patients were under extracorporeal membrane oxygenation (ECMO). ICU mortality was higher in severe hypoxemic patients as compared to mild and moderate (50.7 vs. 21.3 and 28.5% respectively, p < 0.001). ICU length of stay in ICU survivors was not statistically different between groups. Conclusion: Severe hypoxemia, independently from ARDS, worsens the prognosis of ICU patients. Even though ARDS might be underdiagnosed, a protective ventilation was respected in severe hypoxemic patients. Introduction: Major changes in septic shock management raise the questions of the relevance of the classical risk factors of nosocomial infections in the current era and the link with the primary infectious insult. We herein investigated the risk factors and the outcomes of ICUacquired infections in a recent cohort of septic shock patients. Patients and methods: This was a 9-year (2008-2016) monocenter retrospective study. All adult patients diagnosed for septic shock within the first 48 h were included. Septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. Patients who survived the first three days were eligible for assessment of the risk of the first ICU-acquired infections. The diagnosis of nosocomial infections were based on current international guidelines. Patients were classified according to the development of pulmonary or non-pulmonary ICU-acquired infections. The determinants of ICU-acquired infections were addressed in a multivariate logistic regression analysis. Results: 938 patients were admitted for septic shock. 788 patients remained alive in the ICU after the first three days and could then be evaluated for the risk of ICU-acquired infections. Hence, 554 patients remained free of secondary infections, 138 patients first developed an episode of nosocomial pneumonia and 96 patients first developed an episode of non-pulmonary infection. The mortality rates of patients with ICU-acquired pneumonia, non-pulmonary ICU-acquired infections and without secondary infections were 49, 49 and 14%, respectively (p = 0.0001). In multivariate analysis, the development of ICU-acquired pneumonia was independently associated with male gender (OR 2.23, CI 95% [1.28-3.48 ], p = 0.003), renal replacement therapy (OR 2.15, CI 95% [1.35-3.42 ], p = 0.001), platelet transfusion (OR 2.38, CI 95% [1.4-4 .04], p = 0.001) and a primary pulmonary infection (OR 8.06, CI 95% [2.69-24 .12], p < 0.001). The development of non-pulmonary infections was independently associated with renal replacement therapy (OR 4.6, CI 95% [2.7-7 .85], p < 0.001), fresh frozen plasma transfusion (OR 2.49, CI 95% [1.42-4.37] , p = 0.001), healthcare-associated septic shock (OR 1.8, CI 95% [1.1-2.91 ], p = 0.01). Conclusion: ICU-acquired pneumonia occurs preferentially in patients with septic shock of pulmonary origin. In addition, we identified the transfusion of blood products as a risk factor for pulmonary and nonpulmonary nosocomial infections.

Introduction: Human serum albumin is used for the restoration of blood volume, emergency treatment of septic shock patients. Several experimental studies suggested that albumin could have additional protective effects on the vascular wall and more specifically on endothelial functions. However, the in vivo effect of albumin in human endothelium remains unknown. The aim of this study is to assess the effect of albumin or saline infusion on skin endothelial function in septic shock patients requiring volume expansion.

We performed a prospective randomized monocentric study in an 18-bed medical intensive care unit. All patients with septic shock who required fluid administration were included between H6 and H24 after vasopressor starting. Patients were randomized to receive either 500 ml of saline solution 0.9% or 100 ml of albumin 20%. Norepinephrine dose was not modified 1 h before and during the procedure. Endothelium-dependant vasodilatation in the skin circulation was assessed by iontophoresis of acetylcholine before and after fluid administration. The improvement of skin blood flow in response to acetylcholine after fluid administration was compared between groups. For each patient, age, sex, SAPS II, site of infection, global hemodynamic parameters and clinical microcirculatory parameters were recorded. Results are expressed as mean ± SD. Qualitative data were compared using Chi-2 or Fisher's exact test while quantitative data comparisons used Student t Test or Mann-Whitney as appropriate. Results: Twenty-two patients were included (12 women, age: 79 ± 17, SAPS II: 42 ± 12). Twelve patients received saline and 10 received albumin. Apart from age, no statistical difference was found between groups regarding demographic characteristics and baseline hemodynamic parameters. Norepinephrine dose and mean volume of infused fluid before inclusion was not different between groups (Table 1) . Before fluid replacement, endothelial response to acetylcholine iontophoresis was not different between groups (AUC 3514 vs 3378; p = 0.16). Volume expansion induced a slight increase of systolic arterial pressure, significantly higher in the albumin group (7 vs 2%; p = 0.02) with no difference regarding cardiac output variations between groups. Next, we compared the variations of endothelium response to iontophoresis before and after fluid infusion. The improvement of endothelial response after acetylcholine challenge was significantly higher in the albumin group (196 vs 44%, p = 0.01). Conclusion: In the early stage of septic shock resuscitation, we showed that albumin infusion had protective endothelial effects. This result has to be confirmed in a larger cohort. 418] + all p < .001). We found no correlation between cognitive scores at hospital discharge and the severity of EEG-defined encephalopathy during the 7 days of ICU or during the first 48 h after admission. However, sepsis survivors' scores were lower than controls' (p < .001) ( Table 1) . Conclusion: In this study, EEG was more sensitive than clinical tools to detect SAE but clinical scales correlated with the EEG grade. Encephalopathy was not associated with short-term cognitive function. Further study and a larger cohort are needed to determine which early EEG Introduction: There is growing evidence that corticotherapy improves survival from septic shock. This observational study aimed at evaluating at bedside resistance to corticosteroids in adults with sepsis. Patients and methods: Participants-ICU adults with septic shock or without sepsis admitted to the Raymond Poincaré university hospital. We also evaluated 10 healthy controls. Intervention-resistance to corticosteroids was assessed using a skin test. 10 µl of dermocorticoid cream (class III, Betamethasone) was applied on a 3 cm 2 surface of the skin. At 24 h, two independent physicians scored the blanching of the skin from 0 to 4-0-no blanching + 1-< 50% of surface + 2-50 to 75% of surface + 3-75 to 100% of surface, and 4-blanching beyond application area. Cohen's kappa was used to measure concordance. A mean score of < 2 indicated corticoresistance and a score of 4 indicating normal sensitivity to corticosteroids. We also performed a 250 µg ACTH test. Results: We enrolled 110 patients, 47 patients with septic shock (22 males, ) and 63 patients without sepsis (28 males, ). Overall, 81 95 (85%) with two measurements patients had concordant evaluation of score by the two physicians + while 14 had a difference of 1-point in scores, resulting in a kappa of 0.78 (95% CI 0.65-0.91). In patients with septic shock, 32 (78%) have corticoresistance, i.e. a mean score < 2, 8 (20%) a score of 2 or 3, and 1 (2%) has normal sensitivity to corticosteroids. In non-septic critically ill, 30 (56%) have corticoresistance, 20 (37%) a mean score of 2-3, and 4 (7%) have normal sensitivity to corticosteroids. Hence, as compared to non-septic patients, patients with septic shock were more likely to have corticoresistance (p = 0.04). Discussion: Topic application of corticosteroids on the skin results in activation of glucocorticoid receptors present within the vessels. Subsequently, activation of lipocortin 1 may inhibit the activity of phospholipase A2, regulator of prostaglandins, leucotrienes and platelet activating factor. Then, the coupling of alpha adrenoreceptors to their agonists is potentiated, increasing vessels smooth muscles sensitivity to catecholamines. The subsequent local vasocontriction is reflected by skin blanching. Thus, the observed lack of skin blanching in septic patients may reflect altered coupling between gluocorticoids and glucocorticoids receptors. Conclusion: Roughly one out of two adults with septic shock may develop a resistance to corticosteroids as assessed by a skin blanching test in response to betamethasone.

Introduction: Mild therapeutic hypothermia, currently recommended in the management of cardiac arrests with shockable rhythm could promote infectious complications and especially ventilator-associated pneumonia (VAP) (Mongardon et al. Crit Care Med 2011). Despite high incidence of VAP and retrospective trials suggesting a benefit of shortterm (48 h) antibiotics in this setting (Davies et al. Resuscitation 2013) , systematic use of antibiotic prophylaxis is not recommended in patients treated with mild therapeutic hypothermia after cardiac arrest. The primary objective was to demonstrate that systematic short-term antibiotic prophylaxis with amoxicillin-clavulanic acid can reduce incidence of early VAP (< 7 days) in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest. Secondary objectives were its impact on incidence of late VAP and on Day 28 mortality. Patients and methods: Multicenter two parallel-group doubleblinded randomized trial. Adult patients hospitalized in ICU, mechanically ventilated after out-of-hospital resuscitated cardiac arrest related to initial shockable rhythm and treated with mild therapeutic hypothermia were eligible. Exclusion criteria were pregnancy, need for extracorporeal life support, ongoing antibiotic therapy or pneumonia, known chronic colonization with multiresistant bacteria, known allergy to beta-lactam antibiotics and moribund patients. Patients received either intravenous injection of amoxicillin-clavulanic acid (1 g 200 mg) or placebo three times a day for 2 days. The primary endpoint was the onset of early VAP. All suspected pulmonary infections were adjudicated by a blinded independent committee. Results: Out of 198 patients included, 196 were finally analyzed, 99 in treatment group and 97 in placebo group (mean age 60.5 ± 14.4 years, sex ratio = 4, SOFA score 8.7 ± 3.1). Characteristics of cardiac arrest were similar in both groups (no flow = 3.5 ± 4.8 min vs 3.8 ± 4.0 min, low-flow = 21.8 ± 13.7 min vs 18.2 ± 10.1 min). 51 early VAP were confirmed, 19 in treatment group vs 32 in placebo group, with an incidence of 19.2 vs 33.0%, respectively (HR = 0.546 + IC 95% = [0.315 + 0.946], p = 0.031) (Fig. 1 ). The procedure did not affect occurrence of late VAP (> 7 days), respectively 4 vs 5. Day 28 mortality was similar in both arms (41.4 vs 37.5%, p = 0.58) and no adverse event was related to study treatment. Conclusion: Short-term antibiotic prophylaxis with amoxicillin-clavulanic acid significantly decreases incidence of early VAP in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest related to shockable rhythm. Introduction: Immunosuppressed (IS) patients are prone to develop respiratory failure and to need ventilatory support. Invasive ventilation shared a grim prognosis in the past and non-invasive ventilation had been recommended in these patients, however NIV efficacy has been recently challenged and the advent of high flow oxygen therapy had brought even more complexity in the management of such patients. Using the data from a recent point-prevalence-day of hypoxemia in ICU, we compare the frequency, management and outcomes of hypoxemia in IS and immuncompetent (IC) patients. Patients and methods: The SPECTRUM study was conducted in 117 French-speaking ICUs in 7 countries during spring 2016. IS was retained in case of malignant hemopathy, HIV positivity, immunosuppressive drugs, recent chemotherapy, neutrophil count < 0.5 G L. Hypoxemia was defined as a PaO 2 FiO 2 ratio > 300 and separate into severe (> 100), moderate (> 200) and mild (> 300). We focused on the causes of hypoxemia, the ventilatory management and the outcome. Results: Among the 1604 patients included, 187 (12%) were IS out of whom 99 (53%) were hypoxemic, proportion similar to the IC patients. Mean age and IGS-2 of hypoxemic patients were similar in IS and IC patients. Hypoxemia was mild in 46 (46%), moderate in 43 (43%) and severe in 10 (10%) IS patients with a similar distribution compared to hypoxemic IC patients. The causes of hypoxemia were also similar pneumonia being the leading cause. 24 (24%) hypoxemic IS patients fulfilled the Berlin criteria for ARDS in a similar proportion to IC patients. Respiratory support used in hypoxemic IS patients was ambient air in 3, low flow oxygen in 24, high flow in 11, NIV in 5 and invasive ventilation in 56 patients, with a different distribution from the IC patients (more patients on high flow therapy and less invasively ventilated). The day of the study, thoracic CT scan and echocardiography were performed in a similar proportion in IS and IC patients whereas broncho-alveolar lavage was more frequently performed in IS patients (14 vs 6%, p < 0.001). Finally, as expected, ICU mortality was higher in hypoxemic IS patients (38 vs 25%, p < 0.01). Conclusion: Immunosuppression in the ICU seems not to be associated with hypoxemia, severity of hypoxemia or ARDS. Oxygenation management is slightly different from immunocompetent patients with more frequent use of high flow therapy. 59 (13) mmHg, pH 7.26 (0.1). 142 were included in the 2 L/kg/min group and 145 in the 3 L/kg/min group. No difference was observed between groups for baseline characteristics. Failure rate was not different between groups-38.7 vs 39.3% + p = 0.92. No center effect was observed for failure. Discomfort was more frequent in the 3 L kg min group-7 vs 17% + p = 0.006. The length of stay was shorter in the 2 L kg min group-5.3 (2.8) vs 6.4 (5) days + p = 0.048. Intubation occurred in 4 142 patients in the 2 L/kg/min group vs 10 145 patients in the 3 L kg min group (p = 0.12). Conclusion: HFNC with a flow rate of 3 L/kg/min did not reduce the risk of failure compared to 2 L/kg/min at the initial respiratory management of AVB in young infants.

Comparison of epinephrine and norepinephrine for the treatment of cardiogenic shock following acute myocardial infarction. OPTIMA CC study Levy Bruno 1 Introduction: Despite the frequent use of vasopressors which are administered in 90% of patients in cardiogenic shock (CS), there is only limited evidence from randomized trials comparing vasopressor in CS. Hence, the OPTIMA CC study was designed to compare epinephrine and norepinephrine in cardiogenic shock following myocardial infarction. Patients and methods: Multicenter, double-blind, randomized trial in 8 french ICU. Cardiogenic shock patients due to myocardial infarction treated by PCI were randomized to receive epinephrine or norepinephrine to maintain MAP at 70 mmHg. Dobutamine was introduced at the physician discretion according to a combination of parameters-echocardiographic parameters, cardiac index, lactate clearance, SVO2 and Swan-Ganz derived parameters. Results: 56/57 patients were ventilated (98%). There were no differences in the duration nor in the maximal dose or cumulated dose of epinephrine or norepinephrine. Dobutamine was used in 18/27 (67%) in the epinephrine group and in 20/30 (67%) in the norepinephrine group. There were no differences in the duration, in the maximal or cumulated dose. Arterial pressure evolution was similar. Heart rate increased significantly in epinephrine group and did not change in norepinephrine group. Cardiac index and cardiac power index increased significantly more in the epinephrine group than in the norepinephrine group. Cardiac double product, a surrogate of myocardial oxygen consumption increased in epinephrine group and did not change in norepinephrine group. Epinephrine use was associated with a lactic acidosis from H2 to H24 while arterial pH increased and lactate level decreased in norepinephrine groupEpinephrine was significantly associated with an higher incidence of refractory shock-10/27 (37%) versus 2/30 (7%) p = 0.008). The incidence of arrhythmia was identical (epinephrine-41% versus norepinephrine-33%, p = 0.59). ECMO was used in 3/27 (11%) in the epinephrine group and in 1/30 (3%) in the norepinephrine group (p = 0.34) Mortality was 11/30 (37%) in the norepinephrine group and 14/27 (52%) in the epinephrine group (p = 0.25) Epinephrine use was associated with a trend to an increased risk of death (p = 0.08) and an increased risk of death plus ECMO (p = 0.031) at 7 days. There was a trend for an increased risk of death plus ECMO at J28 (p = 0.064). Conclusion: In patients with cardiogenic shock following myocardial infarction, epinephrine use was associated with a lactic acidosis, an higher incidence of refractory shock and an increased risk of death plus ECMO at J7.

High dose immunoglobulins in toxic shock syndrome in children: a pilot randomized controlled study (IGHN study) Javouhey Etienne 1 , Leteurtre Stéphane 2 , Tissières Pierre 3 , Joram Nicolas 4 , Wroblewski Isabelle 5 , Ginhoux Tiphanie 6 , Dauger Stéphane 7 , Kassai Behrouz 8 1 Hôpital Mère Enfant, Bron, France; 2 Hôpital Jeanne de Flandre, Lille, France; 3 Hôpital du Kremlin-Bicêtre, Le Kremlin-Bicêtre, France; 4 CHU Nantes, Nantes, France; 5 CHU Grenoble, La Tronche, France; 6 Hospices Civils de Lyon, Bron, France; 7 Hôpital Robert Debré, Paris, France; 8 Hospices Civils de Lyon, Bron, France Correspondence: Javouhey Etienne -etienne.javouhey@chu-lyon.fr Annals of Intensive Care 2018, 8(Suppl 1):CO-67 Introduction: Superantigen toxins synthesized by S. aureus or by S. pyogenes are responsible for toxic shock syndromes (TSS) which lethality can reach 28%. High dose intravenous immunoglobulins (IVIG), able to neutralize these toxins, are frequently used even tough evidence of its efficacy is not supported by randomized controlled study (RCT) . Moreover, IVIG are expensive and possibly harmful. Before conducting a RCT, a pilot study was first designed to assess the feasibility in the context of pediatric critical care. Patients and methods: A double blinded RCT was performed comparing 2 g kg of IVIG to isovolumic 4% albumin perfusion within the first 12 h of TSS in children aged between 1 month to 17 years. A priori criteria to determine the feasibility were defined as a rate of inclusion among eligible patients > 50%, a rate of protocol's deviations < 30% (treatment delivery, non-respect of blinding, premature stop), and by the practical and financial aspects of the protocol. Secondary objectives were to assess the efficacy of IVIG on organ dysfunction (using Pelod-2 score), on mortality at day 60 and their safety. The study was promoted by the Hospices Civils of Lyon, approved by the CPP Sud-Est and registered at clinical trial (NCT02219165). Inform consent from both parents was required before randomization. This study was funded by CSL-Behring company. Results: During the 30 months study period, 21 patients were included in 9 centers. The inclusion rate was of 71% (5 parent's refusals, 3 parents were absent at admission). Two patients were wrongly included (pneumococcal shocks), one patient didn't receive the treatment because he was transferred for ECMO in a non-investigator center, three patients were treated after 12H, and in two patients one bottle of treatment was missing. The blinding was well respected. Missing data on the Pelod2 score and mortality was lower than 10%, and no premature stop was reported. The eCRF completion was judged easy by investigators. The inclusion of children within the first 12 h was judged challenging. The treatment delivery had to be improved, requiring the help of research assistants. Seven serious and one severe adverse events were registered, all patients recovered and no death was reported. Conclusion: This pilot study suggested that a RCT is feasible. It provides crucial information to improve the recruitment, the respect of the protocol and the correct measure of organ failure. However, inclusion of international centers is necessary to attain the sample size required.

indirect calorimetry-based method for the work of breathing assessment when compared to esophageal pressure (Pes) measurement and Electrical Activity of the Diaphragm (EAdi) during a spontaneous breathing trial in continuous positive airway pressure. Patients and methods: A prospective single center study. All intubated and mechanically ventilated children > 1 months and < 18 years old, hospitalized in the pediatric intensive care unit were eligible. Patients considered as ready to extubate were included. Simultaneous recordings of VO2, Pes and EAdi were performed during 3 steps: before, during and after the spontaneous breathing test in continuous positive airway pressure. Results: Twenty patients, median 5.5 months, were included. Half of the patients were admitted for a respiratory reason. Predicted resting energy expenditure was overestimated as compared to measured resting energy expenditure (51 [47-55] vs 23 [21] [22] [23] [24] [25] [26] [27] [28] [29] kcal kg day, p < 0.001). Spontaneous breathing test was associated with an increase in Esophageal Pressure-Time Product from 23 to 83 cm H 2 O s min. The same trend was observed in respiratory drive, assessed by EAdi which increased from 7.5 [3.2-16.3 ] to 15.9 [5. 2-22.1] . Oxygen consumption obtained by IC was higher during spontaneous breathing test as compared to conventional ventilation (3.8 [3.0-5.2 ] vs 3.6 [3.1-4.6 ] ml kg min) but non significantly. Changes in work of breathing as assessed by VO 2 was poorly correlated with measurements from Pes and EAdi whereas we found a moderate correlation between Pes and EAdi values. Spontaneous breathing test and extubation were successful in 20 (100%) and 18 (90%) patients, respectively.

Conclusion: During weaning from mechanical ventilation, spontaneous breathing test in continuous positive airway pressure induced an increase in work of breathing, both in respiratory drive, as measured by EAdi and in respiratory mechanics, as measured by Pes. Oxygen consumption measured by Indirect Calorimetry does not seem to be a reliable tool to assess work of breathing in mechanically ventilated children.

Ben Gheriba Khalil 1 , Grimaud Marion 1 , Heilbronner Claire 1 , Roy Emeline 1 , Hadchouel Alice 1 , Renolleau Sylvain 1 , Rigourd Virginie 1 1 Hôpital Necker Enfants Malades, Paris, France Correspondence: Ben Gheriba Khalil -bg.khalil@gmail.com Annals of Intensive Care 2018, 8(Suppl 1): Introduction: During the winter season 2015-2016 we had evaluated breastfeeding disruption after hospitalization for bronchiolitis in our hospital in infants under 6 month (n = 84). We observed 51% of mothers whose breastfeeding was stopped of modified. Clinical severity had no impact on breastfeeding but 63% of mothers stated that lack of support and advice was the first cause of breastfeeding disturbance. We conducted this second phase to evaluate the potential impact of actions to promote breastfeeding on unwanted weaning during hospitalization for bronchiolitis. Patients and methods: This is a cross sectional study during two epidemic seasons of bronchiolitis in a tertiary care hospital. All patients aged 6 months or younger hospitalized with acute bronchiolitis and receiving at least partial breastfeeding were eligible for the study. Patients discharged at home whose parents accepted to be contacted by phone were included. A bundle of actions to promote breastfeeding in patients with bronchiolitis was implemented (posters, flyers, staff training, equipment with breast pumps) between the two epidemic seasons. The data was extracted from the charts and from a phone survey two weeks after discharge to evaluate breastfeeding in eligible patients in our hospital. Phase I (before action) had included 84 patients hospitalized between December 2015 and March 2016 in all wards hosting patients with bronchiolitis. Phase II (after action) included 50 patients hospitalized from October 2016 to December 2016. The data from phase II was compared with data from phase I. Results: Fifty patients could be included during the second step of the study, with a mean age of 37 days. Breastfeeding was exclusive for 78% of mothers (vs 77% in phase I). The median length of stay was 6 days (vs 3 days in phase I). Twenty-one (42%) patients spent time in PICU vs. 32% in phase I, 3 21 needed intubation, 18 21 received non invasive ventilation for a median length of 4 days (vs. 3 days in phase I). The number of patients needing nutritional support was 35 50 (70%) during phase II vs. 44 84(52%) during phase I. After implementation of our actions, 40 50 (81%) mothers kept breastfeeding as before (vs. 49% in the previous epidemic season, p < 0.05), 4 mothers (8%) stopped, 4 (8%) switched to partial breastfeeding and 2 (4%) reduced without stopping. Conclusion: Bronchiolitis is a high risk event for breastfeeding disruption but staff training and correct advices and support for mothers during hospitalization seems to diminish that risk.

Benefits of using a high temporal resolution database in the automatic real-time pediatric ARDS screening Nardi Nicolas 1 Introduction: Pediatric acute respiratory distress syndrome (PARDS) is frequent in pediatric intensive care units (PICU), potentially lethal and the diagnosis is often missed or delayed (PALICC 2015) . In PICU, data are usually recorded between 5 to 60 min which leads to only a minority of the arterial partial pressure of oxygen (PaO2) that are usable to calculate a valid oxygenation index (OI). If not available, PaO2 should be replaced by the SpO2 if < 98% to calculate the oxygen saturation index (OSI). Using a high temporal resolution (HTR) database that records data every 5-30 s, we aim to develop a relevant clinical algorithm of mass data aggregation to improve PARDS screening with the automatic OI and OSI calculation. Patients and methods: All the patients admitted to our Pediatric ICU between May 2015 and August 2017 were included. The HTR and the electronic medical records (EMR) were queried through Structured Query Language (SQL) following these steps-(1) Data selection (2) Extraction to a linear format (3) Date and time synchronization (4) Data pivoting (5) Aggregation through a 10-min moving average (6) Hypoxemia calculation. Statistical analysis included proportions, correlations and Bland-Altman analysis. Results: Between May 2015 and August 2017, 1793 patients (2210 stays) were admitted to the PICU. Approximately 46 million rows were retrieved from the databases including 19,189 PaO2 values. The algorithm was able to calculate 11,320 (59% of the PaO2) OI and 5204 OSI. The comparison between OI and OSI showed that 97.4% of the results were between the limits of agreements (− 17.2 + 10.6), a bias of − 3.3 and a correlation R2 = 0.643. The comparison between the OIs from the HTR and EMR databases showed that 94.6% of the results were between the limits of agreements (− 5.47 + 5.39), a bias of − 0.04 and R2 = 0.904. Conclusion: Using a mass data aggregation algorithm on a HTR database allows more PaO2 to be used to calculate an OI than the usual EMR. The OI results differ slightly between the HTR and the EMR. The accuracy is probably in favor of the HTR because of the shorter timelapse between the OI parameters. The OSI is possibly a biased OI surrogate and should be interpreted with caution. Our next step will be to measure the impact of the algorithm on the PARDS real-time diagnosis and PARDS severity categories. Introduction: Early administration of appropriate antibiotic therapy with adequate concentration is the cornerstone of the severe sepsis and septic shock's treatment. Adult studies showed alteration of distribution and elimination which can lead to insufficient drug concentration in septic patients. In children, studies are lacking and antibiotic dosing may be suboptimal. We aim to describe the plasma concentration of the most used beta-lactam in critically ill children, to describe the rate of patients with suboptimal exposure and associating clinical and biological factors. Patients and methods: This was a prospective, single center, observational study designed in 32 beds Pediatric Intensive Care Unit (PICU) and high dependency care at the Necker Hospital (Paris, France) from January 2016 to May 2017. Were included, children with severe sepsis or septic shock, aged less than 18 years and weighing more than 2.5 kg, and receiving one or more of the following antibiotics-amoxicillin, cefotaxime, cefazolin, ceftazidime, piperacillin-tazobactam, meropenem and imipenem for suspected or proven infection. Betalactam plasma concentrations were analysed using High Performance Liquid Chromatography. Results: We enrolled 37 children (severe sepsis, n = 22 (59.5%) + septic shock, n = 15 (40.5%)) with a median age of 19 months (4-64. Bacteria were identified in 26 patients (70.3%). A total of 132 blood samples were analysed at a median of 2 days (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) following the onset of sepsis. Twenty-four patients (64.8%) had insufficient concentration (cefotaxime 7 14 (43%) + piperacillin-tazobactam, 10 13 (77%) + amoxicillin 6 7 (86%) + meropenem 3 6 (50%), cefazoline 1 4 (25%), imipenem 0 2 (0%) + ceftazidime 0 1 (0%)). Insufficient concentrations were associated with early measurements (< 72 h from the sepsis' onset) (p = 0.035) and creatinine clearance increase (p = 0.01). Adequate concentrations were associated with small age (p = 0.048).

In conclusion, current standard beta-lactam dosing in children with severe sepsis or septic shock could be inadequate to reach the target concentrations. That could lead to the risk of clinical and bacteriological failures as well as the emergence of bacterial resistance. Further pharmacokinetic studies are mandatory to improve antibiotic therapy in this vulnerable population. Introduction: Intermittent hemodialysis is a key support therapy in ICU. Despite protocol-based optimization, intradialytic hemodynamic instability (IHI) remains a common complication and could account for mortality and delayed renal recovery. The identification of patients at high risk for IHI is crucial but remains poorly explored. Our objective was to test whether tissue perfusion parameters assessed at the bedside (mottling, index capillary refill time (iCRT), and lactate) predict IHI and to develop and to validate a predictive score of IHI. Patients and methods: Prospective observational study in a 18-bed medical ICU in a tertiary university hospital including hemodialysis sessions performed for acute kidney injury. Exclusion criteria were patients with dark skin and dialysis performed in extreme emergency. Mean arterial pressure (MAP), mottling score, iCRT, and lactate were recorded just before starting hemodialysis. First episode of IHI requiring therapeutic intervention was recorded 60, 120, and 240 min after hemodialysis starting. Results: Ninety-six hemodialysis sessions performed in 43 patients were recorded. Half of the patients received vasopressors (n = 43, 45%). IHI occurred in 22 (23%) sessions and was more frequent among patients receiving vasopressors (42 vs 7%, p < 0.0001). Mottling were more frequent (59 vs 26%, p = 0.005), lactate levels higher (2.8 [1.4-6.9 ] vs 1. 1 [0.8-1.5 ] mmol L, p < 0.0001) and iCRT longer (3.3 [1.6-4.6 ] vs 1.1 [0.8-2.0] s, p < 0.0001) before sessions with IHI compared to sessions without, independently of MAP (p < 0.0001). The incidence of IHI increased with the number of tissue perfusion alterations (3, 11, 41 , and 55% for 0, 1, 2, and 3 alterations, respectively, p < 0.0001). A tissue hypoperfusion score, defined as iCRT (seconds) + lactate level (mmol L) + 1 if mottling presence was predictive of IHI independently of MAP (OR 1.18 [1.05-1.32 Introduction: Epidemiological data suggest an increased risk of longterm chronic kidney disease after acute kidney injury (AKI). In survivors of out-of-hospital cardiac arrest (OHCA), AKI is frequent and is associated with numerous factors of definitive renal injury. We made the hypothesis that AKI after OHCA was a strong risk factor of long-term chronic kidney disease (CKD). We aimed to evaluate renal outcome of OHCA survivors according the occurrence of AKI in ICU. Patients and methods: We used the cohort of consecutive OHCA patients admitted between 2007 and 2012 in a tertiary medical ICU previously described (Geri et al. ICM. 2015) . AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Long-term creatinine level was the last blood creatinine assessment we were able to retrieve. The main outcome was the occurrence of CKD, defined by an estimated glomerular filtration rate (eGFR) lower than 60 mL min 1.73 m 2 according to the MDRD equation. Long-term mortality was evaluated as well. Factors associated with CKD occurrence were evaluated by competing risk survival analysis (Fine Gray and Cox cause specific models providing sub-hazard ratio (sHR) and Cox sub-hazard (CSH)). Results: Among the 246 OHCA patients who were discharged alive, we were able to retrieve the outcome of 133 patients (median age 55 [iqr 46, 68] , 75.2% of male) who were included in the analysis. During a median follow-up time of 1.8 [0.8-2.5 ] years, CKD occurred in 17 (12.7%) patients and 24 (18%) patients died. A previous history of arterial hypertension (sHR = 3.28 [1.15 + 9 .39], p = 0.027 + CSH = 4.83 [1.57 + 14.9 ], p = 0.006), AKI during ICU stay (sHR = 3.72 [1.40 + 9 .84], p = 0.008 + CSH = 5.41 [1.79 + 16.3] , p = 0.003) and an age higher than 55 (sHR = 6.13 [1.55 + 24.3] , p = 0.009 + CSH = 2.16 [1.72 + 43.8 ], p = 0.006) were independently associated with CKD occurrence. AKI was not associated with long-term mortality (sHR = 0.73 [0.27 + 1.99], p = 0.55 + CSH = 0.75 [0.28 + 2.01], p = 0.57).

In OHCA survivors resuscitated from an OHCA, CKD was a frequent long-term complication. AKI during ICU stay was a strong determinant of long-term CKD occurrence. Introduction: Many critically ill patients have a moderate to high risk of bleeding but they also require prolonged intermittent dialysis to ensure a negative water balance without hemodynamic adverse events. Thus, a heparin-free easy-to-use anticoagulation within the dialysis circuit is needed but, to date, usual protocols (iterative saline flushes, heparin grafted membranes) lead to 20-50% of premature clotting and sessions that last greater than 240 min are rarely achievable. We assessed the safety and efficiency of heparin-free regional citrate anticoagulation of the dialysis circuit using a calcium-free citrate-containing dialysate, with calcium reinjected according to ionic dialysance (an online measure of the instantaneous clearance of small molecules available in most of dialyzers). Patients and methods: We prospectively reported the clotting events that occurred during all the heparin-free dialysis sessions that were performed with a regional anticoagulation based on calcium-zero citrate-containing dialysate (Citrasate, Hemotech, France) between January 2016 and August 2017 in a 28-beds ICU. Results: A total of 186 dialysis sessions were performed in 70 patients (mechanical ventilation n = 93 + norepinephrine n = 20). Median duration of dialysis was 240 min (IQR, 240-300 + maximum 360 min), and median ultrafiltration volume was 2 L (IQR 1. 3-2.6 ). When assessed, urea and Beta2-microglobulin reduction rates were 64.5% ± 0.4% and 48% ± 0.13%, respectively. Postfilter ionized calcium was 0.35 ± 0.17 and 0.38 ± 0.14 mmol L at 1 and 3 h, respectively, within the extracorporeal circuit. A major clotting event that led to premature termination of the session occurred in only 5186 sessions (2.7%) . In these five cases, major catheter dysfunction occurred before clotting within the circuit. Prefilter ionized calcium remained within narrow ranges (before after change +0.07 ± 0.006 mmol L), and total-to-ionized calcium ratio, a surrogate marker for citratemia, was unchanged and always below 2.5. In 85 sessions, no ionized calcium measurement was required. Conclusion: Dialysis anticoagulation with calcium-free citrate containing dialysate is an easy-to-use, efficient, and inexpensive form of heparin-free regional anticoagulation. Calcium reinjection according to ionic dialysance allows prolonged hemodialysis sessions in critically ill patients without the need to systemically monitor ionized calcium. Sessions can be safely extended according to the hemodynamic tolerance to ensure an adequate dose of dialysis and a negative water balance, a major point in patients with severe AKI.

Introduction: Brain injury is the first cause of death after cardiac arrest (CA) and multimodal neuroprognostication is a cornerstone of postresuscitation care. Among the different usable information provide by electroencephalogram (EEG), the aim of this study was to evaluate the predictive value of EEG reactivity regarding neurological outcome at discharge. Patients and methods: Using our prospective registry of successfully resuscitated patients admitted to a cardiac arrest center between January 2007 and 2016, we studied all consecutive comatose patients still alive at 48 h and in whom at least one EEG was performed during coma. In addition to usual clinical findings, we collected EEG (patterns and reactivity, status epilepticus) and somatosensory evoked potentials characteristics. The EEG reactivity was evaluated by a blinded neurophysiologist and was defined as a reproducible change of the tracing (in amplitude or frequency) provoked by an auditory and a nociceptive standardized stimulation. We evaluated the predictive values of persistent lack EEG reactivity and other indicators regarding their respective ability to predict a favorable or unfavorable outcome. Recovery of a level 1 or 2 on the Cerebral Performance Category (CPC) scale at discharge was considered as a favorable outcome, as opposed to recovery of a CPC level 3-5 (unfavorable outcome).

We included 428 patients who were mostly male (71%), with median age of 63 years. CA occurred in a public place in 32% of cases, and it was witnessed in 89% of cases. Bystander CPR was initiated in 61% patients and the initial cardiac rhythm was shockable in 49% patients. Median time to EEG was 3 days (1-4) and 43% of patients were still sedated during the examination. A favorable neurologic outcome was observed in 85 patients (20%). An EEG reactivity was present in 78 85 patients (92%) with favorable outcome and in 117 343 patients (34%) with unfavorable outcome. The positive predictive value (PPV) of a persistent EEG reactivity for prediction of favorable outcome was 40% . By contrast, the PPV of lost EEG reactivity for prediction of unfavorable outcome was 97% (IC 95% 94-99) with a false positive rate (FRP) of 2.8% (1.2-4.4 ). EEG electroencephalogram, SSEP short-latency somatosensory evoked potentials, PPV positive predictive value, NPV negative predictive value, FPR false positive rate

In this population of post-cardiac arrest patients, the presence of EEG reactivity was poorly predictive of a favorable neurologic outcome. The absence of reactivity was highly predictive of unfavorable outcome. In combination with other indicators, searching for EEG reactivity may have important implications in the neuroprognostication process. Conclusion: This subgroup analyses of a randomized controlled trial, found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.

Introduction: Goal of a fluid challenge (FC) is in fine to increase the stroke volume (SV) or the cardiac index (CI) when an episode of hypovolemia or a preload dependence status are suspected. FC is one of the most common practices in ICUs, however, the way to assess the response to FC is not standardized. The present study aimed to evaluate whether the trans-thoracic echocardiographic (TTE) assessment of the response to FC immediately at the end of the infusion or delayed 20 min later could affect the results of the FC. Patients and methods: Prospective, observational, multicentre study including all ICU patients in septic shock requiring a FC. Were excluded patients with-arrhythmias, poor echogenicity and severe mitral or aortic regurgitation. FC was performed administering 500 mL of crystalloids over 10 min. Fluid responsiveness was defined as a > 15% increase in stroke volume (SV). The following echocardiographic parameters were recorded-E wave, A wave, E A ratio, velocity-time integral (VTI), Ea wave and Sa wave. MAP, HR and TTE variables were collected at baseline (T0), at the end of fluid challenge (T10) and 10 (T20) and 20 min (T30) after the end of fluid challenge. Quantitative data are expressed as mean and standard deviation (SD) or median and interquartile (IQR), according to their distribution. Qualitative data are expressed as absolute number and frequency (%). Results: From May 20th 2014 to January 7th 2016, a total of 143 patients were enrolled in 11 French ICUs (mean age-64 ± 14 years, median IGS II-53 , median SOFA score-10 [8] [9] [10] [11] [12] ). Among the 76 143 (53%) patients responders to FC at T10, 37 patients were transient responders (TR), i.e. became non-responders at T30 (49%, 95% CI = [37-60]) and 39 (51%, 95% CI = [38-62])) patients were persistent responders (PR), i.e. remained responders at T30. Among the 67 non-responders (NR) at T10, 4 became responders at T30, (6%, 95% CI = [1.9-15.3] ). In the subgroup analysis, no statistical difference in haemodynamic and echocardiographic parameters was found between non-responders, transient responders and persistent responders (Fig. 1) .

Conclusion: The present study shows that, after a 15% VTI increase at the end of the FC, VTI returns to baseline at 30 min in half of the responders. Blood volume status (normo or hypovolemia) before initiating the fluid infusion could explain the transient or persistent response to FC observed in septic patients.

Mottling score is a strong predictor of Day-14 mortality in sepsis patients independently of catecholamine dosing and other tissue hypoperfusion parameters Dumas Guillaume 1 , Joffre Jérémie 1 , Hariri Geoffroy 1 , Bigé Naike 1 , Baudel Introduction: Sepsis is a frequent critical condition. Mottling score, an hypoperfusion parameter, is well correlated with outcome. However, uncertainties persist regarding its value not only as a marker of patient severity but also as an independent predictor of mortality and treatment efficacy.

We performed a post hoc analysis of four published prospective studies including sepsis patients with or without shock. We analyzed the relationship between the mottling score (from 0 to 5) and Day-14 mortality according to other prognosis covariates such as catecholamine dosing, urine output and plasma lactate levels. First, factors associated with outcome were determined by multivariate analysis. Second, mottling score-by-covariate interaction was studied to better understand its effect on mortality. Finally, effect of mottling score variation at different time point (H0-H6-H12-H24) was assessed. whereas ECMO was successfully weaned in 6 (33%) patients. Proportion of Perfused Vessel (PPV), Perfused Vessel Density (PVD), Micro Flow Index (MFI) and Heterogeneity Index (HI) were severely impaired before ECMO. Re-establishing high and stable peripheral blood flow with VA-ECMO led to a rapid decrease in heart rate and vasoactive inotropic support and significantly improved all microcirculation parameters within 12 h. Total vessel density and PVD, measured before and after ECMO initiation, were better in patients successfully weaned from ECMO (p < 0.05) (Fig. 1) . Conclusion: Cardiovascular support with ECMO-VA rapidly improved macro and microcirculation in refractory cardiogenic shock patients. Total vessel density and perfused vessel density were significantly better in survivors 12 h after ECMO initiation and might therefore help to predict outcomes. Further studies are now needed to better define the utility of this technology in larger groups of VA-ECMO patients.

Introduction: Thyroid storm is a rare but life-threatening disease related to thyrotoxicosis. It can lead to multiple organ failure including cardiovascular disorders or neurological impairment. To date, data on this disease in ICU patients are scarce and limited to case reports. We therefore aimed to describe clinical presentation, outcomes and management of thyroid storm in ICU patients. Patients and methods: Local diagnoses coding database (from January 2000 to July 2017) from 22 French ICU were interrogated for main and secondary diagnoses codes including thyrotoxicosis based on the International Classification of Disease 10th revision. Thereafter two investigators reviewed all the medical records selected. Inclusion criteria were thyroid storm based on the diagnostic criteria of the Japan Thyroid Association (T. Satoh, Endocrine Journal 2016). It combines thyrotoxicosis with elevated levels of free triiodothyronine (FT3) or free thyroxine (FT4) with at least two of the following symptoms-central nervous system manifestation, fever, tachycardia > 130 bpm, congestive heart failure, or total bilirubin level more than 50 micromol/l. Clinical presentation, therapy used, and outcome were recorded. Results: Sixty-two patients (median age 57 years (interquartile range 44-67) + SAPS II 45 (32-66) were included. Thyroid storm was the first manifestation of thyrotoxicosis in 18 (29%) patients. Graves' disease (27%), amiodarone induced thyroiditis (26%), autoimmune thyroiditis (11%), and toxic multinodular goitre (10%) were the main causes of hyperthyroidism. Amiodarone, thyroid hormone toxicity, antithyroid drugs withdrawal or infectious trigger were identified in 59 (95%) patients. Organ support including mechanical ventilation, catecholamine infusion, renal replacement therapy and veno-arterial ECMO were used in 34, 31, 11, and 12 patients, respectively. Main thyroid storm treatments included antithyroid drugs (81%), betablockers (69%), corticosteroids (45%), and plasmapheresis (13%). Lastly, ICUmortality was 16%, with multiple organ failure responsible of death in all patients.

Although its incidence appears low, ICU physicians should be aware of the multiple clinical features of thyroid storm. Our preliminary data reported various specific therapeutic management of this potentially fatal disease. Prompt initiation of targeted therapies is required for atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP), but no specific therapy is consensual for Shiga toxinassociated hemolytic uremic syndrome (STEC-HUS). Thus, rapid differentiation of STEC-HUS is mandatory to tailor the initial treatment. Furthermore, apart from large outbreaks, characteristic features of this syndrome in adults have not been described.

In this study, we retrospectively compared the characteristics of STEC-HUS, aHUS and TTP patients at admission in two expert ICUs. Patient were included if they presented with the triad of mechanical hemolytic anemia, thrombocytopenia and organ damage, and TMAs were classified using international criteria. Other causes than STEC-HUS, aHUS and TTP were excluded. Results: Amongst 236 TMAs admitted between September 2003 and January 2017, 12 STEC-HUS, 21 aHUS and 91 TTP were included. STEC-HUS patients were older (64) than aHUS (36, p = 0.02) and TTP patients (43, p < 0.01). They presented with more frequent digestive symptoms (92 versus 62 and 37% for aHUS and TTP, p = 0.01 and < 0.01), but bloody diarrhea was rare (17%) and non-statistically different from other TMAs. Confusion was more frequent in STEC-HUS (33%) than aHUS patients (5%, p = 0.05). Biologically, STEC-HUS patients displayed elevated fibrinogen levels (5.1 vs 3.2 and 3.6 for a HUS and TTP, both p < 0.01) and severe renal failure. Forty-two percent required renal replacement therapy and 83% were treated with plasma exchange before the distinction from other TMAs could be made. Only 1 (8%) STEC-HUS patient died in the ICU (Fig. 1) . Conclusion: Characteristics supposed to identify STEC-HUS are largely shared with other TMAs. In particular, the differential diagnosis between aHUS and STEC-HUS appears to be more difficult than the stereotypical description derived from pediatric studies.

Severe hyperglycemia in 1000 ICU patients: a higher mortality rate and a higher incidence of diabetes in a long-term follow-up study .87], p = 0.04) but not when admitted for coma, sepsis or cardiac arrest. Mortality rate was significantly higher in patients with severe hyperglycemia compared to those without, regardless of preexisting diabetes (HND HD vs. NHND NHD groups + p < 0.05). Patients with severe hyperglycemia had a higher incidence of type 2 diabetes at 6 (16 vs. 8% + p = 0.01) and 12 months (14 vs. 9% + p = 0.08) compared to those who did not. Conclusion: Severe hyperglycemia occurring in the first 3 days of ICU admission was associated with higher mortality rate and an increased risk of diabetes in the following months regardless of preexisting diabetes. Introduction: Vitamin D deficiency is frequent in Northwestern countries and could represent a modifiable risk factor for critically ill patients, in relation with its pleiotropic effects (1) . Some studies reported an association between 25OH vitamin D (25OH) deficiency, chronic health status and ICU-and hospital-related outcomes. However, a large supplementation study have not been found to improve outcome of patients with moderate 25OH deficiency (< 20 ng ml) (2) . The aim of the study is to analyze the relationship between the severity of 25OH deficiency at ICU admission, severity of illness and outcomes and ultimately to identify subgroups of patients in whom the likelihood of benefit of supplementation is larger. Patients and methods: Consecutive patients admitted over a 4-month period who stayed at least 48 h in a medical surgical 32-bed ICU were included. In these patients, demographic data, Charlson comorbidity score, severity scores (SAPS 3 and SOFA) and 25-OH (chemiluminescence, DiaSorin) were collected at admission. ICU and hospital length of stay (LOS) and mortality were recorded. Correlations were searched between 25OH and the different scores, and vital outcomes (41-74)). Hypothyroidism was unknown before ICU admission in 68% patients. Median SOFA score at ICU admission was 6 (4-10). Myxedema coma, circulatory failure, respiratory failure, and severe hypothermia were respectively the main admission reason in 60, 18, 10, and 5% patients. A precipitating factor such as drugs thyroid toxicity, thyroid hormone withdrawal or infection was found out in only 13 (32%) patients. Main causes of hypothyroidism were thyroiditis and thyroidectomy. Thirtytwo (80%) patients had alteration of consciousness with a median Glasgow score at 10 (6-13). In addition, median heart rate at ICU admission was 50 (35-65) bpm while hypothermia < 35 °C was noted in 24 (60%) patients. Median TSH level at admission was 78 (43-135) mUI l, T3 and T4 levels respectively 0 (0-0.45) pmol l and 2 (0-5.07) pmol l. Rhabdomyolysis was frequent with median CPK level 539 (192-1500) UI l. Organ support including mechanical ventilation, catecholamine infusion and, renal replacement therapy were respectively used in 58, 45, and 20% patients. Lastly, 70% patients received oral levothyroxine whereas the intravenous form was used in others. Overall ICUmortality was 22%.

Our preliminary data showed that severe manifestations of hypothyroidism leading to ICU admission represent de novo hypothyroidism in two-thirds of patients, leading to a high mortality. Introduction: When it comes to infections of the central nervous system (CNS), the greatest challenge in the Emergency Department (ED) is to identify patients that have a rare life-threatening diagnosis. Alone or in combination, fever, headache, altered mental status encompass a broad differential diagnosis. Antibiotics or antiviral therapy should be given as soon as possible, ideally after both blood and cerebrospinal fluid (CSF) have been obtained. Early treatment is associated with a lower mortality. Patients and methods: We present here, a four-year (2012-2015) retrospective and monocentric study. During the period of the study, we included all adult patients with the diagnosis of CNS infection (positive CSF culture). We collected and analyzed all clinical, biological, imaging, treatments and evolution datas during the stay. A total of 67 patients with CNS infection have been included for statistical analysis. We analyzed a second group (n = 25) with suspected CNS infection (negative CSF) as a control group. Results: In the study population, mean age was 43 ± 21.5 years old and the sex-ratio was 1.2. There were no difference between the two groups in terms of clinical signs except for more altered mental status in the control group (p = 0.02). All patients of the study (n = 92) benefited of lumbar puncture (LP) in the ED with an average time of 381 ± 370 min after admission. This delay was the same between the two groups (p = 0.76) but was significantly higher in the encephalitis subgroup (n = 13, p = 0.03). Patients who had imaging (CT or MRI) during the ED stay had more likely a delay in LP realization (450 vs 193 min, p = 0.0005). Patients where the CNS infection diagnosis was firstly evoke by the triage nurse had LP more quickly (p = 0.03).

The median door to-antibiotic-time was 339 min with no difference between the two groups of the study (p = 0.7). 94% of all patients were hospitalized for an average length of stay of 11.7 ± 15.5 days and 10% of them were admitted in the ICU. The inhospital mortality was 14% in the study population. Introduction: There are numerous causes of acute exacerbations of COPD (AECOPD), the most common of which are bronchial and or pulmonary infections. Viral etiologies may account for 30% of AECOPD, but this rate is likely underestimated because of the limited performance of the conventional diagnostic tests. Multiplex molecular diagnostic tests may identify several pathogens including viruses and bacteria, from a single respiratory tract sample, with high sensitivity. Using these tests, respiratory viruses are identified in 30 to 60% of cases, according to the series. The objective of this work was to describe the microbial epidemiology, the management and the outcome of patients admitted to the intensive care unit (ICU) with moderate to severe AECOPD, in the era of multiplex testing.

A prospective non interventional multicenter study conducted in two university-teaching hospitals. In addition to the usual samplings, a nasopharyngeal swab was performed for multiplex polymerase chain reaction (PCR), using respiratory panels Fil-mArray Biomérieux (17 viruses and 3 bacteria) or ePlex automaton (22 viruses and 4 bacteria) depending on the center.

The preliminary results involve the 37 patients (29 males + 70 years (55-87)) included in Tenon hospital over a 6-month period. The mean FEV1 was 37% (21-60) median 35% [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] . Drug therapies included anticholinergics (n = 21 + 62%) and beta-2-mimetics (n = 24 + 71%), inhaled (n = 16 + 47%) or oral (n = 2 + 6%) steroids, and azithromycin (n = 5 + 23%). A respiratory virus was identified in 11 patients (30%), alone or in combination with a bacterium (n = 6). A bacterial pathogen was identified alone 9 times (21%). Therapeutic interventions did not differ depending on whether a virus was detected or not-exposure to antibiotics (10 ± 1.8 vs. 12.5 ± 2 d + p = 0.4), administration of oseltamivir (5/6 vs. 8/18 + p = 0.39), steroids (1/7 vs. 3/15 + p = 0.12) and mechanical ventilation (11/11 vs. 20/26 + p = .08). The ICU length of stay (5.8 ± 0.8 vs. 7.8 ± 1.1 d + p = 0.29) was similar. The ICU and 90d-mortality rates were 5.4 and 13.5%, respectively. Conclusion: Respiratory viruses are frequently involved in moderate to severe AECOPD. The respiratory multiplex PCR should be performed in this setting and the results should be taken into account to more adequately use the anti-microbial treatments. Introduction: Prophylactic non-invasive ventilation (NIV) is a well established method for prevention of post-extubation acute respiratory failure in hypercapnic patients. However, its role in the postextubation period, in traumatic brain injury patients, is uncertain. Especially, because of effects of the brain injury, on respiration and airway control. We perform a study to assess the impact of prophylactic NIV after extubation among patients with severe traumatic brain injury. Patients and methods: Over a period of 1 year, adult patients with isolated severe traumatic brain injury, who were under invasive mechanical ventilation for more than 48 h were eligible for inclusion in the study. They were randomized, after decision of extubation, to receive conventional therapy or conventional therapy associated with NIV. Conventional therapy consisted of oxygen delivery by facial mask, semi-recumbent position, mucus suctioning and nebulization therapy.

The main objective of the study is to assess the impact on reintubation rate. Extubation succes was defined by the absence of need for reintubation within the 7 days. The secondary objective is to evaluate the effect on ICU length of stay after extubation. The clinical benefit of non-invasive ventilation (NIV) in patients with acute hypoxemic respiratory failure (ARF) is being called into question. Indeed, in a multicenter randomized trial recently conducted in hypoxemic ARF patients (Pa02 Fi02 < 300), intubation rate in the NIV group was 50% and intensive care unit (ICU) mortality rate was 25%, numbers higher than in the standard-oxygen group (1) . An excessive tidal volume under NIV is a hypothesis to explain these bad outcomes (2) . Our experience does not seem to support these data. Therefore we wanted to-investigate the rate of NIV success in hypoxemic ARF and global in-ICU mortality. Estimate the average expired tidal volume and identify predictive factors of NIV failure. Conclusion: Though limited by its design, our study seems to show a similar efficacy of NIV following UE as compared to planned extubation, with a safety concern for rescue NIV and a potential interest for "prophylactic" NIV. Further data is warranted. which is yet operator dependent and time-consuming, or by invasive methods including esophageal pressure or diaphragmatic electromyogram measurements. The main purpose of this study was to assess the relevance of Curvex as a noninvasive diagnostic and classification tool for asynchronism management.

This project is based on a prospective physiological tracing data-warehousing program (Rea STOC, clinicaltrials.gov # NCT02893462) that aims to record 1500 consecutive ICU patients, over 3-years. All consecutive patients were recorded for a 2-hours period during 24-h following ICU admission. All measurements were recorded with the patient laying supine, with a 30° bed angulation. Raw ventilatory pressure and flow curves were transferred to a centralized server using a dedicated network. The physician in charge of the study was informed of the online analysis on a routine basis. Physiological recordings were associated with metadata collection. Asynchronisms detection is based on a non-parametric hypothesis testing (Random Distortion Testing), that requires no prior information on the signal distribution. Beside Asynchrony Index monitoring (AI), five asynchronism's types were qualified-ineffective efforts (IE), short cycles (SC), multiple cycles (MC), prolonged inspiration (PI) and premature cycling (PC Introduction: International guidelines recommend ultrasound (US) guidance for central venous catheter (CVC) insertion. However, evidence is lacking for several aspects of guidance such as probe shape or whether the needle has to be in plane (IP) or out-of-plane (OOP). We assessed these issues in a randomized trial. Success at first pass, number of attempts (needle passes), success, times between skin contact and needle skin penetration and between needle skin penetration and liquid back flow in the syringe were recorded. Qualitative and quantitative values are expressed as number (percentage), and median (range), and were compared using the Wilcoxon matched pairs test and the Fisher exact test, respectively. Results: For IJV puncture, first attempt success rate was more than 80% and was neither influenced by probe shape nor approach (Table 1) . Conversely for RAV puncture, using LP with IP approach was more frequently successful at first attempt (45 vs 34%, p = 0.2). Time elapsed between needle skin penetration and liquid back flow was shorter for RAV puncture using IP approach (16 s vs 34 s, p = 0.03). Time elapsed between probe appliance on skin and liquid back flow was significantly shorter with the linear probe for IJV whatever the approach and for RAV using IP approach. RAV puncture was more frequently impossible with MCP (10 vs 3%, p = 0.08). Arterial puncture occurred more frequently with MCP (7 vs 3%, p = 0.08). LP use and IP approach were associated with more free event puncture ( ± 20) . Minimal ANI, reflecting intense stress was 33.7 (± 9.9). Objective and subjective stress of each team leader is shown in Fig. 1 .

There was a significant negative linear correlation between minimal ANI and maximal HR (Rho = − 0.52, p = 0.001). There was no significant correlation between self-reported stress VAS (neither pre HFS or maximal stress) and minimal ANI. Conclusion: HRV monitoring is a feasible method to evaluate continuous physiological stress for team leaders in highly stressful simulationteaching. Upgrading signal connection by Bluetooth 4.0 or Wi-fi could improve the method. Focusing on specific stressful time points might improve stress assessment and its correlation with performance. Introduction: Simulation training has become available in Health sciences faculties and proposed in many specialties. Intensive Care is one of the fields of development of simulation based training. The aim of the present study was to report the experience of the Faculty of Medicine of Monastir Simulation Center in training medical students and residents in Intensive Care and to compare their respective perceptions.

This was a descriptive study including students (5th year of the medical curriculum) and residents who received training during the last academic year (2016) (2017) , in the simulation center during their ICU traineeship. Simulation training was based on high-fidelity mannequins for students and seminars with high fidelity and procedural simulation training for residents. Three sessions per group were organized for students and a total of five sessions for residents. We collected participant characteristics and used Likert scale (from 1 to 5) to assess participant satisfaction, simulation fidelity, impact on clinical practice, stress level and instructor behaviors. Chi 2 test was used to compare students' and residents' perception of the simulation based-training. Results: During the study period 91 students (of the 269 students' whole promotion) and 88 residents actively participated at least in one of the simulation-based training sessions. Median students' and residents' ages were respectively 24 years (24-24) and 29 years ( Introduction: Hospitals are encouraged to edit local antibiotic therapy guidelines. ANTIBIOGARDE ® is an electronic antibiotic prescription referential developed by a multidisciplinary team of French physicians, regularly updated, and locally customizable, which has been purchased by more than 170 French hospitals. We compared adequacy Fig. 1 Team leader's objective (heart rate and ANI) and subjective stress (declared VAS stress)

of initial antibiotic prescription by ICU clinicians, ANTIBIOGARDE ® proposal and national or international guidelines. Patients and methods: Between January and June 2016, initial antibiotic prescriptions in an ICU were retrospectively analyzed when microbiologically documented. ANTIBIOGARDE ® and guidelines proposals were simulated, considering data available at the time of initial prescription. Adequacy was defined when all bacteria responsible for infection were sensitive to at least one prescribed proposed antibiotic. National guidelines were used when published after 2011. Otherwise, most recent international guidelines were used. Results: 120 initial prescriptions were analyzed (45 monotherapy) in 97 patients (median age 63y, median SAPS II 53, median SOFA on prescription 7, ICU mortality 41%, 17% immunocompromised). Main sources of infection were lung (n = 75) and intra-abdominal (n = 23). Leading isolated bacteria were Enterobacteriaceae (n = 67, antibiotic resistance in 14), Streptococci (n = 55), non-fermenting Gram negative bacilli (n = 27, antibiotic resistance in 12) and Staphylococci (n = 25, resistance to methicillin in 5). In the 120 clinical settings analyzed, there was a proposal by ANTIOGARDE ® in 97 (81%) and a guideline available in 102 (85%) (p = 0.39 Introduction: Intubation is plagued with a high morbimortality, especially in emergency situations. It is now acknowledged that a seated position allows for optimized preoxygenation (1) . However, there is no guideline concerning the patient's position for intubation. The patient is most often laid in a supine position, leading to a higher risk of aspiration (2) . Face-to-face intubation in sitting position (FtFi) would allow for an easier intubation and a lower morbidity. We focused on learning the FtFi technique using the Macintosh laryngoscope and the Airtraq videolaryngoscope in simulated difficult intubation situation and comparing the performance of the FtFi with the classic technique.

The participants would intubate a high-fidelity manikin (SimMan3G, Leardal, Norway) configured with a tongue edema (Cormack 2b-3). For each trial, time to intubate (TTI), success and complication rate, intubation difficulty and glottis exposure were noted. In classic position, three trials were performed with the Airtraq followed by the laryngoscope in order to obtain baseline parameters.

In FtFi, at least 30 intubations were performed by each participant for each device. The utilization order was randomized. Results: Thirty physicians, with an experience of at least 200 intubations each, were included. Figure shows the learning curves of the FtFi based on the evolution of the TTI measured for the Airtraq and the laryngoscope. In classic position, the mean TTI with the Airtraq was 30.5 ± 19.1 s versus 27.3 ± 16.7 s with the laryngoscope (p = ns). In FtFi, once the technique mastered, the TTI was 14 ± 2.9 s with the Airtraq versus 17.5 ± 2.4 s with the laryngoscope (p < 0.05). Success rate, TTI, complication rate, intubation difficulty and glottis exposure were better using FtFi versus classic intubation (p < 0.05). These parameters were even better with the Airtraq than with the laryngoscope (p < 0.05).

The learning profile of FtFi is different between the Airtraq and the laryngoscope. It could be due to the participants' lesser familiarity with the Airtraq. The better performances in FtFi could be due to better ergonomics allowing easier glottis exposure and learning (3) . Conclusion: Face-to-face intubation in sitting position is easy to learn. It provides better performances and fewer complications than the classic intubation technique which might result in a lower morbidity. The Airtraq provides even better results than Macintosh laryngoscope. All participants recommend their colleagues to be trained in face-toface intubation. Among non-invasive respiratory support, NIV with bilevel pressure was the most frequent (n = 68, 50%) before CPAP (n = 23, 17%) and high flow oxygen (n = 21, 15%). The proportion of patients on NIV was up to 71% in the centres hosting more ACS patients. Conclusion: Despite the absence of evidence from randomized controlled trials NIV is nowadays commonly used in PICU and HDU for SCD patients with ACS, especially in centres taking in charge a high number of SCD patients. Future physiological studies and randomized controlled trials might help to choose between the different ventilatory support options for ACS. In transfused patients, the pre-transfusion hemoglobin was 8.1 (7.5-9.3) g dL in moderate PARDS and 7.5 (6.9-7.3) g dL in severe PARDS. The evolution of hemoglobin, OSI, ScvO2 and lactate after the transfusion is reported in the Table 1 .

In our PICU, a relatively restrictive policy of RBC transfusion was observed even in patients with severe PARDS. Decision to transfuse seemed associated with the general severity status of the patient and with the hemoglobin level. Further studies are needed to explore the generalizability of these findings, and to investigate the impact of transfusion on oxygen transport consumption balance in pediatric acute respiratory distress. Introduction: Pharmacokinetic parameters are altered in critically ill patients. For instance, in adult patients, it has been well demonstrated that augmented renal clearance results in subtherapeutic antibiotic concentrations. Our objectives were to build a pediatric population pharmacokinetic model for Piperacillin, in order to optimize individual dosing regimen. Patients and methods: All children admitted in pediatric intensive care unit, aged less than 18 years, weighing more than 2.5 kg, and receiving intermittent Piperacillin infusions were included. Piperacillin was quantified by high performance liquid chromatography. Pharmacokinetics were described using the non-linear mixed effect modelling software MONOLIX. Monte Carlo simulations were used to optimize dosing regimen, in order to maintain plasma concentration above the minimum inhibitory concentration (16 mg L −1 for Pseudomonas aeruginosa) throughout the dosing interval (100% fT > MIC). Results: We included 50 children with a median (range) post natal age of 27.2 (1.1-222.9) months, median (range) body weight of 11.9 (2.7-50) kg, median (range) PELOD-2 score of 4 (0-16) and median (range) estimated creatinine clearance of 142 (29-675) mL.min -1 .m -2 . A one compartment model with first-order elimination adequately described the data. Median (range) values for Piperacillin clearance and volume of distribution were respectively 3 (0.71-10) L h −1 and 3.8 (0.72-25.8) L. Body weight (allometric relationship), estimated creatinine clearance and PELOD-2 severity score were the covariates explaining the estimated between subject variability. A third of the cohort attained the target, according to our dosing regimen and to the European guidelines. To reach the target and according to the simulated dosing regimens, children with acute kidney injury should receive intermittent infusion every 6 h, administered on 30 min. Those with augmented renal clearance should receive a continuous infusion.

To reach the target, standard intermittent Piperacillin dosing regimen in critically ill children is not appropriate. In addition to body weight, dosing regimens should take into account the creatinine clearance. Continuous infusion is adequate for children with augmented renal clearance. Piperacillin individualized dosing regimens and therapeutic drug monitoring are mandatory in pediatric intensive care unit. Introduction: All data support the need for early recognition, evaluation of pain in the NICU. Multiparametric analysis including physiological parameters could be useful to have a more objective evaluation of pain in the NICU compared to scales built on external-evaluation. The Newborn Infant Parasympathetic Evaluation (NIPE ® ) was developed to assess pain in newborns and infant, from preterm to the age of 2 years. Patients and methods: We conducted a monocentric, prospective study to compare the instantaneous NIPE ® index value (NIPEi ® ) to the DAN scale during acute procedural pain (PICC line insertion) in preterm infants (under 37 GW). The operators and the nurse were blinded to the continuous recording of NIPEi ® during the entire procedure. DAN scale was assessed every 5 min by a third person, trained to this scale and blinded to NIPEi ® . A direct correlation assessment between the DAN scale and the NIPEi ® was performed by calculating the Pearson's linear correlation coefficient. The differences between the NIPEi ® of non-painful (DAN < 3) and painful (DAN ≥ 3) infants were estimated by the Wilcoxon-Mann-Whitney test. The usefulness of NIPEi ® as a new tool for pain assessment in neonates was estimated by the corresponding ROC curve. Our study was approved by our local ethic institutional review board. Results: Thirty-five preterm infants were included, NIPEi ® data were incomplete in 3 infants. Fifty percent of newborns were born before 31 GW, and 66% had non-invasive respiratory support (continuous positive airway pressure CPAP). At the time of the procedure, newborns had a median post-natal age of 3 days and a median weight of 1180 grams. There was a moderate correlation between the NIPEi ® index and the DAN scores (r = 0.605 + p < 0.001). The median NIPEi ® index was 59 for non-painful events vs. 43 for painful events, p < 0.001. The area under the ROC curve was 0.92. For a threshold of NIPEi ® < 50, the sensitivity was 91.3%, the specificity was 83%. Positive likelihood ratio was 5.36 and the negative likelihood ratio was 0.10 ( Fig. 1) .

We showed a correlation between the DAN scale and the NIPEi ® index for pain assessment in preterm infants. The NIPE ® monitor could be a useful and non-invasive tool for pain assessment in neonates. Further studies are needed to confirm our results and to define more precisely the place of such monitors for pain evaluation in daily clinical practice in the NICU. Introduction: The aim was to identify factors associated with the occurrence of acute pituitary hormone dysfunction in children with moderate to severe TBI and to describe the impact of this dysfunction on the stability of the children. Patients and methods: Prospective bicenter study including all children aged between 1 month to 17 years, admitted to PICU for a moderate-severe TBI and with an expected stay > 2 days. Setting-Pediatric intensive care units of Grenoble and Lyon, from 2010 to 2017. Endocrine explorations at the second morning following admission and 24 h before discharge were performed-cortisol 24 h cycle with free cortisol and ACTH dosages every 4 h (or 6 h if no central line) + free 24H urinary cortisol + TSH and T4L, 24H urinary LH and FSH, blood level of testosterone or estradiol for children aged > 10 years, and IGF1. Patients were classified as having cortisol insufficiency if all the cortisol dosages were < 200 nmol l and all ACTH were < 12 pg l. TSH deficiency was defined as T4 l < 11.5 pmol l and TSH < 4.2 mUI l. 

Gonadotropin defciency was defined as urinary LH < 0.14 UI 24 h and urinary FSH < 1.52 UI 24 h for males + urinary LH < 0.018 UI 24 h and urinary FSH < 2.24 UI 24H in female. Patients with deficiency (ACTH and any deficiency) were compared to those without deficiency in terms of hemodynamic instability, respiratory instability, neurological and infectious complications For continuous variables means and 95% confidence interval were calculated and compared by t student test. Chi-2 test was used to compare proportions. Results: Among the 110 patients evaluated, 12 had ACTH deficiency, and 23 had at least one acute pituitary dysfunction. Comparison of patients who presented ACTH deficiency with those who were not deficient found no differences in terms of patients characteristics, cause of TBI, level of severity and level of injury. Paitents with ACTH deficiency required more frequently fluid bolus at day2 (67 vs 34%, p = 0.03). All the markers of severity were higher and the need of vasoactive drugs were more frequent but the differences were not statistically significant. Table 1 shows comparison between patients with at least one pituitary hormone deficiency to those without deficiency. The same result was found. Glycemia levels were lower in the group with deficiency. Conclusion: We didn't find any predictive factors of pituitary hormone deficiency in children with moderate-severe TBI justifying a systematic screening of those patients. Introduction: Most intensive care unit (ICU) patients cannot make decisions themselves. Familiy members are actively involved in the care process as surrogate decision-makers and judges of care quality. However, family satisfaction with care is complex and is not clearly defined. The aim of this study is to evaluate the different procedures (reception book and staff education for aid and relationship) used in a new ICU to improve the family care. Patients and methods: We included in our study patients who had spent more than 48 h in our department. A questionnairy, adapted to our population, was performed by our staff and validated by the Hygiene and Quality Care departement. We proceded by phone calls, 10 months after the inauguration of our ICU. Results: Sixty-five questionnaires were included (Fig. 1 ). The average of age was 52 ± 20 with a sex ratio of 2. The average of the simplified acute physiology score (SAPSII) was 36 ± 17. The median stay was 7 days [4-16] with a total mortality rate of 25%. Mostly, we interrogated first-degree parents (n = 52). Only three families recieved reception book at admission. Visit in patient room was autorised only for 27% (n = 17) of family members. Only four persons said they were disturbed in visit hours for architectural reasons (tight space). Disponibility was found excellent in 40% (n = 24) of cases for medical staff, 45% (n = 26) for paramedicals. Informations provided by physicians were clear in 71.5% (n = 53) of cases. Fifteen of the family members (23%) asked psychology support. Patients were followed up via phone calls during 1 year after discharge. Characteristics on admission and outcomes after discharge were analyzed stratified by ventilation modality NIV vs IMV. The overall survival was analyzed on the basis of the Kaplan-Meier curves. Results: During the predetermined period of data collection, the follow-up involved 60 patients. 24 patients were treated by NIV (group1) and 36 patients needed IMV (group2). There was no difference between the 2 groups in age (p = 0.69), severity of COPD (p = 0.39), physiological reserve at discharge (p = 0.14) and ICU readmission (p = 1). Short term outcomes were not different between the 2 groups-1-month readmission (16.7 vs 25% respectively in NIV and IMV, p = 0.52) and 1-month mortality ( Introduction: Post-intensive care syndrome (PICS) has been recently described as a combination of physical, cognitive and mental impairments appearing during a stay in an intensive care unit (ICU). The prevention and detection of PICS require the participation of each category of healthcare workers. However, the level of knowledge is unknown. We sought to assess the awareness among our ICU staff in preparation for a follow-up consultation.

The study used a short multiple-choice survey filled on a voluntary basis. All members of the staff were asked to fill the questionnaire over a one-week period. The assessment was composed by seven structured questions which aimed measure basic knowledge of post-intensive care syndrome and general strategies to diagnose that syndrome and the tests used. Results: Fifth five workers (30% of the staff ) of the department of intensive care answered the questionnaires (67% nurses, 7% physiotherapists, 20% physicians). The estimated ranges of prevalence of psychological problems were very low (0-25%) for 3.63%, low ( Introduction: Drafting a death certificate (DC) is a procedure considered as a part of doctor's daily practice, especially in emergency and intensive care departments. This certificate represents a civil, social, epidemiological and medico-legal act. It can engage the liability of the certifying doctor. The objectives of our study were to examine the content of DC drafted in emergency and intensive care departments, assess the quality of writing, and analyze drafting errors. Patients and methods: A prospective study extended over a period of 12 months from January to December 2015, including all DC emanating from emergency and intensive care departments and received in the forensic department of Habib Bourguiba hospital in Sfax. Results: During the study period, 120 DC meeting the inclusion criteria were collected. Although confidential, the medical part of the DC was sealed by the doctor in onlyone third of cases. In the administrative section, nine socio-demographic parameters were studied. In 10% of the cases, less than four of the nine criteria were found. In the section concerning the certifying doctor data, 7 parameters were screened. 67.1% of the certifying doctors met at least six criteria. The most frequently missing parameter in this section was the identity of the person to whom the certificate was issued. The identity of the doctor was not mentioned in 10% of the cases. Forensic data (4 items) was complete in over three quarters of the certificates. Nevertheless, in 26.7% of cases, the medicolegal obstacle to burial box was left empty (8.3%) or not ticked even if judicial investigation was required (18.3%). The section on causes of death was the source of almost all of the drafting errors. We have classified these errors into six major ones, according the classifications reported in the literature. The percentage of certificate without faults was 13%. The most common major error was insufficient cause of death found in 40.4% of cases followed by incorrect sequence of causes of death (28.8%), medicolegal obstacle to burial not ticked although required (26.6%), several causes of death mentioned simultaneously (16.7%), unacceptable cause of death (10.8%) and mechanism of death mentioned instead of the cause of death (5.8%).

Our study showed that the quality of drafting of DC suffered from several insufficiencies, which encourages us to provide more effort in training doctors and to review the current official model of DC. Introduction: Septic shock is defined as a sepsis with hyperlactaemia greater than 2 mM after correction of hypovolemia requiring vasopressors to maintain MBP > 65 mmHg [1] . It can be observed in pre-hospital emergency medicine (PHEM). The use of a reliable portable device for measuring lactate in PHEM would allow a better evaluation of septic patient facilitating their orientation towards intensive care unit (ICU) or emergency department (ED). This portable delocalized biology device must be validated against the laboratory reference method (NFEN ISO 22870) [2] . The aim of this study was to clarify the validity of a delocalized measure of lactatemia.

We performed a prospective study including 47 patients admitted into ICU for septic shock (CPP number 2015-08-03 SC). Lactate was measured in parallel on 2 samples-one capillary with the portable device (Lactate StatStrip Xpress, Nova Biomedical) and the other venous on a centrifuge tube for plasma analysis (Architect C16000 Abbott Diagnostics). We evaluated the analytical performance (coefficients of variation (CV) for repeatability and reproducibility evaluated at 2 levels of quality control (QC)-1.6 and 3.6 mM) and then the concordance between lactate levels measured by the devices and lactate levels measured by laboratory analyzer. Results: At the QC concentrations tested, the CVs were in agreement with the limits set by the French Society of Clinical Biology-CV < 3% for repeatability and < 5% for reproducibility. An excellent correlation was observed between the 2 measurements-correlation coefficient R2 = 0.98, slope = 0.95 and ordered at the origin = 0.1. The latter suggested a low positive bias of the device not confirmed by Bland-Altmann graph analysis and graph of the differences.

We verified the analytical performance of the device and showed an excellent correlation with the laboratory measurement. The delocalized measure can be used in PHEM in patients with suspected sepsis syndrome. This measure should allow a more accurate and early assessment of their severity in order to improve triage and hospital orientation between ED and ICU. 

There is an association between mortality at D28 and hyperoxia in patients admitted in ICU for refractory OHCA requiring eCPR. These data underline the potential toxicity of high dose of oxygen and suggest that control of oxygen administration in such patients is an important part of the treatment. A value of PaO2 between 100 and 300 mmHg after starting eCPR seems to be a target during treatment of OHCA treated by eCPR. Introduction: Sepsis has been defined as a dysregulated host response to infection leading to life-threatening organ dysfunction (Singer M et al., JAMA 2016) . A qSOFA score relying on 3 simple clinical criteria (respiratory rate, mental status and systolic blood pressure) has been proposed to better identify septic patients with associated higher mortality outside the intensive care unit (Seymour CW et al., JAMA 2016) . The study aim was to evaluate the ability of qSOFA to predict the development of organ failure and increased 28-day mortality in patients admitted for suspected sepsis in the Emergency Department (ED). Patients and methods: Prospective study conducted over a period of 6 months comparing the prevalence of organ failure and 28-day mortality according to the value of qSOFA at admission to the ED between group A (qSOFA > = 2) and group B (qSOFA < 2). As part of routine care, an electronic sepsis form was specifically created to identify prospectively and exhaustively all eligible patients on-line. For the purpose of the study, sepsis diagnosis was independently validated off-line by an adjudication committee which included three physicians who reviewed clinical, biological and microbiological data. For each patient, demographic data, source of infection, qSOFA and SOFA score, biological data and 28-day mortality were recorded. Seventy-six patients of group A (99%) were hospitalized, of whom 25 were admitted to the intensive care unit (32.5%), and 28-day mortality reached 46.7%. In group B, only 32 patients developed an organ failure (10.7%) and 28-day mortality was 4.3% (Table 1) .

The present study confirmed that the qSOFA score is a reliable and practical tool to predict the development of organ failure and higher 28-day mortality in patients with suspected sepsis in the ED.

Limits of CT scan criteria and intravascular contrast extravasation to define pelvic angioembolization need: a specific assessment on the risk of false- Introduction: Opening of the mitochondrial permeability transition pore (PTP), triggered by Cyclophilin-D (CypD) binding under stress conditions, plays a key role in ischemia-reperfusion injury. We sought to determine, using transgenic mice, whether CypD deletion (CypD −) would improve resuscitability and survival after experimental cardiac arrest (CA). Additionally, we compared the protective effects of CypD deficiency with that of targeted temperature management (TTM). Patients and methods: Anesthetized mice underwent a 5 min asphyxial CA followed by resuscitation (cardiac massage, resumption of ventilation, epinephrine). Four groups of animals were studied-Sham, Control (Ctrl), CypD-CA using mice lacking CypD (knockout mice), and TTM-CA with fast hypothermia induced by external cooling at reperfusion (33 °C for 1 h). Two hours after CA, the following measurements were carried out (n = 6-9 group)-echocardiography, cellular damage markers (including S100B protein and troponin Ic) and mPTP opening in mitochondria isolated from brain and heart. Additional mice (n = 7-12 group) were included in the same 4 groups for survival follow-up (24 h and 7 days). Results: Characteristics of CA were similar among groups. Rate of restoration of spontaneous circulation (ROSC) was significantly higher in CypD-and TTM groups compared to controls (p < 0.05). Time to ROSC was shorter in CypD-versus TTM and Ctrl (p < 0.05). Genetic loss of CypD and TTM prevented to a similar extent CA-induced myocardial dysfunction, increase in blood levels of both S100B protein and troponin Ic (p < 0.05 versus Ctrl). CA resulted in a significant increase in PTP opening only in mitochondria isolated from brain (p < 0.05 versus Sham). CypD deletion as well as TTM limited CA-induced PTP opening in brain (p < 0.05 versus Ctrl). Short-term survival (24 h) was significantly improved in the CypD-and TTM groups when compared to controls (p < 0.05). However, only therapeutic hypothermia improved survival at day 7 (p < 0.05 versus Ctrl).

In our murine CA model, genetic loss of CypD increased resuscitability and short-term survival but, unlike therapeutic hypothermia, failed to improve 7-day survival. Introduction: Early prediction of neurological outcome of post-anoxic comatose patients after cardiac arrest (CA) is challenging. Prognosis of comatose patient relies on multimodal testing-clinical examination, electrophysiological testing and structural neuroimaging (mainly diffusion MRI). This prognostication is accurate for predicting poor outcome (i.e. death) but not sensitive for identifying patients with good outcome (i.e. consciousness recovery). Resting state functional MRI (rs-fMRI) is a powerful tool for mapping functional connectivity, especially in patients with low collaboration. Several studies showed that rs-fMRI can differentiate states of consciousness in chronically brain-damaged patients. A recent study also showed that functional neuroimaging can early detect signs of consciousness in patient with acute traumatic brain injury. However, rs-fMRI has not been assessed for the early prognostication of post-anoxic comatose patient.

We assessed whole-brain function connectivity (FC) of 17 post-anoxic comatose patients early after CA using rs-fMRI. Nine patients ultimately recovered consciousness (good outcome) while eight died (poor outcome). We estimated FC for each patient following a procedure previously described. We statistically compared whole-brain FC between good and poor outcome group, to assess which brain connections differed between them. Then, we trained a machine-learning classifier (a Support Vector Machine, SVM) to automatically predict coma outcome (good poor) based on wholebrain FC of comatose patients. Finally, we compared this outcome prognostication based on functional MRI to those using standard structural diffusion MRI. Results: Good and poor coma outcome groups were similar in terms of demographics, except for time to ROSC. Good outcome group showed significant increase in whole-brain FC between most cortical brain regions + with the strongest changes occurring within and between occipital and parietal, temporal and frontal regions ( Fig. 1 ). Using whole-brain FC and a SVM classifier to predict coma outcome yielded to an overall prediction accuracy of 94.4%(AUC 0.94). Interestingly, automatic outcome prognostication using functional neuroimaging achieved better results that structural neuroimaging methods like DWI (accuracy 70.6%). Conclusion: We used rs-fMRI to predict coma outcome in a cohort of post-anoxic comatose patients early after CA. We deliberately chose to include only patients with indeterminate prognosis after standard multimodal testing, to assess the contribution of rs-fMRI in the early prognostication of coma outcome. We found that automatic prediction based on functional neuroimaging yielded much better results than current DWI methods, notably for identifying patients who recovered consciousness.

Outcomes of post-anoxic comatose patients early after CA, using rs-fMRI in RCTs comparing treatment of severe pneumonia that may influence their ability to demonstrate differences between studied drugs. Clinical cure was the most frequently used endpoint but its definition was highly variable. These results are not surprising as far as even guidance from regulatory agencies on how to evaluate HAP VAP treatments differ. The aim of this work was to reach a consensus on the most appropriate endpoint to consider in future clinical trials evaluating the efficacy of antimicrobial treatment for HAP VAP, using Delphi method. Patients and methods: Twenty-six international experts from intensive care, infectious disease and from the industry were consulted using Delphi method (four successive questionnaires) from January 2016 to January 2017. More than 70% of similar answers to a question were necessary to reach a consensus. Results: According to 60% the experts, clinical cure was the most desirable primary outcome among those found in the literature but two other endpoints were highly rated-all-cause mortality and mechanical ventilation (MV)-free days. Consequently, 88% of the panelists agreed to use a composite endpoints and even a hierarchical composite endpoint to combine these items together in which clinical cure and MV-free days would be assessed at day 28 and clinical cure at day 7 after end of therapy. For VAP, mortality was considered as the most clinically significant item by 75% of the experts, followed by MVfree days and finally clinical cure (Fig. 1) . For HAP, a dual composite endpoint that only included all-cause mortality and clinical cure was chosen ( Fig. 1 ). Among the various elements of clinical cure definition found in the literature, only three were retained by the experts-resolution at end of therapy of signs and symptoms present at enrolment, no further antimicrobial treatment needed and resolution or lack of progression of radiological signs of pneumonia. Finally, we found a consensus on the signs and symptoms that should trigger the suspicion of pneumonia-worsening of gaz exchange, purulent tracheal secretions, hypotension and or vasopressor requirements and fever or hypothermia.

We provide here two consensual endpoints (for VAP and HAP) that would help addressing the efficacy of antimicrobial molecules for HAP VAP treatment in future clinical trials. (Table) . 93 SM-VAP were matched with 380 control patients. In univariate analysis, risk factors for SM-VAP weremale gender, chronic heart failure, respiratory, cardiovascular and coagulation SOFA scores two days before VAP, median number of antibiotics used, percentage of time with antibiotics before VAP, parenteral nutrition, dialysis, catecholamine use and exposure to Ureido-carboxypenicillin, Ciprofloxacin, Tazobactam or Imipenem-Meropenem during the week before VAP (Table) . Patients with SM-VAP were less likely to receive initial adequate therapy (56 vs 70%, OR 0.53, p = 0.01). There was no statistical difference for ICU or D30 mortality. D60 mortality was higher for SM-VAP (Table) . In multivariate analysis, exposure to Imipenem-Meropenem during the week before VAP, respiratory and coagulation SOFA scores two days before VAP were independent risk factors for SM-VAP.

SAPSII: Simplified Acute Physiology Score; SOFA: SOFA (Sequential Organ Failure Assessment); SOFA Resp: SOFA respiratory score; SOFA coag: SOFA coagulation score; SOFA cardio: SOFA cardiovascular score

Conclusion: SM-VAP represented 6.2% of VAP. We observed no differences in patients characteristics between the groups. Imipenem-Meropenem use during the week before VAP was the most important risk factor for SM-VAP. The higher risk of inadequate initial therapy with SM-VAP had no impact on D30 mortality but D60 mortality was significantly higher. Introduction: Education of undergraduate students is key to improve Hand hygiene (HH) behavioral changes amongst doctors [1.2] . Our aim was to evaluate personal feedback using Ultraviolet (UV) light inspection cabinets in a 2 years program. Our hypothesis was that its use for Alcohol hand rub (AHR) application on first year would increase complete AHR application on 2nd year. Patients and methods: This was a simple blind randomized trial comparing HH training with personal feedback using UV cabinet to a control group. On first year, students had access to a theoretical formation then were convened by groups for a demonstration of the correct execution of world health organization's (WHO) procedure [3] . Before HH training, each group underwent a cluster randomization. In the control group, the student hand rubbed under visual supervision and advises of a trainer. In the intervention group after the same visual assessment, completeness of AHR hand application was recorded under UV light and shown to the student. He was given free access to the UV cabinet to repeat the technique, until perfect application complete under UV light. An enhancement with a scenario-based learning was proposed to both groups. On second year, every student were asked to hand rub with the fluorescent AHR. A supervisor blinded to the group of randomization assessed the quality of the HH procedure visually, the completeness of hand application under UV light and compliance with the WHO's opportunities for HH during the simulation. Results: After randomization 140 students were included in the intervention group and 102 in the control group. On second year, the rate of complete application of the AHR under UV was increased in the intervention group as compared with the control group (60% versus 30.4% p < 0.001) ( Fig. 1 ) despite that visual assessment of HH procedures was similar between the two groups. In a logistic regression model including gender, intercurrent HH formation, intercurrent UV cabinet use, surgical unit traineeship and report of regular use of AHR, the hazard ratio for the intervention was 3.837 (IC 2.086-7.058). The rate of perfect compliance with the HH opportunities in the intervention group was increased (58.1% versus 42.4% p < 0.018) and the effect persisted in the logistic regression. Conclusion: UV cabinets for undergraduate students' HH education improve the technique and the compliance with HH opportunities. Included in a multifaceted education program, it must be considered a key tool for training. Results: Among the 56 patients who underwent ECMO support for more than 48 h, the BSI prevalence was 27.4 cases per 1000 ECMO days and microorganisms associated were most frequently gramnegative bacilli. As for positive TA cultures, microorganisms associated were oropharyngeal germs and gram-negative bacilli. Two risk factors were associated with nosocomial bacteria occurrence in TA cultures-prior antibiotics and duration of mechanical ventilation more than 5 days. We demonstrated a link between "positive TA culture" and "positive blood culture" and we showed a protective effect of using an antibioprophylaxis on "positive TA culture" and "global positive cultures" development. Introduction: Delirium in the ICU is often under-diagnosed despite its related burden and impact on patients' morbidity, mortality and prolongation of hospital length of stay. The aim of this study was to assess the medical and paramedical community beliefs and practices regarding delirium in Tunisian ICUs. Patients and methods: Between August 1st and 31/2017, healthcare professionals working at the ICUs of university hospitals of Monastir and Mahdia (Tunisia) were asked to participate in the survey by completing a questionnaire anonymously (that specified participants' characteristics (age, gender, function, years of experience in ICU) and their knowledge and perception of delirium in ICU. The questionnaire consisted in 10 questions of different types: Likert style (: widespread scale in psychometric questionnaires in which the respondent expresses his or her degree of agreement or disagreement with an assertion), multiple choice, ranking and yes/no). Results: During the study period, 96 respondents out of 163 (60% female, nurses: 52%), aged between 20-30 years in 70%, responded to the questionnaire. Healthcare professionals experience in the ICU was < 1 year in 39.6%; 1-5 years in 32.3%, and > 5 years in 28.1%. Participants asserted that the "most characteristic signs of delirium" were: insomnia (25%); confusion (22%); agitation (21%) and aggressiveness (20%). Three-quarters of participants said they did not systematically search for signs of delirium in their patients. 33% thought that delirium was "an insignificant problem" or that "it was not a problem". Only one and three participants respectively, said they attended a conference and read an article about delirium in ICU the last year.

Half of the respondents felt that the most appropriate treatment for a patient with delirium was restraint. Nearly one-third of participants thought that delirium was an under-diagnosed entity and only 6% felt that it was associated with long-term neuropsychological deficits. Factors considered to be determinant in the occurrence of delirium were ARDS, shock, age, mechanical ventilation, postoperative status in 70, 66, 63, 55 and 17%, respectively. Conclusion: Most Tunisian healthcare professionals consider delirium as a common, underdiagnosed, and serious problem in the ICU. Yet, few participants actually monitor this condition.

The influence of sedation choice on the delirium occurrence in critically ill poisoned patients: a randomized controlled trial Khzouri Takoua Introduction: Delirium is a common manifestation of acute brain dysfunction in critically ill patients. It is associated with a healthcare cost increase, and extension of the hospital stay length. The present study aimed to explore influence of patient characteristics and analgesicsedation on delirium incidence and to analyze its risk factors. Patients and methods: It is a prospective single blind randomized controlled trial, started on the first July 2017 in a 12-bed toxicological Intensive Care Unit, including all mechanically ventilated patients requiring sedation who were admitted for acute poisoning. They were randomly divided into two groups G1 et G2 receiving respectevily Propofol-Remifentanil and Midazolam-Remifentanil. Delirium assessment scores were judged not adapted to our population and we retained the diagnosis of delirium on arguments inspired from diagnostic and statistical manual of mental disorders fourth edition (DSM-IV). Results: Until the 15th September 2017, 35 patients were included, with 22 patients in G1 and 13 in G2. The two groups were comparable in terms of epidemiological characteristics. Delirium was developed in 9 patients (26%) (n = 5 in G1 and n = 4 in G2) with an average duration of 18 ± 13 h with no difference between the 2 groups (13 ± 10 h for G1-24 ± 16 h for G2, p = 0.268). Compared to those without delirium, no differences were found in the patient characteristics among these two groups with regard to sex, age, psychiatric history and severity of illness (APACHE II, IGS II score) and even with regard to hypnotic choice (5 vs 4 p = 0.599). Delirium was associated to prolonged duration of mechanical ventilation (69 ± 73 h vs 39 ± 69 h, p = 0.280) and length of ICU stay (91.51 h vs 54.05 h, p = 0.132) without significant differences. Delirious patients had more hypotension (p = 0.008), and received more atropine (0.026). Multiple logistic regression analysis identified atropine (OR 2.333, 5%Cl 0.992-5.489, p = 0.026) as an independent risk factor for delirium.

The diagnosis and prevention of ICU delirium are subjects of multiple ongoing investigations. We carried out this study to detect the risk factors of delirium in order to prevent it. It is important to note that our results are influenced by the studied population and are only preliminary. We rely on the study pursuit and the sample enlargement to better inform us as well on risk factors as protective. Introduction: Background: Severe alcohol withdrawal syndrome is a common cause of hospital admission. Delirium tremens is a potentially fatal complication of alcohol withdrawal. In severe delirium, very large dosages of benzodiazepines can be required despite well described side effects, such as coma and hypoxic cardiac arrest, although there is no recommendations for standardized treatments. Objective -The aim of this study was to describe outcomes and risk factors for complications in patients with severe alcohol withdrawal syndrome treated in intensive care unit with continous infusion of benzodiazepine (BZD).

We retrospectively reviewed the medical records of all patients hospitalized for alcohol withdrawal syndrome between 2006 and 2016. Only those who received continous-infusion of BZD, associated with close clinical monitoring and the evaluation of RASS and Cushman scores, without systematic recourse to mechanical ventilation, were included. Results: We studied 104 patients hospitalized in ICU for severe alcohol withdrawal syndrome. The mean age (SD) was 48.7 ± 8.7 years, mean ICU admission SAPS (simplified acute physiology score) II score was 20 ± 6.1. All of them have received continous infusion of midazolam, with a median maximum perfusion velocity of 8 mg h (interquartile range, (5, 12)). The median duration of treatement was 2 days (interquartile range, (1, 3) ). Thirteen patients (12%) developed pneumonia, and or required intubation, and 8 (8%) have had seizures. No cardiac arrest and death was observed. ICU length of stay (LOS) was 3 days (2, 5) (median, interquartile range). Patients who requiried intubation and or developed pneumonia, received substantially more BZD (median total dose, 428 mg of midazolam vs. 147 mg in the non-complicated group + p < 0.001), and their ICU LOS was higher (median, 5 days vs. 3 days + p < 0.001). Endotracheal intubation and or development of pneumonia were associated with a higher maximum perfusion velocity of midazolam (> 8 mg h) (OR 18.83, IC 95% (2.11-168.15), p = 0.009). Previous episodes of delirium tremens before ICU admission were associated with higher complications such as mechanical ventilation and or pneumonia (OR 11.29, IC 95% (1.45-87.60), p = 0.02).

In severe delirium, very large dosages of benzodiazepines can be used without systematic mechanical ventilation with a low incidence of complications. Introduction: Delirium is frequent in intensive care unit (ICU) patients and is associated with increased mortality, increased hospital stay, increased cost and long term cognitive impairment in survivors. Numerous pharmacological and non-pharmacological strategies have been investigated for delirium treatment without success. Therefore delirium prevention strategies are recommended by current critical care practice guidelines. Among the potentially modifiable risk factors for delirium, the impact of daylight exposure on delirium incidence and or duration has not been studied. The objective of this study was to investigate whether daylight exposition would reduce delirium burden in critically ill patients.

We conducted a prospective study in a 27-bed medical intensive care unit (ICU) over a 1-year period (January 2016-January 2017). All consecutive adult patients receiving invasive mechanical ventilation (MV) for 2 days or more were eligible for the study. Patients were assigned to a room with windows allowing daylight exposure ("Light" group) or without window ("Dark" group), depending on bed availability. Delirium was evaluated with the Intensive Care Delirium Screening Checklist (ICDSC) for a maximum period of 28 days. Delirium was defined by a ICDSC score ≥ 4 for two consecutive days. Agitation was defined by a RASS > or = +2. The primary endpoint was cumulative incidence of delirium. Data are presented as median (interquartile range) or number (percentage).

Results: A total of 195 patients were included (age-50 [50 + 69] years, SAPS2-51 [36 + 64], SOFA score-9 [7 + 11], medical admission-69%). Of them, 110 patients were admitted to a "Light" group and 85 to a "Dark" group. Incidence of known risk factors for delirium was similar in the two groups. Delirium occurred in 65 (64%) patients in the "Light" group and in 55 (71%) patients in the "Dark" group (p = 0.28). The duration of delirium was 3 [1 + 7] days. Patients in the "Light" group received significantly less neuroleptics to treat agitation than patients in the "Dark" group (13 vs. 25%, p = 0.04). This protective association persisted after adjustment for confounders in multivariate analysis (Odds ratio = 0.40 + [0.17 + 0.90] + p = 0.03).

Daylight exposure does not impact on delirium burden in ICU mechanically ventilated patients. However, daylight exposure is independently associated with a reduced prescription of neuroleptics to treat agitation. Introduction: Patients with convulsive status epilepticus (CSE) frequently require mechanical ventilation (MV), either for general anesthesia in case of refractory generalized CSE, or for airway protection. Guidelines for the management of refractory generalized CSE currently recommend general anesthesia for 24-48 h, followed by gradual withdrawal. Our objective is to evaluate the incidence of refractory generalized CSE among patients who required MV during pre-hospital management of status epilepticus, and to describe the management of general anesthesia in intensive care unit (ICU).

This ongoing multicenter retrospective observational study is conducted in 4 French ICUs. All patients admitted in ICU under mechanical ventilation between 01-01-2014 and 12-31-2016 with disease-code "Status Epilepticus" are included. Exclusion criteria are-age < 18 years, post anoxic SE, acute traumatic brain injury, initiation of MV in ICU, transfer from another ICU, inclusion in a therapeutic trial on SE, non-convulsive SE. Collected data include reason for MV, antiepileptic treatment, dosage and duration of general anesthesia, mode of EEG monitoring. Outcomes are-relapse of SE, MV duration, in-ICU length of stay and mortality. Results: Among the 211 medical files reviewed, 77 met the inclusion criteria and were analyzed, and 134 were excluded. A minority of patients (18.2%) had a refractory generalized CSE, most patients (64.9%) had a non-refractory generalized CSE + the others had mostly partial CSE. The main reason for intubation was coma (n = 45, 58.4%). The duration of general anesthesia was not significantly different in refractory CSE patients compared to non-refractory CSE patients (p = 0.18). Data regarding main outcomes are summarized below-.

These preliminary data suggest that the majority of the patients admitted in ICU under MV for CSE do not have a refractory status. Indication of MV is mainly coma without persistent convulsions. The mean duration of general anesthesia before withdrawal is < 24 h, and thus in discrepancy with guidelines, but does not seem associated with a frequent relapse of SE. If this low rate of RSE for patients admitted in ICU and the safety of rapid withdrawal of GA are confirmed, the recommended 24-48 h duration of general anesthesia in ICU could be challenged. Introduction: Induced coma in intensive care patients protect them against pain and neurologic disorders. However, a few of them may present a delayed wake-up when the sedation is interrupted. The aim of this work is to assess brain imaging findings in patients with this condition. Patients and methods: Retrospective review of imaging data of 27 patients (21 males and 6 females), aged between 32 and 84 years, admitted in intensive care unit (ICU) between June 2015 and September 2017, who had sedation or general anesthesia and presented a delayed wake-up. They were explored either by MRI (n = 11) or computed tomography (CT) (n = 16). Patients with traumatic lesions were excluded. Results: Patients were admitted in the ICU because of chronic obstructive pulmonary disease exacerbation (n = 7), infectious pneumonia or pleural effusion (n = 6), acute respiratory failure (n = 5), heart disease (n = 2). Two patients underwent general anesthesia. Septic shock and circulatory collapse occurred in 3 and 5 patients respectively. MRI and CT showed lesions that may explain the wake-up delay in 6 of 11 and 4 of 16 patients, respectively. Brain anomalies included anoxic lesions (n = 4) with basal ganglia involvement (n = 3), ischemic or hemorrhagic strokes (n = 4), hepatic encephalopathy (n = 1) and herpetic encephalitis (n = 1). Conclusion: Brain imaging techniques help diagnosing causes of delayed wake-up after induced coma. Anoxic lesions and strokes are mostly behind this condition. MRI is more accurate than CT. Introduction: Gastric tubes are common in intensive care units used for enteral feeding, administration of drugs or aspiration of the digestive tract. These tubes offer an excellent tolerance but malposition may have serious consequences that can lead to patient's death. The actualy gold method to confirm their correct placement is chest X-ray. We report a study which evaluate the performance of gastric ultrasonography for the validation of the good positioning of the gastric tube.

We carried out a prospective, monocentric study in a Medical Intensive Care Units. For each included patient, we compared the results of a gastric ultrasonography to the interpretation of a chest X-ray. Results: One hundred and thirteen gastric ultrasonographies were performed from July 2016 to May 2017. In 87 cases, ultrasonography concluded that the gastric tube was correctly positioned, confirmed by chest X-ray. In 24 cases, ultrasonography did not visualize the tube in gastric area. Among these 24 cases, only 4 malpositions were detected by the chest X-ray. The sensitivity and specificity of gastric ultrasonography were 0.81 [0.72 + 0.87] and 1 [0.51 + 1]. Positive and negative predictive values were 1 and 0.17, respectively. The ultrasonography was performed 54 min [50.3 + 57.6] after the gastric tube placement while the chest X-ray was interpreted 211 min [170.9 + 251.7] after this same placement (p < 0.0001).

Our results suggest a good performance of gastric ultrasonography to check the positioning of the gastric tube. This result must be interpreted with caution because of a low power of the study. We planned a multi-center study to confirm our results.

Giabicani Mikhael Introduction: Prognosis of cirrhotic patients hospitalized in intensive care unit (ICU) remains poor. In many ICUs, cirrhotic patients are widely admitted and revalued after receiving optimal treatments. Little is known about risk factors involved in the evaluation of the prognosis at day 3, except the persistence of organ failure. This susceptibility to organ failure would be related to an alteration of the regulation mechanisms of the systemic inflammatory response. The blood neutrophil-to-lymphocyte ratio (NLR) is an inflammation biomarker reported to predict clinical outcome in unselected critically ill patients and in patients with stable liver cirrhosis, but has never been studied in critically ill cirrhotic patients. The aim of this study was to evaluate the blood NLR as parameter to predict mortality of cirrhotic patients hospitalized > 3 days in ICU.

Retrospective monocentric study including consecutively cirrhotic patients hospitalized in a medical ICU from 2010 to 2016. For each patient, clinical and biological data at admission and day 3 were collected. NLR at admission ("NLRD0"), at day 3 ("NLRD3") and its variation between admission and D3 ("delta NLR") were calculated. Statistical analysis used appropriate non parametric tests and Cox regression for survival analysis. The ability of the variables to discriminate survivors from non-survivors was determined using ROC curves and a Net Reclassification Index (NRI). Results: 140 patients (median Child-Pugh score = 9 [7-11], median MELD score = 25 [19-30]) were hospitalized more than 3 days in ICU. The major causes for ICU admission were sepsis (56.4%), gastrointestinal bleeding (15%) or respiratory failure (6.4%). Patients were followed up for 38.5d . 74 (53%) patients died-38 (27%) in ICU, 21 (15%) after ICU discharge and 15 (11%) after hospital discharge. In univariate analysis, factors significantly associated with mortality wereat D3, NLR, MELD and SOFA scores + and between D0 and D3-delta NLR, delta SOFA and delta MELD. Predictors of death in multivariate analysis are shown in Table 1 . Area under delta NLR ROC curve was 0.74 (CI = 0.69-0.79). NRI revealed that delta NLR was more efficient than delta SOFA (NRI = 8.7%) to identify patients with a 85% mortality risk at least.

Conclusion: NLR is a novel inflammation index known to predict poor clinical outcomes. Delta NLR is an independent predictor of mortality in critically ill cirrhotic patients and could be more effective than delta SOFA in predicting hospital mortality in these patients.

Severe liver dysfunction acute liver failure related to exertional heatstroke: outcomes, histological features and role of liver Introduction: Severe acute liver injury and failure (sALI ALF) is a grave complication of exertional heatstroke (EH). Liver transplantation (LT) may be a therapeutic option, but the criteria for, and timing of, transplantation have not been clearly established. The aim of this study was to define the profile of patients who require transplantation in this context.

This was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related sALI ALF with a prothrombin time (PT) lower than 50%, with or without hepatic encephalopathy. Results: 24 male patients (median age-27.5 years) with ALI ALF related to exertional heatstroke were studied + nine of them (37.5%) were listed for emergency LT. The latter differed from those who were not listed with respect to their more severe liver failure after D1, a clear deterioration in their PT and ALT values between D0 and D3, and more marked organ dysfunction. Four of these nine patients were subsequently transplanted. At the time of LT, all had PT levels lower than 10%, a marked rise in bilirubin levels and required support for at least one organ (or x organs were involved). Histological findings on the explanted livers demonstrated massive or sub-massive necrosis and little potential for effective mitosis with a mitonecrotic appearance. The 15 unlisted patients (62.5%) were still alive 6 months later and had not experienced any after-effects. Conclusion: Survival without liver transplantation in patients with heatstroke-related ALI ALF reaches 83.5%. The indication for liver transplantation is based on an evolving dynamic. The lack of any signs of an improvement in liver function at or after D3, in patients presenting with other organ dysfunctions or failure, means that liver transplantation should be envisaged. The peculiar histological features observed on all the explanted livers, and the aspect of abortive mitoses in hepatocytes could be attributed to the effects of heatstroke. . On admission, the mean PT was 18.5% (8-42), the mean total bilirubin was 157 umol l. Paracetamol poisoning was the principal etiology with 45% of the patients-66% in the Prometheus group versus 25% in the standard group (p = 0.106). The hepatic encephalopathy grade was significantly higher in the Prometheus group-3 versus 0.5 in the standard group (p = 0.029). There was no difference between the two groups concerning mortality on day 28 (p = 1) or day 90 (p = 0.59). There was no difference concerning the length of stay in intensive care unit or in hospital between the two groups. 13 patients (37.1%) were transplanted. There was a statistical difference between the two groups concerning liver transplantation (p = 0.041)-4 transplant (40%) in the Prometheus group versus 9 transplant (75%) in the standard medical care group. There was a significant improve of encephalopathy after the Prometheus session (p = 0.002). therapy in our ICU were included consecutively and prospectively in the cohort. MARS ® therapy performed using a double lumen dialysis catheter in the femoral or jugular vein. We used the monitor MARS ® 1 TC (Teraklin) coupled with the dialysis machine Prismaflex ® (Gambro). The albumin dialysate circuit consisted of 500 ml of 20% human albumin and was regenerated by an anion-exchange column and an uncoated charcoal column (diaMARS ® IE250, diaMARS ® AC250). Results: Ninety patients were included for 300 sessions. The mean duration was 7 h 38 min (± 1 h 43 min). The population treated consisted of 5 groups-acute-on-chronic liver failure (AoCLF), acute liver failure (ALF), post-surgery liver failure (post transplantation, post hepatectomy), refractory pruritus and drug intoxication ( Fig. 1 ). Regarding biological efficacy-total bilirubin was lowered in AoCLF and post-surgery groups (p < .001), also in the ALF group although not significatively. MELD score was lowered in the AoCLF and ALF group (p < .001). However clinical variables (Glasgow score and encephalopathy) didn't improve significatively. In the refractory pruritus group,

pruritus decreased in 20 out of 25 patients (p < .001). Bile acid levels decreased to 34.8% of its mean baseline level (p < .001). In the drug intoxication group improvement of the Richmond Agitation-Sedation Scale (RASS) from deeply sedated (RASS < = − 3) to minimal sedation (RASS > = − 2) was obtained in 5 out of 6 patients. Out of 300 sessions, catheter-related adverse effects were low (1.3%), thrombocytopenia was the main adverse effect (26.7%). Conclusion: We report our MARS ® experience with the largest cohort of patients referred from a single hospital. We showed biological efficacy in all 5 indications, although clinical efficacy was uneven. MARS ® therapy in patients with refractory pruritus yielded promising results. Tolerance was good and the main adverse effect was thrombocytopenia. Global transplantation-free survival was low in patients with liver failure, reinforcing the need for a liver transplantation center when using MARS ® . Introduction: Colonoscopy is crucial for the management of lower gastro-intestinal disorders, but its profitability is discussed in critically ill patients, mainly because of the complexity of colonic preparation.

As the profitability of colonoscopy in Intermediate or Intensive Care Units (CICU) has been scarcely reported (1), we investigated its indications and usefulness.

Patients and methods: Retrospective bicenter observational study (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) . Main endpoint: diagnostic profitability of CICU in unselected critically ill patients. Profitability was a priori defined as "high" if CICU led to adapt ongoing therapies; allowed an endoscopic intervention; or participated in the decision to limit therapeutic effort. Secondary endpoints: describe the quality of CICU and its preparation; determine its position in diagnosis strategy; describe its morbidity. ) + investigation of a Gram negative bacilli sepsis (n = 7, 6%) + sigmoid volvulus (n = 4, 4%) + and cancer diagnosis (n = 4 + 4%). CICU profitability was deemed high in 50% (n = 56), with an endoscopic intervention performed in 32% (n = 35). The CICU lead to antimicrobial adaptation (n = 9), emergent surgery (n = 10), or to limit therapeutics effort (n = 2). In 23 cases (21%) the CICU was considered normal. Patients' preparation was rated as good in 27% (n = 30) + and the colonoscopy was complete in 33 (30%). The CICU was mainly performed as a 2nd (58%) or 3rd (40%) investigation after an abdominal CT-scan or an upper digestive endoscopy (respectively performed in first instance in 69 and 55%). Three CICU were complicated by 3 hemodynamic and 2 respiratory failures, none were fatal. Discussion: In our series of unselected critically ill patients, CICU were mainly performed to investigate lower gastro-intestinal bleeding. Despite a low rate of good preparation, CICU is safe and its profitability is high in the majority of cases. Conclusion: Although performed in poor conditions, CICU seems useful in the diagnostic and the therapeutic management of critically ill patients, and not only in gastro-intestinal bleeding. (1) Church, Surgical endoscopy 2014. Introduction: Accurate pain assessment is associated with better outcomes in intensive care unit (ICU) patients. Specific scales for noncommunicative patients have been developed and validated but their routine use still remains inaccurate and subjective. Analgesia Nociception Index (ANI) is based on high-frequency heart rate variability. This study objective was to assess the correlation between the Behavioral Pain Scale (BPS) and ANI during care procedures in deeply sedated patients.

We conduced a French multicentric prospective observational study with blinded continuous recording of ANI during 8 h with spotting of care procedures in patients with RASS less or equal to − 2. We compared pain assessment using BPS and ANI before (t1) and during (t2) each care procedure. The cares analyzed included prick glycaemia, turning, catheter insertion, dressing change and others. A behavioral pain reactivity (BPR) was defined by a BPS elevation of at least 1 point. We analyzed minimal ANI values and its variations with calculation of DeltaANI (ANIt1-ANIt2). Because of the analysis of several cares per patient we used a Bonferroni's correction in comparison of BPR and no BPR groups with a significant p value < 0.025 for this comparison. For others analyses the p value considered as significant was p < 0.05. Correlation between ANI and BPS was analyzed using a Spearman correlation rank test. Introduction: The pain associated with burn was one of the most painful injuries to treat. Pain was induced by therapeutic acts such as wound debridement, dressing and other painful procedures. Burn pain caused changes in neurophysiology and pharmacokinetics that may make standard pharmacologic analgesic therapy less effective than usual.virtual reality has been explored as an adjunct therapy for the management of acute pain for a number of conditions. In our study, we attempt to assess the impact of virtual reality on management of burn pain during dressing changes. Patients and methods: Before the therapeutic procedure (dressing changes), the concept of virtual reality therapy was explained to the patient (technology and equipment used). The video used was snow mountain. During the act, pain was assessed until the end of the procedure. The assessment of pain was based on visual analog scale (vas). For pain intensity, the scale was most commonly anchored by "no pain" (score of 0) and "very intense pain" (score of 10). Results: During the study period, 20 patients were included. The mean age was 32 ± 17 years. 75% of our patients were adults aged over 20 years. They were 17 men and 3 women. the average burned surface area was 30 ± 13%. Pain was evaluated before the start of the therapeutic procedure. The mean initial pain severity score was 8.85 ± 0.74 (range 8 to 10). The pain assessment after virtual reality condition showed a significant decrease in the intensity of pain (p < 0.01). The mean pain decreased from 8.85 to 4.6 ± 0.84 with extremes ranging from 1 to 4. Conclusion: Our study supports the use of virtual reality, simple noninvasive, as an adjunct therapy in the management of pain associated with dressing changes in burn patients. Introduction: Hypno-analgesia (HA) is used in the operating room and for complex pain. Before implementation of HA in our intensive care unit (ICU), most protocols for algogenic procedures included intravenous or epidural morphine and Nitrous Oxid. Since 2016, many caregivers have been trained, HA has been implemented and patient comfort is evaluated using 1) a specific analogic scale of comfort (0 to 10) before and after the procedure + 2) at the end of the procedure, a score of patient and caregiver comfort using a five item questionnaire (5 to 20 points).

This pilot prospective study compares HA versus the standard protocol in the removal of abdominal drains after digestive surgery. The main objective was to evaluate the patient comfort before after the procedure using a scale of comfort + the secondary objectives were to test the patient and caregiver comfort scores and evaluate in the impact on consumption of analgesic. Between May 2016 and September 2017, two groups were obtained, according whether the procedure was performed by HA-trained or non-HAtrained professionals (depending on caregivers availability in the unit). The number of subjects required to compare scales of comfort before vs. after drain removal was 66, using a nonparametric Wilcoxon-Mann-Whitney test. Results: Eighty-eight patients were analyzed. The mean note in the comfort scale remained unchanged after vs. before drain removal in patients without HA (n = 43, +0.04 points, ± 2.8), while it increased in patients with HA (n = 45, +2.07, ± 2.7 + p = 0.001). Using our specific five item comfort score, patients and caregivers had a comparable level of satisfaction in HA and non-HA groups (Patients 17.4 20 and 16.3 20 + caregivers-19 20 in both). A trend was observed in reduction of the consumption of morphine and Nitrous Oxid with HA, without altering their comfort. Discussion: Despite its limitations (mainly, its open non-randomized design), this study suggests that-HA may be used for algogenic procedures and is willingly adopted in ICU by patients and professionals + specific scales scores, adapted for HA, may be useful to assess the effectiveness + finally, HA seems to be at least as efficient as classical procedures and could reduce the use of analgesic drugs. Conclusion: HA adds value to patients and to all caregivers. Prospective randomized studies are needed to valid the comfort scores we proposed, and to prove that HA reduces the consumption of analgesic drugs. Introduction: Pain has long been a focus of concern for doctors and caregivers. In intensive care unit, the inability to verbalize discomfort and pain are major stressors for patients. Music therapy has demonstrated in many international studies its effect on the blood pressure and on the respiratory frequency. In this context, we conducted a study to evaluate the effects of standardized musical intervention on pain during painful cares in vigils patients hospitalized in critical care. Patients and methods: Design-We conduct a prospective, observational, randomised, single blind, mono center study. 140 painful cares were studied and then distributed in two groups (n = 70 with music, n = 70 without music). The patients were equiped with a Bose© helmet, and had or not music therapy during the care. Our main criteria was the pain, it has been evaluated by a numeric scale before and after the painful care. We also estimated anxiety with the COVI's heteroevaluation scale before and after the car. We also noticed if the care were stopped because of the pain, then we used a semi quantative numeric scale in order to estimate the feeling of the caregiver and the patient on the session. Results: Concerning pain, there is no significant difference between the two groups (p > 0.005). However, in the music group, pain decreased by 35% after the care (p < 0.001). Anxiety was way lower in the music group than in the group without music (p < 0.001). We also noticed a decrease of 50% of the anxiety in the music group. The patients and the caregivers' feeling were the same in the two groups, with no significant difference (p > 0.05). On the other hand, caregivers tended to underestimate the difficulty of the session in comparison with the patients' (p < 0.01) in both groups. Conclusion: Music therapy did not improve the pain in a significant way, in the music group versus the group without but allowed a decrease of 35% of the pain after the care. Nevertheless, music reduced by two patients'anxiety. Introduction: Sedation and analgesia is one of the basic themes in ICU as complications associated with excessive sedation negatively impact the morbidity and mortality of patients. The objective of this study is to show that the nurse implementation of a sedation and analgesia algorithm is beneficial to the patient in terms of sedative drugs reduction and thus overall decrease in duration of mechanical ventilation (MV) and the morbidity and mortality which is associated with it, without altering patient comfort and tolerance of the environment. Patients and methods: A before and after prospective, observational, non-interventional study was conducted in surgical ICU in Caen University Hospital, between November 2014 and April 2017. Mechanically ventilated patients under sedation predicted to last 48 h or more were included. During the "Before" period, sedation and analgesia was managed by the physician, while during the "After" period, it was managed by the nurses according to the protocol. Results: 1156 intubated and mechanically ventilated patients were admitted during the study period. Among the 145 eligible patients, 100 were included during "Before" period and 45 during "After" period. The duration of MV after inclusion was significantly shorter in group "After" (10.5 [7 + 18] vs 8 [5 + 11.5] days, p = 0.042), as the duration of target RASS (-2 à 0) was significantly longer ( The patients experienced less of ventilator-acquired pneumonia (VAP) and delirium during the "After" period (55 vs 24.4%, p = 0.004, and 41 vs 26.7%, p = 0.015, respectively).

The nurse implementation of a sedation and analgesia algorithm was associated with a trend towards reduction in duration of MV, ICU and hospital length of stay. Moreover, prevalence of VAP and delirium was reduced, in correlation to the significant decrease in sedative drugs. This type of algorithm is necessary to reduce morbidity and mortality associated with MV. Introduction: Central venous catheter insertion is a common practice for anesthetists and intensivsts. This invasive procedure generates pain and anxiety for patients. We aim to demonstrate that remifentanil improves the analgesia during scheduled central venous catheter insertion in mindful patients. Patients and methods: A prospective, randomized, double-blind, controlled study in patients requiring central venous access. Patients were randomly assigned to receive 3 ng ml −1 remifentanil target controlled infusion (TCI) and local anesthesia (LA) with lidocaine or placebo and LA. All patients were monitored in intensive care or postintervention care unit and systematically received oxygen. Patients were asked to assess verbal numeric rating pain scale (VNRPS) during the procedure. The primary outcome was the maximal VNRPS. Secondary outcomes were pain at each step, anxiety, patient satisfaction, operator ease and side effects. Results: Ninety patients were included (45 in each group). All patients were analyzed. Remifentanil significantly reduced maximal pain-VNRPS 20 (95% confidence interval [CI] 16-40) vs 50 (95% CI 40-60) in the placebo group p = 0.0009 (Table 1) . We did not observe any adverse event during this study, and there were no significant difference between the 2 groups regarding side effects. Conclusion: TCI remifentanil is a safe procedure to reduce pain during central venous catheter insertion in awake patients. Trial Registration-clinicaltrials.gov Identifier-02206022, REMIDOLCATH. Introduction: Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential interests of this strategy have not been clinically demonstrated. Patients and methods: Before-after study. We compared two sedation regimens (propofol-remifentanil, period P2 vs midazolamfentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. Results: 460 patients (326 in P1, 134 in P2) were included. CAHP score in P2 and P1 did not significantly differ (p = 0.93). Sixty percent of patients awoke in both periods (194 326 vs 81 134, p = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% in P2 vs. 29% of patients in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2 + p < 0.001). Patients in P2 had significantly more ventilator-free days, and lower catecholamine-free days between admission and day 28. Survival and favorable neurologic outcome at discharge did not differ across periods.

Time course for awakening according to sedation period. These figures report the time course of patients included after discontinuation of sedation. At each time point, we report in the upper part, proportion of patients awoken after discontinuation of sedation, in the lower part, patients who died without awakening, and in the middle part (in white), patients still comatose. Red dots indicate, for each period, the last patient awakening (after 12 days in P1 and 5 days in P2). Black dots indicate the median time to awakening (too early to appear for period 2). Conclusion: During TTM following resuscitation from CA, sedation with propofol-remifentanil compared with midazolam-fentanyl was associated with an earlier awakening, and an increase in ventilator-free days. The new recommendations of the French society of anesthesia-intensive care (SFAR) on perfusion and medication errors were revised in 2016 to promote proper use relating to drug administration with medical devices. To advance that of inquiry, practices of our intensive care unit (ICU) were assessed in order to improve drug administration by central venous catheter (CVC). Patients and methods: Prospective evaluation by pharmacist resident and technical nurse during seven weeks, using a standard evaluation tool, in a 16 bed ICU. Drug recommendations and SFAR documents from 2016 were used as referential of conformity. The following parameters were evaluated-1 Central venous lines mounting, 2 Drug administration and identification with a focus on narrow therapeutic index (NTI) drugs. Results: 50 patients with CVC were analyzed between June and July 2017. 19 entered directly in the ICU. 23 were hospitalized for surgical reasons. 42 had triple-lumen CVC. Regarding the first parameter, no conformity was found due to lack of line identification (100%) or anti-return valve well positioned (96%). Perfusion ramp position was above heart level in 10%, infusion tubing had contact with floor in 6%, and absence of plug on non-used lines is found in 8% of cases. Regarding second parameter, non-conformities were due mostly to syringe label-absence of drug's concentration (72%), preparator identification (99%), patient identification (99.7%), drug identification (3.5%, all concerning propofol), date and time of medication preparation (67%), lack of color code of labels (100%). Regarding NTI, 70% were not administrated according to the recommendations-absence of dedicated line (63%), absence of administration on the nearest insertion site of the catheter (67%). Conclusion: The evaluation highlight some improvement axis such as complete identification on syringes, sensitizing of ICU healthcare team, or homogenization of CVC perfusion system. It calls for a second evaluation round after implementation of improvements. Introduction: Sedation is a corner stone of the care of patients receiving mechanical ventilation in the ICU. Sedation was associated with increased comfort and adherence to care, but also with increased morbidity, including delirium, increased duration of mechanical ventilation and length of ICU stay. Previous studies reported beneficial impact of reduced doses of sedative drugs and careful monitoring of patients comfort and consciousness. Our goal was to assess the impact of the introduction of a nurses-dedicated sedation protocol in our ICU. Patients and methods: This monocentre retrospective before-after study included all the patients admitted in our ICU, over two threemonth periods, from July 2015 and January 2016, treated with invasive mechanical ventilation for more than 24 h and older than 18yrs. After the first period, all physicians and nurses were trained to a new sedation management protocol. Analysis was performed to assess the prescription and application of the protocol, its impact on the use of sedative drugs, ICU length of stay, and duration of mechanical ventilation. Major complications were also recorded. Results: 134 patients were included-78 before and 56 after the protocol implementation. Patients in both groups had similar baseline characteristics (Men 67 vs. 50%, p = 0.08 + mean age 56 ± 18 vs. 60 ± 16 years, p = 0.1 + weight 73.2 ± 20.6 vs. 70.2 ± 15.9 kg p = 0.61 + IGS2 44 ± 17 vs. 44 ± 19, p = 0.99 + medical admission 91 vs. 88%, p = 0.51). Recordings of RASS and BPS did not differ between groups (9 ± 4 vs 10 ± 9, p = 048 + 19 ± 25 vs, 16 ± 11, p = 0.25). The duration of sedation was significantly shorter after introduction of protocol (4.1 ± 4.7 vs 1.9 ± 1.0, p < 0.0001), as was the duration of mechanical ventilation (9.3 ± 13.8 vs 4.1 ± 3.2, p = 0.001) and ICU length of stay (12.3 ± 15.8 vs 7.3 ± 5.3, p = 0.028). There was no difference in major ICU complications, nor in mortality between groups (25 and 30%). Conclusion: Although the implantation of a sedation protocol did not translate in increased recording of RASS and BPS scores, it was associated with improved outcomes. Our data suggest that, more than the protocol by itself, beneficial effects reported after the implementation of a sedation protocol may be ascribed to increased awareness of the care givers and thus better management of sedation. Introduction: Workload affects the quality of care and the prognosis of critically ills patients. Measuring workload in intensive care units (ICU) has thus become essential for allowing a better matching between the activities required and the management of resources.

In March 2016, the medical ICU of the university hospital of Monastir (Tunisia) moved into new buildings (more space and beds, computerbased prescriptions and monitoring, etc.). The aim of the present study is to compare the level of workload before and after the change of the ICU buildings. Patients and methods: During the two study periods (period 1-July-September 2015 and period 2-July-September 2017) adult patients consecutively admitted, for more than 24 h, in the medical ICU for ARF and or sepsis were included in the analysis. Data collected were the demographic characteristics (age, sex, Body Mass Index (BMI), comorbidities, Simplified Acute Physiology Score (SAPS) III), the nursing workload measured using the Therapeutic Intervention Scoring System (TISS-28) and hospital survival. Results: Thirty-six patients (22 male) were included in the study (14 during Period 1 and 22 during the second period). The medians of age, SAPS III and BMI were respectively 65 (IQR = 21) years, 46 (IQR = 12) and 27.7 (IQR = 9.4). The main comorbidities were hypertension, COPD and neurological disease respectively in 36, 25 and 20%. The demographic characteristics were similar during the two periods. Nurse workload was characterized by m TISS-28 = 18 (IQR = 7) and Time of nurse's care of 190 min (IQR = 74). These two workload indicators were significantly higher during the second period (Table 1) . During the second period, "standard monitoring" and "frequent dressing changes" (> 3 time day) were the activities with significant increase from, respectively 81 to 91% (p < 0.0001) and from 41 to 88% (p < 0.0001).

The relocation of our ICU in in new buildings was associated with a significant increase of the nurse workload with regard to patients with ARF and or sepsis. . Bland-Altman analysis showed excellent accuracy and precision between recorded and collected data for all tested variables within clinically significant pre-defined limits of agreement. However, 82 (2.5%) data were missing and a delay was observed between videotaped and collected times. This delay was less than 28 s and remained stable through all data for each patient. We identified that the missing data were due to a limit in the number of data being processed in the database at the same time and the delay between data presentation and data collection in the database was due to different server time settings. Both technical issues were corrected. Conclusion: Our study identified two issues in the data collection process that slightly limited the accuracy of our high resolution electronic database. We recommend the performance of such validation study before using a high resolution database for clinical or research purposes. Introduction: Fluid overload, and also its variations, is known to jeopardize the outcome of ICU patients. However, fluid balance remains difficult to assess accurately. In that context, our study aims to assess the prognostic value of body weight variations (BWV) from Day 3 to Day 7 on the 30-day mortality, length of stay (LOS) and the occurrence of ventilator-associated pneumonia (VAP) and bedsore in critically ill patients with shock. Patients and methods: Adult patients admitted in ICU with shock between 2002 and 2012, and requiring mechanical ventilation during the first 48 h, were extracted from a prospective multicenter cohort for a retrospective analysis. BWV was defined as the difference between the body weight of the day of interest and the body weight on admission. Case mix, severity on admission, and outcomes were collected. Fine and Gray sub-distribution survival models were used, with ICU discharge as competing event, adjusted on comorbidity and illness severity at admission at each landmark, from Day 3 to Day 7. The impact of BWV on ICU stay duration was estimated through a multivariate negative binomial regression model.

The median age and SAPS 2 score of the 2 374 included patients were 67 (IQR, 55-77) years and 53 (IQR, 41-65), respectively. The BWV increased from 0.4 kg (IQR, 0-4.8) on Day 3 to 3 kg (IQR, − 0.4 to 8.2) on Day 7. The 30 day in-hospital mortality, the ICU occurrence of bedsore and VAP were 27, 3 and 19.6%, respectively. Four categories of BWV were defined according to BWV interquartiles: weight loss, stable weight, moderate and severe weight gain. Categories of BWV were independently associated with death on Day 5 and Day 6 (Day 5 : sHR 1.27; 95% 0.99-1.63 p = 0.06; Day 6: sHR 1.43; 95% CI 1.08-1.89, p = 0.01) (Fig. 1) . A weight loss tended to be associated with increased occurrence of bedsore, and weight gain with increased occurrence of VAP. The extent of BWV increased the duration of ICU stay independently of other severity factors. Discussion: BWV may be another clinically relevant tool to assess the risk of death, mostly after Day 4. The increased risk of bedsore in case of weight loss deserved to be confirmed. Conclusion: Body weight should be daily monitored for better prognostication. BWV-based restrictive strategies should be further evaluated.

The clinical effectiveness of multi-layer silicone dressings in preventing ICU acquired pressure ulcers: a randomised controlled trial Introduction: The development of pressure ulcers (PU) in critically ill ICU patients result in additional morbidity and may contribute to mortality in some cases. The minimisation of ICU acquired PU remain an international challenge. This paper describes Australian research that used multi-layer soft silicone sacral and heel dressings to prevent PU in critically ill patients. Patients and methods: A total of 440 critically ill patients were enrolled into an 18-month randomised controlled trial in one of Melbourne's trauma centres. Patients were randomised on admission to the Emergency Department and either had standard PU prevention or standard care plus the application of prophylactic sacral and heel

dressings. Patients were observed daily for PU development for the duration of their ICU stay. Results: Patients in the dressing group has significantly reduced incidence rate of PU development compared to patients receiving standard PU prevention alone (3.1 vs 13.1%, p < 0.03). Patients in the dressings group had a relative risk reduction of 80% and a 10% absolute risk reduction for developing a PU regardless of their critical illness. Results indicate the number needed to treat to prevent one PU was 10. Additionally, we calculated the cost-benefit of this intervention and found the patients treated with prophylactic dressings cost 3.6 time less than the standard care group for wound care. Discussion: The use of prophylactic dressings to prevent PU at our hospital have proved to be very effective in ICU and subsequent studies have confirmed our results. It appears that the main mechanism of PU protection provided by these dressings is the reduction of pressure and shear forces leading to tissue distortion and cell death rather than the previously accepted ischaemic model of PU development. Our current policy is now to use these dressings on all patients with a high risk of developing PU.

The use of prophylactic multi-layer silicone dressings to prevent PU in critically ill patients is effective but it does not replace standard PU prevention methods. The use of these dressings sould be considered complimentary to best practice in PU prevention.

Iatrogenic events in intensive care unit: incidence, risk factors and impact on outcome Ayed Samia 1 , Merhebene Takoua Introduction: Iatrogenic events (IEs) are defined as harm resulting from medical intervention and health care, and not explained by underlying disease. Mortality is reported to be as high as 13.6% in cohorts of hospitalized patients experiencing IE. Both length of stay and cost of hospitalization are increased by IEs occurrence. We perform this study to determine the incidence, risk factors, and impact on outcome of IEs in intensive care unit (ICU). Patients and methods: All patients admitted more than 24 h to the 22-bed ICU of a teaching hospital were prospectively screened. Patients were monitored daily for adverse clinical occurrences. Time and data about each IE were collected and they were considered as preventable or life-threatening events. For each patient, the followings were recorded-basic demographic data, indication for admission, severity scores on admission (SAPSII and APACHEII), need and duration of mechanical ventilation (MV), length of stay (LOS) in ICU, intensive care work load score (OMEGA), global mortality and IEs related mortality. Results: During the 6 months period, 167 patients were included and 65 (38.9%) were judged to have developed an IE while hospitalized. We recorded 282 IEs over 2004 days in ICU so a density incidence of 14 IE for 100 patient-day. IEs were considered preventable in 34% of cases and life-threatening in 22% of cases. IEs occurred in a mean delay of 6 ± 6 days. Global mortality rate was 36.5% and IEs related mortality rate was 13.7%. Patients with IEs were significantly severe on admission, with a longer duration of MV and LOS in ICU. OMEGA score was significantly higher. Multivariate analysis showed that OMEGA score was the independent risk factor of IEs occurrence (OR 1.031 IC 95% [1.015-1.047], p < 10 -3 ). Dead patients were significantly severe on admission and experienced more IEs than survivors. OMEGA score, duration of MV and LOS were significantly higher. In multivariate analysis, IEs and life-threatening IEs were independent factors of mortality (OR 6.171 IC 95% [3.087-12.339 ], p < 10 -3 and OR 21.482 IC 95% [5.077-90.889], p < 10 -3 respectively). Conclusion: IEs in ICU are common and frequent but one-third is preventable. Work load ICU score is the independent risk factor of their occurrence. IEs impact largely the outcome especially the lifethreatening ones. Efforts must be focused on preventing programs to reduce IEs and improve the outcome. Introduction: Based on the recent SEPSIS-3 definitions, septic shock is defined by the combination of vasopressor requirement and serum lactate level > 2 mmol/L. However hyperlactatemia and lactate kinetics may result from both increased production and impaired clearance in the critically ill, and may therefore not only rely on the severity of circulatory failure. We herein addressed the determinants of hyperlactatemia (> 2 mmol/L) and the factors likely to impact on early lactate clearance in septic shock. Patients and methods: This was a 9-year (2008-2016) monocentric retrospective study. All adult patients diagnosed for septic shock within the first 48 h were included. Septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. The first lactate value (L1) was measured at the time of ICU admission. Hyperlactatemia was defined as a first lactate level > 2 mmol/L. The second value (L2) was measured within 12 h following the first measurement. Lactate clearance was calculated as (L1-L2) L1 time between L1 and L2 measurements) and expressed in mmol hour. Parameters associated with initial hyperlactatemia and lactate clearance were investigated using multivariate logistic regression analysis. Introduction: Cardiac surgery with cardiopulmonary bypass (CPB) induces immunosuppression which has considerable implications for patients. CPB induces a significant increase in circulating neutrophils. Neutrophil activation, associated with production of antibacterial peptides, reactive oxygen species (ROS), cytokines, and other inflammatory mediators, as well as release of DNA into the extracellular milieu (Neutrophil extracellular traps (NETs)), plays a central role in innate host defense and modulation of inflammation. However, it has been shown that, in septic shock or systemic inflammation as major surgery, immature circulating neutrophils can induce immunosuppression and increase the risk of secondary infections. Staphylococcus aureus (SA) is one of the most commonly encountered bacterial pathogen responsible for poststernotomy mediastinitis, and neutrophils alterations may favor postoperative infections. The main objectives of this study were to evaluate the direct effects of CBP on neutrophils functions and to study the impact of different strains of SA on neutrophils bactericidal functions. Patients and methods: Blood samples were collected before and 24 h after cardiac surgery with CPB and bone marrow samples were harvested directly after sternotomy, before initiation of CPB, and at the end of CPB, before sternal closure. Septic patients were included as controls. Circulating neutrophils analysis was performed using flow cytometry. We also studied NETosis, ROS production and bactericidal activity in isolated neutrophils before and after surgery using two strains of SA-one responsible of postoperative mediastinitis and one isolated from nasal carriage.

Results: Blood cell count with differential demonstrated a significant increase in neutrophils 24 h after surgery. Flow cytometry analysis of blood samples indicated neutrophils were matures with a significant increase in degranulation marker (CD66b). Neutrophils life span was also increased after CBP. Flow cytometry analysis of bone marrow samples showed no difference in cell composition and maturation before and after CBP. The neutrophil production of ROS was significantly higher after CBP. However, CBP did not impact NETs formation, phagocytosis and bactericidial function. Moreover, there was no difference regarding the phagocytosis and the bactericidial activity when exposed to the two strain of SA. As expected, immature neutrophils count was significantly increased in septic patients compared to cardiac surgery patients.

These results indicate that CBP promotes the recruitment of matures neutrophils via a demargination process. CBP does not induce neutrophil dysfunction. Neutrophils should not be targeted to decrease postoperative infection after CPB. Introduction: Protein Tyrosine Phosphatase 1B (PTP1B) is a negative regulator of both NO production and insulin signaling and has been shown to be an aggravating factor in septic shock. Stress hyperglycemia frequently occurs in critically ill patients and is associated with poor outcome. Experimental studies on transgenic mice have shown that PTP1B deletion resulted in a reduced insulin resistance and in a better survival during experimental model of sepsis. The main objective was to study the correlation between the PTP1B gene expression and organ failure (through the delta SOFA score between day 1 and day 5) or insulin resistance. Patients and methods: Twenty-seven healthy male volunteers have been included in this clinical trial. The product was administered by continuous intravenous infusion (CIV). A single ascending dose design with 8 dose levels was used. Cohorts 1 and 2 received a 15-min single dose of MOTREM (1 and 10 mg and one and two volunteers respectively). Then, cohorts 3 to 8 received either a 15-min loading dose (from 0.5 mg kg to 5 mg kg) followed by 7.75-hours maintenance dose (from 0.03 mg kg h to 6 mg kg h) of MOTREM or a matching placebo (3-1 ratio). All volunteers were carefully monitored. Before escalation to the next dose level, safety and PK data of the previous dose level were reviewed by a safety review committee. Since immune system is at rest in normal individuals and thus TREM-1 pathway is not activated, no pharmacodynamics parameters were analyzed. The main objectives of this trial was then to study the safety and pharmacokinetic profile of MOTREM. Results: No product related changes in vital signs, clinical nor laboratory parameters were observed. No product-related adverse events were reported. The PK of MOTREM was linear; The main clearance was estimated at 463L/h/70 kg which is higher than the hepatic blood flow in human (i.e., 90L/h/70 kg) and is therefore indicative of an extensive enzymatic metabolism in blood + effective half-life was calculated to be about 3 min. Conclusion: MOTREM was found to be safe and well tolerated up to the highest dose tested (5mg/kg for a 15-min loading dose and 6 mg kg h for a 7.75-hours maintenance dose). Safety and pharmacokinetics of MOTREM is currently being studied in septic shock patients in a phase IIa randomised, double-blind, two-stage, placebo controlled, international, multicenter clinical trial (www.clinicaltrials.gov NCT03158948). -1) is an immunoreceptor expressed on neutrophils and monocytes macrophages whose role is to amplify the inflammatory response driven by Toll-Like Receptors engagement. The pharmacological inhibition of TREM-1 confers protection in several pre-clinical models of acute inflammation. In this study, we aimed to decipher the role of TREM-1 on the endothelium.

We evaluated the expression of Trem-1 in vessels and isolated endothelial cells by flow cytometry, qRT-PCR and confocal microscopy. We generated an endothelium-conditional Trem-1 ko mice and submitted them to polymicrobial sepsis through CLP. Organs and blood were harvested at different time points and analyzed for cellular content, cytokine chemokine concentrations, and vasoreactivity. Survival was monitored for 1 week. Results: Trem-1 was expressed in aorta and pulmonary vessels from animals, and inducible after LPS stimulation or during sepsis. These results were confirmed in human pulmonary microvascular endothelial cells. The pharmacological inhibition of TREM-1, using the synthetic inhibitory peptide LR12, decreased the LPS-induced Trem-1 expression. Sepsis induced a profound vascular hyporeactivity in WT animals, both in terms of contractility and endothelium-dependent relaxation.

Although contractility was still impaired in EndoTREM-1-mice, vasorelaxation was completely restored. Soluble TREM-1 concentrations, a marker of TREM-1 activation, were markedly increased in the plasma, the peritoneal lavage fluid and the lungs from WT septic mice compared to control. In EndoTREM-1-mice, sTREM-1 level was reduced. Plasma concentrations of soluble VCAM-1 and IL-6 were also reduced in EndoTREM-1-animals. We observed an accumulation of neutrophils and inflammatory Ly6Chigh monocytes in the lung of WT septic mice. This accumulation was dampened in EndoTrem-1-mice. By contrast, endothelial Trem-1 deletion favored the accumulation of reparative cells (Ly6Clow monocytes). Finally, survival was clearly improved in the EndoTrem-1-group as compared to the WT group. Conclusion: We reported that TREM-1 is expressed and inducible in endothelial cells and plays a direct role in vascular inflammation and dysfunction. The targeted deletion of endothelial Trem-1 conferred protection during septic shock in modulating inflammatory cells mobilization and activation, restoring vasoreactivity and improving survival. The effect of TREM-1 on vascular tone, while impressive, deserves further investigations including the design of endothelium specific TREM-1 inhibitors. -50.5 ]. 14 patients suffered from pneumonia, 6 from intra-abdominal sepsis. We measured serum levels of total and free thiamine, thiamine mono di and triphosphate (TMP, TDP and TTP respectively), as well as the erythrocyte transketolase activity and arterial lactate at the time of admission. We also recorded the vital status at the end of the ICU stay. Results: 50% of our subjects exhibited particularly low levels of free thiamine (< 7 nmol/L). There was no correlation between free (r = − 0.4; p = 0.85), or total (r = − 0.19; p = 0.34) thiamine concentration and lactate levels. There was no correlation between TMP (r = 0.02; p = 0.91), TDP (r = − 0.19; p = 0.34), TTP (r = − 0.15; p = 0.46) and lactate levels in the whole population. No correlation was found between the concentration of thiamine derivatives and arterial lactate levels in the subgroup of patients exhibiting the highest levels of lactate (> 2 and > 4 mmol/L). Total thiamine and TDP concentration at the time of admission were significantly higher in ICU survivors than in non-survivors (p = 0.031 and p = 0.028).

During sepsis, we did not find any correlation between thiamine and lactate concentration. Lower thiamine diphosphate concentration may be associated with ICU-mortality. Introduction: A positive fluid balance in sepsis is a determining factor for mortality. In previous experimental studies, sodium lactate has been shown to improve hemodynamic and avoid fluid overload (1).

To understand these beneficial effects, we investigated the impact of sodium lactate on capillary leakage, in comparaison to saline on capillary leak in a rat model.

The sixteen sedated, mechanically ventilated rats were challenged with intravenous infusion of E.coli lipopolysaccharide (10 mg/kg). Two groups of eight animals were randomised to receive a continous perfusion (5 mL/kg/h) of sodium lactate 11.2% (treatment group) or 0.9% NaCl (control group). In order to inject the same caloric load in the two groups, a 4.35 mL/kg/h of either water of 10% dextrose solution were perfused. Mean arterial pressure, heart rate, urine ouput were measured over a 210 min period. An echocardiography was then performed and Evans Blue (1%, 30 mg/kg) was intravenously injected 30 min before sacrifice. Organs were withdrawn and organs wet dry ratio and Evans blue dye extravasation were measured. Results: Fluid balance, organs wet dry ratio and Evans blue dye extravasation were not significantly improved in sodium lactate group. Hemodynamics parameters were not significantly enhanced after sodium lactate infusion. Discussion: Previously, lactate administration has improves renal perfusion. In our study, the volume of urine output was decreased in the 2 groups reflecting the severity of our model. and the vascular filling (9.35 ml/kg/h) higher than in the literature could impact our results. (1) Recently, the pressure Electricy index-Pmus Eadi index (PEI) has been described. (2) The purpose of this study was to assess muscular pressure (Pmus) using PEI with our NAVA protocol. Patients and methods: Observational study, patients recovering from pneumonitis and acute respiratory failure. SBT was Pressure Support Ventilation with 7cmH20 of assist and no PEP. PEI was calculated under NAVA and during SBT from airway pressure drop during end-expiratory occlusions, muscular pressure (Pmus) was estimated from PEI (2) . Another index, patient ventilator contribution index (PVBC) was also measured using the inspiratory peak of EAdi and Vt (inspiratory) during assisted and non-assisted breaths. We calculated PVBC-squared because it has been shown that it is more correlated to Pmus Ptot. Results: Results are summarized in the Introduction: In ICU, intubation is a high risk procedure associated with high morbidity. Despite procedure's improvement with systematic application of fluid loading, early use of vasopressors and checklist use, morbidity remains high. First pass success is strongly correlated with adverse event occurrence. A recent study by Semler et al. concluded than "sniffing" position is better than "ramped" position to increase first pass success even the primary outcome prespecifiedpulse pressure saturation was not different between the two groups. We conducted a post hoc analysis of the randomized clinical trial MacGrath Mac video laryngoscope or Macintosh laryngoscope for intubation in the intensive care unit (MACMAN) to determine the best position for intubation in the ICU. Patients and methods: MACMAN was a multicentre, open-label, randomized controlled superiority trial. Consecutive patients requiring intubation were randomly allocated to either the McGRATH MAC videolaryngoscope or the Macintosh laryngoscope, with stratification by centre and operator experience. An only inclusion criterion was-"Patients must be admitted to an ICU and require mechanical ventilation through an endotracheal tube". Patients were excluded if-contraindication to orotracheal intubation (e.g., unstable spinal lesion); insufficient time to include and randomize the patient (e.g., because of cardiac arrest); age < 18 years; pregnant or breastfeeding woman + correctional facility inmate; patient under guardianship + patient without health insurance; refusal of the patient or next of kin to participate in the study; previous enrolment in a clinical randomized trial with intubation as the primary end point (including previous inclusion in the present trial). Post-hoc analysis was performed to assess association between patient position (sniffing or supine) and first pass success. Between-groups baseline difference was adjusted for baseline covariates significantly associated with the group membership (p < 0.2). Results:

Failure of first pass Introduction: During acute exacerbation of COPD oxygen should be titrated to avoid both hypoxemia and hyperoxia. The recommendations are not followed and automated oxygen titration may be useful in this population. The aim of this study was to evaluate a new device developed to automatically titrate oxygen based on SpO2 target (FreeO2, Oxynov, Canada) and to compare oxygenation parameters with usual administration (manual flowmeter).

The study is an observational monocentric study. We prospectively included patients hospitalized for acute exacerbation of COPD receiving oxygen. Written informed consent was obtained from all patient. In the first part of the study, we evaluated oxygen flowrate and SpO2 during 30 min at baseline based on management of the physicians in charge. The oxygenation parameters were compared with automated titration (FreeO2 during 1 h). In the second part of the study, oxygen was delivered with FreeO2 until oxygen weaning or a maximum of 72 h. We evaluated the oxygenation parameters during prolonged utilization, the duration of oxygen administration, a new Bluetooth SpO2 connection compared to wire SpO2 connection (evaluated by Visual Analog Scale 0-10). Results: We present preliminary data of 23 COPD patients (sex ratio M F = 9 14). Mean age (± SD) was 72 ± 11 years, mean FEV1 (± SD) was 0.9 ± 0.3L. Oxygenation data in both parts of the study are displayed in the Table 1 . Time in the SpO2 target was significantly increased with FreeO2 in comparison with manual titration and oxygen flowrate was reduced by half. In the second part of the study, the % of time in the SpO2 target with automated oxygen titration was above 80% and time with hypoxemia and with hyperoxia were low. In 11 patients, we compared comfort with wire SpO2 connection to Bluetooth wireless SpO2 connection. The comfort was significantly increased with wireless connection (7.0 ± 2.9 vs. 9.7 ± 0.6, p < 0.001). Duration of oxygen administration after inclusion (2.3 ± 4.3 days) and hospital length of stay after inclusion (5.7 ± 5.3 days).

Conclusion: Automated oxygen titration maintains the patients within predetermined SpO2 target more than 80% of the time and reduces oxygen flowrate in comparison with manual oxygen titration. The second part of the study demonstrates the feasibility to use automated oxygen titration during several days with similar outcomes as previously reported in similar population. There are several limitations of the study and additional evaluations of this device are required. Introduction: Hyperoxemia occurs up to 50% of mechanical ventilation days in the ICU [1] and is associated with increased mortality as compared to patients ventilated in normoxemia [2] . INTELLiVENT-ASV is a full closed loop ventilation mode adjusting automatically oxygenation's settings FiO2 and PEEP according to SpO2 for passive and spontaneously breathing mechanically ventilated patients. This post hoc analysis of a monocentric randomized controlled parallel group study compared frequency of hyperoxemia (PaO2 > 120 mmHg and or SpO2 > 96%) and hypoxemia (PaO2 < 60 mmHg and or SpO2 < 90%) and the percentage of ventilation time with SpO2 > 96% and the percentage of ventilation time with SpO2 < 88% between INTELLiVENT-ASV and conventional ventilation mode in mechanically ventilated ICU patients.

The randomized controlled trial was performed in the general ICU of Hôpital Sainte Musse, Toulon, France. Eligible participants were adult aged 18 or over, invasively ventilated for less than 24 h at the time of inclusion with an expected duration of mechanical ventilation of more than 48 h. Exclusion criteria were broncho-pleural fistula, ventilation drive disorder and moribund patients.

Patients were allocated to INTELLiVENT-ASV group or to conventional ventilation group (volume assist control and pressure support modes) using blocked randomization. The post hoc analysis was performed by the comparison of all arterial blood gases (ABG) performed during the study period-the number of ABG with hyperoxemia and hypoxemia, the median PaO2 and SpO2 for these arterial blood gases and FiO2 associated were compared according to group. Results: 60 patients were included, 30 patients in each group. The total number od ABG was 333 (mode conventional) vs 316 (mode INTEL-LiVENT-ASV) (p = ns). The number of ABG with PaO2 > 120 mmHg was respectively 54 versus 33 (p = 0.032) with SaO2 > 96% was 203 vs 153 (p = 0.001) with PaO2 < 60 mmHg was 57 vs 56 (p = 0.121) + with Sao2 < 90% was 88 vs 86 (p = 0.951). The percentage of time of ventilation spent with Spo2 > 96% was 32% vs 29 (p = 0.438), and with Sao2 < 88% was 0.6 vs 0.5 (p = 0.615).

The continuous control of oxygenation settings provided by INTELLiVENT-ASV decreases significantly the number of blood gas with hyperoxemia as compared to manual oxygenation setting without increasing the risk of hypoxemia. Introduction: In invasively mechanically ventilated patient, dyspnea is frequent and severe. Relying on self-report, its measurement remains challenging in patients unable to communicate. A 5-item observation scale, namely the intensive care-respiratory distress observation scale (IC-RDOS), has been proposed as a surrogate of dyspnea-visual analogic scale (D-VAS) self-report in intensive care unit (ICU) patients [1] . However this scale has been validated among non-intubated patients and included one item "supplemental oxygen" not thoroughly adapted for intubated population. We sought to develop a dyspnea observation scale more suitable for intubated patients and to evaluate its performance to detect dyspnea. Patients and methods: Ancillary analysis of data prospectively collected from 220 ICU communicative patients enrolled for the validation of the IC-RDOS. Factorial principal component analysis was first performed to select variables that mostly contributed to the principal axes, among a set of 21 observable variables with possible clinical relevance.

To identify the best correlation between these variables and D-VAS, were performed an iterative partial least square regression process (PLS).

Iterative PLS procedure identified five variables, of which the combination and weighting allowed optimal correlation with D-VAS (r = 0.61; 95% CI 0.50 to 0.72; p value < 0.0001), which constitute the IC-RDOS [1] . In a first step, we removed "supplemental oxygen", not relevant in intubated patients. We obtained a 4-items IC-RDOS (r = 0. Introduction: Lung ultrasound (LUS) has emerged in different clinical settings, such as in intensive care medicine (ICM). Early diagnosis of ventilator-associated pneumonia (VAP) remains a challenge to the intensivist. However, scientific evidence is little available on whether LUS reliably improves the diagnosis of VAP. The aim of this prospective study was to assess whether LUS could be an alternative to pulmonary computerized Tomography (CT) for assessing diagnosis of VAP in ICM. Patients and methods: Twenty-one patients ventilated for duration more than 5 days suspected of VAP were included. LUS was performed by a well-trained operator who was blinded of the VAP diagnosis.

The diagnostic gold standard of VAP was on the basis of pulmonary CT and positive culture pulmonary. All clinical criteria for the diagnosis were collected the same day of LUS and pulmonary CT. The ultrasound exam included anterior, lateral and posterior views from both sides of the chest with superior and inferior views. We classed patient in 4 groups according diagnosis of VAP with pulmonary CT (VAP + or VAP-) and LUS (LUS + or LUS-). LUS characteristics of VAP diagnosis included 9 profils-asymetric line B (profil A B), without sliding (profil B'), sub pleural consolidation (profil C), consolidation with punctiforme bronchogram (PB), linear air bronchograms (LB) or dynamic bronchograms (LBD), posteror lateral alveolar pleural suffusion (PLAPS), pleural effusion pathological (PEP), shred sign (SS and complications according to insertion site. The advantage of this method is that it gives a pragmatic view of the real clinical situation. Patients and methods: Ancillary study of the AKIKI trial, an open pragmatic randomized controlled trial published in 2016, in which patients with severe acute kidney injury were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. Results: Among the 619 patients included in AKIKI, 462 received RRT at least once and 459 patients were finally included in the analysis (3 missing data), leading to a total of 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular site (n = 256, 43%) and subclavian site (n = 23, 4%). Investigating center was the sole factor significantly associated with the choice of insertion site in multivariate analysis (p = 0.01). Higher weight did not affect choice of insertion site. Mean duration of catheter use was 6.6 (+-5.0) days without difference according to site. Catheter dysfunction was the main reason for replacement (n = 61, 49%). Suspicion of infection led to replacement of many catheters (n = 40, 32%) but was actually seldom proven (n = 4, 3% Introduction: Long standing dialysis (SLED or CRRT) allows a better hemodynamic tolerance as well as a greater performance to achieve a negative fluid balance in intensive care unit. Dialysis alter hemodynamics mainly by short term variation of blood volume. In this study we took advantage of a continuous monitoring of blood volume during dialysis session to decipher the relationship between the variation of relative blood volume (RBV) with mean arterial pressure (MAP).

This study is observational prospective, including all prolonged (> 8 h) dialysis sessions in Saint Etienne nephrology intensive care unit between January and June 2017. Exclusion criteria were ongoing blood transfusion and blood volume controled ultrafiltration. Medical records were compiled along with cardiac ultrasonography at the beginning when available. The statistical analysis was perfomed in two parts. The first part studied the performances of the first hour deltaRBV (defined by RBV before minus RBV after 1 h of dialysis) to predict a drop of MAP below 65 mmHg (hypotension). This analysis excluded sessions with hypotension and intervention during the first hour. The second study was the modelization of the relationship between deltaRBV and deltaMAP for every hour of dialysis without any intervention on blood pressure. Both analyses were performed using mixed effects linear and generalized models. Fig. 1 Vancomycin PK during SLED Results: A total of 82 sessions on 23 different patients were performed during the period. The characteristics of patients were as follows-sex ratio at 1, age (SD) 64.3 (9.0), weight 83.3 kg (17.2), SAPSII score 48. 3 (13.6) . 20 patients on 23 were taken in charge for fluid overload. In the first set of analyses (per sessions), 27 sessions were excluded for intervention in the first hour. The adjusted DeltaRBV did not predict hypotension during the session (generalized mixed effect model, session and patients set as random effects, estimate 0.14, p = 0.71). In the second set of analyses (per hour without any intervention), 535 h were analyzed. Adjusted DeltaRBV correlated strongly and inversly with deltaMAP (linear mixed effect model, random effects were sessions, patients and hour order in the session, estimate 1.42, p < 0.0001). Conclusion: In our mostly fluid overloaded patients, the drop of RBV correlated with an increase of MAP. Introduction: Kidney transplant recipients (KTR) are at risk of ICU admission because of prolonged immunosuppressive therapy and a higher risk of cardiovascular events, severe infections or drug-related toxicities. Several retrospectives studies reported the short-term outcome of KTR admitted to the ICU, but data concerning the risk of chronic kidney disease and anti-HLA immunization are scarce. Patients and methods: In this retrospective study, we addressed the in-hospital and long-term mortalities of the 200 KTR admitted in a French ICU (10 beds) between January 2010 and June 2016. Predictive factors for death, long-term renal function and HLA immunization were identified. Results: The main causes for admission were acute respiratory failure (27.5%), sepsis (26.5%), post-operative period (peritonitis, hemorrhage + 23%). At the admission, mean age, SAPS2 and SOFA score were 58 ± 13 years, 52 ± 19 and 6.7 ± 3.3, respectively. Renal replacement therapy, mechanical ventilation and vasopressors were required in 103 (51.5%), 107 (53.5%) and 97 (48.5%) patients. Immunosuppressive regimen was modified in 155 patients (76.1% + steroids increase 68%, calcineurin inhibitors or antimetabolites withdrawal 25 and 37%, respectively). In-hospital mortality was 20% (30.1 and 38.2% at months 12 and 36). By multivariate analysis, EBV blood proliferation in the 6 months preceding the admission in the ICU, and the SAPS2 gravity score at admission independently predicted the in-hospital and long-term mortalities. Among the 113 patients alive at month 6 after the admission in the ICU and with available data, 34 (30.1%) and 51 (45.1%) progressed to a more severe CKD stage at months 1 and 6, respectively. Both, the severity of the AKI and the preexisting CKD predicted the risk of progression of the CKD. Last, de novo anti-HLA immunization at month 6 was identified in 18 119 patients (15.1%, donor specific antibodies 11 18 (61.1%)) and was significantly associated with the occurrence of acute transplant rejection (p = 0.002). In five patients who developed anti-HLA antibodies, RBC transfusion during the ICU stay was the only immunological trigger identified. Discussion: Outcome of KTR is closed to the general population admitted in ICU and better than other immunocompromised patient, like patients from oncohematology. Conclusion: Worsening of the renal function and HLA immunization are frequent and may impact mid to long-term prognosis because of the high risk of transplant rejection, end-stage renal disease and further transplantation contraindication. Introduction: Acute kidney injury (AKI) is associated with a poor prognosis. Although pulmonary embolism (PE) may promote AKI through renal congestion or hemodynamic instability, its frequency as its impact on the prognosis of patients with acute PE have been poorly studied. Patients and methods: Using data from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry, we assessed the frequency of AKI at baseline, and its influence on the 30-day mortality rate of patients with objectively confirmed PE. AKI was defined according to the "Kidney Disease-Improving Global Outcomes" definition. We used multivariate analysis to assess whether or not the presence of AKI independently influenced the risk for 30-day death.

The study included 21,131 patients with acute PE, of whom 6222 (29.5%) had AKI at baseline. Of these, 4385 patients (21%) were in stage 1, 1385 (6.5%) in stage 2 and 452 (2%) in stage 3. The proportion of patients with high-risk PE in those with no AKI, AKI stage 1, AKI stage 2 and AKI stage 3 was-2.8, 5.3, 8.8 and 12%, respectively (p < 0.001). After 30 days, 1236 patients (5.85%) had died. Overall mortality was-4% in patients with no AKI, 8.4% in AKI stage 1, 14% in AKI stage 2, 17% in AKI stage 3, all p < 0.001). On multivariable analysis, AKI was independently associated with an increased risk of death at 30 days (odds ratio = 1.25 + 95% CI 1.02-1.54), after adjusting for the initial severity of PE, age > 65 years, chronic heart failure or chronic lung disease, cancer, anemia and liver cirrhosis. Conclusion: One in every 3-4 patients with acute PE had AKI. Moreover AKI was an independent predictor of poor outcome in PE patients. This study suggests that PE (and its severity) should be considered as a risk factor for AKI and AKI may deserve to be evaluated as a prognostic factor in patients with acute PE. Introduction: Metabolic acidosis is frequently observed as a consequence of global ischemia-reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assessing the impact of metabolic acidosis on outcome after OHCA. Patients and methods: We included all consecutive OHCA patients admitted between 2007 and 2012. Using admission data, metabolic acidosis was defined by a positive base deficit and was categorized by quartiles. Main outcome was survival at ICU discharge. Factors associated with acidosis severity and with main outcome were evaluated by linear and logistic regression, respectively. Results: 826 patients (68.3% male, median age 61 years) were included in the analysis. Median base deficit was 8.8 [5.3, 13.2] mEq/l. Male gender (p = 0.002), resuscitation duration (p < 0.001), initial shockable rhythm (p < 0.001) and post-resuscitation shock (p < 0.001) were associated with a deeper acidosis. ICU mortality rate increased across base deficit quartiles (39. 1, 59.2, 76.3 and 88 .3%, p for trend < 0.001) and base deficit was independently associated with ICU mortality (p < 0.001). The proportion of CPC 1 patients among ICU survivors was similar across base deficit quartiles (72.8, 67.1, 70.5 and 62.5%, p = 0.21) and 11.7% of patients with a base deficit higher than 13.2 mEq l survived to ICU discharge with a good neurological recovery.

Severe metabolic acidosis is frequent in OHCA patients and is associated with poorer outcome, in particular due to refractory shock. However, we observed that about 10% of patients with a very severe metabolic acidosis survived to ICU discharge with a good neurological recovery. Introduction: Precarious socio-economic status can directly influence health, need for hospitalisation and mortality, according to a previous study performed in 22 European countries. Similar findings have been reported from Anglo-Saxon countries in the setting of intensive care. Due to the different structure of the healthcare system in France, we aimed to investigate whether socio-economic status influences initial severity of disease and 3 months mortality in patients admitted to intensive care in France. Patients and methods: Prospective, multicentre, cohort study including 1396 adult patients admitted to one of 8 participating intensive care units (ICUs) between 2012 and 2016, and presenting failure of one or more major organs. Patients were considered to have a precarious socio-economic status if they presented at least one criterion of social vulnerability or a high EPICES deprivation score. Results: Data on social vulnerability were available for 1281 patients, of whom 54.3% were considered to be socially vulnerable. Compared to non-vulnerable patients, socially vulnerable patients were younger (64.8 vs 67.2 years, p = 0.006), more frequently had chronic disease (18.0 vs 12.0%, p = 0.003 respectively for congestive heart failure and 26.8%vs 18.1%, p = 0.0002 for chronic respiratory disease), had higher levels of physical dependency (9.2 vs 4.7%, p = 0.002), and were more often classed as having long-term health conditions (67.1 vs 62.1%, p < 0.0001). Conversely, non-vulnerable patients had greater severity of disease at admission to the ICU than those classed as vulnerable, both in terms of SAPS II and SOFA scores (respectively 53.16 vs 50.09 (p = 0.001) and 8.35 vs 7.77(p = 0.002)). Findings were similar after adjusting for major confounders (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) [0.48-0.81], p = 0.0005). Mortality at 3 months was not significantly different between socially vulnerable patients and those not considered vulnerable, respectively 34.6 vs 36.10% (p = 0.62), even after adjustment for initial severity. Conclusion: Despite less severe disease at admission to the ICU among patients considered socially vulnerable, 3-month mortality did not differ significantly between those who were socially vulnerable and those who were not. These findings suggest that the French healthcare system provides good protection for the most disadvantaged members of society, particularly when they are admitted to the ICU. Introduction: An approach of the quality of care may involve assessing the patients' satisfaction. However, the extended caregiverpatient and family relationship, specific to the critically ill patients, may also require to assess the proxies' satisfaction. The OpinionFamily tool was developed to assess the satisfaction of the critically ill patients' proxies, in an anonymous and continuous fashion.

We conducted a study in the ICU of Tenon hospital (Paris, France) between Mars and August 2017. The Opinion-Family questionnaire, built with 6 categories (4 items each), aimed to measure the proxies' satisfaction regarding their perception of the quality of care. All the proxies were invited to express voluntarily and anonymously his her degree of agreement as a response to a statement by the selection of the corresponding stars (strongly disagree-1 star, disagree-2 stars, neither agree nor disagree-3 stars, agree-4 stars, strongly agree-5 stars) using a secure touch screen disposed 24 7 in the waiting room of the ICU. Results: Altogether, 456 patients were hospitalised during the study period, and 148 proxies completed the questionnaire. All the responders spoke French. Only 12 responders (9%) answered more than one time. Of the responders, 105 (71%) were the referring person, 47 (32%) were children and 26 (17%) were spouses. During the study period, 50 (34%), 59 (40%), and 38 (26%) responders had visited their relative 1 to 3 times, 4 to 10 times, and more than 10 times, respectively. The different categories assessed by the OpinionFamily tool were related to «the family and the patient» (Fig. 1A) , «the family and the environment» (Fig. 1B) , and «the family and the caregivers-availability, trust, support, and information» (Fig. 1C) . The corresponding levels of satisfaction (responses of at least 4 stars) were respectively 67, 78, 65, 77, 78, and 79%. Some items were associated with a poor satisfaction (participation to the care, identification and availability of the caregivers). Conclusion: The implementation of the OpinionFamily tool allowed a continuous evaluation of the satisfaction of the critically ill patients' proxies. A systematic implementation of this tool in the ICUs may be useful to the caregivers for a better understanding of the needs of the proxies. In addition, this tool may allow rapid changes in ICU organizations and behaviours to improve the proxies' satisfaction, which may ultimately, improve the care of patients. Many factors influence end-of-life decisions (EOL). We describe EOL decisions in patients with acute respiratory failure and their impact on patients' prognosis. Patients and methods: An international observational study included all patients with acute respiratory distress over a 1-month period. 459 ICU in 50 countries were involved. Demographic, clinical and biological data were compared between patients with and without decision of LST limitation. We also compared surviving patients after LST limitation decision to those who eventually died. Results: Among the 4041 patients, mortality was 37.2%. A decision of LST limitation was reported in 948 patients (23.4%). In univariate analysis, patients with LST limitation decision were older and more frequently hospitalized for a medical condition, had a lower body weight, a higher SOFA score, and presented active neoplasia immunosuppression or chronic liver failure more frequently (p < 0.001 for all). Patients admitted after trauma, drug overdose or pulmonary contusion were less subject to have an LST limitation decision (p < 0.001). In contrast, patients with non-cardiogenic shock were more subject to these decisions (p = 0.018). EOL decisions were less frequent in lower-middle income countries as compared to high and middle-high income countries (p < 0.001). Multivariate analysis will be presented. Among 948 patients with an LST limitation decision, 148 survived (15.6%). Mortality was higher in this group than in the whole study population (p = 0.001). In univariate analysis, death after decision of LST limitation was associated with admission for a medical condition (p = 0.02), severe ARDS, higher inspiratory pressure, non-cardiogenic shock, higher SOFA score with or without respiratory component and chronic liver failure (p < = 0.001 for all). On the contrary, admission for trauma was associated with survival (p = 0.001). Regarding the 1503 patients who died during their hospital stay, 703 did not receive a decision of LST limitation (46.8%). Decision of LST limitation was more frequent in older patients (p < 0.001) and in high-income countries. Conclusion: Decisions of LST limitation are frequent in the ICU, and are associated with increased age and medical severity. However, a significant percentage of these patients survived. Interestingly, almost half of the patients who eventually died during their hospital stay had not been subject of a decision of LST limitation.

Evaluation of the decision-making process leading to a decision not to readmit a patient to the intensive care unit during a same hospital stay Introduction: The risk-benefit ratio of (re-)admission to the intensive care unit (ICU) has been widely discussed in the literature. However, the ethics of non-readmission during a single hospital stay have not been widely addressed. A decision not to re-admit a patient to the ICU could be seen as a limitation of therapy, thus falling within the scope of the law dated 22 April 2005, by denying the patient access to potentially-available healthcare resources. In this context, we aimed to-(1) investigate whether decisions not to re-admit patients to the ICU are taken in accordance with French legislation + and (2) identify the characteristics of patients concerned by this type of decision. Patients and methods: This study was based on data from the prospective, multicentre IVOIRE cohort (Influence of socio-economic vulnerability on initial severity and prognosis of patients admitted to the ICU + PHRC-IR 2012). We identified patients included in two large regional university hospitals in the East of France for whom a decision not to re-admit was taken during a single hospital stay. The decisionmaking process was evaluated based on a questionnaire comprising 13 items developed by a sociologist from semi-directive interviews with clinicians. Results: Among 857 patients discharged from the ICU alive, a decision not to re-admit to the ICU during a same hospital stay was noted in the medical file of 63 patients (7.3%). This decision was primarily made on the day of discharge (42.6%), and those involved in the decision included-the family, an outside consultant, and the patient themselves in 54, 31.7 and 15.9% of cases respectively. The decision was justified in medical terms in 92.1% of cases, and the main reasons cited were-(1) therapeutic impasse (52.4%) + (2) comorbidities (44.4%) + (3) degree of dependence of the patient (34.9%). Patients concerned by decisions of this type were generally older (75 vs 65.6 years, p < 0.0001), with more comorbidities (median 4 vs 2, p = 0.001), greater loss of dependence according to Katz's activities of daily living (5 vs 6, p < 0.0001), and longer duration of life-sustaining therapies (7.5 vs 5 days, p = 0.028). Conclusion: Although the profile of the patients identified in this study likely justified the decision not to re-admit the patient to the ICU, there is room for improvement in the decision-making process. Introduction: Most of organ donors are brain dead patients. In some cases, patients are identified as potential donors before brain death and will undergo intubation and mechanical ventilation for the sole purpose of awaiting brain death. The aim of this study is to evaluate the practices of professionals in charge of potential donors. (Table 1 ). In this case, the issue of organ donation was addressed to the relatives before intubation by 42% of ICUp and 68% of non ICUp (p = 0.03). 29% of participants never addressed organ donation before the brain death. For the 71% who have done so at least once, organ harvesting never happened in 20% of cases. Legitimacy and difficulties ( Table 1 )-21% of respondents felt that when a decision of treatment withdrawal or withholding is taken, the patient should not go to ICU for any reason and 29% think that these patients should be allowed to die "quietly". The prospect of an extubation if brain death does not occur or in case of organ donation refusal is a problem for 24% of ICUp and 38% of non ICUp (p = 0.08). 88% of ICUp and 93% of non ICUp think they would need to receive training. Conclusion: This study shows that pursuing mechanical ventilation for the sole purpose of awaiting brain death and organ harvesting is a common practice, and that intubating a patient for this purpose alone is done in most of cases but could still be more generalized. On the other hand, information to the relatives should be improved. 1-7.3] . The effect of PP on the monitored parameters varies significantly between each patient but also between each session for the same patient. In positive responders, the effect continues statistically for 7 to 20 h depending on the parameter studied-10.5 h for Vd Vt, 19.5 for Phase 3 slope, 7 for PetCO2 and 9 for Cdyn.

The maximum effect of prone positioning on selected parameters seems to be obtained after 20 h of therapy. 

The acute respiratory distress syndrome (ARDS) is characterized by lung infiltration with activated neutrophils. Neutrophil extracellular traps (NETs) are antimicrobial structures released by neutrophils. NETs have also been associated with tissue damage in experimental models of acute lung injury. Whether NETs are involved in the pathogenesis of human ARDS and could be a potential therapeutic target is unknown. We aimed to quantify alveolar NETs production in patients with pneumonia and ARDS and assess its relationship with outcomes. Patients and methods: Prospective monocentric study. Patients admitted in the ICU in 2014 2015 with pneumonia and moderate severe ARDS were included. Immunosuppressed patients were excluded. NETs (DNAmyeloperoxidase) levels were measured by ELISA in broncho-alveolar lavage (BAL) fluid and serum samples of ARDS patients and in those of

control patients (n = 4). Patients with higher and lower BAL fluid NETs levels were compared using the median as a cutoff value. Results: Thirty-five patients with bacterial (n = 18), viral (n = 11) or non-microbiologically documented (n = 6) pneumonia and ARDS were included. NETs levels were significantly higher in BAL fluid than in blood of ARDS but not of control patients (Fig. 1 Introduction: The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2 FiO2 or P F) is daily used to assess patients' evolution under ventilatory support. Some studies reported the reliability of percutaneous oxygen saturation (SpO2) to appreciate PaO2 easy to get on bedside. Thus two equations have been proposed-Rice equation and Ellis equation. However, no large prospective study assessed the reliability of such equations to estimate the P F at the bedside in real conditions. Using the SPECTRUM (Severe hyPoxemia-preva-lEnCe, TReatment and oUtcoMe) study, we aimed to evaluate the reliability of SpO2 obtained by Rice and Ellis equation.

This study is a planned companion of SPEC-TRUM study, a recent prevalence-point-day conducted by the SRLF Trial group in 117 french-speaking ICU aiming to report the patterns and outcomes of hypoxemic patients (defined by P F < 300 mmHg). We included in the analysis all patients under mechanical ventilation with SpO2 < 98% (according to limit of the Rice study). SpO2 and FiO2 were measured simultaneously to arterial blood gas were drawn. Results: Among 1656 Patients of the SPECTRUM study, 421 were on mechanical ventilation and had undergone arterial blood gas with simultaneously recorded SpO2 and FiO2. Of note, P F was < 100 mmHg for 132 + between 100 and 200 for 191 + and between 200 and 300 for 29. Pairwise correlations of truth P F with estimated P F was good (Rice-Spearman's rho = 0.84, p < 0.001-Ellis-rho = .85 p < 0.001). Bland-Altmann test showed an important variability of results (P F vs Rice (Figure) -0.02 ± 57.8-P F vs Ellis-14.3 ± 45.5). The variability decreased with lower P F. Caution may be used to interpret our results because we did not reported the quality of SpO2 signal at the bedside. Conclusion: Regarding the variability of the results, whatever the used equation, caution may be used to predict the P F by the SpO2 FiO2 ratio in patients under mechanical ventilation. Introduction: Morbid obesity and ARDS both affect respiratory mechanics mainly through their respective impacts on chest wall and lung elastances. We present a unique series of patients combining very severe morbid obesity and moderate to severe Acute Respiratory Distress Syndrome (ARDS). We describe the use of trans-pulmonary pressures (TPP) measurements for optimization of external PEEP setting. Patients and methods: The monocentric observational study was performed in 8 morbidly obese patients admitted for moderate to severe ARDS. We performed an incremental PEEP trial (5 cm H2O steps) with TPP measurement (NutriVent probe, Sidam, Italy) in a semirecumbent position as previously described. A decremental PEEP trial after a recruitment maneuver was not performed since the safety of such a maneuver in this specific population is largely unknown. We defined two ways for determination of external PEEP setting-(1) PEEP necessary to obtain a positive expiratory TPP and (2) PEEP necessary to obtain a plateau pressure between 28 and 30 cm H 2 O (maximal alveolar recruitment Express strategy). Data are expressed as numbers (%) and medians (interquartile range). Statistical analysis was made using the XLSTAT software. Results: We enrolled during 5 years 8 morbidly obese patients (BMI 63 (IR 59-69)) admitted for a moderate to severe ARDS. Clinical characteristics are displayed in Table 1 . The Express strategy indicated a PEEP setting of 15 cm H 2 O (IR 15-20) whereas TPP-guided PEEP was 30 cm H 2 O (IR 25-32), p = 0.03. Driving pressure was higher in the Express strategy PEEP setting (10.7 cm H20 (IR 9-12)) than in the TPP-guided PEEP (10.2 cm H20 (IR 9.5-13)), p = 0.92. TPP-guided PEEP setting was higher than indicated by the Express strategy in all but one patient. One patient suffered from transient hypotension when external PEEP was set at 25 cm H 2 O, while no patient displayed an inspiratory TPP higher than 25 cm H 2 O. Additional data will be provided during the meeting-pressure-volume curve at ZEEP (6 patients), CRF measurements (4 patients) and ABG and capnometry values at each PEEP level (3 patients) .

In our ARDS patients with extremely severe obesity, an incremental PEEP trial with TPP measurements appeared to be safe and indicated a PEEP setting significantly higher than for the commonly-used ARDS strategies. Such an approach deserves further comparisons with other modalities of monitoring, such as CRF measurements, EIT studies, etc.

Severe poisoning by cardiotoxic drugs and circulatory assistance: 5-year experience at French university hospital Tardif Elsa 1 , Conil Jean-Marie 1 , Georges Bernard 1 , Marcheix Bertrand 1 , Crognier Laure 1 , Bounes Fanny 1 , Delmas Clement 1 1 CHU Rangueil, Toulouse, France Correspondence: Tardif Elsa -tardif.elsa@gmail.com Annals of Intensive Care 2018, 8(Suppl 1):F-106 Introduction: Toxicity from cardiac drugs is associated with a large number of fatalities, significant morbidity and healthcare consequences. Severity of these poisonings can be explained by a refractory cardiogenic shock not responding to optimal conventional treatment. Criteria of circulatory assistance indications remain unclear. The aim of the study was to describe and to compare patients intoxicated by cardiotoxic drug treated with or without veno-arterial ExtraCorporeal Membrane Oxygenation (VA ECMO). Patients and methods: Retrospective cohort study conducted at French university hospital. All patients intoxicated with cardiotoxic drugs between January 2012 and March 2017 were included. Patients were divided into 2 groups-with and without VA ECMO. Results: Among the 105 patients included in the study, 18 patients were treated with VA ECMO (17%) and 87 patients with conventional therapies. ECMO was respectively employed for refractory shock and cardiac arrest in 13 and 5 cases, all patient required vasopressor support. In-hospital mortality was 10.5% and was significantly higher in the ECMO group (44.4%). Beta-blockers with membrane stabilizing activity and non-dihydropyridine calcium channel blockers poisoning were the most commonly reported in the ECMO group. Mean time from hospital admission to initiation of ECMO was 11 h and the average ECMO duration was 2.6 days [1] [2] [3] [4] [5] [6] [7] [8] . No serious adverse reaction was reported during this period. Results expressed in median value ± confidence interval Conclusion: Refractory cardiogenic shock following cardiotoxic drug poisoning requiring circulatory assistance is associated with significant mortality. Even if its use seems justified by the literature, the implantation criteria must be specified and this after an optimal conventional treatment to prevent multiple organ failure. The CDV of patients in the EDASS group was significantly higher (p < 0.0001) at all-time points after the introduction of catecholamines than among those without EDASS, as early as 6 h from catecholamine initiation (Fig. 1) . A strategy in two steps (CDV > 800 µg kg at 6 h and or CDV > 2600 µg kg at 24 h) was able to predict EDASS with sensitivity of 45%, specificity 97%, positive predictive value 78% and negative predictive value 94%. Overall, this two-step strategy identified 18 high-risk patients at 6 h, of whom 15 presented EDASS. Conclusion: Overall, our results confirm that early death directly attributable to septic shock could be effectively predicted by the CDV in the first hours of treatment. These results will help to select patients eligible for innovative therapies aimed at improving early mortality in septic shock. Introduction: In patients with cardiac arrest, end-tidal CO2 (EtCO2) has been proposed to monitor the efficacy of cardiopulmonary resuscitation (CPR) but uncertainty persists on its interpretation. We hypothesized that exhaled CO2 may also by affected by occurrence of "lung airways" collapse previously noticed during CPR. Because this closure may possibly also limit oxygenation + analysis of the entire exhaled CO2 time waveform-may give information of high clinical value to manage CPR. We report preliminary results from a clinical and bench study aimed at describing the pattern of the capnogram during CPR. induces a systemic inflammatory response associated with an immune dysregulation and a significant pulmonary dysfunction which has been well characterized. Surprisingly, there are only a few data available on immunological changes induced by ECLS. We believe that ECLS leads to immune dysfunction that could expose patients to nosocomial infections. Patients and methods: A two-phase study was lead. First we analyzed blood cell count with differential (including lymphocyte, neutrophils and monocyte counts) in all patients who received ECLS in our institution from 2014 to 2017 within the first week following ECLS initiation. Secondly, Monocytes, granulocytes, dendritic cells and lymphocytes function were assessed at day 0, day 1 and day 3 using flow cytometry and functional tests in patients receiving ECLS and compared to patients with cardiogenic shock without ECLS. Results: Among 159 patients with ELCS we found an early and persistent lymphopenia and a late neutrophilia (found to be associated with poor outcome in critically ill patients). Compared to control (n = 7), we found in patients who received ECLS (n = 6) a significant increase in immature granulocytes (104.107 ± 47.106 on day one versus 95.105 ± 96 ± 105, p = 0.01) and lymphocytes apoptosis. ECLS induced changes in Myeloid derived suppressors cells proportion (3.69% ± 3.5 on day three versus 0.58% ± 0.49 before ECLS, p = 0.05), which has been recently associated with a higher incidence of nosocomial infections and seems to be major actors of sepsis-induced immune suppression. Complement component 5a receptor (C5aR) from the neutrophil cell surface, was also decreased after ECLS initiation (ratio of mean fluorescence index 0.73 ± 0.22 on day one, p = 0.03) which is a sign of complement-induced neutrophil dysfunction in septic patients. Conclusion: ECLS induces quantitative and qualitative leukocytes dysfunctions that can lead to a greater susceptibility to nosocomial infections which contribute to the poor outcome observed in several studies. Introduction: Aspiration pneumonia is a common complication of cardiac arrest. Although its real incidence remains undetermined, probabilist antibiotherapy is frequently or even systematically prescribed in these cases. We assessed the incidence of out-of-hospital cardiac arrest-related aspiration pneumonia and the impact of a microbiological documentation in regard to antibiotherapy course. Patients and methods: All patients admitted for out-of-hospital cardiac arrest from 1 1 2014 to 1 8 2017 were studied. In our ICU, aspiration pneumonia is suspected when a clinical syndrome (fever, per resuscitation constatation) and or chest radiography infiltrates were present. In case of suspected aspiration pneumonia, a microbiological documentation was performed before initiation of probabilist treatment with amoxicillin-clavulanate. We retrospectively defined if patients have aspiration pneumonia using the following criteria-per resuscitation constatation, chest radiography infiltrates, fever. The number of microbiological documentation leading to an antibiotherapy modification was recorded as well as pathogens types. Data are expressed as numbers (%) and medians (interquartile range). Statistical analysis was made as appropriate using the XLSTAT software. Results: 176 patients were studied. Clinical characteristics are displayed in Table 1 . 80 (45) received a probabilist antibiotherapy and 79 (45) were retrospectively considered with aspiration pneumonitia. Results of microbiological documentation were 94 (53) positive microbiological sample and 68 (38) with a positive threshold whose 6 (3) were considered colonized (i.e. no clinico-radiological sign). On the entire positive culture sample, 51 (54) were positive with oropharyngeal flora as unique pathogen, 14 (15) Introduction: This study aimed to assess whether augmented renal clearance (ARC) impacts negatively on piperacillin-tazobactam pharmacokinetic pharmacodynamics (PK PD) target attainment in critically ill patients receiving 16 g day by continuous infusion. Patients and methods: Over an 8-month period, all critically ill patients treated by piperacillin-tazobactam for a suspected or documented sepsis without renal impairment were eligible. During the first three days of antimicrobial therapy, every patient underwent 24-hour creatinine clearance (CrCL) measurements and therapeutic drug monitoring at steady state. The main PK PD outcome investigated in this study was the rate of empirical target non-attainment using a theoretical target MIC of 16 mg L −1 for piperacillin and 2 mg L −1 for tazobactam. The secondary clinical outcome was the rate of therapeutic failure in microbiologically documented infections, defined as an impaired clinical response with a need for escalating antibiotics during treatment and or within 15 days after end-of-treatment.

Over the study period, 60 patients were included in the primary pharmacological analysis and 45 in the secondary clinical analysis. Using a MIC of 16 mg L −1 for piperacillin, the rate of empirical target non-attainment in the overall population was 17%, with a strong association with CrCL ( Fig. 1 Introduction: Invasive fungal infections are a major burden in solid organ transplantation, especially in patients receiving liver graft. However, their incidence has decreased thanks to the development of an antifungal prophylaxis in the post-transplantation period. In patients at high risk of invasive fungal infection (IFI), this strategy is recommended, whereas its benefit remains controversial in low-risk patients. However, there is no clear definition of these two patients groups. Our aim was to provide recent data on epidemiology, mortality and IFI risk factors in the early post-operative course in a population without any antifungal prophylaxis. Results: The number of beta-lactam antibiotics was 119. Of these 119 requests, half were for piperacillin (49.6%), and onethird were for amoxicillin (30.3%). The other dosages were mainly for cloxacillin, cefepime, cefotaxime and ceftriaxone. The results confirmed that serum concentrations of piperacillin (21.6 ± 4.0 vs 98.2 ± 16.8 mg L −1 < 0.0001) and amoxicillin (35.8 ± 13.0 vs 157 ± 72 mg L −1 < 0.0001) significantly were higher in patients with neurological disorders or wakefulness delays. The ROC curves allowed the predictive values associated with the presence of neurological disorders attributable to antibiotic treatment, corresponding to residual serum concentrations of piperacillin of 66 mg L −1 and amoxicillin of 160 mg L −1 . A predictive value for neurological disorders of these concentrations is proposed for residual serum concentrations greater than 40 mg L −1 for both antibiotics (80% specificity and sensitivity). Conclusion: Our results suggest that there is an association between a residual concentration of piperacillin and amoxicillin greater than 40 mg L −1 and the occurrence of neurological disorders. Pharmacological therapeutic monitoring of beta-lactams in critically ill patients may be a useful intervention to optimize the antibiotic regimens and to avoid antibiotic-related toxicities. (2011) (2012) (2013) (2014) (2015) . Patients with a GNB-BSI were included and were divided into two groups according to the resistance (R) profile (BSI due to a R isolate or not). The following resistances were considered-all GNB-BSI including Pseudomonas spp., Acinetobacter spp., Stenotrophomonas spp. and Enterobacteriacae (Eb) for which the following antimicrobial resistances were considered-ticarcillin and ceftazidime (cefta) (Pseudomonas (PA)), third generation cephalosporin (3GC) (Eb) and imipenem (all GNB). After variable selection using random forest and univariable mixed logistic regression models, a multivariable analyses using a mixed model with a random effect (center). Sub-group analyses were performed according to species (PA and Eb) and resistance for Eb. Results: From 189,020 patients admitted in an annual median of 198 French ICUs, 6837 experienced an ICU-acquired (> 48 h.) BSI, 3462 (51%) BSI due to GNB, including 1345 (41%) BSI due to R isolates. PA was identified in 828 (24%) (MDR-PA BSIs 248 (30%)) and Eb in 2933 (86%) (MDR-Eb BSIs (1126 (38%)). The raw mortality rate was 18% in the overall population and 38% in the patient with GNB BSI. It was significantly higher for R GNB BSI (41 vs 36% for susceptible GNB BSI, p < 0.01). After adequate adjustment in a multivariate analysis, we showed that R-GNB BSI was significantly associated with mortality compared to susceptible strains (Fig. 1) . By considering species subgroup, the effect was not significant for resistant Pseudomonas aeruginosa (p = 0.54) but remained significant when considering only Eb. Considering Eb resistance, the impact of 3GC R showed a trend to an increased mortality risk whatever there was no effect of IMI R (N = 45 (2%)) on prognosis. Limitation-The absence of information about antibiotic consumption may partly explain the remaining significant center random effect in the final models. Conclusion: in a large French database, after adequate adjustment on prognostic factors, Resistant BGN-BSI was associated with a higher ICU mortality than susceptible one. The effect was mainly due to Eb 3GC R. severely injured group versus 3.1 ± 6.4 days for the non-severely injured patients (p < 0.0001). In multivariate analysis, heart rate (> 100 min) and Vittel score (≥ 2 criterias) were related to the probability of belonging to the severely injured group (p = 0.03). The 24-hour mortality rate was 0.5% in the ED and the 30-day mortality rate was 1.5%.

The development of a network in the ED hosting non vital polytraumas remains crucial. Its primary goal will be to meet technical and time requirements and establish in-hospital triage algorithms based on clinical variables, in order to detect these patients at an early stage and offer them priority care in our overcrowded EDs. Introduction: The trauma of traffic accidents and particularly cranial trauma are, due to their frequency and severe consequences in both the short and long term, a real public health scourge on a global scale. Studies of the epidemiology of cranial trauma by traffic accidents and their prognosis are rare at least in underdeveloped or developing countries. In addition, the impact of extracranial lesions on cranial trauma prognosis has long been discussed. The purposes of our study were to examine the epidemiological aspects and to determine the factors correlated to the immediate and distant prognosis of isolated cranial trauma. Patients and methods: Retrospective cohort spread over 4 years (from 2009 to 2012) and including 242 patients with isolated Cranial trauma by traffic accidents (mean age 30.9 years, sex ratio-7). We proposed to study the factors correlated with a poor prognosis in terms of death in hospital and Glasgow Outcome Scale (GOS) at 6 months unfavorable in dual analysis (univariate and then multivariate). For the GOS study, patients were divided into 2 groups-GOS favorable for patients with good recovery (GOS = 5), recovery with a light handicap (GOS = 4), GOS unfavorable for those having survived with a severe disability (GOS = 3), a vegetative or pauci-relational state (GOS = 2) and those who died (GOS class 1). Results: Hospital mortality was 26% and the GOS at 6 months was distributed as follows: death (27.3%), vegetative state (2.9%), severe disability (11.2%), mild disability (28%) and good recovery (30.6%). The 6-month GOS was deemed unfavorable in 41.4% of the cases. Various after effects were observed in survivors: physical (42%) dominated by headache (24.4%), sleep disorders (14.2%) and epilepsy (7.2%); memory disorders (27.8%) or concentration (16.5%) and finally emotional after effects (32.4%) with irritability (30.7%) and aggressiveness (9.7%).

In multivariate statistical analysis, independent predictors of mortality were arterial hypotension, hypoxia extradural hematoma (EDH),, acute subdural hematomas (SDH), diffuse axonal injury and ventilator associated pneumonia. Those correlated with an unfavorable GOS were an age ≥ 38 years, hypotension, cerebral edema, coma duration ≥ 5.5 days, EDH and H24 glucose ≥ 7.15 mmol/l. Conclusion: Although the short-term prognosis of head trauma seems to be improved at present, the long-term consequences of cranial trauma remain fairly frequent, and often underestimated, which underlines the importance of their screening and their proper care. The average age of the survivors (30.83 ± 13.08 years) was lower than the mean age of the deceased (36.81 ± 16.68). RA was the cause of the trauma in 76% of the cases followed by the fall found cat 17% of the patients. Prehospital care only concerned 4% of patients. The univariate analysis showed that the main factors of occurrence of death were age (p = 0.02), glasgow score (p = 0.0001) anisocoria (p = 0.0009), shock (p = 0.002) 26% of deaths were due to intracranial hypertension, haemorrhagic shock in 15% of patients and ARDS in 7% of polytrauma patients. Conclusion: The management of polytrauma can not be improvised. The medical teams must be coordinated by an emergency physician in prehospital, a doctor anesthesiologist-resuscitator at the reception. Some systematic gestures such as preparation of the reception allow to optimize the management of the time. Introduction: Benign cranial trauma is a major public health problem due to both its frequency and the health costs it creates. The aim of this study was to identify relevant clinical factors that could predict the achievement of brain CT and situations at risk for neurosurgical care and for which CT was a necessity. Patients and methods: This is a 24 month prospective study, including 404 patients with benign traumatic brain injury (Glasgow coma score GCS ≥ 13), patients under 16 years of age and patients with GCS < 13 were excluded. Epidemiological, clinical, paraclinical, therapeutic and evolutionary parameters were studied. A multivariate and univariate statistical study was carried out to reveal the predictive factors of a CT anomaly and the predictive factors for the neurosurgical care. Data were entered and analyzed using SPSS 16.0 and Excel 2007 software. Results: The average age of patients was 34 years with a predominance of male, and sex ratio of 4.05. The cause of the BTB was mainly represented by the accidents of the public road in 73.27% of the cases. 28.22% of the patients were asymptomatic, the most common symptomatology was dominated by the initial loss of consciousness (52.72%), headache (35.64%). The Glasgow Coma Score was distributed as follows-GCS 15 (54.95%), GCS 14 (35.9%) and 13 (9.15%). 38.9% of patients had clinical signs of trauma to the skulland or face. Brain CT was performed in 88.4% of patients, and 25.5% had abnormal CT. The use of neurosurgical care was of the order of 3.22%. In univariate analysis-the predictive factors for a CT abnormality were the Intoxication during the brain trauma, the GCS < 15, Signs of trauma in the skull face, the vomiting, the Initial loss of consciousness, the Comitial crisis and the predictive factors of neurosurgical care were the GCS < 15, the anisocoria, Headache, the vomiting, the amnesia, the Initial loss of consciousness, the Comitial crisis, the anormal CT, the Extradural hematoma or the Subdural hematomat In multivariate analysis-the predictive factors for a CT abnormality were the GCS < 15, the Initial loss of consciousness and the predictive factors for the use of neurosurgical care were the GCS < 15, Signs of trauma in the skull face, the amnesia, the Comitial crisis, the HSD. Conclusion: an algorithm must be applied in collaboration between resuscitators and neurosurgeons to improve the quality of benign cranial trauma management.

Prognostic value of hyperchloremia in patients with traumatic brain injury: a prospective observational study Taghouti Introduction: Background-Traumatic brain injuries (TBI) are a major public health problem. They are the leading cause of death among those aged less than 40 years. Hyperchloremia is a common electrolyte disturbance in patients with TBI. Hyperchloremia has been associated with increased morbidity and mortality in critically ill patients + however, its prognostic significance in TBI patients is poorly documented. The aim of this study is to describe the prevalence and outcomes of hyperchloremia in patients with TBI admitted to the intensive care unit. Patients and methods: In a prospective design, we included 43 consecutive patients with TBI (37 males + median age-52 years) admitted to the ICU in Charles Nicolle Hospital of Tunis from Mars to September 2017. Adult patients (aged ≥ 18 years) with isolated TBI or associated with minor extra-cranial injuries (defined as all non-head Abbreviated Injury Scale < 3) were included. Hyperchloremia was defined as a chloride level > 110mEg/l. Clinical and laboratory variables were compared between survivors (n = 36) and non-survivors (n = 7). We assessed the association between hyperchloremia 24-h post-admission and 30-day mortality. p < 0.05 was taken to indicate statistical significance. Results: The median SOFA score at T0 was 7 points and the median IGS 2 score was 32 points. The median ISS was 25 points. There were 11 cases of mild head injury, 12 moderate head injury and 20 severe head injury. The 30-day mortality was 16%. Hyperchloremia occurred in 15 patients (35%) and the incidence was significantly different between survivors and non-survivors (28 vs. 72%, respectively, p < 0.001). In addition to hyperchloremia (p = 0.018), other laboratory variables were associated with 30-day mortality-hypernatremia (p = 0.011) and hypoalbuminemia (p = 0.024). Conclusion: Hyperchloremia 24-h post-admission was associated with 30-day mortality in patients with TBI. This index could be useful prognostic marker. Efforts should focus on the prevention of hypernatremia and hyperchloremia in this vulnerable group of critically ill patients.

Child traumatic brain injury Naili Amine 1 1 Blida Rp, ALGÉRIE Correspondence: Naili Amine -drnailiamine@yahoo.fr Annals of Intensive Care 2018, 8(Suppl 1):P-07 Introduction: Brain injury in children is common and mild in most cases, but it remains the leading cause of death and disability in children over 1 year of age worldwide. The peculiarity of the child is that he possesses not mature brain and that the consequences of injuries acquired by traumatic brain injury can lead to the loss of capacities, as well as the non-acquisition of function, but above all the risk impact on learning abilities. The objective of the study is to define the incidence rate of cranial trauma in children as well as the mortality and morbidity of this scourge which presents a major public health problem. Patients and methods: It is a descriptive retrospective study of a series of 186 children hospitalized in neuro-resuscitation service during the period January 01 to December 31, 2016, including 22 children admitted for cranial trauma. Clinical, para-clinical, etiological and therapeutic data were collected from hospitalization records. Results: In a series of 186 children hospitalized during the defined period, 22 children were admitted for cranial trauma, i.e. a frequency of 12%. The average age was 6 years [6 h of life-14 years], with a sex ration of 1 Among the 22 children, 12 had severe head trauma, a rate of 55% + whose causes are variable-6 road accidents, 3 domestic accidents, 2 traffic accidents, and 1 obstetric accident, admitted with a pediatric Glasgow score between 5 and 10, and all required mechanical ventilation of the 22 head trauma, 10 were operated for different lesions-3 extra-dural hematomas, 3 cranio-cerebral wounds, 2 subdural hematomas, 1 decompressive craniectomy, and 1 embarrure. 02 children had died following severe head trauma, i.e. a mortality rate of 9%, the morbidity rate of head trauma in the Tipaza wilaya was 1.1 100,000 children year, the average length of stay in intensive care units was 22 days, with several complications of decubitus, and functional due to the primary and secondary lesions of the cranial trauma.

The head trauma of the child is a public health problem, its functional prognosis can be dramatic when it is severe, its management must be early and multidisciplinary. Introduction: The aim of the study was to identify factors predicting lung contusion in trauma children. Patients and methods: Retrospective study conducted for a period of 8 years (January 01, 2005-December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared-those with lung contusions (C + group) and those without lung contusions (C − group). Results: We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2 + 95% confidence interval [CI], 1.2-8.6 + p = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1 + 95% CI 1.1-1.2 + p = 0.017), hepatic contusion (OR 4.8 + 95% CI 1.3-17.1 + p = 0.017), and pelvic ring fracture (OR, 3.5 + 95% CI 1.1-10.5 + p = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C + group (OR, 2.5 + 95% CI 1.2-5.4 + p = 0.021). However, mortality was not differentbetween the 2 groups after adjusting for PRISM score (OR, 1.2 + 95% CI 0.5-2.9 + p = 0.752) or after adjusting for Injury Severity Score (OR, 0.7 + 95% CI 0.3-2.1 + p = 0.565). Conclusion: Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patientswith road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture. Introduction: Chest trauma is often associated with pleural effusion (hemothorax and or pneumothorax). Drainage of the pleural space by a chest tube is a common intervention in such situations. Blunt dissection technique with a Kelly clamp is preferred to classical trocar techniques to prevent severe complications, like perforation of thoracic or abdominal organs. Despite these precautions, malposition remains the most common complication of tube thoracostomy. We investigated a new technique of bougie-assisted chest tube insertion to prevent chest tube malposition after chest drainage of post traumatic pleural effusion. Patients and methods: We performed a controlled before-and-after study to assess the ability of a bougie-assisted chest tube insertion technique, compared to a standard blunt dissection technique, to prevent chest tube malposition. For the bougie-assisted group, we used a disposable Eschmann-style bougie, commonly used to guide the endotracheal tube during difficult intubations. Technique consisted in blunt dissection until the parietal pleura is opened. Thoracostomy tube was preloaded onto the bougie and bougie was advanced alongside the finger, with apical or caudal direction after entering the chest cavity, depending on the type of pleural effusion. Thoracostomy tube was then advanced forward utilizing a Seldinger technique. The primary end point was optimal position of the chest tube. The tube position was blindly assessed on standard chest X-ray. In pneumothorax, optimal position was apical (above the aortic arch), and in hemothorax or mixed-effusion it was basal (2 cm above the diaphragm or lower). Results: A total of 58 patients were enrolled (bougie-assistedn = 30 + conventional-n = 28). Chest tubes were optimally position in 29 (96%) in bougie-assisted group and 12 (43%) in conventional group, OR 38.5, IC 95% = [4.6-325.16], p < 0.0001. Efficacy of chest drainage (defined on chest X-ray as the absence of visible pleural line for pneumothorax and as a clear costophrenic angle for hemothorax) was assessed in 29 (96%) in bougie-assisted group and in 15 (53%) in conventional group, OR 25.13, IC 95% = [3.00-210.93], p < 0.001. Average procedure time was 281 s (95% CI 120-360 s) for bougieassisted group and 558 s (95% CI 318-900 s) for conventional group, p < 0.0001. No severe complication was observed in both groups. Conclusion: Bougie-assisted chest tube insertion technique prevents chest tube malposition, is safe, effective and shortens procedure time for the post traumatic pleural effusion drainage. Introduction: Infectious complications determine the prognosis of burned patients. However, the emergence of bacterial resistance to antibiotics threatens treatment efficacy, which is due to an inadequate antibiotic consumption inqualitative and quantitative terms. The objective of this study was to describe the profil of consumptionand susceptibility to antibiotics. And, to explore the predictive factors for theemergence of MRB in the service of burns and plastic surgery. Patients and methods: It is a retrospective study including 122 severe burnedpatients hospitalized for 2 years in the plastic surgery department of theuniversity hospital Ibn Rochd from January 2015 to December 2016. Bacterialecology was described, and the distribution of the seeds by group, by species andby period of time was detailed. The DDD 1000JH (daily defined dosage reportedin 1000 days of hospitalization) was used to assess the consumption of antibiotics. P correlation coefficients were calculated to explore the association betweenconsumption of antibiotics and the emergence of the BMR (Multiresistantbacteria), and identified predictors of this emergence. Results: On 512 samples taken, 539 bacterial and fungal strains were identified, with a predominance of P. aeruginosa (21.15%), A. baumani i (13%) and S. aureu s (13%), the number of strains increased with the duration of the stay reaching itsmaximum from 28 days in hospital. The ceftazidine (212.7 DDD 1000DH), imipenem (139.7 DDD 1000DH), and amikacin (122.4 DDD 1000DH) were themost used antibiotics during our study, also + the profile of consumption increasedbetween 2015 and 2016.362 BMR were isolated + the EBLSE were at the top (24.5%) follow up of theCRPA (21.8%), followed by the IRPA (20.7%) follow-up of the CRAB (17.1%) then the IRAB (13.5%) and finally the MRSA with a portion of 2.2%. The profile of bacterial resistance has varied significantly for severalantibiotics bacteria pairs. Conclusion: It remains difficult to show correlations between antibioticconsumption and bacterial resistance. However, these data are particularly usefulin the epidemiological surveillance of bacteria to better guide probabilisticantibiotic therapy.

Introduction: Eclampsia is a rare but serious threat to maternal and fetal well-being. The aim of this study was to assess the incidence of eclampsia and its morbidity and mortality. Patients and methods: We conducted a retrospective survey in a third level Tunisian university teaching hospital from January 2004 to December 2016. We included all patients with the diagnosis of eclampsia. Results: In study period 129847 deliveries were registered. 83 women with eclampsia were identified hence the incidence of eclampsia was 6.39 per 10000 deliveries. The median gestational age at the time of eclampsia was 36 weeks. No maternal deaths due to eclampsia were recorded. The delivery mode was caesarean section in 100% of eclamptic patients. The recurrence of eclampsia despite magnesium sulfate prevention was observed in 6% of patients. Severe complications of eclampsia were recorded in 10.8% of patients-4 posterior reversible encephalopathy syndrome, 2 acute pulmonary edema, and 3 HELLP syndrome. 10.8% of new born were preterm. There were 5 stillbirths and 2 neonatal deaths. Conclusion: The incidence of eclampsia was very high probably due to center effect. It's essential to raise awareness among mothers in the community regarding early signs and symptoms of preeclampsia eclampsia and to design a better tracking system for antenatal care program. Introduction: To monitor maternal mortality which is an indicator of the quality of obstetrical care and anesthesia resuscitation, Our country worked to set up several programs targeting maternal and child health. The aim of this work was-To evaluate the maternal mortality rate in our department and its evolution. To Identify the cause of death and classify it depending on whether it is preventable or not. To spot the deficiencies either in the care management or the organization of the care system. To propose ways to improve our care and to fill the failures. Patients and methods: It was a retrospective study about maternal death, performed at the Department of Gynecology and Obstetrics, over a 25-year period (from 1990 to 2015) , that have reported 14 cases of maternal death according to the World Health Organization definition. Results: The Maternal Mortality Rate (MMR) was 22.43 for every 100,000 live births. The average age of our patients was 32.3 years. The main risk factors for maternal mortality are unfavorable socioeconomic conditions, high-risk pregnancies, multiparity, primiparity and a poor follow-up of the pregnancy. The main causes of maternal death are represented by direct obstetric causes (80%) allocated as followspostpartum hemorrhage (45%), pregnancy toxemia (14%), acute fat hepatic steatosis (7%), infection (7%) and complications of anesthesia (7%). Indirect obstetric causes were found in 20% of deaths. Death was considered avoidable in 78.58% of cases. Conclusion: At the end of this work, we were able to pull several recommendations in order to reduce M.M.R. Health education. Facilitate access to care for the parturient, improve care and conditions of childbirth. Continuous training of the medical and paramedical staff. 

Introduction: Mechanical ventilation can help improve the prognosis of sepsis. While adequate delivery of oxygen to tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at intensive care unit (ICU) admission affects mortality at day 28 (D28) in patients with septic shock subjected to mechanical out-of-hospital ventilation. Patients and methods: We performed a monocentric retrospective observational study on 77 patients with septic shock admitted to the ICU. PaO2 was measured at ICU admission in patients subjected to invasive ventilation before any hospital admission. The primary outcome was mortality at day 28 (D28). Results: Forty-nine (64%) patients with septic shock were mechanically ventilated before any hospital admission and transferred to the ICU. The mean PaO2 at ICU admission was 153 ± 77 and 202 ± 82 mmHg for alive and deceased patients at D28, respectively. PaO2 was significantly associated with mortality at D28 (p = 0.04). Using a ROC curve, the corresponding AUC was 0.70 [0.54-0.85]. For a PaO2 > 150 mmHg, the OR for mortality at D28 was 4.20 [1.25-15 .95] (p = 0.02), whereas for a PaO2 < 150 mmHg, the OR was 0.24 [0.06-0.80] (p = 0.02). Conclusion: In this study, we report a significant association between hyperoxemia at ICU admission and mortality at D28 in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The adjustment of the PaO2 is a crucial prognosis factor in patients with septic shock subjected to invasive out-of-hospital ventilation to avoid the toxic effects of hyperoxemia. However, blood gazometry is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of prehospital invasive ventilation. Introduction: Nowadays, benefit of enhanced CT-scan in positive diagnosis of acute pulmonary embolism (PE) is well established. It also allows evaluation of PE's burden on the right heart and shows several signs of acute cor pulmonale (ACP). Objectives -We aimed to assess benefits of control CT-scan 24 h after thrombolysis in acute PE. Patients and methods: We retrospectively enrolled patients with confirmed PE whom have been thrombolysed between January 2014 and August 2017 and controled with an enhanced CT-scan 24 h after thrombolysis. Assessement criteria were: Qanadli obstruction index; Signs of ACP-right ventricle diameter left ventricle diameter (RVD LVD) and paradoxical interventricular septum (IVS). Non inclusion criteria were: lack of initial or control CT-scan. Results: During the study period (3 years and 8 months) we admitted 1790 patients from whom 98 patients had acute PE (5.5%). Very severe patients that were thrombolysed as rescue therapy without initial CTscan and those who died before control CT-scan were not included. We enrolled 33 patients-high risk mortality PE (n = 10, 30.3%) and intermediate high risk PE (n = 23, 69.7%). Mean age was 60 years and sex-ratio was 1.06. At admission, mean severity scores were 22.1 ± 9.4 for SAPS II and 7.6 ± 4.2 for APACHE II. Evolution criteria are listed in Table 1 . Conclusion: Control CT-scan is highly useful 24 h after thrombolysis. It allows evaluation of response to pharmacological thrombolysis of acute PE and shows significative resolution of arterial obstruction degree and signs of ACP.

In December 2016, after cancellation of the budget for a Christmas tree, the nurses and caregivers of the night team spontaneously made and hung Christmas decorations in our Intensive Care Unit to make patients and their families feel better. The context was difficult with controversies around secularity. The town of Paray Le Monial had been forced to remove a Nativity scene and the city of Melun had been criticized for setting one up. So we found it important to assess the perception of the approach by patients and relatives. Patients and methods: Decorations -Hand-colored patterns about Christmas theme printed on A4 paper Decorations brought by the staff or already possessed by the unit-Christmas balls, garlands, silver starDecorations made with service equipment-Christmas tree consisting of inflated non-sterile gloves, cardboard, figurative Nativity scene without a recognizable figure in a cardboard box with cotton, bed sheet to simulate snow. Evaluation -All visitors and conscious patients received an anonymous single choice questionnaire with numerical scale and free fields from December 15th to December 31st, 2016. Results: 59 answers were received, including-No negative opinion. 1 neutral answer by a person who had not noticed the decorations. 54 positive or extremely positive opinions. No answer without data. The comments pointed out the originality, the good idea, the warm comforting side. Some asked for more decorations. Others found them sober. 

The results show the good perception of the spontaneous action by the patients and their relatives. There was no negative response, particularly offend persons. However, it is possible that relatives or patients with negative opinions did not dare to express themselves. The initiative demonstrated a good cohesion of the night paramedical team, encouraging the interns and the day teams to take part in the coloring of the decorations. The initiative was initially aimed at the wellbeing of the patients and their relatives. However it has enabled an activity similar to preventing psychosocial risks among the healthcare team, allowing them to adopt a positive attitude in their approach to care. In addition, no significant costs were incurred thanks to the use of cheap materials, mainly recycled cardboard and standard quality white paper.

The spontaneous decoration of our Intensive Care Unit by the night care team was very well received by the patients, their families and their relatives. The initiative also made possible to enhance team cohesion and to value it. The associated costs were negligible. ventricular contractions. BP monitoring revealed a greater diastolic BP throughout 24 h as well as during night-time. Systolic BP higher than 125 mmHg during sleep time was observed in 55% of participants. The frequency of arrhythmias and blood pressure variability are correlated with the increase in work stress and conflicts. Conclusion: Our results highlight the extent incidence of arrhythmia and blood pressure variability during intensive care unit night's shift probably due to the increased neuroendocrine stress response. (55%) and QRS enlargement (50%). AMI was responsible for a significantly deeper coma (p < 0.0001) but fewer seizures than CLO (p = 0.02). Three patients (5%) died. Based on a univariate analysis, factors associated with death were cardiac arrest onset (p = 0.003), elevated plasma lactate concentration (p = 0.005), low arterial pH (p = 0.007), reduced PaO2 FiO2 ratio (p = 0.007) and prothrombine ratio (p = 0.008), increased aspartate aminotransferases (p = 0.009), alanine aminotransferases (p = 0.01) and serum creatinine concentration (p = 0.01) as well as marked catecholamine infusion rate (p = 0.02).

The pharmacokinetic study showed significant increase in AMI (43 h vs. 24 h) and CLO (55 h vs. 21 h) elimination half-lives in overdose compared to pharmacological conditions, highlighting the contribution of organ failure to the delayed elimination of both toxicants. Conclusion: AMI and CLO poisonings did not disappear and are still responsible for significant morbidities and mortality. AMI was responsible for deeper coma with fewer seizures in comparison to CLO. AMI and CLO elimination half-lives were significantly prolonged in overdose due to organ failure. Introduction: Severe poisonings and fatalities have been attributed to buprenorphine (BUP) despite its ceiling respiratory effects, mainly if abused in co-ingestion with benzodiazepines. We previously showed that diazepam (DZP) BUP combination induces severe respiratory depression in the rat, while each drug by itself does not. The objective of this study was to investigate the mechanisms involved in this drug-drug interaction using 11C-BUP PET imaging and diaphragmatic electromyography in the Sprague-Dawley rat. Patients and methods: 11C-BUP was administered intravenously, 30 mg kg unlabeled BUP intraperitoneally and 20 mg kg DZP subcutaneously. PET acquisition started with 11C-BUP PET injection, 15 min after DZP or its vehicle (VEH + N = 5 group) administration. SUV normalized time activity curves (TACs) were generated and 11C-BUP binding potential [BPND, i.e. the ratio of the total receptor density (Bmax) on the equilibrium dissociation constant (KD)] were modeled in different brain regions using a simplified reference tissue model with cerebellum as reference region. dEM, implanted under anesthesia 7 days before the experiment, was recorded during 240 min in rats receiving VEH VEH, DZP VEH, VEH BUP or DZP BUP (N = 6 group). After filtering and half-wave rectification, the first 60 min AUC of diaphragm contraction and workload were determined and compared between the groups. Results: TACs and 11C-BUP BPND were not different between the DZP BUP and the VEH BUP groups in all studied brain regions. Diaphragm contraction was significantly increased in the VEH BUP group in comparison to the DZP BUP group (p < 0.05). Diaphragm workload was significantly increased in the VEH BUP group in comparison to the DZP VEH and the DZP BUP group (p < 0.05 and p < 0.01 respectively). Discussion: DZP did not affect the 11C-BUP brain distribution and brain binding suggesting that DZP does not affect BUP transport across the blood brain barrier and BUP receptors density affinity. BUP administration induced an increase in diaphragm contraction and workload. This increase was inhibited in the presence of DZP suggesting that DZP BUP combination-induced respiratory depression is mostly related to DZP. Conclusion: Respiratory depression related to DZP BUP combination results from a pharmacodynamic drug-drug interaction. Introduction: Since the banning of dextropropoxyphene from the market, overdoses and fatalities attributed to tramadol, a WHO step-2 opioid analgesic, have increased markedly. Tramadol overdose results not only in central nervous system (CNS) depression attributed to its opioid properties but also in seizures, possibly related to nonopioidergic pathways, thus questioning the efficiency of naloxone to reverse tramadol-induced CNS toxicity. Our objective was to investigate the most efficient antidote to reverse tramadol-induced seizures and respiratory depression in overdose. Patients and methods: Sprague-Dawley rats overdosed with 75 mg kg intraperitoneal (IP) tramadol were randomized into four groups to receive solvent (control group), diazepam (1.77 mg kg IP), naloxone (2 mg kg intravenous bolus followed by 4 mg kg h infusion) and diazepam naloxone combination. Sedation depth, temperature, number of seizures and intensity, whole-body plethysmography parameters and electroencephalography activity were measured. For each parameter, we compared the areas under the curves using Mann-Whitney tests for two-by-two comparisons between the four groups. Regarding the effects of treatments on seizures, comparisons were performed using two-way analysis of variance followed by multiple comparison tests using Bonferroni's correction. Results: Naloxone reversed tramadol-induced respiratory depression (p < 0.05) but significantly increased seizures (p < 0.01) and prolonged their occurrence time. Diazepam abolished seizures but significantly deepened rat sedation (p < 0.05) without improving ventilation. Diazepam naloxone combination completely abolished seizures, significantly improved rat ventilation by reducing inspiratory time (p < 0.05) but did not worsen sedation. Based on the EEG study, tramadol-treated rats experienced electro-clinical seizures as soon as 5 min after the injection, characterized by spike-waves and polyspikes with progressive decreased frequencies and inter-critical phases of slow delta waves until the next crisis. After diazepam naloxone injection, EEG waveforms consisted in 8 Hz-alpha rhythms and slow-down theta rhythms of drowsiness. None of these treatments significantly modified rat temperature. Conclusion: Diazepam naloxone combination is the most efficient antidote to reverse tramadol-induced CNS toxicity. Our experimental data greatly encourage administering this combination rather than naloxone alone as first-line antidote in tramadol-poisoned patients as an alternative to tracheal intubation. Introduction: Rubigine ® poisoning is a medical emergency that causes a major public health problem in underdeveloped countries, as it is frequently fatal. This poisoning is rare in France, but frequent in the French overseas departments (DOM). The Rubigine ® , made of fluoride and used as a rust remover, is the main source of poisoning in the Caribbean. In Martinique, the exact incidence of this intoxication is unknown, as there is no national and regional register. It could represent up to 8-10% of severe acute poisoning. It was not until April 1994 that, following a prefectural order on the declaration, classification, packaging and labeling of substances, the composition of Rubigine ® was modified to significantly reduce the mortality induced by its ingestion. The objective of our study was to describe the clinical features and complications that can occur after ingestion of Rubigine ® as well as to determine the prognostic factors of death.

We conducted a retrospective study over 16 years, from 2000 to 2016, including all patients admitted to emergency and intensive care units of the University Hospital Center (Martinique) for acute Rubigine ® poisoning. The usual demographic and clinical data were collected and comparisons between surviving and deceased patients were performed using a univariate analysis. Results: Fifty-five patients (mean age-43 years (15-82) + sex ratio male female-1,1) were hospitalized at the University Hospital of Martinique. One-quarter of patients had no significant history. The average length of stay was 3.3 days (1-37). Forty percent of patients experienced hypocalcaemia after initial intravenous calcium supplementation. Complications included acute respiratory failure requiring invasive mechanical ventilation (22% of patients, duration of ventilation-2.8 days, (1-16)), renal failure (20%, of which 50% required extrarenal treatment, hemodynamic failure (16%), hepatic failure (15%), coagulation failure (15%), neurological failure (12%) and multi-visceral failure (10.9%). Three patients presented cardiogenic refractory shock requiring VA ECMO (5.5%) and another patient with digestive perforation (1.8%). The mortality was 10.9%, allowing the identification of prognostic factors of death. Conclusion: Rubigine ® poisoning is responsible for significant morbidity and mortality, despite optimal management. However, its incidence seems to have decreased sharply in recent years thanks to the strong mobilization and awareness of the population following the implementation of an information system by the University Hospital 's clinical toxicology and toxico-vigilance unit, and different preventive measures introduced by the health authorities. Introduction: Since dextropropoxyphene withdrawal from the market, overdoses and fatalities attributed to tramadol, a WHO step-2 opioid analgesic drug, have increased markedly. Besides central nervous system depression, tramadol overdose may result in seizures, usually included in the related serotonin syndrome. However, the serotoninergic mechanism of tramadol-induced seizures has been recently questioned. We investigated the effects of various specific pretreatments on tramadol-induced seizure onset and alterations in brain monoamines in the rat. Patients and methods: Sprague-Dawley rats were randomized into five groups (N = 6 group) to be pretreated with various agonists antagonists before receiving 75 mg kg tramadol intraperitoneally-1.77 mg kg IP diazepam + 2 mg kg IV bolus followed by 4 mg kg h infusion naloxone + 10 mg kg IP cyproheptadine, and 15 mg kg IP fexofenadine. Seizure severity was graded according to the modified Racine Score (1). We measured neurotransmitter concentrations in the frontal cortex using high performance liquid chromatography coupled to flurorimetry or radioenzymatic assay, as required. We used positron emission tomography-computed tomography to investigate Interactions of tramadol with GABA-A receptors. The effects of treatments on seizures were compared using two-way analysis of variance followed by multiple comparison tests with Bonferroni's correction. The Areas under the curves of the effects on monoamine concentrations and the binding potentials in the PET-imaging study were compared two-by-two using Mann-Whitney U tests. Results: Diazepam abolished tramadol-induced seizures, by contrast to naloxone, cyproheptadine and fexofenadine pretreatments. Interestingly, despite seizure abolishment, diazepam significantly enhanced tramadol-induced increase in the brain serotonin (p < 0.01), histamine (p < 0.01), dopamine (p < 0.05) and norepinephrine (p < 0.05) while no significant modifications were observed with the other tested pretreatments. Based on Positron emission tomography imaging using 11C-flumazenil fixation in the rat brain, we demonstrated molecular interaction between tramadol and γ-aminobutyric acid (GABA)-A receptors not related to a competitive mechanism between tramadol and flumazenil on the benzodiazepine binding site.

Our findings clearly ruled out the involvement of serotoninergic, opioidergic, histaminergic, dopaminergic and norepinephrinergic pathways in tramadol-induced seizures while strongly suggested tramadolinduced specific allosteric change in GABAA receptors that could contribute to seizures onset in overdose. Conclusion: Tramadol-induced seizures in overdose are mainly related to the GABAergic pathway. Introduction: Heparin-Induced Thrombocytopenia (HIT) is a serious iatrogenic complication of heparinic treatments. The diagnosis of HIT is difficult in the resuscitation environment because thrombocytopenia is a frequent and multifactorial phenomenon. The aim of this work was to study the clinical and biological presentation of patients with HIT and the consequences attributable to HIT on the evolution of patients in terms of morbidity and mortality and to develop a diagnostic strategy for HIT for resuscitation patients.

This was a retrospective, monocentric, descriptive and evaluative study conducted in our intensive care unit (ICU) over a period of 4 years 6 months. An anti-PF4 antibody test was performed in patients who developed thrombocytopenia or a 30% drop in their initial platelet kinetics and the clinical picture. Results: The incidence of HIT was 1.71% in patients hospitalized in ICU. The clinicobiological severity scores, the reasons for admission to resuscitation were similar in both groups (HIT+ and HIT−) as well as the characteristics of the heparins used. The time of occurrence of thrombocytopenia was similar in the two groups. The diagnosis of HIT was more often the only plausible diagnosis in the HIT+ group. The 4T's score was significantly higher in the HIT+ group. The evolution of the platelet count was similar in the two groups, in the decay phases as well as in the recuperation phase. HIT+ patients showed significantly more thrombosis than HIT− patients. There was no significant difference between the transfusion needs of HIT+ and HIT− patients. Mortality was identical in both groups, as was the length of stay in ICU. Conclusion: HIT is a rare disease. There was no evidence of a predisposing factor for the occurrence of the disease in a uniform resuscitation population. The diagnosis of HIT is based on a cluster of arguments and not on an isolated event. Biological tools are indispensable, in a complementary way to the clinical picture.

Pulmonary embolism in patients with sickle cell disease in intensive care unit: a challenging diagnosis Jamoussi Amira 1 , Zayet Souheil 1 , Merhebene Takoua Results: During the study period, a total of 26 patients with SCD were admitted. Among them, 20 presented with respiratory distress and chest pain and then benefited first of trans-thoracic echocardiography that often showed right ventricle dilation and systolic PAP > 30 mmHg (n = 11). All the 20 patients underwent enhanced CT-scan and the diagnosis of PE was finally retained in 6 cases (18.8%) and hence colliged.

The average age was 32.5 years ± 9.4 [20-42 years] with a sexratio = 1. The mean of APACH II score was 7. SCD were diagnosed at the age of 8.2 years ± 6.2 [3-15 years] with a regular follow up in 83%. The reason for admission was acute respiratory failure in all cases. Patients had clinical symptoms of pneumonia: pleuritic chest pain (n = 6), dyspnea (n = 5) and fever (n = 2). All patients had a chest X-ray showing an alveolo-interstitial syndrome in 4 cases (66.6%) and an associated pneumonia in 2 cases ( Introduction: Acute chest syndrome (ACS) is the most severe complication of sickle cell disease and its evolution is unpredictable. Acute pulmonary hypertension (PH) in ACS is associated with an increased mortality, but its mechanism remains poorly known. Our hypothesis is that acute PH is associated with a biological state of hypercoagulability in ACS.

In a prospective single center study, all consecutive SCD patients with ACS admitted to the intensive care unit (ICU) of Tenon hospital were included. Specialized haemostasis dosages were performed on ICU admission. A trans-thoracic echocardiogram was also performed on admission, and was repeated at steady state. Results: Among 29 patients with ACS, 22 had a trans-thoracic echocardiogram and 6 had a high echocardiographic probability of acute PH, including 1 patient with bilateral pulmonary embolism and 1 patient who developed multiple organ failure and died. There were no significant clinical, biological or radiological differences between patients with a low-intermediate probability of acute PH and those with a high probability of acute PH+ their evolution was similar. The exploration of haemostasis did not show between-group differences, regarding each parameter of haemostasis. However, when using a hierarchical cluster analysis, distinct profiles of coagulation were evidenced, defining 3 biological classes. The subset of patients with a high echocardiographic probability of acute PH was more frequent in biological classes 2 and 3 which corresponded to hypercoagulability states. Acute PH was transient in patients (n = 17) with a repeated echocardiography at steady state. Conclusion: Acute PH may likely occur in patients with ACS and a biological condition of hypercoagulability. Further studies are needed to confirm these findings.

Gorham Julie were the two independent predictors of survival after hospital discharge.

In lung cancer patients admitted into the ICU, the mGPS is an independent predictor of survival after hospital discharge but not for mortality during ICU stay. This inflammatory score could therefore be used as a long-term prognostic marker in this population of patients and would be more reflective of cancer, than reflecting the acute complication leading to ICU admission. Prospective and multicentric studies must be carried out to validate these results. Introduction: Recombinant active factor VII is a pro-hemostatic treatment used in obstetric haemorrhage, but no study has made it possible to specify its exact place in the decision algorithm. The objective of our work is to evaluate the efficacy and the benefit risk ratio of recombinant factor VIIa in the treatment of severe postpartum hemorrhage.

We conducted a prospective study at the IBN JAZZAR University Hospital in Kairouan during the period from January 1, 2015to December 31, 2016. In total, we collected 15 cases of recombinant factor VIIa in one postpartum haemorrhage. Results: The mean age of our patients was 31 + 5.96 years. The rate of childbirth was 33.33%. The caesarean was the mode of delivery chosen for 10 patients. The causes of postpartum haemorrhage in our series were-uterine atony in 5 cases, uterine rupture and cervicouterine tear 3 cases each, retroplacental hematoma and placenta accreta 1 cases for each two and placenta praevia in 2 cases. Our patients were treated in an intensive care unit and the average hospital stay was 4.1 days. Sulprostone was reported in 7 cases (46.6%), and all patients received a massive transfusion. The average time to administer rFVIIa was 6 h 40 min. The mean dose of factor VIla recombinant was 78.8 ± 9.24 μg kg. Five patients received a single dose, 8 patients received a second injection and 2 patients received 3 doses. Clinical efficacy-After a single injection, clinical efficacy with reduction in bleeding was observed in 8 patients, i.e. 60%. The most frequent complication was insufficiencyrenal in 7 cases including 2 requiring hemodialysis, CIVD in 4 cases, OAP in 2 cases, a multivisceral failure in 2 cases, a septic shock in 1 case and a mesenteric infarction in 1 case. The progression was favorable in 12 patients, while 3 patients died (21.9%). Conclusion: It is important that new studies be carried out and shared experiences around the world on this drug appear to be effective and prevent invasive actions in the therapeutic arsenal of postpartum heamorrhage. Introduction: Post-partum haemorrhage (PPH) is a life-threatening complication and remains a leading cause of maternal morbidity worldwide. The WOMAN trial* estabished that early administration of Tranexamic Acid (TA) reduces mortality due to the bleeding in women with PPH. Our study purpose was to determine the effects of early administration of TA and fibrinogen concentrate on death, hysterectomy and transfusion in women with severe PPH. Patients and methods: This retrospective, monocentric study was performed in a third level Tunisian hospital providing healthcare for more than 10000 pregnant women per year. Were included in this study women with diagnosis of severe post partum haemorrhage after a vaginal or caesarean delivery from 2014 to 2016. Patients who received TA and fibrinogen concentrate were assessed in group 1(G1) and who not in group 2(G2). Results: The incidence of severe PPH was 35/10000 deliveries. 166 women were retained for data analysis G1 (n = 109), G2 (n = 57). Anthropomorphic and obstetrics characteristics were not significantly different between the two groups. There was a significant difference between the two groups regarding to transfused units of red blood cells however, no difference in term of the use of frozen plasma and platelets concentrates was observed. Perioperative hemoglobin nadir was significantly higher in G 1. The frequency of hysterectomy and pelvic packing were higher in G2 (Table 1) . No thromboembolic events and no haemorrhage related mortality were observed in the two groups.

Conclusion: In this retrospective study, early administration of tranexamic acid and fibrinogen reduces risk of hysterectomy transfusion. These encouraging results strongly support the need for a large, international, double-blind study to investigate the potential of the association "TA-Fibrinogen concentrate" to reduce maternal haemorrhage related morbidity and mortality. Introduction: Immunodeficiency, acquired or congenital, is the first comorbidity associated with poor outcome in pediatric patients with acute respiratory distress syndrome 1(ARDS). The aim of this study was to describe outcome of pediatric patient with hematologic disease hospitalized in our intensive care unit for respiratory failure and to investigate the clinical variables associated with mortality. Patients and methods: It was a retrospective monocentric descriptive study including all immunodeficient pediatric patient (malignant hemopathy, congenital immunodeficiency, bone marrow transplanta-tion…) from hematology hospitalized in our 14 beds pediatric intensive care unit with the diagnosis of respiratory failure between January 2003 and February 2017. Results: Fifty one patients were included corresponding to 53 admissions. Nighty percent of the patients met criteria for pediatric ARDS-67% were severe, 15% moderate and 2% mild. Extracorporeal circulation (ECC) was needed for 7 patients. Global mortality rate at PICU discharge was 47%. Twenty four patients (45%) received noninvasive ventilation (NIV). Height of them (33%) did not need invasive mechanical ventilation (IMV). In patients who received IMV, mortality rate was significantly higher if patients received before NIV (81 vs. 41%) p = 0.001. All patients who needed IMV after more than 24 h of NIV died (n = 3). Mortality was higher in children with griffon versus host disease (80 vs. 40% p = 0.04). Mortality of patients receiving ECC and renal replacement therapy (RTT) was respectively 71 and 80%. Conclusion: In our study, most of the patients hospitalized for respiratory failure met criteria for pediatric ARDS. If NIV decrease IMV requirement, it could be associated with higher mortality rate in case of failure. This result support recent recommendation2 that immunodeficiency is not a sufficient criteria to delayed IMV. . Flow and airway pressure were recorded at the ASL inlet and mouth pressure into the manikin mouth. We defined "device driving pressure" as the peak mouth pressure minus the tele-expiratory mouth pressure. Continuous data are reported as mean ± SD. Results: As compared to the oxygen mask, Vt increased significantly with M-NIV and H-NIV whatever the simulated respiratory effort (599 ± 201 and 537 ± 217 vs. 307 ± 121 ml respectively with the moderate simulated effort, p < 0.001; Fig. 1 ). HFNC and CPAP were associated with a slight but non-significant decrease in Vt as compared to the oxygen mask. Overall, for a given respiratory effort, Vt was influenced by the "device driving pressure", which tended to decrease when using HFNC and CPAP and markedly increased with M-NIV as compared to the oxygen mask. Therefore, Vt in M-NIV with a simulated low effort was significantly higher than Vt in CPAP and HFNC with a simulated moderate effort (456 ± 162 ml, 252 ± 95 ml, and 262 ± 90 ml respectively, p = 0.01 for both comparisons). Conclusion: In our bench model, the Vt value was significantly influenced by the noninvasive ventilatory device. NIV was invariably associated with significantly higher Vt than with other devices, even when dividing by two the simulated inspiratory effort during NIV. 

Introduction: In ICU, intubation is a high risk procedure associated with high morbidity. Despite procedure's improvement with systematic application of fluid loading, early use of vasopressors and checklist use, morbidity remains high. Several recent trials has been conducted with different metrics choose as primary outcome. However any evidence exists to choose one more than another: time to intubation, first pass success, difficult intubation. First pass success sine hypoxia and hypotension (DASH-1A) has been highlighted recently and choose by the GAME program without any scientific evaluation. We conducted a post hoc analysis of the randomized clinical trial MacGrath Mac video laryngoscope or Macintosh laryngoscope for intubation in the intensive care unit (MACMAN) to determine the best metric to choose for primary outcome for the next intubation studies in ICU. Patients and methods: MACMAN was a multicentre, open-label, randomized controlled superiority trial. Consecutive patients requiring intubation were randomly allocated to either the McGRATH MAC videolaryngoscope or the Macintosh laryngoscope, with stratification by centre and operator experience. An only inclusion criterion was-"Patients must be admitted to an ICU and require mechanical ventilation through an endotracheal tube". Patients were excluded if-contraindication to orotracheal intubation (e.g., unstable spinal lesion) + insufficient time to include and randomize the patient (e.g., because of cardiac arrest) + age < 18 years + pregnant or breastfeeding woman + correctional facility inmate + patient under guardianship + patient without health insurance + refusal of the patient or next of kin to participate in the study + previous enrolment in a clinical randomized trial with intubation as the primary end point (including previous inclusion in the present trial). Post-hoc analysis was performed to assess association and prediction of life threatening complication (mild to moderate, severe, mild to severe) by different metric existing-time to intubation, first pass success, difficult intubation, first pass success sine hypoxia and hypotension. Each metric was compared with another one. Area under curve was built for every metric and all metrics were then compared. Results: DASH-1A was superior to all others metrics included in the analysis for prediction of life threatning complications (all p < 0.001).

Failure of first pass Conclusion: All metrics are not equal to predict severe life threatening complications during intubation in the ICU. In this context, we recommend adoption of definitive airway sine hypoxia or hypotension at first attempt (DASH-1A) as primary outcome for intubation studies in the ICU or as metric indicator tracked in quality improvement program.

Benbernou Soumia Introduction: IntroductionAcute respiratory failure (ARF) is a common cause of emergency use and one of the major reasons for admission to intensive care unit. It associates a vital risk imposing immediate symptomatic treatments and an etiological approach. [1] Among the etiologies of the ARF, Acute Lung Edema (ALE), decompensation of chronic obstructive pulmonary disease (COPD), chest trauma and pneumonia are the most frequent @It is a life-threatening pathology with a high incidence of mortality, since mortality is reported to be 20-40% [4, 5] for ARF secondary to cardiogenic ALE. The prevalence of ARF in Algeria remains unknown + the TAHINA study showed that respiratory diseases were the leading cause of consultation in the hospital [2] . The The objective of this study is to estimate the frequency of use of the NIV and to determine the associated factors of failure of the NIV for the adult patients hospitalized for ARF in the emergency department of Oran hospital from January 2015 to November 2016. Prevalence of COPD was found in the 31.5% of tobacco subjects [3] . The number of patients hospitalized for chest trauma continues to increase, resulting in an increase in the number of patients admitted for ARF secondary to chest trauma. Patients and methods: This is an observational and exhaustive study during the month of November, from the files of patients. The population-all subjects over 16 years hospitalized for an ARF at the reception and resuscitation units of the emergency department of Oran Hospital from January 2015 to November 2016. Results: Ninety-seven patients were hospitalized for ARF during this period. NIV was used for 37 patients. 24 patients were acute lung edema. Univariate analysis showed that SPO2 was the only failure factor in this series. The failure rate of this technique was 32.4%.

NIV is a technique that should be used more in the emergency rooms, which would make it possible to use less intubation specially in indications where the level of proof in the literature is important. demographic characteristics, etiology of exacerbation, comorbidities, the SAPSII score, arterial blood gases at admission, respiratory, hemodynamic and neurological parameters, use of noninvasive or invasive ventilation, nosocomial infection, duration of NIV, length of stay and mortality. Results: During period study 160 patients (58% women with a SAPSII score 29 ± 15) were included. The etiology of exacerbation was bronchitis in 45% of cases and pneumonia in 40%. Only 3 patients have NIV at home and 6 patients have oxygen. Pseudomonas aeruginosa was isolated in 6 cases. Twenty percent of the patients had developed a nosocomial infection, Acinetobacter Baumanii and Pseudomonas aeruginosa were isolated in 60 and 25% respectively. NIV was used in 89 patients at admission and the rate of NIV failure was 29%. The duration of mechanical ventilation was 9 ± 8 days and the length of stay was 12 ± 10 days. The mortality was 12%. NIV and oxygen at home were prescribed for 21 patients. In univariate analysis survivors and non-survivors were comparable regarding baseline and clinical characteristics. Nosocomial infections (53 vs. 16%), and SPASSII score were significantly more elevated in non-survivors. 

In emergency department, the management of hypercapnic acute respiratory failure with HFO is limited. Hypercapnia and acidosis remain moderate. Patients are old with comorbidities. The mortality rate is high but expected given the number of limitation of active therapy. HFO appears to be effective for a majority of patients, but half of them required NIV too. The NIV HFO association seems an interesting option. But our methodology is perfectible and would require a randomized control tria.

Severe chronic obstructive pulmonary disease with chronic respiratory failure in intensive care unit: mortality and prognostic factors Arnout Chloé 1 , Faure Morgane 1 , Novy Emmanuel 1 CHU Nancy, Nancy, France Correspondence: Arnout Chloé -arnout.chloe@gmail.com

Introduction: Last decades, the number of patient with chronic respiratory failure due to chronic obstructive pulmonary disease (COPD) admitted in intensive care unit (ICU) increased. Data about their real prognosis in the ICU are lacking. The objective of this study was to evaluate mortality rate at 6 months and to identify prognostic factors of COPD patients with chronic respiratory failure, treated with long term oxygen therapy (LTOT), admitted in ICU. Patients and methods: A retrospective cohort study was conducted in the French university hospital of Nancy during years 2014-2015 on all COPD patients treated with LTOT admitted in ICU. Only the first admission was analysed. Patients were included if they had spirometry, blood gas and oxygen flow in the year before admission in ICU. Other causes of chronic respiratory failure, and patients with tracheostomy before ICU admission were excluded of the cohort. Hospitalizations were selected using the International Classification of Diseases, 10 th revision (ICD-10). Results: One hundred and thirteen patients were included, 37 (33%) died in the first 6 months after ICU admission. Mortality rate in ICU was 10%. Severity of COPD was-mean BODE score 7 ± 2.1, number of exacerbation per year requiring hospitalization 3 ± 1.4. LTOT was used for 3.7 ± 3.3 years. Acute respiratory failure was the main frequent cause-38% pneumonia, 34% acute exacerbation of COPD, 14% acute lung oedema. The Sequential Organ Failure Assessment score within the first 24 h of ICU admission was 11 ± 4. Need for mechanical ventilation was noted in 22% of cases and was associated to mortality with an Odds Ratio of 3.5 (CI 95% [1.4-9] p = 0.01). In presence of other organ failure, mortality rate tends to increase. Patients with median PaO2 FiO 2 ratio > 196 on first blood gas had a reduced risk of death (OR 0.4 + CI 95% [0.1-0.9], p = 0.01). Conclusion: This is the first study to assess mortality at 6 month of patients with severe COPD requiring LTOT admitted in ICU. Severity of hypoxemia and use of mechanical ventilation are two prognosis factor of mortality. The addition of another organ failure seems to increase the mortality rate. Severity of the chronic respiratory insufficiency less influenced short and long term outcome. This data have to be included in the global decision to admit a COPD patient with LTOT in ICU. Introduction: The remarkable progress in the outpatient care of the asthmatic patient (development and access to inhaled drugs) has made the admission of these patients exceptional in the ICU. We have noticed a recent upsurge in asthmatic afmissions in the ICU, and are investigating whether this fact was related to modifiable factors (access to adapted drugs) or an increase in the severity of the disease. Patients and methods: Retrospective, observational, three-center study conducted in three Tunisian medical ICU from January 2016 to July, 2017. Were included all consecutive patients admitted for severe acute asthma in three ICUs. Were assessed-patient's demographic characteristics, asthma severity and its actual control based on Global Initiative for Asthma classification (GINA) 2016, clinical characteristics of the acute episode, length of ICU stay, ventilatory free days and mortality. Results: Out of the1142 patients admitted within the study period, 34 (3%) had severe acute asthma. The mean age was 37 years (IQR32-50.5). Sex ratio was 1. Asthma was allergic in 84% with an average ancienty of 14.7 years. Over all asthma was not very severe with no prior ICU admission for acute severe asthma 38.2% were mechanically ventilated at least one time. Were classified severe and moderate persistant asthma respectively in 42.9(%) and 19(%). 57.1% were consideredpoorly controlled. Low educational level and socio-economic status are the main determinants of poor control-20% of analyzed patients didn't have a social care, and thus no accesse to prescribed anti-asthmatics + 40% didn't have a regular follow up and 23.5% were jobless. When admitted to the ICU-23 patients (67.6%) needed invasive mechanical ventilation, one patient received NIV. The mean length of stay was 8 days (IQR 3.5-12.5). Levels of auto PEEP and PIC pressure at ICU admission were respectively 6 (IQR 1-12) and47.5 (IQR 37, 25-58.5) cm H 2 O. Mortality rate was 3%.

This study suggests that Low educational level and socioeconomic status (especially the lack of social care and joblessness) are the main determinants of poor control of asthma and may lead to the increase of rate of ICU admission for severe acute asthma requiring mechanical ventilation. Introduction: In emergency medicine, the Boussignac system (BS) is sometimes used to administer oxygen and continuous positive airway pressure (cpap). In this case, FiO 2 value depends on the ratio between O 2 flow and inspiratory flow (IF). In some cases, the FiO 2 decreases due to the IF increase. The aim of this study was to test a modified Boussignac system in order to limit the FiO 2 decreases during inspiratory flow rate increases.

The study was conducted on bench with BS connected to a two compartment adult lung model (Dual Test Lung ® ) (DTL) controlled by a Maquet Servo I ® ventilator. Three minute ventilation (MV-7.5 15 22.5 L min) with Ti Ttot = 0.33 were investigated. FiO 2 and MV measurements were made using an iWorx ® GA207 gas analyzer. With a BS, two Peep were analyzed-3 and 10 cm H2O. The BS was supplied by an O 2 flow. In order to increase the FiO 2 , we have evaluated the addition of a T piece connected to a nebulizer at the air-room admission of a BS. The aerosol was supplied by an O 2 flow of 9 L min. The O 2 flow was analyzed in continuous with a calibrated mass flow meter (Red Y Vogtlyn ™ ). Results: When MV increases, the FiO 2 decreases (p < 0.05). When Peep increases, FiO 2 increases too (p < 0.05). The addition of an aerosol (O 2 -9 L min) to a BS increases the FiO 2 (p < 0.05). However, in this last case, the gap between both FiO 2 decreases with increases MV (Fig. 1) .

The addition of an aerosol connected to an O 2 flow rate (9 L min) at the entry of a BS limits the FiO 2 decreases during the MV increases. Introduction: Burned patients are at high risk of yeast colonization and thus of invasive fungal infections, particularly to Candida (C.) spp., leading to an increase in morbidity and mortality. While pre-emptive antifungal therapy has improved survival, it may lead to an increase in antifungal resistance. The objectives of this work were to describe Candida species distribution and to determine the antifungal susceptibility of Candida isolates acquired in a burn unit.

Our study is a retrospective review of 17 severely burned patients admitted to the burn unit of the Ben Arous Traumatology and Burns Center with one or more positive culture sites for Candida, during the 16-month period from May 2016 through August 2017. A total of 42 isolates were thus obtained. The susceptibility to 6 antifungal drugs (5-fluorocytosine, fluconazole, ketoconazole, micronazole, itraconazole, amphotericin B) was determined using the Fungitest ® broth dilution method for patients with infected normally sterile body sites or a Candida colonization index superior or equal to 0.4. Since echinocandin and anidulafungine were recently introduced in Tunisia, the susceptibility to these antifungal classes was tested for only one patient from our cohort. Results: Nasal and buccal sites were the most colonized body sites (21.4% each), followed by axillary (11.9%) and rectal sites (9.5%) and urines (9.5%). C. albicans was the predominant species (45.2%), followed by C. glabrata (38.1%), C. tropicalis (7.1%) and C. parapsilosis (4.8%). Among the strains whose antifungal susceptibility was determined, majority of Candida isolates were susceptible to fluconazole (77.8%), which is the most frequently used molecule as a pre-emptive treatment in such cases in Tunisia due to its availability and its efficiency. On the other hand, 11.1% of the isolates were intermediate and 11.1% were resistant to this antifungal drug, mainly C. glabrata for both groups. As for the other tested azoles, high rates of intermediate strains were noticed (81.5% to itraconazole, 40.7% to ketoconazole and 33.3% to miconazole), mostly C. glabrata. Only one strain was resistant to amphotericin B, which is not usually used in these cases due to its nephrotoxicity and the frequency of kidney failure in burned patients.

Our study demonstrates that C. albicans is the most frequent species in burn unit-acquired candidiasis. No major antifungal resistance was observed, apart from high rates of intermediate strains (mainly C. glabrata) to azole class antifungal drugs.

Introduction: Infection, especially bacteremia, is a major cause of morbi-mortality in severely burned patients. Mortalityrelated to bacteremia in burn patients was about 30% [1] . We performed this study to determine the prevalence, the causative agents and outcomes of bacteremia in burned patients. Introduction: Carbapenems, the last line of therapy, are now frequently needed to treat nosocomial infections, and increasing resistance to this class of β-lactams limit antibiotic options in critically ill patients especially in burns. The objective of our study was to assess the impact of the detection of carbaménépases in optimizing treatments in burned. Patients and methods: A prospective, monocentric study was carried out at the intensive care unit of burn in Tunisia over 6 months (March-August 2017). Were included all patients who have had a carbapenemase research. The sample was carried out by rectal swab. All samples were analyzed by polymerase chain reaction (PCR) methods for presence of carbapenemase.

During the study period, 30 patients were included. The mean age was 30 ± 11 years. They were 24 men and 6 women. The average burned surface area was 41 ± 17%. Patients were transferred from another hospital structure in 87% of cases with a delay of 86 h. 90% of patients had a septic complication with a delay of 5 ± 3 days. Antibiotic treatment was empirical in 23 cases. The therapeutic failure rate was 60%. Results of carbame-nepases detected by PCR are detailed in Table 1 . In the group of patients PCR (+), the antibiotic treatment was changed in 18 cases. The most association of antibiotics were-tigecycline in combination with colistin or in combination with fosfomycine and fosfomycin in combination with colistin. This leads to reduce therapeutic failure by 20%. Conclusion: Detection of carbapenemase in our study was higher (80%), allows us to identify regions with high risk of carbapenemase, improve therapeutic efficacy and strengthen infection control measures by isolation of all carbapenemase producing patient. Introduction: ICU-acquired bacteraemia is prevalent and poses a grave threat. Providing information about the main causative bacterial agents and determination of their susceptibility to antibiotics may improve empiric therapy and early detection of emerging antimicrobial resistance. The aim of this study was to investigate the species distribution and antibiotic susceptibility of isolated strains from blood culture in Burn Intensive Care Unit during a five-year period. Patients and methods: From January 2012 to December 2016, a total of 2,182 non repetitive strains were isolated from blood cultures. Incubation of blood culture vials and the detection of bacterial growth were performed by the BACTEC system. All Isolated organisms were identified on the basis of standard microbiological techniques. Antibiotic susceptibility testing was carried out by the agar disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to CA-SFM 2013 and 2015 guidelines. Data were analyzed using the SIR-system. Minimum inhibitory concentrations of colistin, imipenem and vancomycin were determined using the Etest ® method (bioMérieux). Results: Of the 2,182 strains isolated, the most frequently identified species were Staphylococcus aureus (21%), Acinetobacter baumannii (11%), Klebsiella pneumoniae (10%), and Pseudomonas aeruginosa (9%). The rate of methicillin-resistant Staphylococcus aureus (MRSA) was 70%. Resistance to tigecycline and linezolid was 15 and 1%, respectively. All strains were susceptible to glycopeptides. In addition, isolated Acinetobacter baumanii strains showed high rates of resistant to all tested antibiotics except colistin. Eighty per cent of these strains were resistant to ceftazidime and 94% to imipenem. Resistance to rifampicin was 15% in 2014, and has increased steadily to 67% by 2016. Similarly, high resistance rates were observed among Klebsiella pneumoniae and Pseudomonas aeruginosa to ceftazidime (70 and 39% respectively), ciprofloxacin (68 and 67%) and imipenem (15 and 72%).

Conclusion: This study investigated on the local distribution patterns of causative organisms of bacteraemia in burn patients and the corresponding antimicrobial susceptibility profiles. Multidrug-resistant pathogens, especially MRSA and Acinetobacter baumanii, were the most frequently isolated organisms. Hygiene measures and antimicrobial stewardship should be implemented to prevent the spreading of these resistant strains. Introduction: Pseudomonas aeruginosa is known opportunistic pathogen frequently causing serious infections in burned patients. Multidrug resistance in this pathogen is increasing throughout the world and is a major problem in the management of these pathogens. Analysis of serotype and resistance profile to antobiotics of P. aeruginosa help to establish a prompt control and prevention program. The aim of this study was to evaluate the frequency of antimicrobial resistance and the prevalence of Pseudomonas aeruginosa serotypes isolated in the burn unit. Patients and methods: During a period of 4 years (from 01 01 2012 to 31 12 2015), 485 strains of Pseudomonas aeruginosa were isolated from burned patients. Conventional methods were used for identification. Antimicrobial susceptibility testing was performed with disk diffusion method and susceptibility data were interpreted according to breakpoints recommended by the French Society of Microbiology (FSM). Serotypes were identified by slide agglutination test using P. aeruginosa O antisera (Biorad). The imipenem-resistant strains have benefited from a research of carbapenemase production by the EDTA test. Results: In our study period, 3464 bacterial isolates were found among which Pseudomonas aeruginosa was the second most frequent bacterium isolated from burned patients (14%) after Staphylococcus aureus (18%). The most frequent sites were-cutaneus infection (36%), blood culture (24%) and catheter (16%). The most prevalent serotypes were-O12 (72%), O1 (10%), O2 (6%), O11 (1%) and O6 (1%). The survey of antibiotic susceptibilily showed high pourcentage of resistance to the different antibiotics-21% of strains were resistant to ceftazidim, 69% to ticarcillin, 66% to ciprofloxacin, 62% to amikacin and 56% to imipenem. Among the 272 imipenem resistant strains, 34% were metallo-beta-lactamase producers. The antibiotic to which P. aeruginosa was the most susceptible was colistin (100%). Multidrugresistance was associated with O12 serotype in 67% of the cases.

The global frequency of serotypes O12, O1 and O2 was more than 88%. Multidrug resistance and carbapenemase being associated with serotype O12. Serotyping of the strains isolated from burned patients will help to guide the first antibiotherapy. The dissemination of carbapenemases strains must be contained by implementation of timely identification, strict isolation methods and better hygienic procedures. And respiratory disorders (43.5%)…). The therapeutic management was based on per operative resuscitation, organ failure treatment, probabilistic antibiotic therapy and median laparotomy surgery. The main etiologies of abdominal sepsis were-digestive perforations (43.5%), purulent effusion (38%), intestinal necrosis (14%), cholecystitis (12.5%). The bacteriological profile was -predominance of BGN (82.7%) dominated by E. Coli (28%) followed by Klebsiella pneumoniae and Acinetobacter baumanii (13.46%), the mean duration of the hospitalization was 7.03 ± 6.65 days. The mortality rate was 57%. The main prognostic factors in our study in univariate analysis were-the advanced age, the diabetes, the organ failure, the increased gravity scores, the time to management, the use of catecholamines and the development of septic shock. The multivariate analysis showed a statistically significant association between the development of septic shock, the stercoral effusion, the peptic ulcer perforation, the operator and the therapeutic descalation.

The abdominal sepsis is a serious affection, with great mortality. The improvement of its prognosis is based on a revision of the medical and surgical protocols, and an adapted antibiotic therapy depending on the direct examination of the samples, also of the bacterial ecology of the service. Introduction: Severe acute respiratory infections (SARI) are common in critically ill patients. Viruses can be found in immuno-competent patients. However, the main problem for viral infections is the diagnosis, isolation of the pathogen is often difficult and the symptoms not specific. The aims of this study were to describing the epidemiological characteristics of viral respiratory infections, to identify factors predictive of a poor outcome. Introduction: In septic shock there are physiological changes with an increase in the volume of distribution, with implications for pharmacokinetics of antibiotics that make recommended doses potentially inadequate for target organisms with highest minimal inhibitory concentrations. To cover these bacteria, peak serum concentration (Cmax) target is 64-80 pg ml. Identification of predictive factors for insufficient Cmax, in common practice, would make it possible to target the patients at risk in order to optimize dosage of antibiotic to be administered. Objective of this study was to determine predictive factors of Amikacin's Cmax insufficient independently of the dosage. Patients and methods: This was a retrospective study carried out between August 2013 and November 2015 in ICU of our Hospital. All adult patient receiving an initial injection of Amikacin between 20 and 30 mg kg were included. Clinical data collected were-Amikacin dosage, Body Mass Index (BMI), Mechanical ventilation (MV), mean arterial pressure (MAP), use of Noradrenaline and continuous hemofiltration (CVVH). Biological elements were collected and for each, the last result in the 24 h prior to admission and that at the patient's entry into ICU were added to analysis. A comparison of this clinical and biological variables was made between two groups-the first one with an ineffective Cmax of Amikacin (< 64 pg ml) and the second with an effective Cmax of Amikacin (> 64 pg ml). Results: 191 patients were selected for statistical analysis. Median dosage was 22.5 mg kg for a median Cmax at 72.1 mg l. For 77 patients, Cmax was less than 64 mg l and in 53 patients, it was greater than 80 mg l. There was a statistically significant relationship between a Cmax greater than 64 mg l and MV, BMI, PCT measured before and after admission, albumin after admission, hemoglobinemia, hematocrit level after admission, the rate of urea after admission (Table 1) . A low BMI was associated with Cmax < 64 mg l. Discussion: These results remain comparable to those found by Taccone in 2010, with dosages of 25 mg kg having only 70% of the peaks above 64 mg l + comparable also to Montmollin's study in 2014.

Conclusion: MV, BMI, pre-and post-admission PCT, and albumin, hemoglobin after admission, hematocrit and urea after admission seems to be predictive criteria for insufficient amikacin's Cmax independently of dosage. Our study was limited to one ICU, a heterogeneous recruitment, and that all samples have been taken at the right time. Introduction: This study aimed to assess whether augmented renal clearance (ARC) impacts negatively on ceftriaxone pharmacokinetic pharmacodynamics (PK/PD) target attainment in critically ill patients receiving 2 g day by intermittent infusion. Patients and methods: Over an 8-month period, all critically ill patients treated by ceftriaxone for a first episode of sepsis without renal impairment were eligible. During the first 3 days of antimicrobial therapy, every patient underwent 24-hour creatinine clearance (CrCL) measurements and therapeutic drug monitoring at trough concentrations. The main outcome investigated in this study was the rate of empirical target non-attainment using a theoretical target MIC of 2 mg/L. Results: Over the study period, 21 patients were included (63 samples analyzed for therapeutic drug monitoring). The rate of PK/PD target non-attainment was 62%, with a strong association with CrCL (p < 0.0001) ( Table 1 ). There was no statistical association between PK/ PD target non-attainment and therapeutic failure.

Conclusion: When targeting 100%fT > MIC of the less susceptible pathogens, patients with CrCL > 150 mL/min are at risk of subexposure in ceftriaxone (2 g day). These data emphasize the need of therapeutic drug monitoring in patients with ARC, especially when targeting less susceptible pathogens or surgical infections with limited penetration of antimicrobial agents. Introduction: The septic shock is a major concern of the intensive care unit in the world because of its frequency and especially of its mortality which remains high in spite of the progress made in the optimizing care. The aim of our work is to analyze the prognosis factors related to death among patients with septic shock in the ICU of the military hospital Avicenna of Marrakesh, and to focus on the physiopathological and therapeutic data of the septic shock in the light of last acquisitions in this field. Patients and methods: We proceed to a prospective study including all patients with septic shock at admission to ICU or secondary, over a 3-year period (January 2014 -December 2016). Prognosis factors related to death in patients with septic shock were studied in univariate and multivariate analysis. Results: Eighty-six cases of septic shock were collected from 1290 ICU admissions, the incidence is 3.33%, the mean age was 58 ± 14.7. The sites of infection most often involved were the abdomen and lung (50%), there was a predominance of Gram-negative bacilli, the number of organ failure is in average 2.6 ± 1.1. The overall mortality was 65.1%. Prognosis factors related to mortality retained after logistic regression are cardiovascular organ failure followed by neurological. Indeed, the number of patients with 3 or more failures was 22 (78%) in the group of patients who died. As the second factor influencing the high mortality found severity score 53.6 ± 14.7, age is also considered a prognosis factor since 21 of 28 patients were over 60 years. The average age of the deceased was 66 ± 7 years versus 51 ± 7 years in survivors (p < 0.001), yet the mortality according to the infectious agent was not found as factor influencing mortality (p = 0.75). Conclusion: Septic shock is a frequent reason for hospitalization in ICU. The improvement of prognosis requires an early and adapted management of sepsis as well as increases efforts for control and prevention of nosocomial infection. Introduction: Vitamin D deficiency is common in critically-ill patients.

In addition to its role in the regulation of phosphor-calcic metabolism, vitamin D is of paramount importance for the immune system. The aim of the current study is to assess the prognostic value of vitamin D deficiency in patients with septic shock. Patients and methods: Retrospective study conducted over 6 months. All the adult patients with septic shock and vitamin D level screening performed within the first 24 h of admission were included in the study. We excluded patients with chronic kidney disease and those receiving vitamin D supply. Two groups were compared: those with a serum Vitamin D level < 10 ng/ml (G1) and those with higher level (G2 Introduction: Since immunity plays a central role in neoplasms surveillance, it is likely that sepsis induced immune dysfunctions may impact on the underlying malignancy. We developed a research project investigating the reciprocal relationships between bacterial sepsis and cancer. We reported that sepsis-induced immune suppression promoted tumor growth in post-septic mice inoculated with cancer. In a reverse cancer-then-sepsis model we observed that sepsis may conversely inhibit tumor growth. This study aimed at investigating the cellular and molecular mechanisms of sepsis-induced tumor inhibition, and most especially the role of monocytes macrophages and Toll-like receptor (Tlr) signaling. Patients and methods: We used C57BL 6 J wild-type (WT), Tlr4-/-, Tlr2-/-and Myd88-/-mice. Mice were first subjected to tumor inoculation by subcutaneous injection of MCA205 fibrosarcoma cells. Fourteen days after, mice were subjected to polymicrobial sepsis induced by cecal ligation and puncture (CLP). Controls were cancer mice subjected to sham surgery. Alternatively, cancer mice were subjected to an i.p. challenge with Tlr agonist (LPS or heat-killed Staphylococcus aureus (HKSA)). The distribution of tumor-associated immune cells was assessed by FACS at days 1 and 7 following surgery. The activation status of tumorinfiltrating monocytes macrophages was assessed by FACS (MHCII, CD40, CD86, PDL1, PD1). F4/80 + cells were purified by FACS and we assessed cytokines production (rt-qPCR) and bacteria phagocytosis. 

We confirmed polymicrobial sepsis dampens tumor growth in WT mice. A similar CLP-induced tumor growth inhibition was observed in Tlr2-/-mice, but neither in Tlr4-/-nor Myd88-/-mice. A challenge with LPS resulted in a marked anti-tumoral effect, whereas a challenge with HKSA had no impact on tumor growth. Tumor-infiltrating immune cells analysis retrieved monocytes/macrophages predominance with two different subsets based on F4/80 expression (F4/80High and F4/80Low). Late-onset (day 7) tumors from CLP-operated mice displayed increased proportions of F4/80High. As compared to F4/80Low cells, F4/80High cells displayed a more immature status with a lower expression of CD40, MHCII and PDL1, and a higher phagocytic activity. Interestingly, F4/80High cells from CLP-operated mice exhibited a higher phagocytic activity than those from sham-operated mice. Conclusion: Polymicrobial sepsis drives a potent antitumoral activity in cancer mice, which is associated with changes in the distribution and functions of tumor-associated monocytes macrophages subsets.

Our results converge on a critical role of Tlr4 signaling, that should be further investigated. Conclusion: Post-agressive immunosuppression in ICU is not specific to sepsis. In septic shock, the low counts in circulating ILC3 s could be explained by ILC plasticity (conversion of these cells into ILC1 s), by migration from the blood or by an exacerbated apoptosis. ILC2 s expansion, associated with a higher risk of secondary infection, could be promoted by IL-33, released by tissue injuries. ILC2 s could activate regulatory T cells via IL-10. These preliminary results must be confirmed on a larger cohort. They play a suppressive role in the immune system by the secretion of negative regulatory cytokines such as interleukin-10 or by immune cell contact inhibition. The objective of this pilot study was to develop and test a protocol to determine the Breg level in septic patients.

The level of Breg were measured on whole blood sample by flow cytometry the first day of hospitalisation in septic patients. B cells were identified on the single-parameter expression CD19 combined with scatter. The Breg were identified as subpopulation expressing CD24/hiCD38hi or CD24/hiCD27+ (see Fig. 1 ). The results were expressed as percentage of the parental lineage gate and absolute value per microliter. This protocol has been optimised in order to be able to transfer technic into clinical practice. Results: We include 8 patients hospitalized in intensive care unit with severe sepsis or septic shock. The percentage of CD19 + CD24hiC-D38hi was 6.6 ± 5.2% with a mean of 4.6 ± 2.3 cells microliter. The percentage of CD19 + CD24hiCD27 + was 9.1 ± 4.7% with a mean of 8.8 ± 6.4 cells microliter. We are able to measure and follow the evolution of Breg during severe sepsis or septic shock. Because Breg could inhibit body immune function, we wish to conduct a prospective study to evaluate the correlation between Breg level and the prognosis of patients with sepsis.

The neutrophil/lymphocyte ratio (NLR) reflects an inflammatory state. The NLR has recently emerged as a prognostic marker in colorectal cancer patients, acute coronary syndrome and pulmonary embolism (Kayrak M, Heart Lung Circ 2014). The aim of this study was to assess the prognostic value of NLR in patients with septic shock.

We performed a prospective observational study in septic shock ICU patients within 72 h of admission from January to July 2017 in Charles Nicolle Hospital of Tunis. Exclusion criteria were age < 18 years, pregnancy + oncohematological patients, recent blood transfusion, post-cardiac arrest and brain-death. NLR was measured soon after admission and 24h, 48h, and 72h after. Demographic, clinical and biochemical parameters, severity scores, life-support therapies (vasopressors, ventilation), and length of ICU stay were recorded. The primary endpoint was 28-day mortality. Results: Sixty-five patients (50 males, median age, 48.5 years) with septic shock were included in the study. The 28-day mortality was 54%. The median SOFA score at T0 was 12 points and the median IGS2 score was 55 points. The sources of infection were as follows: the lungs (n = 27), the urinary tract (n = 14), the central nervous system (n = 4), the abdomen (n = 8), skin and soft tissue (n = 12). The parameters that were identified through univariate analysis to be associated with 28-day mortality were IGS2 score, lactate level, the NLR elevation at H24, H48 and H72. Median NLR levels were significantly higher in non-survivors (n = 35) than survivors ( Introduction: The autonomic nervous system (ANS) is highly adaptable and allows the organism to maintain its balance when experiencing stress. Heart rate variability (HRV) is a mean to evaluate cardiac effects of ANS activity and a relation between HRV and outcome has been proposed in various types of patients. We evaluated the feasibility of a automated HRV monitoring, based on standard electrocardiography monitoring, and investigated the different parameters that should be recorded. This project is based on a prospective physiological tracing data-warehousing program (Rea STOC, clinicaltrials.gov # NCT02893462) that aims to record more than 1500 ICU patients over a 3-years period. Patients and methods: Physiological tracings were recorded from the standard monitoring system (Intelliview MP70 Philips), using a dedicated network and extraction software (Synapse v1, LTSI INSERM U1099) that enables simultaneous recording of 5 different physiological curves, at their native resolution (500 Hz for ECG, 125 Hz for other). Raw data were subsequently stored on a dedicated local server, before anonymization and analysis. All consecutive patients were recorded for a 2-hours period during the 24-hours following ICU admission. All measurements were recorded with the patient laying supine, with a 30° bed head angulation. Physiological recordings were associated with metadata collection by a dedicated research assistant. HRV parameters were derived from electrocardiography monitoring using Kubios HRV premium ( Introduction: Acute Cor Pulmonale (ACP) is a frequent complication of acute respiratory distress syndrome (ARDS). It occurs in 22% of cases and might be associated with an increased mortality rate. It is defined by a ratio of telediastolic surfaces of right ventricular (RV) on left ventricular greater than 0.6 and a septal dyskinesia. However, systolic dysfunction defined by the guidelines of the American Society of Echocardiography has not been well studied in ARDS and in particular concerning the RV free wall longitudinal strain (RV-FW-LS). The aims of the present study were to identify the prevalence of RV systolic dysfunction and ACP in ARDS, and to evaluate the effects of inhaled nitric oxide (NOi) and prone positioning.

We prospectively included patients to a mild to severe ARDS, and proceeded to standardization of ventilation and systematic echocardiography in semirecumbent position, with NOi and in prone position. Interpretation of examination was blinded to the investigator. We evaluated the presence of ACP, systolic dysfunction identified by classical cardiologic criteria (RV fractional area change, RV Tei index, Tricuspid annular plane systolic excursion, Velocity of the tricuspid annular systolic motion) and also by RV-FW-LS. Results: Sixteen patients were included. Thirty-seven percent of patients were in severe ARDS. The prevalence of ACP was 25% while right ventricular systolic dysfunction was identified in 37.5% of patients with the classic cardiologic criteria and 68.7% with the impairment of RV-FW-LS which represented the most sensitive test for right ventricular dysfunction detection (Table 1) Introduction: The use of Extra Corporeal Membrane Oxygenation (ECMO) is increasing. Brain complications may occur, resulting in an increased morbidity and mortality. The objective of our study was to analyze the incidence of neurological complications while receiving ECMO, the risk factors, and to describe morbidity and mortality in a large cohort of patients in intensive care unit. Patients and methods: This was an observational, mono-centric, 2-year retrospective study in patients who received ECMO. Primary outcome was the occurrence of neurological complication until D7 after ECMO.

Results: One hundred and eight patients were included in the analysis. Twenty-seven patients (25%) presented a neurological complication. Of these, 16 died at D30. There were 13 ischemic sequelae (24.5%), 5 intracranial haemorrhages (9.4%), 4 cerebral edema (7.6%) and one other lesion (1.9%). The median time before occurence of a neurological complication was 8 days after the implementation of ECMO. Multivariate analysis revealed the presence of hyperlactatemia > 5.4 mmol L, neurological deficit at the beginning of the management, as well as the history of stroke before the ECMO implementation as predictive factors of neurological complication (OR 44.15, .

The incidence of neurological complications under ECMO is about 25% and ischemic sequelae are the most frequent. History of stroke and low cerebral flow associated with ischemia-reperfusion seem to increase the occurrence of these complications and must lead to greater vigilance in these patients. -122] . Eighteen patients (16%) survived at ICU discharge with a good neurological outcome. By multivariate logistic regression analysis, female sex, initial shockable rhythm, and pre-ECMO arterial blood pH ≥ 7.1 were independent predictors of survival with good neurological outcome. All of the patients presenting with CPC score of 1 or 2 at ICU discharge had a shockable rhythm and or pH ≥ 7.1 before ECLS implantation. 28% of the patients presenting with these criteria had a good neurological outcome at ICU discharge. All of the patients presenting with non-shockable rhythm and pH < 7.1 before ECLS implantation died in the ICU. Conclusion: About one third of the patients presenting with shockable rhythm and or pH ≥ 7.1 before ECLS implantation had a good neurological outcome at ICU discharge. On the contrary, all of the patients presenting with both non-shockable rhythm and pH < 7.1 before ECLS implantation died in the ICU. These simple parameters might help to identify cardiac arrest patients which could benefit from ECLS implantation.

Radjou Aguila Introduction: The decrease of lung volume is a keystone for the management of patients under mechanical ventilation in intensive care units. This procedure has not only led to a reduction of morbimortality in ARDS but also in all patients mechanicaly ventilated in intensive care units as well as in major surjery. Nevertheless, the incidence of high volume (VT) on morbimortality is extremely variable (about 8 to 70%). Our main objective is to assess the incidence of high volume ventilation (> 8 ml/kg predicted body weight, PBW) in our hospital intensive care units. Moreover we were interested in determining the risk factors of high volume ventilation.

We conducted a retrospective observational study from January to March 2015 in three intensive care units of a tertiary university hospital. All patients ventilated under sedation in VAC mode during the 24 h after admission were included in the study.

Of the 502 patients admissions during the period, 71 one of them (14%) have no height mentioned in their medical file and were exluded. Among the 351 patients considered, 110 (31.3%) were ventilated with high VT (Fig. 1 ). 98% of patients had a positive expiratory pressure ≥ 4 cmH2O. In multivariable analysis, height (smaller) and weight (lower) are the only associated factors with a high volume ventilation (p < 0.0001 and p = 0.015, respectively). Discussion: The observed incidence on high VT patients is higher than that reported in most papers in literature (Jaber et al. 18%, Hess et al. 8%) . Nevertheless, both studies were conducted in operating room with higher VT cut-off (10 ml/kg). Walkey and al showed that 34% of patients in ARDS were ventilated with VT › 8 ml/kg of PBW. Moreover, the same associated factors (smaller height and lower weight) have found in the study. Older studies revealed higher BMI as factor to high volume ventilation. This difference could be explained by the use of predicted body weight. Conclusion: Although the growing literature and the recommandations aim to reduce the lung volume between 6 to 8 ml/kg of PBW, still one third of the patients in intensive care units are ventilated with too high lung volume. (Fig. 1 ). with either a NC overlap on one nostril or not. Results: When the MV increases, the FiO 2 decreases. When the mouth opens, the FiO 2 decreases. When the prongs are overlapping one nostril the FiO 2 decreases slightly (mean 5 ± 2% in absolute value). Statistical differences were found between closed and open mouth and between overlap on one nostril and not (p < .05), except between TMO and CM at two MV (14 and 17 L/min) when NC overlap on one nostril (Fig. 1) . Conclusion: When the prongs of NC are not correctly placed in the nostrils, the FiO 2 decreases, but this impact is limited in our bench study. The impact of MV increases and mouth opening on the FiO 2 values is also important. Introduction: The weaning of mechanical ventilation is an essential and delicate phase in the management of a resuscitation patient. The neurosurgical patient presents a number of specific problems, such as impaired control ventilatory control, coughing or the pharyngo-laryngeal intersection. However, it often allows short-term ventilatory withdrawal in the neurosurgical patient, probably largely by the simple fact that it authorizes the definitive cessation of sedation. The objective of the study and demonstrate the place of tracheotomy in neuro-resuscitation patients, and prevent its complications.

A retrospective descriptive study of 597 patients hospitalized in the neuro-resuscitation unit during the period 1 January to 31 December 2016, of which 113 patients benefited from surgical tracheotomy, is a frequency of 19% of all inpatients during this period. Clinical, para-clinical, etiological, and therapeutic data were collected from hospitalization records.

In a series of 597 hospitalized patients, during the defined period, 113 patients had surgical tracheotomy, a frequency of 19%, in the literature two studies or the data were extremely variable, with 29% in the study Namen versus 2.9% in the Coplin study. Of the 113 tracheotomies, 6 were performed by neurosurgeons, and 107 by resuscitators at a frequency of 95%. The tracheotomy was performed on average 7 days after the intubation of the patients, after verification of the impossibility of the extubation of the latter either for central affection of the ventilatory controls, or reached the mixed nerves and disorders of the laryngo-pharyngeal intersection and according to expert recommendations in 2017-Tracheotomy should not be performed in the intensive care unit before the fourth day of mechanical ventilation. Different pathologies that patients suffered and required tracheotomy were: post-operative complications of brain tumors (brain stem and mixed nerves) with 52 patients, a rate of 46%, vascular pathologies (stroke and CVT)), with 32 patients (28%), traumatic pathologies, with 29 patients (26%). 21 cases, 19%, 4 cases of secondary bleeding of the orifice, 2 cases of tracheal stenosis, and 1 case of tracheomalacia. The decan made after pharyngolaryngeal neurological examination, and according to SFAR 2017 recommendations experts suggest that a multidisciplinary decanulation protocol available in resuscitation departments. Conclusion: Tracheotomy in neuro-resuscitation has its place, especially in view of the different complications specific to this type of patient, but no study has demonstrated its improvement in vital prognosis. Post-tracheotomy complications can be considerably reduced if the protocols and expert recommendations are applied. Introduction: Noninvasive ventilation (NIV) in intensive care (ICU) is associated with the occurrence of frequent asynchronies related to the leaks around the interface, mainly auto-triggering and delayed cycling. Their detection requires a respiratory muscles activity monitoring. Diaphragmatic ultrasonography is a simple imaging technique available at bedside to assess diaphragm motion. Whether diaphragmatic ultrasonography would allow detecting asynchronies due to leaks during NIV is unknown. The aim of this study was to assess two methods of diaphragmatic ultrasonography (excursion and thickening), coupled with the airway pressure signal to detect patient-ventilator asynchronies during NIV. Patients and methods: Nine healthy subjects were placed under NIV and subjected to intentional inspiratory and expiratory leakage on the ventilator circuit to generate delayed cycling and auto-triggering, respectively. The flow, airway pressure and diaphragmatic electromyogram were collected in order to identify the asynchronies generated by the leaks. In the meantime, an ultrasound recording of the excursion of the right diaphragm and of the thickening of the right

diaphragmatic zone of apposition were performed and combined with the display of airway pressure on the ultrasound screen. These records were analyzed a posteriori to define the diagnostic performance [including sensitivity (Se), specificity (Spe), positive predictive value (Ppv), and negative predictive value (Npv)] of the excursion and the thickening to detect asynchronies.

The experimental setup generated a median of 34 asynchronies per subject (interquartile range 24-44). Auto-triggering was correctly identified by continuous recording of both excursion (Se = 93%, Spe = 99%, Ppv = 93%, and Npv = 99%, Fig. 1A ) and thickening (Se = 94%, Spe = 99%, Ppv = 95%, Npv = 99% + Fig. 1C ). Delayed cycling was detected with a slightly lower performance by diaphragm excursion (Se = 85%, Spe = 98%, Ppv = 84%, Npv = 98% + Fig. 1B ) and thickening (Se = 89%, Spe = 98%, Ppv = 86%, Npv = 99% + Fig  D) . Discussion: These encouraging results may be tempered by a variable effectiveness of the technique from one subject to another, in particular concerning the excursion. Moreover, their generalization to critically ill patients may depend on several factors including echogenicity, stability and amplitude of the ultrasound signal in this population. Conclusion: Ultrasound is a simple clinical tool available at the bedside to detect delayed cycling and auto-triggering associated with NIV leaks, provided that the airway pressure curve is displayed on the screen of the ultrasound machine. Further studies are needed to assess its usefulness in detecting other types of asynchronies and its feasibility in critically-ill patients. Introduction: Although extra-corporeal CO2 removal (ECCO2R) is not recommended, strong rational supports the concept. We aimed to describe our single-center experience of ECCO2R in the setting of mild to moderate acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD).

We performed a retrospective case note review of patients admitted to our tertiary regional intensive care unit (ICU) and commenced on ECCO2R from November 2015 to August 2017. Demographic data, physiologic data (including pH and partial pressure of carbon dioxide in arterial blood [PaCO2]) before ECCO2R starting, and at day 1 were recorded. Results: Twenty one patients received ECCO2R. Thirteen were managed with Hemolung ® device, seven with Prismalung ® and one with ILA ® . Indication for ECCO2R were COPD exacerbation (n = 11), mild to moderate ARDS (n = 8), uncontrolled hypercapnia due to pneumonia (n = 1), and hypercapnia due to bronchial compression by mediastinal adenopathy (n = 1). Before starting ECCO2R, median minute ventilation, pH and PaCO2 were respectively 7. 2 [6.5, 8.5 Conclusion: Our observational cohort shows that ECCO2R therapy is effective to reduce PaCO2 and improve pH in the settings of mild ARDS and COPD exacerbation. However, early weaning of sedation and pressure support ventilation might limit the decrease of respiratory rate and tidal volume. Introduction: Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder, caused by mutations in the DMD gene. Respiratory failure is classical in the natural history of this disease. Little is known about the diaphragm echographic pattern and the spectrum of patients with diaphragmatic paralysis in this disease. We aimed to assess the relationship between age and diaphragmatic motion and thickening fraction (TF) and to characterize the spectrum of patients with diaphragmatic paralysis. Patients and methods: We included retrospectively DMD patients who experienced diaphragmatic echography and spirometry in our institution. Diaphragmatic paralysis was defined as a diaphragm with TF < 20%. Results: 38 DMD patients were included in this study. All DMD patients were wheelchair bound. DMD patients had severe respiratory insufficiency with a median VC at 11% of predicted value [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] . 87.5% of patients were on home mechanical ventilation (HMV) and 28% were invasively ventilated. Right diaphragmatic motion at deep inspiration was severely altered with a median of 8.4 mm [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] . Right TF of the diaphragm was severely altered with a median of 13. 3% [7.7-27.2] . 66.6% of patients disclosed a paralyzed diaphragm pattern with a right TF < 20%. The age was inversely correlated with TF of the diaphragm (r = -0.56, p 0.016) and with the right diaphragm inspiration motion (r = − 0.68 p < 0.0001). Patients with diaphragm paralysis were older with median age at 32.5 years [31-39.5], with severe respiratory impairment (median sitting CV = 6%) and median cumulated annual HMV duration at 12.5 years. Conclusion: In DMD, age is inversely correlated with diaphragm function. Diaphragm paralysis is frequent in older adult non-ambulant DMD. . The final probability model included the previous identified factors in addition to age and SAPS II score, this model exhibited good calibration (Hosmer-Lemeshow X 2 , p = .98) and good discrimination (ROC-AUC, 0.94 + 95% confidence interval, 0.92-0.96) (Fig. 1) . Conclusion: Our cohort study identified risk factors of ICU death, mainly collected at admission among patients with AECOPD. The proposed probability model has a good performance in predicting the short-term prognosis. Further evaluation in other cohorts is needed. Introduction: Precarity is a complex notion including several components, and its definition is still debated. It is more subtle than financial poverty alone, and can increase population's health insecurity. We hypothesize that patients with precarity features may have different epidemiologic characteristics and ICU outcomes than the general population. The aim of this study was to describe precarity features and outcomes of patients admitted to an ICU located in a high poverty rate territory. Patients and methods: We conducted a prospective single-center observational study of all patients admitted to ICU of the Saint-Denis 

general hospital, from February to July 2017. Precarity features were classified in 4 categories-absence of health insurance, lack of incomes or minimum allowances, homelessness or social home or hotel, and social isolation (no social link, or associations or neighbors). Others social data were collected (speaking fluent French and education level) as well as usual clinical ICU data. Results: Among 241 patients included, precarity features were found in 83 patients (35.3%). Income precarity was the most common, followed by accommodation precarity, health precarity and relation precarity (Table 1) . Precarity was not associated with hospital mortality (37 vs. 25.7%, p = 0.20). All types of precarity were significantly associated with each other. Precarious patients were younger (63 vs. 40 years-old, p < .01) and had less comorbidities. We found no differences concerning hospital or ICU length of stay (12 vs. 11 days, p = 0.53) or concerning education level between precarious patients and the others.

Conclusion: Our pilot study shows that precarity features are indeed very frequent and are often cumulated. With respect to the small patient sample, precarity does not seems to be associated with hospital mortality or length of stay. Further investigations with larger patient samples and multicenter designs are warranted to investigate properly the impact of precarity on ICU management and outcomes. Introduction: Population aging is a global and expanding phenomenon. Elderly people are particularly vulnerable, and often need health care. This demographic evolution also affects Intensive Care Units, and 80 years old patient are now frequently admitted-it corresponds to 15% of admission in France. Indeed we have analyzed the change in management of this very elderly people (80 years old and more) over the past 14 years in a French medical intensive care unit in a provincial University Hospital. Patients and methods: A retrospective cohort study was conducted using medical intensive care unit registry for demographic, physiological and diagnostic data from January 2003 to December 2016. Characteristics and treatment intensity during medical ICU stay were specified, and short term and long term mortality were also recorded.

Results: A total of 6608 admissions, including 689 octogenarians and older, were registered during the period. The proportion of very elderly people gradually increase from 4 to 11%. Intensity of treatment (organ support) increased from 1.14 from 1.31 per patient between the primary and the second part of the period, notably linked to mechanical ventilation (56 vs. 66%, p < 0.01) and vasopressor infusion (35 vs. 46%, p < 0.01). Even if severity score increased (SAPS 2 increase from 52.7 to 60.5, p < 0.01), the ICU mortality remains constant (34 vs. 32.8%). However, we were surprised to observe an increase in 1 year mortality (62 to 74%, p < 0.01). Conclusion: Between 2003 and 2016, proportion of admission of very elderly people has increased two fold in our ICU. Although treatment intensity increases for more severe patients, ICU mortality remains the same. Nevertheless, absence of beneficial effect after 1 year remains questioning. Could ICU to ward transfers and care course after hospital be optimized? lived alone at home, 40% in couple or with ther family, 21 (9%) in retirement home and 16 (7%) in nursing home. 40 (17%) had a simplified ALD score lower than 4 indicating good functional independence. The more frequent diagnosis were acute pulmonary oedema and exacerbated COPD. The mean simplified acute physiology score (SAPS II) was 53 ± 21. The treatment were were invasive mechanical ventilation 84 (36%), only with noninvasive ventilation 50 (21%), vasopressor agents 79 (33%) and 4 (2%) with renal replacement therapy. The average length of stay was 5.9 ± 6.1 days. After adjustment on SAP-SII (without age), those invasive treatments were not associated with mortality no more than age. Global mortality rate was 28%. 53 (22%) were subject of a procedure for limiting therapeutics, among which 35 (66%) died in the unit versus 17% for the other patients. The decision of therapeutic limitation was associated with severity of illness as measured by the SAPSII (p = 0.01) but not with age. Frequency of therapeutic limitation were similar in ICU and intermediate care units.

The mortality rate is lower than the older studies (S de Rooij 2005-38%). Unlike the study of P. Biston (2013) which covers only the most serious cases, the mortality for any type of gravity remains reasonable. The procedure for limiting care were frequent especially for the most severe pathologies but all the patients who a decision of limiting care were stated were not dead.

The patients over 85 years old admit in french ICU are very chosen. Any major treatment appear to enhance mortality. Introduction: Due to advancements in medical technology and management of illnesses, an increasing proportion of critically ill patients are elderly. Few information is available on the prognosis of these patients after ICU discharge. The aim of this study was to analyze the clinical characteristics and long-term outcomes of elderly admitted to ICU. Patients and methods: Monocentric, observational prospective study was performed. All elderly survivors (aged ≥ 65 years) after an ICU stay in a medical Tunisian ICU between January 2014 and December 2015 were included. Data collected were: clinical features at admission, acute management procedures, functional characteristics and vital parameters (Blood Pressure, Heart Rate, ABG's) at ICU discharge. Patients were followed during 1 year via phone calls. A multivariate regression analysis was used to identify risk factors for one-year mortality. Results: During the two-years study period, 102 elderly patients were discharged alive. 60 (58.8%) were male. Clinical features of elderly survivors were: Mean age, 74.9 ± 6.54 years, median of Charlson index, 2 [0-7], Chronic respiratory disease, 70 (68.6%), hypertension, 46 (45.1%) and diabetes 39 (38.2%). The most common reason for admission was acute respiratory failure in 80 (78.43%) patients and mean SAPS II was 34.9 ± 9.7. 45 (44.1%) patients required invasive ventilatory support, 43 (42.2%) vasoactive drugs and 3 (2.9%) received renal replacement therapy. The median of ICU length of stay was 6 days. The follow up was possible for 80 (78.4%) patients. Mortality rate at 1 year was 37.5%. Predictors of one-year fatal outcome in univariate analysis were as follows-SAPS II (p = 0.009), Heart rate at discharge (p = 0.039), decline in functional status (p = 0.000), World health organization (WHO) performance status at discharge (p = 0.000) and readmission within 1 month (p = 0.000). Multivariate regression showed that SAPS II (OR, 1.11 + 95% CI [1.02-1.20] + p = 0.01), WHO Performance status at discharge (OR, 3.64 + 95% CI [1.92-6.9] + p = 0.000) and heart rate (OR, 1.06 + 95% CI [1.01-1.12] + p = 0.01) were independent risk factors of one-year mortality. Conclusion: This study suggests that age and comorbidities should not be exclusion criteria for ICU admission. In the long-term only SAPS II, performance status and heart rate were significantly associated with one-year mortality in the elderly ICU survivors. Introduction: Triage is an act performed at the entrance of emergency departments (ED's), it allows the classification of patients in different categories according to the seriousness and the priorities of treatment. Vital emergencies are geared towards resuscitation room. In our ED, triage is not codified and is «done» in most cases by an unqualified staff. The aim of this work is to show the impact of absence of triage on the functionning of the resuscitation room. Patients and methods: It's a prospective study, conducted in the ED of a university hospital, over 6 months, including all patients over 15 years old, admitted at the resuscitation room. Epidemiological and clinical data of patients, their CCMU classification (Classification Clinique des Malades aux Urgences) have been specified, as well as their outcomes.

We collected 366 patients. The average age was 51.24 years old (15-97 years), for a sex ratio of 1.57. Forty patients (10.1%) arrived «standing» at the ED. Patients CCMU 1 and 2 represented 41.3% of these admissions. The systolic blood pressure was under 90 mmHg in 25% of cases, the Glasgow coma scale < 8.15 in 18% of cases, and the SpO2 < 90% in 23% of cases. Mortality was 5.5%. The other patients were admitted at the intensive care unit (36%), at the short stay hospitalization unit (33.6%), at the operating room (13.4%), or transferred to other departments (9.2%). Discussion: The patients CCMU 1 and 2 arrived by ambulance, «lying» , were considered as severe. The proximity of the resuscitation room of consultation rooms allows it to be used sometimes in flows' management and as a place of triage. The patients transferred straight to services didn't show signs of vital distress motiving their initial admission at resuscitation room or even at ED. Those admitted at the short stay hospitalization unit were steady, but needed complementary examinations, specialized expert advice, or were waiting for a downstream bed. Conclusion: A triage system must be introduced at the entrance of our emergency departments. The staff involved in that sorting must be identified, and disposing of a triage scale in order to figure out the degree of priority associated to patients conditions, and direct the ones needing urgent care towards the resuscitation room. Results: One hundred patients were included, with average age of 59.5 years old (25-84) and sex ratio of 1.12. These patients were brought to emergencies by their family in 83% of cases. Reasons for admissions were varied, severe deterioration of their general condition (41%), alteration of consciousness (28%), respiratory distress (13%), convulsive seizures (12%). Therapeutic interventions were cardio-pulmonary resuscitation (2%), fluid volume expansion (91%), mechanical ventilation (15%), administration of vasopressors (23%) and anticonvulsants (12%). Mortality at the resuscitation room was 13%. Thirty eight patients were admitted at the intensive care unit, equally at the short stay hospitalization unit (SSU) of ED. Two patients returned home at the request of their family. Discussion: These results show that ED's remain the last resort in front of oncology patient who is deteriorating, the occurrence of complications, and sometimes, the psychological exhaustion or family's obstinacy.

Emergencies departments continue admitting patients with terminal cancer, but are not organized for medium and long term care. The creation of a palliative care unit and the organization of home-based care will allow the prevention and treatment of complications as well as a psychological care, thus improving the living quality of these patients and their relatives.

Refusal of intensive care admission: assessment of a Tunisian ICU practices Merhabene Takoua Introduction: Need of intensive care exceeds its availability in several countries. As a consequence, rationing intensive care unit (ICU) beds is common and often leads to admission refusal. Purpose-To report refusal determinants and characteristics of patients associated with decisions to deny ICU admission.

This study was performed at the ICU of Abderrahman Mami Hospital, a 22-bed ICU in Ariana, Tunisia. It was a prospective study enrolled between 1st January and 31th December 2016. No predefined admission criteria were determined. Decisions to admit are based on a combination of patient-related factors, severity of illness and bed availability. All consecutive patients referred for admission to ICU during the study period were included. 2 groups were defined GI-Admitted patients and GII-refused patients. The reasons for refusal were categorized as follows: too well to benefit, too sick to benefit, patient or family refusal, necessity of other exploration not available in our institution and unit too busy. Results: During the study period, ICU admission was requested for 1081 patients of whom 590 were admitted (54%). Of the 491 patients refused, only 41 were admitted to ICU later. Refusal of ICU admission came in 23% of cases from the emergency room and wards of our hospital, in 65% from other hospitals of whom 30% without ICU. Reasons of refusal were no beds availability (76.2%), too sick to benefit from ICU (13%), too well (9.4%) and necessity of other exploration (1.4%).

No differences in demographic characteristic between the two groups were noted. Among the refused patients, when compared with admitted patients, we found higher proportions of hematologic malignancies (p < 0.01) and cardiocirculatory arrest (p = 0.01). On the other hand, admitted patients were more likely to have cardio-respiratory comorbidities (437/590 vs. 297/491, p = 0.01) and more need to mechanical ventilatory support (404 590 vs. 166 491, p = 0.016). Conclusion: Our study confirms that ICU refusal rate still high. It depends on both ICU organization and patient characteristics.

Acute heart failure syndroms in intensive care: clinical features, management and outcome Jamoussi Amira 1 , Ajili Achraf 1 , Merhebene Takoua Introduction: Classification of acute heart failure (AHF) into 5 clinical scenari (CS) was first proposed to facilitate early management (1) . A decade after implementation of this approach, epidemiological and evolutive data based on this classification are interesting to investigate. That is why we aim to describe frequencies, management and mortality of each AHF syndrom in intensive care.

A prospective study of patients > 18 years with AHF admitted to the medical intensive care unit (ICU) of Abderrahmen Mami hospital from January 2017 to August 2017 was conducted. Patients were classified according to the 5 clinical scenari (1). Clinical, therapeutic and outcome findings were recorded. Results: During the study period (8 months), we admitted 291 patients in ICU from whom 43 (14.8%) presented with AHF and then enrolled. The median age was of 63 ± 18.6 years and sex-ratio 1.05. A medical history of COPD (20.9%), hypertension (46.5%), diabetes (20.9%), ischemic cardiopathy (28%) and valvular cardiopathy (16.3%) were noticed. At admission, severity assessement scores were: median APACHE II 18.5 ± 10.5 and median SAPS II 30 ± 17.6. Clinical and evolutive characteristics according to clinical scenari are listed in Table 1 . Conclusion: CS 2 and CS 1 are the most frequent AHF syndroms in ICU and also have the best outcome. Introduction: In cardiac arrest patients resuscitated from an ischemic ventricular fibrillation or tachycardia (VF/VT), both incidence and risk factors of recurrent severe arrhythmia are unclear. Whether it is useful to give a prophylactic anti-arrhythmic (AA) treatment during the first hours and days is debated, particularly when a successful coronary reperfusion was provided. We aimed to evaluate the incidence of severe arrhythmia in patients resuscitated from an ischemic VF VT and to identify risk factors for developing arrhythmia during their ICU stay.

The PROCAT registry captures all data from patients admitted in a tertiary hospital center after a resuscitated cardiac arrest (CA). We selected patients with an initial VF VT caused by an acute coronary syndrome (ACS) and who were successfully treated with early percutaneous coronary intervention (PCI) on admission. The primary endpoint was the recurrence of major arrhythmia between ICU admission and ICU discharge. All arrhythmias resulting in CA recurrence and or severe arterial hypotension requiring infusion of vasopressors were classified as major arrhythmias. Multivariate logistic regression identified factors associated with the occurrence of major arrhythmias. Results: Between 01/2007 and 12/2016, 256 consecutive CA patients were included in the analysis. All patients underwent a successful PCI of the infarct-related artery on hospital arrival. The only drug used as a prophylactic AA treatment was amiodarone, which was employed in 104/256 patients (41%). Overall, 29/256 patients (11.3%) had a major arrhythmia recurrence during their ICU stay. A large majority of these major arrhythmia recurrences (79.3%) occurred during the first 24 h. Characteristics of patients with and without major arrhythmia recurrence are described in the Table 1 . In multivariate analysis, public place location (OR 0.3 [0.1-0.9], p = 0.029) and male gender (OR 0.3 [0.1-0.9], p = 0.036) were both associated with a lower risk of major arrhythmia recurrence during the ICU stay. Prophylactic AA treatment was not associated with a lower risk of recurrences of major arrhythmias (OR 0.9 [0.3-3.1], p = 0.870). Conclusion: Despite an early coronary reperfusion, more than 10% of our post-cardiac arrest patients experienced a recurrent severe arrhythmia during the post-resuscitation period, mostly during the first 24 h in the ICU. This proportion is much higher than what is reported in common acute coronary syndrome (without cardiac arrest) and further studies are needed to explore protective strategies. Introduction: During symptomatic treatment of septic shock, markers of anaerobic metabolism may be used in a goal-oriented strategy. The recent International Guidelines for Management of Sepsis and Septic Shock 2016 suggested guiding resuscitation to normalize lactate as a marker of tissue hypoperfusion. The purpose of this study was to evaluate the kinetics of lactate and other markers during the first three hours and to compare their levels between survivors and non survivors.

We conducted a prospective, observational, single-center study of patients admitted to a general ICU from the May to August 2016. Inclusion criteria were patients age ≥ 18, intubated and under mechanical ventilation with septic shock as defined by the Third International Consensus Conference. Simultaneous sampling of arterial and central venous blood gas were collected at H0 and H3 to obtain lactate (mmol/l), and ScvO2 (%). Delta PCO2 (mmHg) and delta PCO2/CavO2 (mmHg/ml) were computed by our Patient Data Management System and presented as a chart with additional hemodynamic data for clinical decision support. Comparisons of values between groups were made by Mann-Whitney U test as appropriate. p < 0.05 was considered statistically significant. All reported p values are two-sided. Statistical analysis was performed using Systat ver. 11.0. Results: We studied 19 intubated septic shock patients aged 71 ± 10 years, SAPS II 68 ± 23, SOFA 11 ± 3.6. Community pneumonia and peritonitis were the major sources of infection. ICU mortality rate was 58%. All patients received norepinephrine (0.62 ± 0.5 µg/kg/ min), two patients received Dobutamine (5.5 ± 0.2 µg/kg/min). The evolution of markers is summarized in Table 1 . At H0 and H3, arterial lactate levels were higher in non-survivors than in survivors, but did not decrease at H3 in both groups. At H0 there was no statistical difference concerning ScvO2, delta PCO2 and delta PCO2/CavO2. After three hours of resuscitation, delta PCO2 and delta PCO2/CavO2 ratio decreased and ScvO2 increased in survivors. Survivors had lower delta PCO2 and delta PCO2/CavO2 ratio than non survivors. Conclusion: Although high lactate level is a key signal of anaerobic metabolism, it did not decrease during the first three hours in this group of severe septic shock patients. Instead of using lactate, delta PCO2 and delta PCO2/CavO2 kinetics could be integrated in a goaloriented strategy for septic shock resuscitation. Introduction: To assess whether, in patients under mechanical ventilation, fluid responsiveness is predicted by the effects of short respiratory holds on cardiac index estimated by oesophageal Doppler (CIDoppler). Patients and methods: In 28 patients, before infusing 500 mL of saline, we measured CIDoppler before and during the 5 last seconds of successive 15-second end-inspiratory occlusion (EIO) and endexpiratory occlusion (EEO), separated by 1 min. Patients in whom volume expansion increased cardiac index (transpulmonary thermodilution) > 15% were defined as "fluid responders". Results: EEO increased CIDoppler more in responders than in nonresponders (8 ± 2 vs. 3 ± 1%, respectively, p < 0.0001) and EIO decreased CIDoppler more in responders than in non-responders (-9 ± 5 vs. -4 ± 2%, respectively, p = 0.0002). Thus, when adding the absolute values of changes in CI observed during both occlusions, CIDoppler changed by 18 ± 5% in responders and 7 ± 2% in nonresponders. Fluid responsiveness was predicted by the EEO-induced change in CIDoppler with an area under the receiver operating characteristic (ROC) curve of 1.00 (95% confidence interval-0.88-1.00) and a threshold value of 4% increase in CIDoppler. It was predicted by the sum of absolute values of changes in CIDoppler during both occlusions with a similar area under the ROC curve (0.99 (0.86-1.00)) and with a threshold of 9% change in CIDoppler, which is more compatible with oesophageal Doppler precision. In this case, the sensitivity was 100(77-100)% and the specificity was 93(66-100)%. Conclusion: If consecutive EIO and EEO change CIDoppler > 9% in total, it is very likely that volume expansion will be efficient in terms of cardiac output.

The measurement of cardiac output using a signal morphology-based form of impedance cardiography (Physioflow ® ) in intensive care unit: comparison with the trans thoracic echocardiography. Introduction: In the Intensive care units, the cardiac output (CO) is one of the main hemodynamic parameters required to manage patients in shock. The Physioflow ® is a new non-invasive method using the waveform analysis of the thoracic impedance signal (TI) to assess CO. In hemodynamicaly unstable patients, no studies have evaluated the level of agreement between the CO estimated by transthoracic echocardiography (CO-TTE) and that measured using the waveform analysis of thoracic Impedance Physioflow ® (CO-TI). The objective of this study was to evaluate the ability of CO-TI relative to CO-TTE to estimate the absolute CO value and detect the expected variation CO (V-CO) in critically ill patients. Patients and methods: Fourteen patients sedated and mechanically ventilated, in shock under catecholamines and monitorred with TTE and TI Physioflow ® were included. Hemodynamic datas, stroke volume (SV) and CO with two monitoring were performed at baseline 2 min before passive leg raising (PLR), 30 s after PLR and 2 min after volume expansion (VE) of 500 ml of saline solution. Responders were defined by an increase > 12% of cardiac output (V-CO) after PLR. Results: Fourteen pairs of TTE and TI measurements were compared. The median (IQR) age was 69 years (55-76), IGS2 was 54 (40-69). Only 3 patients were responders after PLR. There was a significant correlation between the CO-TTE and CO-TI measurements (r = 0.807, p < 0.0001). The median bias was 0.8 L/min and the limits of agreement (LOAs) were −3.5 and 1.9 L/min. There was a significant correlation between V-CO-TTE and V-CO-TI (r = 0.77, p = 0.0022) (Fig. 1) . The median bias was-5.2% and the LOAs for V-CO were respectively -26.5 and +16.5%. Conclusion: The CO measured with PhysioFlow ® , a signal morphology-based impedance cardiography, is correlated to the CO measured with TTE. However, the high LOA observed in this preliminary study underline the necessity to remain careful and wait for further inclusions. -9] vs. 5.5 [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] days, p = 0.05). Despite imbalancedunderlying characteristics in terms of demographics and comorbidities, in-ICU mortality rates were similar between patients (35.7 vs. 37%, p = 0.75). Conclusion: Prior BB treatment have limited impact on the severity of acute circulatory failure in septic shock and is not associated with increased mortality despite the underlying frailty of patients. Introduction: Cardiac output monitoring is a key component in the management of critically ill patients. Cardiac output estimated by transthoracic echocardiography is documented in patient with atrial fibrillation, but a large part of transpulmonary thermodilution validation studies excluded this specific population. The objective of this study was to evaluate cardiac output mesurement and trend ability by transpulmonary thermodilution relative to transthoracic echocardiography in critically ill mechanically ventilated patients with atrial fibrillation. Patients and methods: Thirty mechanically ventilated patients requiring hemodynamic assessment were included in a prospective observational study. Cardiac output was mesured simultaneously with transpulmonary thermodilution and transthoracic echocardiography.

Seventy-four pairs of cardiac output measurements were compared. The two measurements were significantly correlated (r = 0.769 et p < 0.0001). The mean bias was -0.7 l/min, the limits of agreement were -2.9 and +1.6 l/min, and the percentage error was 39.81%. Thirty-four pairs of cardiac output variation measurements were compared. There was no significant correlation between cardiac output variation measurements by transpulmonary thermodilution and transthoracic echocardiography. The mean bias was −0.19 l/ min and the limits of agreement were −1.82 and +1.43 l/min. With a 15% exclusion zone, the four-quadrant plot had a concordance rate of 78.6%. The polar plot had a mean polar angle of 14.2° with 95% confidence interval between − 14.2° and 42.7°. Conclusion: In critically ill mechanically ventilated patients with atrial fibrillation, cardiac output measurements with transpulmonary thermodilution and transthoracic echocardiography are not interchangeable. Introduction: Basic critical care echocardiography (CCE) relies on transthoracic echocardiography (TTE). We sought to assess the diagnostic capacity of a next-generation micro-digital broadband beamformer in patients with cardiopulmonary compromise.

All patients with acute circulatory respiratory failure underwent two basic TTE assessments using successively a next-generation micro-digital broadband beamformer (64 elements, 1-4 MHz) incorporated in a sector phased array probe with twodimensional, M-mode and color Doppler mapping capacities which was connected to a touchscreen interface (Lumify, Philips), and using a compact full-feature imaging system (80 elements, 1-5 MHz + Cx50, Philips). TTE examinations were independently performed in random order by two intensivists with expertise in CCE, within a 10-min time frame without therapeutic intervention. Imaging quality was graded from 0 (no image in the corresponding view) to 3 (clear identification of 100% of endocardial boarders). The concordance of qualitative data was assessed using the Kappa test and agreement of two-dimensional measurements (left ventricular end-diastolic diameter [LVEDD], ratio of right ventricular (RV) and LV end-diastolic diameters [RVEDD LVEDD] + end-expiratory inferior vena cava diameter [DexpIVC]) was evaluated using intraclass coefficient correlation (ICC). Results: Thirty consecutive patients were studied, without any exclusion for absence of TTE images (age, 56 ± 19 years, SAP-SII, 45 ± 18, 70% ventilated, 60% under catecholamines, lactate, 3.9 ± 3.3 mmol l). The proportion of echocardiographic views eligible for interpretation and mean duration of TTE examinations were similar with the miniaturized and full-feature systems (79 vs. 77%, 7.1 ± 2.7 vs. 7.9 ± 4.1 min, p = 0.31). Two-dimensional imaging quality grade was lower with the miniaturized system ( system. Concordance of two-dimensional measurements was also good-to-excellent (Table 1) . Conclusion: For basic CCE use, next-generation micro-digital broadband beamformer appears providing reliable information with good-to-excellent diagnostic capability, accurate two-dimensional measurements, and adapted therapeutic suggestions. These preliminary data require further confirmation. Introduction: Acute kidney injury (AKI) in very old patients (over 80 years) admitted in intensive care unit (ICU) is a frequent issue and is known to be associated with a severe prognosis. We aimed at describing the clinical characteristics and prognosis of such a population. The objective of the study was dual: first to evaluate the short and long term mortality of these patients, second to determine the factors associated with a poor outcome. Patients and methods: We conducted a descriptive, retrospective and monocentric study based on the hospital records of patients over 80 years with AKI admitted in our ICU between January 2013 and December 2016. The patients were selected according to the KDIGO criteria (1) . Survivals at the discharge from hospital, at day 90 and at 1 year were assessed. The factors associated with mortality at 1 year were scrutinized. Results: After excluding 30 patients for an initial therapeutic limitation, the data of 171 remaining patients were reviewed. The patients were 84 years old (interquartile range, IQR 81-86) and were predominantly male gender (61%). SAPS II and SOFA score at admission were 62 (IQR 57-74) and 8 (IQR 5-10) respectively. 57% of the patients needed for mechanical ventilation and 69% of them needed for catecholamine use. Septic (44%), prerenal (38%), iatrogenic (17%) and cardiogenic injury (10%) were the leading cause of AKI. Dialysis was performed in 42% of patients. The overall mortality at the discharge from ICU, at day 90 and at 1 year was 39, 52 and 66% respectively (Fig. 1) . Neither were the age, the comorbidities, the etiology of AKI nor the need for dialysis associated to a significant increase in mortality. A stepwise Cox regression analysis revealed SAPS II and blood lactate level at ICU admission as independent risk factors associated with 1 year mortality. Conclusion: AKI at admission in ICU is associated with a high mortality at 1 year in an elderly population. Main long term prognostic factors are linked to the initial severity at ICU admission. Introduction: The proportion of elderly around the world doesn't stop growing and increases the consumption in health care. However, lots of studies report the impact of the age on the decision to admit a patient to the ICU despite no triage recommendation exists. The primary objective was to determine prognostic factors of death for the 80 years and over at admission to the ICU and secondly to evaluate their functional prognostic at short and medium term after their exit. Patients and methods: Prospective and observational study conducted in our ICU 30 beds unit from August 2015 to February 2017. Patients of 80 years and over were listed. The dying patients arriving after a pre-hospital resuscitation for whom no therapeutic plan has been initiated and those admitted for an organ donation were excluded. The primary outcome was the duration between the admission and the potential death during the follow-up. The secondary outcomes were the necessity to entry an healthcare institution or the loss of one autonomy point on the ADL French scale after the hospitalization.

Results: 107 patients of the 1763 admissions were included. The IGS II and SOFA average scores were respectively 70.23 ± 22.47 and 9.02 ± 3.79. The most common diagnosis were a septic shock (23 patients), a cardiopulmonary arrest (21 patients), a cardiogenic shock (9 patients) and a pulmonary oedema or a lung infection (8 patients Fig. 1 Survival of very old patients with AKI in ICU (%) each). 75 patients (70.03%) died during the follow up-50 at the ICU, 13 during ward and 12 during re-education or after their home return. From a multivariate analysis (Table 1) , anisocoria, cardiopulmonary arrest and acute kidney injury (AKI > 0) seem to be independent risk factors of death. 32 patients were alive at the end of the follow up. 11 recovered their previous autonomy, 8 needed a place in a specialized institution. All the other lost a part of autonomy 3 months after their home return with the average loss of one point on the ADL autonomy French scale. Conclusion: Anisocoria, AKI and cardiopulmonary arrest seem to be independent risk factors of death for those patients. Concerning the survivors, a stay at the ICU lead to an increased dependency. Other studies have to be led to evaluate which of our patients could have get the best benefit of their stay to prevent from a misuse of the structure.

Introduction: Context-Among the severe complications of preeclampsia, acute kidney injury (AKI) poses a dilemma if features of thrombotic microangiopathy (TMA) are present. Although a HELLP syndrome is considerably more frequent, ruling out a flare of atypical haemolytic and uremic syndrome (HUS) is then of utmost importance. Objective-To improve the differential diagnosis procedure in cases of post-partum AKI. Patients and methods: A hundred and five cases of post-partum AKI, admitted in the last 5 years (2011) (2012) (2013) (2014) (2015) in French ICU from 9 different regions, were analysed. Initial and final diagnosis, renal features, haemostasis and TMA parameters were all analysed, paying a special attention to their dynamics within the first days following the delivery. Results: The main circumstances of AKI were severe preeclampsia (n = 40), post-partum haemorrhage (PPH, n = 20) and primitive TMA (n = 14, including 10 atypical HUS and 4 thrombotic thrombocytopenic purpura). Among the thirteen cases of renal cortical necrosis, 11 were associated with preeclampsia. Congruence between the initial and the final diagnosis was low (63%). Thus, none of the women referred to our centers for a suspicion of non-placental TMA has received a final diagnosis of non-placental TMA (and instead had a PE or a PPH). Conversely, all women with a final diagnosis of nonplacental TMA were referred for a suspicion of PE-related TMA, or with a PPH which polluted the diagnosis. Tranexamic acid was largely used in the context of PPH (82%), at a dose up to 5 grams total. Taking into account the final diagnosis, we subjectively concluded that plasma exchanges and eculizumab were abusively indicated in 5 and 2 cases, respectively, of typical HELLP syndrome. Plasma exchanges were in itiated in all 14 cases, a mean 84 h following the admission. Dynamics of hemoglobin, haptoglobin, and liver enzymes were poorly discriminant. The dynamic pattern of LDH and of platelets, in contrast, was statistically different between primitive TMA-related AKI and other groups-at day 3, platelets increased in preeclamptic women, and in other circumstances, but not in patients with primitive TMA. A classification and regression tree (CART) independently confirmed the usefulness of platelets and LDH trajectory in the diagnostic algorithm (Fig. 1) . Conclusion: The trajectory of LDH and platelet count is useful to identify the cause of post-partum AKI, and the clinician may reasonably take therapeutic decisions at day 3 post-delivery. Introduction: Continuous veno-venous hemofiltration (CVVHF) is a common practice in intensive care units (ICU). Because it is continuous, the choice of anticoagulation is essential-regional anticoagulation Fig. 1 Analysis of post-partum AKI cases with citrate or systemic with unfractionned heparin or low molecular weight heparin (LMWH). Filter's lifespan is a major issue regarding filtration's effectiveness and cost. In this study, we compared the filter's lifespan between LMWH and citrate anticoagulation. Patients and methods: A monocentric retrospective study was led from January to October 2016. All the CVVHF sessions during this period were included. Prismaflex© monitors (Hospal) were used. Practioners were free to choose between citrate or LMWH defining 2 groups. We aimed a post filter ionized calcemia between 0.25 to 0.5 mmol/L in citrate group + and a post filter anti Xa activity between 0.2 to 0.5 UI/mL in LMWH. Results: 95 CVVHF sessions were included-64 with LMWH anticoagulation, and 31 with citrate. Patients were 62 years old on average, primarly males (65%), with an initial average SAPS II score of 73. ICU mortality was 51%. Patients' hemostasis was measured before each CVVHF session, without any significant difference between the 2 groups. Global filter's lifespan was 47 h + 54 h in citrate group versus 44H in LMWH, without significant difference (p = 0.236) (Fig. 1) . No serious side effect, especially hemorrhage in the LMWH group, was reported. Filtration efficiency, represented by the urea reduction ratio during the first CVVHF session, was similar, 30% ± 20% in LMWH group versus 20% ± 20% in citrate group (p = 0.235). Conclusion: Both anticoagulation-systemic with LMWH or regional with citrate can be used in ICU. Both methods enable long and comparable filter lifespan, with similar filtration efficiency and without serious adverse events. Our results need to be confirmed by a randomized propective study. Introduction: ARF during the post-partum period is a rare complication. The main etiologies are post-partum haemorrhage (PPH) and thrombotic microangiopathy (TMA). RRT may be required. The aim of this study was to identify variables associated with RRT in this population admitted in ICU. Patients and methods: We conducted a study using retrospectively collected data in a cohort of patient with post-partum ARF according to the KDIGO criteria and requiring ICU in the University hospital of Lille from 2008 until 2016. Two groups were compared-RRT and non RRT patients. Demographic and obstetrical data as well as data during ICU stay and patients' outcome were collected. Etiologies of ARF, KDIGO stage, anuria, hemolysis parameters and biological data at ICU admission were studied. Comparisons were made using a Chi-two or Fisher Exact test or a Mann-Whitney U test. Odds Ratio (OR) for the statistically different criteria were studied. Results: Twenty-two patients requiring RRT were compared to the 49 patients without RRT. The two main etiologies of ARF were TMA (50.7%) and PPH (35.2%). Vaginal delivery was significantly more frequent in the RRT group compared with caesarian delivery (p = 0.04). Use of RTT was significantly increased after PPH compared the others etiology of ARF (p = 0.03). In the RRT group, the ICU length of stay was longer (p < 0.0001) and IGS II score was higher (p < 0.0001). Higher KDIGO score was observed in RRT patients (in the RRT group-KDIGO 1 = 0, 2 = 9%, 3 = 91%, and without RRT-KDIGO 1 = 38.8%, 2 = 36%, 3 = 36%, p < 0.0001). Anuria 24 h after ICU admission was more frequent in cases of RTT (86.3% versus 20.3%, p < 0.0001). Hemolysis was greater in RRT patients with lower haptoglobin (p = 0.02) and increased Lactate Deshydrogenase (LDH) (p = 0.04). The association with RRT requirement was stronger with the duration of anuria, with an OR at 6 h at 31. 3 [8.1-121.7 ] and at 24 h at 72. 2 [8.3-622] . A lower haptoglobin was associated with a higher risk of RTT (OR 3.7 [1.2-11.7 ]), as well as PPH (OR 3.1 [1.1-8.8] ) and vaginal delivery (OR 2.9 [1.02-8.1]). Conclusion: Hemolysis parameters and anuria seemed useful criteria to identify patients at higher risk of RRT early during their ICU admission. Introduction: Renal replacement therapy (RRT) has three aimsrestoring homeostasis, ensuring survival and preserving the potential for renal recovery. The main indication of RRT in ICU is acute renal failure, correlated with a very important rate of mortality despite the progress made in its management. Patients and methods: The objective of this work is to take stock of the indications and the objectives of the RRT in ICU. Through a prospective study, we report a serie of 39 cases, collected at the multipurpose resuscitation unit of the Avicenna military hospital in Marrakech between September 2015 and September 2016. Results: The average age of our patients is 65, 10 ± 24, 89 years with extremes ranging from 34 to 90 years and a male predominance (77%). The main reasons for admission were hemodynamic distress in 43.5% of cases, followed by septic shock in 30.7% of cases, neurological and respiratory distress were noted in 20.5 and 5.3% of cases, respectively. RRT indications were severe acidosis in 27% of patients, followed by 21% hyperkalaemia, acute pulmonary edema in 13%, hemodynamic instability in patients with chronic renal failure in 12%, acute renal failure in 8%, and hyperuriaemia in 5% of cases. The technique chosen is conventional intermittent hemodialysis with a synthetic membrane. The main duration of the sessions was 2 h 06 min ± 45 mn. Vascular access was a right internal jugular catheter in 49.7% of patients and left in 2.5%, right femoral catheter in 34.8% of patients and left in 2.4%, arteriovenous fistula (FAV) and a tunneled catheter in 7.9 and 2.7% of patients. Mortality was 61, 55%, chronicity progressed in 10.25% of cases and total or partial recovery of normal renal function in 28% of cases. Conclusion: we have a high rate of mortality in our ICU that's why we will focus on prevention of risk of renal failure in our patients. Introduction: There is limited information on the outcome of acute kidney injury (AKI) in patients with traumatic intracranial hemorrhage (tICH). TICH patient with AKI was related high mortality rate. The aim of this study is to estimate the outcome using different renal replacement therapy on the survival rate and rate of long term renal-replacement therapy in adult tICH patient. Patients and methods: We retrospectively identified a total of 310 tICH patients with AKI who required glycerol or mannitol therapy admitted to the intensive care unit during a 10-year period ending DEC 2010 from the National Health Insurance Research Database. Demographic data, severity of tICH, medication, level of care, type of head surgery were collected. All patients subjects were older than > 18 years. We also excluded patients diagnosed with tICH before the cohort entry date, hemodialysis before tICH, chronic kidney disease cancer coagulation defects purpura and other hemorrhagic conditions, mortality mechanical ventilation ischemic heart disease before tracking. The primary outcome was overall survival at day 30. The secondary outcome was the rate of long term HD therapy. Results: A total of 310 patients were enrolled. The Kaplan-Meier estimates of mortality at day 30 did not differ significantly between the continuous veno-venous hemofiltration (CVVH) and hemodialysis (HD) strategies + 5 deaths occurred among 134 patients receiving CVVH-strategy group and 9 deaths occurred among 176 patients receiving HD-strategy group (adjusted hazard ratio: 0.782, 95% CI 0.239 to 2.558; p = 0.685). The rate of long term HD was higher in the HD-strategy group than in the CVVH-strategy group (15.34 vs. 7.46%, p = 0.021) especially in injury severity score ≥ 16 group (Table 1) . Discussion: In our study, tICH patient with AKI receving CVVH may have effect on renal blood flow protection or cytokine removal which lower the rate of long term HD. Conclusion: These clinical data provides readers interventions to improve outcomes in this population and future study are needed to confirm the result. This study highlights the importance different renal replecement therapy in the tICH with AKI population (Table 1) .

Khaleq Khalid 1 , Hattabi Khalid 1 , Bensardi Fatima Zahra 1 , Bouhouri M. A 1 , Nciri A 1 , Hamoudi D 1 , Alharrar R 1 Introduction: The combined progress of abdominal surgery and anesthesia lead to more frequent surgical indications, including for fragile patients or serious pathologiesPostoperative morbidity and mortality is an element that requires evaluation and analysis in surgical resuscitation. Although pathological processes and new therapeutic approaches in surgery are currently well known, data on risk factors for morbidity and mortality are less available. The aim of our work is to evaluate the post-operative morbidity and mortality rate and to identify the main predictive factors. Patients and methods: A retrospective-cohort, unicentric study that included all consecutive patients hospitalized in the surgical resuscitation department after abdominal surgery regardless of the operated organ, during 3 years. The structured sheet of data collection included more than 100 items on all perioperative data concerning the patient, the disease, and the operating surgeons. Postoperative mortality and morbidity were defined as in-hospital death and complications. A first descriptive analysis of the various parameters collected was carried out A bivariate analysis was then performed to study the factors affecting morbidity and mortality in digestive surgery The comparison was made using the student's t test for quantitative variables and the Chi square for the qualitative variables. A difference is considered significant when p < 0.05 (5%). Results: Among 360 patients, the in-hospital death rate was 15.08% and the overall morbidity rate was 41.61%, the mean age was 55.54 ± 15, 10 years with extreme ages of 18 years and 85 years with sex ratio of 1.01. Five factors were incriminated in post: operative mortality notably:renal failure p = 0.002, duration of stay p = 0.001, parenteral nutrition p = 0.047, long duration of intubation p = 0.001, perioperative blood transfusion p = 0.001. Three factors influencing morbidity were found: duration of stay p = 0.003, Parenteral nutrition p = 0.018, long duration of intubation p = 0.0001. Conclusion: Knowledge of the true frequency of both mortality and morbidity is crucial in planning health care and research and identifying risk factors. Introduction: Tools to quantify and assess bowl management in critically ill are still very limited and often over-looked. With the primary Fig. 1 Filter's lifespan concern of optimizing patients to preserve life, the problem of bowel care has been given less priority. The aim of this study was to use ultrasonographic measurements of gastric emptying in the critically ill as a tool of measurement of the impact of different specific factors of ICU stay on bowl emptying. Patients and methods: This is a prospective study conducted in an Intensive care unit for 1 months. It included 32 patients. Ultrasonic imaging of antral sections was undertaken every 15 min for the first 1 h and every 30 min thereafter until total emptying. Correlation analyses were calculated, applying an adjusted significance level (Pb < .0125) to correct for multiple testing. Results: All our patients were above the age of 18. The median of age was years old 31. 19 of our patients were male and 13 were female. The total emptying median time was 273 ± 21 min. Significant correlation was observed between length of stay and delay in bowl emptying. Mechanical ventilation had also significant relation with slower bowl progression and gastric emptying. Patients in septic shock had tendencies to earlier delayed bowl emptying compare to others patients included in our study. Conclusion: The study we conducted is a pilot study. Further studies should be conducted and unltrasonografic gastric assessment could be standardized in protocols to assess clinical decision making and improve nutrition and bowl management in ICU patients. Introduction: Enteral nutrition, via a feeding tube, is often used in Intensive care units (ICU) to supply artificial nutrition to critically ill patients. The feeding tube is also commonly used to administrate drug therapy as well. However, there is a lack of knowledge of the nurses about this way of administration. This could be a potential source of medicine-related illness. The purpose of this study was first, to evaluate the nurse's knowledge on enteral drug administration, and second, to observe nurses and to evaluate the adequacy of their practices with guidelines, and to report medication-administration errors. Patients and methods: This prospective study using the observation technique was conducted in 2 ICU (one medical and one surgical). First, a knowledge and practice questionnaire regarding drug administration trough enteral feeding tube was filled by each intensivist nurse. Secondly, Pharmacist performed observations of nurses during preparation and administration of medications. These practices were compared with the original medical prescription and with the data available in the literature. Results: 60 questionnaires were returned. 48 nurses evaluated their knowledge as medium and 9 as inadequate. There was a lack of knowledge on the type of drugs which can be used by feeding tube (65 wrong responses). 30 nurses and 71 different drugs were observed during the drug administration phase. No administration totally complied with our institutional protocol, particularly the crush of tablets. When a tablet was crushed, in 31% an alternative formulation (in syrup for example) existed.

The correct administration of drugs in feeding tubes is important and represents a challenge in ICU. Firstly, crushed tablets is the most frequent cause of obstruction of feeding tubes which have to be changed + secondly, crushed tablets destroys the controlled release of enteric coated dosage forms, resulting in a higher or a lower initial blood level. We have to train nurses for drug administration by feeding tube. On their daily ward, the pharmacist should improve the choice of medication's forms. Introduction: Acute variceal hemorrhage (AVH) is a severe complication of portal hypertension. In addition, the variceal bleeding is still the most common lethal complication of cirrhosis. The most effective modality of treating is based on resuscitation combined with the endoscopic variceal band ligation. The purpose of this preliminary study was to find the factors associated with poor prognosis of AVH in cirrhotic patients. Patients and methods: This is a retrospective study, spread over 12 months between January 2016 and December 2016. Are included all consecutive patients with liver cirrhosis hospitalized for variceal bleeding. We exploited the medical records to identify the clinical, biological and endoscopic parameters. Results: A total of 30 patients hospitalized for AVH occurred during the study period. The mean age at admission was 60 years, and 12 are female. Cirrhosis was post viral in 30% of cases. Patients were classified as Child-Pugh C in 40% of cases. The median presenting model for end stage liver disease (MELD) and CLIF SOFA Were respectively 17 and 8.4. Twelve (12) patients received beta-blockers and 15 have required at least one endoscopic variceal band ligation at the time of the bleeding episode. In the acute phase, pharmacological treatment based on vasopressor (sandostatin)) was instituted in all cases and combining with antibiotic prophylaxis (C3G or fluoroquinolone) in 26 cases. In 8 cases the endoscopy was made within 12 h, Active bleeding at endoscopy was observed in 20 patients. Esophageal avarices (OV) were grade I (2 patients) grade II (10 patients) and grade III (18 patients). The eradication of varices was obtained in 23 patients (76.6% percentage of the cases). The variceal bleeding recurred in 9 of patients (30%of cases) and 6 patients died which 4 within the first 5 days. Spontaneous Bacterial Peritonitis (p 0.010), hepatic encephalopathy (p 0.041) and the hemodynamic instability with schok (p 0.01) are correlated with early mortality at 5 days. Hepatic encephalopathy (p 0.028) and bacteremia (p 0.05) are corrolated with 6 week motality. Non selective betablocker (p 0.013) and primary use of band ligation when indicated (p 0.008) are protective factors and parameters of good outcome. Conclusion: Despite developing of endoscopic tools and respect of actual therapeutic guidelines in AVH, the outcome is still poor. The prognosis appears to be dependent on the clinical condition at admission and primary prevention. Introduction: The French intestinal stroke center based on a multimodal and multidisciplinary management has been developed to improve survival and intestinal viability. Open surgical revascularization was decided for patients unsuitable for radiological revascularization and or suspected of intestinal necrosis. We aimed to study the prognosis of patients suffering from AOAMI in ICU and who have benefited from open revascularization.

Single-center, observational and prospective study was carried out in a surgical ICU of a tertiary center. Patients with AOAMI managed in our intestinal stroke center from 01 2016 to 09 2017 and who underwent open revascularization were included. Results: Data of 15 patients were collected. Patients' characteristics are described in Table 1 . All patients had abdominal computed tomography angiography at the diagnosis, and 11 patients (73%) presented signs of intestinal injury. Thrombosis was the main mechanism of superior mesenteric artery (SMA) occlusion (14 patients, 93%). All patients received antiplatelet therapy, curative unfractionated heparin therapy and digestive decontamination. Open revascularization was performed by SMA endarterectomy (4 patients, 27%), SMA surgical bypass (8 patients, 53%), retrograde open mesenteric stenting (3 patients, 20%) and coeliac artery bypass (2 patients, 13%). Three patients (20%) underwent a radiologic endovascular revascularization attempt before open repair.

Small bowel resection (100 cm ) was achieved in 8 patients (53%). Four patients (27%) had peritonitis. Six patients (40%) had one or more relaparotomy ]), usually for hemodynamic instability (83%). Only one patient died in ICU (7%). ICU lenght of stay was 7 days ] and duration of mechanical ventilation was 3 days [IQR 0-7]. Overall, haemodynamic failure was present in 10 patients (67%). Median duration of vasoactive support was 2 days [IQR 0-4]). Severe acute respiratory distress syndrome was observed in 2 patients (13%) and acute kidney injury in 9 patients (60%, including 2 patients who received renal-replacement therapy, 13%). Enteral feeding was initiated in 6 patients (40%) with a delay of 3.5 days [ . Parenteral nutrition was administered in 13 patients (87%), including 8 patients (53%) without enteral feeding. Five patients (33%) were discharged with small bowel syndrome. Conclusion: ICU patients who underwent open revascularization to treat AOAMI as part of a multimodal and multidisciplinary management in a dedicated intestinal stroke center have low mortality and intestinal resection rates. Larger studies are needed to confirm these results. Introduction: Precise consequences of late transit in ICU remain elusive. We have previously shown that defining late transit by the absence of stool within 6 days after admission was not relevant because it did not identify a group of patients with specific outcome [1] . To further improve this definition, we investigated the differences in outcome among patients according to their bowel movements frequency. Patients and methods: Preliminary results of a prospective, two centers, observational study. All patients admitted to ICU, with a length of stay (LOS) of at least 72 h were eligible and included with the following exceptions-abdominal surgery, bowel infection or any baseline condition known to alter transit time. Patients were compared according to stool frequency-less than 25%, between 25 and 50%, between 50 and 75% or more than 75% of ICU days. We also tested the former constipation definition of more than 6 days after admission without stool passage. We registered demographic data, time spent under mechanical ventilation (MV), ICU LOS, ventilation associated pneumoniae (VAP) and vital status at discharge. Results: Over 10 months, 421 patients were screened and 141 (33.5%) were included, age 64.6 ± 16.7 years, mean SAPS II 45 ± 17, 71 (50.3%) mechanically ventilated. The most frequent exclusion criteria were LOS < 72 h (n = 140). 68% of the patients had stool less than 50% of ICU days. Patients with fewer bowel movements were more likely to be mechanically ventilated, without association with time spent under MV. There was a link between the time to first stool after admission and the stool frequency during ICU (p < 0.0001 VAP n(%) 4 (9.5) 6 (11.1) 2 (6.1) 2 (16.7)

Death n(%) 4 (9.5) 3 (5.5) 5 (15.2) 1 (8.3)

Discussion: This study is limited by the number of patients leading to an imbalance between subgroups therefore limiting the comparison. Conclusion: These preliminary results do not plead for an improvement of the late transit definition based on the frequency of stool. Further data is warranted to better define this condition, and the management to provide. Introduction: Antibiotic therapy during acute exacerbation of COPD (AECOPD) still controversial and not well supported by clinical evidence. In fact half of these episodes are caused by viruses even during severe episodes with need to ventilator support. Procalcitonin is effective to guide antibiotic therapy during acute exacerbation of COPD without compromising patients' outcome, its efficacy in the intensive care setting still not well evaluated.

We have conducted in a 10 bed ICU a before after study. During the first period (January 2012-December 2013) patients with AECOPD were included retrospectively and treated with antibiotics according to Anthonisen criteria (control group). In the second period (January 2014-May 2017) antibiotics were prescribed only if the Procalcitonin level was greater than 0.25 ng ml (procalcitonin group). Results: Ninety-two patients were included, 41 in the Procalcitonin group and 52 in the control group. Antibiotics were administered at ICU admission in 7 patients (17%) in the procalcitonin group and in 27 (52%) patients in the control group, p = 0.001. Only 10% of sputum cultures were positive at ICU admission. Time to recovery was similar between the two groups [7 IQR (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) , 6 IQR (3-10), p = 0.48]. Other patients' outcomes did not differ between the control group and the procalcitonin group with respectively: the mortality (9.5 vs. 19%, p = 0.17), the incidence of PAVM (11 vs. 17%, p = 0.44) and NIV failure (42 vs. 46%, p = 0.69). Readmission to the hospital at day 90 was significantly higher in the control group (38 vs. 17%, p = 0.03). Conclusion: Using Procalcitonin to guide antibiotic therapy during severe AECOPD can reduce the use of antibiotics without compromising patients' outcomes. Our study aimed to assess whether ARC impacts negatively on cefazolin pharmacokinetic pharmacodynamics (PK/PD) target attainment and clinical outcome in critically ill patients. Patients and methods: Over an 8-month period, all critically ill patients treated by cefazolin for a documented respiratory infection without renal impairment were eligible. Patients who underwent an empiric antimicrobial treatment > 48 h before introduction of cefazolin were not included. During the first three days of antimicrobial therapy, every patient underwent 24-hour creatinine clearance (CrCL) measurements and therapeutic drug monitoring at steady state. The main outcome investigated in this study was the rate of PK PD target non-attainment defined by an unbound concentration < 16 µg ml (MIC value for inoculum > 10 7 UFC ml). The secondary outcome was the rate of therapeutic failure, defined as an impaired clinical response with a need for escalating antibiotics during treatment and or within 15 days after end-of-treatment. Results: Over the study period, 11 patients were included (33 samples analyzed for therapeutic drug monitoring). In pharmacological analysis, the rate of PK PD target non-attainment was 64%, with a strong association with CrCL (p = 0.001) ( Table 1 ). In clinical analysis, the rate of therapeutic failure was 36% (4 11), with a strong association with inoculum effect (p = 0.02). There was a strong association between therapeutic failure, CrCL > 200 ml min and PK PD target non-attainment adjusted on the inoculum effect (p = 0.04). Introduction: Vancomycin has long been used as the standard therapy of infections due to Methicillin-resistant Staphylococcus aureus (MRSA). The side effects of this drug as well as the increasing resistance and its pharmacodynamics effects have fostered the development of newly active drugs. Nevertheless it is still widely prescribed and it stands as the mostly used comparator in randomized study. An assessment of our medical practice regarding its use may enhance compliance to guidelines so as to promote a better use of Vancomycin. Patients and methods: In our 1600 bed hospital, the incidence rate of MRSA fell from 0.38 to 0.24 per 1000 patient days from 2007 to 2012 whereas the current proportion of MRSA isolates is about 11%. Vancomycin is the most prescribed empirical or targeted antibiotic therapy covering MRSA in our medical intensive care unit of 20 beds even if a shift towards the use of linezolid in nosocomial pneumoniae has been noticed during the last 3 years. Key points regarding the proper use of Vancomycin have been implemented in our antibiotic stewardship program. Moreover courses concerning this topic are provided to our junior doctors. A retrospective review of the quality of antibiotic use has been carried out in 45 courses of Vancomycin therapy and the following criteria have been assessed-indication, dosing schedules, serum levels of Vancomycin, duration of antibiotic therapy and the overall degree of conformity of the prescription. Results: Regarding indication, conformity was observed in42 cases (93%). The dosing schedule was appropriate in 32 cases (71%) only. Of the remaining 13 cases (29%), all of them were not adjusted to the serum concentration and in 2 cases (4%) the general dosing recommendation was not respected. The loading dose was inappropriate in 23 cases (51%) and the proper follow up of serum levels of vancomycin has not been carried out in 20 cases (44%). The duration of antibiotic therapy was in compliance with the protocol in 42 cases (93%) and a slight longer duration was observed in 3 cases (7%). Finally the overall degree of conformity of the prescription was observed in 7 cases (16%) only. Table 1 .

In the SFAR SRLF guideline, the limitation of the echinocandins use to the benefit of ampho deoxycholate explains most of the poor agreement or consensus rate between investigators. The IDSA ESCMID guideline are more helpful to guide indications of empirical treatment which mainly explains their higher rate of both applicability and agreement rate. The rates of agreement do not reflect whether the choice between different class III antifungal therapies is the best or not. Conclusion: The IDSA guideline seems to take a broader spectrum of clinical situations into account, particularly in guiding more precisely indications of empirical treatments. ESCMID or IDSA reach more often consensus at the first reading. (6 19), and was discovered during a chest X-ray examination for 68% (13 19). Diaphragmatic paralysis was confirmed for all cases with chest ultrasound.39% of patients (7 18) were receiving mechanical ventilation at the moment of the diagnosis. The paralysed hemidiaphragm was left sided in 52% (10 19), and right sided in 48% (9 19). There was no bilateral diaphragmatic paralysis. Hemi-diaphragmatic plication was performed in 30% of the patients (6 20), and median time from cardiac surgery to surgical plication was 21 days (range 8-38 days). Indications for plication were failure to wean from ventilator (100%, 6 6), and respiratory distress (33%, 2 6). Plicatured patients were remarkably younger (median age at cardiac surgery-23 days, range 4-82 days) than non-plicatured patients (7.7 months, range 5 days-5 years). The median ventilation time after plication was 3 days (range 2-6 days). All patients were asymptomatic after diaphragmatic plication. Two patients died (10%). Cause of death was independant from surgical plication (cardiogenic shock, septic shock). Conclusion: Diaphragmatic paralysis is a rare but serious complication of cardiac surgery in children. It commonly occurs after open-heart surgery, and specifically after arterial switch operation. Plicatured patients were younger than non-plicatured patients and needed more frequently a ventilatory support. A closer monitoring may be required for young patients and mechanically ventilated patients. Indeed, both are more likely to be treated by a diaphragmatic plication, reducing mechanical ventilation and intensive care duration. 

A prospective study. Consecutive children aged between 7 days and 18-year-old admitted to the PICU, intubated and mechanically ventilated were eligible and they reached inclusion if they had at least one chest tube. PPL was directly measured by a pressure transducer connected through a needle inserted into the existing chest tube. PES was measured by both a specific probe (Gaeltec probe) and by the feeding tube after mobilization (PES-FT). Results: 12 patients (median age 3 months (interquartile + 1-4)) were included and exploitable signals were finally available in 9 patients, who were included in the analysis. Most of patients (n = 11) were admitted after cardiac surgery and 5 had a spontaneous breathing activity. Median PES measured by Gaeltec probe and by feeding tube was 2.3 (interquartile + 1.8-5.4) and 7.9 (2.8-9.5) cm H 2 O, respectively. Median PPL measured into the chest tube was 4.0 (0.6-9.6) cm H 2 O. Bland-Altman plots are represented in the figure.

Conclusion: Both PPL measured into the chest tube, PES measured by the Gaeltec probe or by the feeding tube are reproducible methods. . Respiratory syncytial virus was identified in 38 infants (70%). An initial caffeine citrate loading dose of 20 mg kg was usually administered, followed by a 5 mg kg day maintenance dose, for a median treatment duration of 3 days [1] [2] [3] [4] [5] [6] . Therapeutic management (invasive and non-invasive ventilation, nutrition support) and clinical outcomes (death, length of stay) were similar between groups. There was no difference in potential caffeine adverse effects between groups or within the caffeine exposed group pre and post-caffeine administration. Conclusion: Caffeine treatment of bronchiolitis related apnea seems to be a standard practice in our PICU. Our study failed to show any influence of caffeine on clinical outcomes in this indication when compared with a small number of patients. Further studies are needed to assess the efficacy and safety of caffeine treatment in this indication as well as the appropriate treatment regimen as pharmacokinetic data suggest that higher dose could be of great interest in this non-prematurely born population. Introduction: During the last decade, many authors have raised awareness concerning the increasing rate of venous thromboembolism (VTE) in critically ill children [1] . The presence of central venous catheter (CVC) is one of the most important risk factor for venous thrombosis in children [2] . The purpose of this study was to analyze incidence and risk factors for catheter-related thrombosis in children admitted in our Pediatric Intensive Care Unit (PICU). Patients and methods: All children aged less than 2 years, admitted in the PICU from January 2016 to June 2017, and receiving at least one tunneled CVC, were included in our retrospective study. Those with venous thrombosis unrelated to CVC placement were excluded. Catheter-associated venous thrombosis (CAVT) was confirmed using Doppler ultrasonography. Introduction: Weaning from the ventilation is a crucial moment in the ICU stay. Because of the risks of mechanical ventilation (MV), such as ventilator-associated pneumoniae, it is recommended to begin the weaning process as soon as weaning criteria occurs [1] . However, extubation is also a hazardous period, with 5 to 15% of subsequent respiratory failure requiring reintubation, harboring a dismal prognosis [2] . International guidelines display the criteria triggering the extubation. Nevertheless, the physician in charge eventually takes the decision to extubate. In this regard, there could be variations from an individual to another. The main goal of our study was to identify the perceived impediments to MV weaning among physicians, from intubation to extubation. Patients and methods: Prospective single center study in a 12 bed university ICU. All patients admitted between February and May 2017 and undergoing MV were included. We daily registered the existence of the criteria recommending a spontaneous breathing trial (SBT), the occurrence of a SBT, the items recommending postponing extubation, and the occurrence of an extubation. The estimated reasons for all the aforementioned decisions were asked to the physician in charge. Results: 25 patients were included, gathering 298 days of MV and 42 SBT. The average duration of MV was 8.25 ± 9.4 days. There was one extubation failure requiring reintubation. There were 9 SBT failures. In 9 cases, SBT was a success but did not lead to extubation because of hypotonia, weak cough, subsequent respiratory failure, hemorrhagic bronchial secretions, hemodynamic instability, absence of weaning criteria, drowsiness (all the aforementioned n = 1), post SBT hypercapnia (n = 2). 23 out of the 42 SBT (55%) were done while one or several weaning criteria were absent. Impediments to weaning trials were different according to the time lag since ICU admission, with fluid overload, muscular weakness and persistent need for assist control ventilation settings being the most frequent reasons advocated after 7 days (figure). No objective assessment of muscular or cough strength was performed at any time, neither was monitored the RR Vt, vital capacity or inspiratory pressure. 8.1% of patients had otolaryngologist follow-up. The overall mortality of the studied population was 30.1% including mortality related to tracheostomy in 2 patients. The tracheostomy for extended mechanical ventilation was significantly associated with an increase of mechanical ventilation duration before tracheostomy (p < 0.0001), duration of mechanical ventilation (p < 0.0001), length of stay in intensive care unit (p < 0.0001) and mortality rate (p = 0.0003). Introduction: Acute renal failure complicating surgery has a particularly harmful prognosis, with a mortality of 40% to 90%. This high mortality rate is attributed to patient-related factors, the severity of the disease and the type of surgery, but not to the acute renal failure itself. The aim of our study is to elucidate the prognostic factors of acute renal failure in the postoperative sepsis in a series of 100 patients.

It is a retrospective analytical descriptive study spread over a period of 4 years (from January 2013 to December 2016), 100 observations of postoperative peritonitis were collected in the service of resuscitation of surgical emergencies of CHU Ibn Rochdof Casablanca. The statistical analysis was carried out using the SPSS 20 software. The results are expressed with OR and 95% confidence intervals (CI at 95%). The results were considered significant when P is < 0.05.

The mean age of the patients was 46 ± 14 years with a sex ratio of 1.94 (66 M 34) . Renal failure was the most frequent failure after hemodynamic failure, 11 patients were oliguric, 4 anuriques and 37 patients had a preserved diuresis, patients were divided according to the RIFLE (R 49%, I 26%, F 25%) and AKIN (I 49%, II 26%, III 25%). The predictive factors of acute renal failure ARI were studied in univariate and multivariate analysis, 2 factors were retained including catecholamines-OR 3.362 + CI at 95% between 1.202 and 3.397 + p = 0.021 + the surgical site-OR 0.367 + CI at 95% between 0.145 and 0.929 + p = 0.034. Conclusion: Acute renal failure is an independent factor of mortality in the post-operative sepsis, but remains that its presence is a pejorative prognostic factor. 

This was a retrospective study performed in a large University Hospital. All patients receiving the molecule were included in the analysis. Indication for sodium lactate, dose, and modality of administration were collected. We also collected clinical and biological variables before sodium lactate infusion, after 6 h (H6), and after 24 h (H24). An analysis of the evolution of these variables at H6 and H24 was performed. Results: Between January 2016 and May 2017, 104 patients, aged 64 years, 66% males, SOFA score 9 [7-12], received an infusion of molar sodium lactate (250 ml ). Main indications for sodium lactate were hyperchloremic metabolic acidosis (68%), vascular filling (15%), mixed acidosis (12%), and intracranial hypertension (5%). 84% of the patients presented with a chloride sodium ratio > = 0.76 at basal time. Sodium lactate was associated with a significant increase of mean arterial pressure at H6 (p = 0.009) and H24 (p = 0.003), a decrease of catecholamine dose (p = 0.002) and heart rate (p = 0.05) at H24, and an increase of diuresis in the 6 h period following initiation of the treatment (p = 0.02). We observed an increase of pH, bicarbonate, base excess, and sodium, at H6 and H24 (all p < 0.0001). Plasma lactate concentration was increased at H6 (p < 0.0001), but was not different from basal value at H24 (p = 0.99). There were no significant variation of plasma chloride. Chloride sodium ratio was significantly reduced. Plasma sodium > = 150 mmol l and pH > = 7.50 at H24 were observed in 5% of the patients.

This retrospective study reports the largest number of critically ill patients having received sodium lactate. Hemodynamic effects observed in this study are concordant with the data of the literature. The metabolic effects observed in this study, with rapid increase of pH, bicarbonate, and base excess, strongly suggest the potential interest of sodium lactate among critically ill patients presenting with acidosis and increased chloride sodium ratio. Introduction: Acute kidney injury (AKI) is a frequent and severe condition in intensive care unit patients that may require renal replacement therapy, most frequently continuous renal replacement therapy (CRRT). Although hypoglycemia is a well-known complication of CRRT using glucose free solutions, euglycemic ketoacidosis (EKA) has never been described in this setting. Patients and methods: All anuric patients with glucose free CRRT solution induced EKA (February 2017-May 2017) were prospectively included and evaluated. Ketoacidosis was deemed possible when nonlactic metabolic acidosis did not improve in patients on CRRT. Because all patients were anuric, we measured ketonemia and used urinary test strip in the effluent fluid. EKA diagnosis was retained when arterial serum bicarbonate was < 20 mEg/l despite CRRT, in the absence of lactic acidosis and in the presence of ketones in the serum or CRRT effluent fluid. Results: Eighteen patients (15% of our patients under CRRT in this period) developed EKA during CRRT using glucose free solution (Phoxilium ® ). Time between CVVHDF initiation and ketonemia detection was 2 (1-3) days. Patient characteristics are presented in the Table 1 . Half of them had for a medical history of diabetes (5 insulindependent). Only 3 patients were receiving insulin and most of them had low glucose or food intake. Increasing glucose intake and insulin infusion resolved ketonemia in all cases. Discussion: We describe for the first time the occurrence of euglycemic ketoacidosis in critically ill patients under CRRT using glucose-free replacement solution. Common features of the patients were multiple organ failure with anuria, normal glycemia without insulin infusion and low glucose infusion or food intake. Critical illness-induced insulin resistance and starvation could altogether contribute to ketoacidosis even if acidosis is unusual in starvation ketosis. By removing substantial amounts of glucose from the blood, CRRT with glucose free solution could worsen this condition, mask hyperglycemia and induce euglycemic ketoacidosis.

In critically ill patients on CRRT using glucose free solution, euglycemic ketoacidosis is common and should be detected, especially in patients with low glucose intake, no insulin infusion and unexplained metabolic acidosis. Importantly, the diagnosis can be missed in anuric patients with normal blood glucose and in the absence of known diabetes. Since, CVVHDF-induced ketoacidosis may contribute to persistent acidemia and its adverse effects, serum or CRRT effluent fluid ketone level should be measured in this setting. 39.5-67] years. Main reasons for admission were hypercalcemia (n = 55 (70.5%)), followed by acute encephalopathy (n = 9 (11.5%)). Median SAPS II and SOFA scores were 32 [22.25-39.5 ] and 3 [1] [2] [3] [4] [5] respectively. Main causes of HCM were hematological malignancies (n = 46 (59%)), solid tumors (n = 15 (19%)), iatrogenic events (n = 9 (9%)) and endocrinopathies (n = 5 (6%)). Median calcium levels at admission, at day 3 and at ICU discharge were 3.68 [3.43-4.21 ], 2.75 [2.55-3.12 ] and 2.56 [2.15-3. 14] mmol L respectively. More than half of the patients (n = 46 (59%)) recovered from HCM 5 days after ICU admission. Acute kidney injury occurred in 65 (83%) patients and 19 (29.2%) patients required dialysis. Neurological complications concerned 27 (34.6%) patients, mainly delirium (n = 23, 29.4%). Digestive events occurred in 29 (37.1%) patients. Cardiovascular events concerned 49 (63%) patients and consisted in de novo hypertension in 18 (23%) patients, and EKG disturbances in 24 (30%) patients. During ICU stay, 9 (11.5%) patients required mechanical ventilation and 6 (7.6%) patients required vasopressors. Volume resuscitation with crystalloids was the first treatment in 73 (93.5%) patients, 63 (80.7%) received bisphosphonates and 48 (61.5%) received corticosteroids. Respective ICU and hospital mortality were 11.5 and 21.7%. There was no correlation between the degree of HCM and ICU mortality (p = 0.1). ICU and hospital mortality were associated with the underlying disease (hematological malignancies (p = 0.04)). Conclusion: HCM is associated with high mortality rates. The increased mortality is a consequence of the main mechanism, mainly underlying malignancy rather than HCM per se. The course of HCM may be complicated by organ failures that are most of the time reversible with early ICU management. Introduction: Sepsis is one of the leading cause of death among patients with chronic kidney disease (CKD). The mechanisms of this higher mortality remain poorly understood. Sepsis and chronic kidney disease are both conditions associated with a higher plasmatic concentration of bile acids. The Farnesoid X receptor (FXR) is a key regulator of the bile acid metabolism and has recently been involved in the regulation of the inflammasome during sepsis. We explored the role of FXR in the prognostic of sepsis in an animal model of CKD. Patients and methods: Sepsis was provoked by the injection of 0.5 mg kg of LPS 6 weeks after the creation of CKD. The CKD was created by unilateral nephrectomy associated with contralateral thermocauterisation. The mice (C57BL6 J) were randomly assigned to one of the following groups-sham placebo, CKD placebo, sham LPS or CKD LPS. A fifth group of CKD LPS mice received a treatment with sevelamer (a bile acid sequestrant) during 6 weeks. Survival of the animals, serum biochemistry and molecular biology in the kidney were performed after sacrifice. Results: Whereas the sham LPS animals survived, all CKD LPS animals died during the 72 h following the injection of LPS. The plasmatic urea, IL1beta and TNFa concentrations increased with the creation of CKD (CKD placebo versus sham placebo animals) and with the creation of sepsis (CKD LPS versus sham LPS groups). Whereas the expression of FXR RNA did not changed with the injection of LPS in the sham animals (sham LPS versus sham placebo), the FXR RNA decreased with the creation of sepsis in the CKD animals (CKD LPS versus CKD placebo groups). The CKD animals treated with sevelamer 6 weeks before the administration of LPS (CKD sev LPS group) had a lower plasmatic concentration of Il1b, TNFa and increased the RNA expression of FXR in the kidney compared to the CKD LPS group. Also, the treatment with sevelamer improved the survival of the CKD LPS animals.

Conclusion: our study demonstrates a relation between FXR and the prognostic of sepsis in CKD animals. The exact link and the potential therapeutic interest of targeting FXR and bile acids metabolism in CKD patients remain to be studied. Introduction: Dysnatraemia, dyskalaemia and hypomagnesemia are frequent metabolic disorders in intensive care, and their causes represent a major concern for the intensivist, especially in urgent conditions. In the diagnostic approach, we often use the urine analysis.

Although measurement of 24-hour urine electrolyte excretion (24-HU) is considered the most reliable method, the great burden and difficulty in collecting complete 24-hour urine has prompted the search for more practical methods, such as spot urine analysis. The aim of the present study was to compare electrolyte excretion in urine samples collected over different time periods, in comparison with a 24-hour urine sample collection considered as the gold standard method. Patients and methods: This prospective and descriptive study included 30 patients admitted in a tunisian medical ICU, between September and December 2015. Baseline characteristics, medications and laboratory data including electrolytes and renal function parameters were obtained from all patients. Multiple urine specimens for analyzing Na + K + Mg + Urea + Ca + phosphate + Creatinine + proteins and uric acid were obtained from 2-hour, 12-hour and 24-hour urine samples during day and night time, and results were compared with those obtained from the gold standard method (24-hour urine collection). Correlation analysis was performed using the spearman test. Results: Significant correlation was found for all biochemistry parameters between 24-hour urine results and those obtained from 2-hour and 12-hour samples regardless of day or night sampling. A comparative analysis for sodium and potassium is shown in Fig. 1 . Conclusion: Determination of electrolyte excretion from urine samples taken over 2 different time periods, 2 and12 h, provides a reliable estimation of 24-hour urine electrolyte excretion. It appears practical for early understanding of the mechanism of electrolyte imbalance. However, further studies are warranted to confirm the usefulness of this approach.

Use of the procalcitonin assay in an adult emergencies department: retrospective experience of a general hospital of the suburb of Paris (7.85-13.4 ). Other markers of infectious were poorly recorded (fibrinemia in34 (11.5% + 5.5 g L [4.6-6.6] + Immature forms on blood count-11.5%). Only 172 (53.6%) had blood cultures in the ED (1 patient [1] [2] ) and 163 (50.3%) other(s) microbiological sample(s), mainly urinary (84 patients [25.9% + among them 33% considered as positive]). 5% of blood cultures were positives, mainly for gram negatives (90%). Final diagnosis in the ED was considered as infectious disease (ID) in only 142 patients (44.1%, including 11 sepsis and 5 septic shocks). 175 (44.6%) was considered as non-infected (NID) and final diagnosis remains unprecise in 8 (1.6%). PCT values was of 0.42 (0-1.38) in the ID vs. 0 (0-1.37) in the NID (p < 0.001), WBC was of 10.68 in the ID vs. 9.75 in the NID (p < 0.013) and CRP was of 88 (22.5-185.5) in the ID vs. 21 (5-76) in the NID (p < 0.001). No correlation was observed between the PCT value and admission to dechocage room admission. . Identification of the involved drug was obtained in 60% of the cases, based on qualitative screening. Management was mainly supportive and included sedation (13%), naloxone (10%) and flumazenil (1%). Tracheal intubation was required in 3 patients (0.4%). One cardiac arrest but no death occurred in the ED. Forty-three patients (6%) were transferred to the intensive care unit. Conclusion: Our dataset provides an interesting insight into the drugs involved in and clinical pattern of toxicity outcome of acute recreational drug toxicity presentations at the ED, despite possible under-declaration and coding. Classical recreational drugs were more common (77%) followed by prescription drugs (20%) and NPS (3%). and drug (59%) consumers + HIV-infected (58%) and depressive (25%) patients) were admitted to the ICU. The main declared compounds were methylenedioxypyrovalerone (MDPV + N = 9), 4-methylethcathinone (4-MEC + N = 6), 3-methyl methcathinone (3-MMC + N = 3) and 4-methyl methcathinone (4-MMC + N = 3), more frequently used in drug mixtures sold as bath salts or in poly-intoxication with conventional illegal drugs (mainly cocaine and gamma-hydroxybutyrate). NPS was used in a recreational (71%), Chemsex (29%) or solitary practice (29%). Binge (63%) and intravenous (50%) self-administration was remarkable. Patients presented acute encephalopathy with psychomotor agitation (46%), confusion (38% + Glasgow coma score-14 [9]), hallucinations (33%), anxiety (17%), seizures (17%), myoclonus (13%) and stereotypes (13%). ECG typically showed sinus tachycardia (70%), QRS QT abnormalities (13%) and atrio-ventricular block (4%). Acute cardiac ischemia (17%) and dysfunction (13%), disseminated intravascular coagulation (8%) and multiorgan failure ( Results: During the first and the second study periods 204 and 244 patients were respectively admitted in the ICU. Total micro-organisms density was 48 and 69.5 for 100 patients for the first and the second period, respectively (p < 0.05). Acinetobacter spp and Pseudomonas Aeroginosa were the predominant isolated microorganisms with a respective density of 13.2 and 11.2 isolates for 100 patients. Figure 1 summarizes the patterns of bacterial ecology and resistance in our ICU before and after transfer to new buildings, showing a significant decrease in Pseudomonas aeroginosa resistance for ticarcillin and ceftazidim, whereas Acinetobacter resistant to carbapenems and Enterobacteriacae ESBL significantly increased.

Our study suggests that transfer of ICU to the new buildings was associated with a decrease of Pseudomonas aeroginosa resistance, whereas Acinetobacter spp resistance and ESBL Enterobacteriacae incidence increased. Introduction: Infections caused by antimicrobial-resistant bacteria (AMRB) are one of the main issues in the spectrum of critically ill patients as they are associated with higher mortality, morbidity, and length of stay. Thus, an appropriate initial antimicrobial therapy is decisive for better patient outcomes. The aim of the study is to determine the adequacy of first-line antibiotic therapy guided by weekly AMRB screenings. Patients and methods: A 9 months prospective study was conducted in 6-bed MICU. Were included all patients with more than 48H of ICU stay. An AMRB screening was conducted upon admission and on weekly basis for all the patients. The choice of antibiotherapy if indicated, was guided by the most recent colonization results. If the patient has received at least one active in vitro antibiotic against the isolated bacteria, the empiric antibiotherapy was considered appropriate. Results: 98 patients were included in the study. Mean age and SAPS II were respectively 56 ± 20 years and 41 ± 20. The median length of stay was 8 days. 11 (11%) patients were colonized by AMRB upon admission. The most frequent isolated microorganisms were-Escherichia coli 5 (55%) and Klebsiella pneumonia 4 (45%). Were assessed 57 hospital-acquired infections (HAI)-32 (56%) in AMRB colonized patients and 25 (44%) in uncolonized ones. The antibiotherapy was considered appropriate in 21 infections (65%). Out of the 20 colonized patients, 15 (75%) developed HAI. 11 (73%) patients had a concordant colonization body site to the infection. Of the 57 nosocomial infections, ventilator-associated pneumonias and central venous catheter infections were the most frequent, both at 38% (n = 22 and n = 22) + followed by urinary tract infections 21% (n = 10) and infective endocarditis 2% (n = 1). (42). Overall, the isolates were-extended spectrum betalactamase productrice-Enterobacteria (43%), imipenem resistant-Acinetobacter baumanii (30%), and multi resistant-Pseudomonas aeroguinosa (19%). 50 NI were documented including 35 caused by MDR bacteria and distributed as follows-ventilator acquired pneumonia-VAP (n = 19), bacteraemia (n = 6), VAP with bacteraemia (n = 4), catheter related infection-CRI (n = 3), CRI with VAP (n = 2) and catheter-related bacteraemia-CRB (n = 1). The performance of MDR bacteria-screening in predicting NI was poor with 71% of sensitivity, 58% of specificity, 41.5% of negative predictive value (NPV), and 83% of positive predictive value (PPV). Nevertheless, the performance of the nasal swab in the prediction of VAP was better with 85% of sensitivity and 92.3% of NPV. Conclusion: MDR bacteria-screening is useful as it allows to identifying the MDR bacteria-carriers and helps for a rational use of antibiotics in severe NI. However, its diagnostic contribution in the occurrence of NI is poor except the interest of the nasal swab in the prediction of VAP owing to its good NPV. We aimed at determining the respective weight of these phenomenon and the physiological determinants of the respiratory variations of the IVC diameter. Patients and methods: In 21 mechanically ventilated patients (tidal volume-6.2 ± 1.0 mL kg of predicted body weight) haemodynamic, respiratory and the intra-abdominal pressure (IAP) signals were continuously computerised. CVP, IAP and the IVC diameter (transthoracic echocardiography) were recorded during 15-second end-inspiratory and end-expiratory occlusions separated by 10 s, before and after the infusion of 500-mL of saline. Patients in whom fluid administration induced an increase in cardiac index (PICCO-2) > 15% were defined as "responders". The respiratory variations of the IVC diameter, CVP and IAP were calculated as the (end-inspiratory-end-expiratory values) mean value. The compliance of the IVC was estimated by the ratio (end-expiratory-end-inspiratory IVC diameter) (end-expiratoryend-inspiratory CVP). Results: Fluid administration increased cardiac index by more than 15% (3.09 ± 1.12 to 3.90 ± 1.42 L min m 2 , p = 0.0003) in 8 patients.

The respiratory variations of the IVC diameter predicted fluid responsiveness (area under the ROC curve-0.822 (95% CI 0.595-0.952), p < 0.05). Before fluid administration, the ratio of changes in IVC diameter over changes in CVP was not different between responders and non-responders (0.73 ± 0.34 vs. 0.88 ± 1.25 mm mmHg, p = 0.75). Before fluid administration, the respiratory variations of the CVP tended to be higher in responders than in non-responders (34 ± 27 vs. 18 ± 8%, p = 0.07). The respiratory variations of the IVC diameter were associated with the respiratory variations of CVP (r = 0.56, p = 0.01) but not with the respiratory variations of IAP (r = -0.15, p = 0.52).

The respiratory variations of the IVC diameter were not explained by a higher IVC compliance but rather by higher respiratory variations of the CVP in responders than in non-responders. Interestingly, it seems that IAP, the IVC extramural pressure, was not involved in the respiratory variations of the IVC diameter. Inclusions are ongoing. During the hospitalization in ICU, there was no significant difference between the two groups regarding the proportion of patients with AKI through ICU discharge. In the intervention group, 28% of the patients had a glomerular filtration rate lower than 75 mL min 1.73 m 2 compared to 14.8% in the control group (p = 0.25) at day-28. We found no significant difference between the two groups neither on hematopoietic effects of Epo or serious adverse events.

In patients resuscitated from an OHCA of presumed cardiac cause, early administration of erythropoietin compared to standard therapy did not confer any renal protective effect.

Salvetti Marie , and the ratio of end-diastolic areas of both the right and left ventricle in the long axis view of the heart (RVEDA LVEDA) were measured. A LVEF < 40% defined LV systolic dysfunction, a CI < 3 l min m 2 defined low cardiac output, and a RVEDA LVEDA ratio > 0.6 (± associated with a paradoxical septal motion in the short axis of the heart) defined RV dysfunction (± acute cor pulmonale). The preload-dependence was evaluated using deltaSVC or deltaVmaxAo. Front-line hemodynamic and metabolic parameters were recorded at the time of TEE assessment. Results: LVEF and CI could be simultaneously measured in 388 of 410 patients (95%). 74 patients (19%) had a low CI related to LV systolic dysfunction (lactate-4.36 ± 3.49 mmol l), 141 patients (36%) had a low CI and a preserved LVEF related to a RV dysfunction or to a sustained preload-dependence (lactate-3.58 ± 3.28 mmol l), 146 patients (38%) had preserved CI and LVEF (lactate-3.38 ± 3.32 mmol l) including only 23 patients (6%) with a hyperkinetic profile (high CI and LVEF > 70%), and 27 patients (7%) had preserved CI but altered LVEF (lactate-3.49 ± 2.95 mmol l) due to a marked tachycardia. None of the front-line hemodynamic parameters was discriminatory to identify the circulatory profile identified by TEE assessment (Table) . Introduction: Aortic end-systolic pressure (ESP) is considered as a reliable index of left ventricular afterload. Recently, the effective arterial elastance (Ea), i.e., the ratio of ESP over stroke volume (SV), has also been proposed as a reliable afterload index. Our aim was to document peripheral estimates of Ea (EapSAP) at the bedside in critically ill patients, and to investigate the haemodynamic mechanisms responsible for Ea changes after fluid administration (FA).

In the validation study, carotid tonometry (Complior) was prospectively performed on 50 haemodynamically stable spontaneously breathing patients equipped with an arterial femoral (n = 21) or radial (n = 29) catheter. Ea was defined as the (0.9 × cSAP) SV ratio, where cSAP was the central systolic arterial pressure directly measured from the calibrated carotid waveform. EapSAP was calculated as the (0.9 x peripheral systolic arterial pressure) SV ratio. SV was obtained by transpulmonary thermodilution or transthoracic echocardiography. In the clinical study, we included 30 patients with invasive haemodynamic monitoring (PiCCO-2), in whom FA was planned.

Results: In the validation study, the Complior allowed estimating Ea in all patients (Ea = 1.73 ± 0.62 mmHg mL). The (EapSAP-Ea) bias was smaller at the femoral than radial artery level (0.08 ± 0.08 vs. 0.18 ± 0.16 mmHg mL, p < 0.05) and was strongly related to the systolic pressure amplification between the carotid and peripheral artery (r = 0.89, p < 0.05). Ea was more strongly related to SV (r = − 0.80) than to ESP (r = 0.48) (each p < 0.05). The four-quadrant plot analysis indicated that 47 patients (94%) exhibited a concordant low Ea high SV pattern or high Ea low SV pattern, while only 33 patients (66%) exhibited concordant high Ea high ESP pattern or low Ea low ESP pattern (p < 0.05). There was a negative relationship between changes in EapSAP and changes in SV in the whole population, in fluid responders (cardiac index increases > 15% after FA), in pressure responders (mean arterial pressure increases > 10% after FA) and in non-responders, while no consistent relationship between EapSAP and ESP changes was documented. Conclusion: Ea may be reliably estimated at bedside by using the (0.9 x femoralSAP) SV ratio. Ea value and Ea changes induced by FA were related to SV rather than to ESP. Thus, Ea should be considered as an index reflecting SV rather than left ventricular afterload in critically ill patients. 

This study included a Sham group (n = 11), a CPB group (n = 9), an IR group (n = 8) and a CPB-IR group (n = 11). Rats were exposed to 45 min of CEC, 30 min of left pulmonary ischemia and 15 min of reperfusion. Fonctional endothelial dysfunction was evaluated by measurement of the pulmonary artery reactivity. Systemic inflammation was evaluated by the plasma assay of IL-1 beta, IL-10 and TNF-alpha. The endothelial glycocalyx was evaluated by plasma assay syndecan-1 and electron microscopy. The statistics were performed using an ANOVA test, p < 0.05.

We showed that CPB associated with IR induce an endothelial vasorelaxation dysfunction mainly mediated by nitric oxyde (NO Introduction: During circulatory shock, the goal of increasing cardiac output is to correct tissue hypoxia, which can be manifested by an increase in oxygen consumption (VO2) associated with an increase in oxygen delivery. We hypothesized that, in patients in circulatory shock, veno-arterial CO2 gradients (Pv-aCO2) could be a good predictor of an increase in VO2 in fluid responders. Patients and methods: We included patients with circulatory shock who received a fluid challenge. Circulatory shock was defined by the association of vasopressor requirements to maintain mean arterial pressure (MAP) and a blood lactate concentration ≥ 2 mmol L. We measured cardiac index (CI) and arterial and central venous blood gases and arterial lactate before and after a volume expansion (500 ml of Plasmalyte ® ). Cardiac index (CI) was measured using a pulse contour analysis method (PiCCO + Pulsion, Munich, Germany). CI responders were the patients in whom CI increased (ΔCI) by > 15%. In those patients, VO2 responders were those in whom VO2 increased (ΔVO2) by > 15%. Receiver operating characteristic (ROC) curves were performed. The data was presented as median (25th percentile-75th percentile). A p < 0.05 was considered as statistically significant. Introduction: The autonomic nervous system (ANS) is highly adaptable and allows the organism to maintain its balance when experiencing stress. Heart rate variability (HRV) is a mean to evaluate cardiac effects of ANS activity and a relation between HRV and outcome has been proposed in various types of patients. While electrocardiographic HRV assessment seems to be the gold standard, we evaluated the feasibility of an automated HRV monitoring based on standard photoplethysmographic monitoring. This project is based on a prospective physiological tracing data-warehousing program (Rea STOC, clinicaltrials.gov # NCT02893462) that aims to record more than 1500 ICU patients over a 3-years period. Introduction: Diabetic ketoacidosis is an acute complication of diabetes, defined as metabolic acidosis with a high anionic gap, associating hyperglycemia > 16 mmol l (3 g l), positive ketonuria, or superior or equal ketonuria to ++, it is a medical emergency which can occur in a known diabetic patient, or not. OBJECTIVE-To describe the clinical therapeutic and prognostic aspects of diabetic ketoacidosis in the intensive Pediatric care unit at the EHS Canastel Oran, Algeria. Patients and methods: Retrospective study carried out over a period of 2 years. From January 1, 2015 to January 1, 2017, in the intensive pediatric care service. The data was entered and analyzed using Excel 2007. Results: 16 cases were retained on 450 hospitalizations per year, 95% of cases had no history with diabetes, 5% occurred in known diabetics with insulin, but are not followed medically. Our patients were aged from 10 months to 15 years, but the average age of these patients was 6 years and 5 months, with a slight female predominance, coma was preceeded by 75% of cases polydipsy polyuria syndrome and 12% weight loss, triggered by an infectious syndrome including 31% of ENT cases, 12% of respiratory infections and 12% of cases with digestive infections characterized by fever, abdominal pain, vomiting. The delay between diagnosis and admission to ICE was 24-7 days. At admission 80% of patients were scored at 11 15 on the Glasgow scale, with presence of the cough reflex, and 20% were scored at < 7 15 requiring tracheal intubation and mechanical ventilation of 48 h with signs of dehydration and ionic disorders, namely hypokalemia and hypernatremia, blood glucose at admission varies between 3.5 and 5 g l with glycosuria at +++ and ketonesuria between ++ and ++++ in only 18% of the patients had metabolic acidosis, a cerebral computed tomography (CT) performed in 13% of cases found a slight cerebral edema. Therapeutic management was the rehydration, correction of metabolic disorders and introduction of insulin into SAP, with monitoring and subcutaneous relaying due to ketonuria negativity. The outcome was favorable for all patients.

Conclusion: Diabetic ketoacidosis is a major complication of diabetes which can be avoided by a good prevention campaign and systematic screening of any child suspected of diabetes, recognition of risk situations such as infections and clinical manifestations in order not to delay the management. Introduction: Scorpion sting is a public health problem world wide with a global distribution of 1500 species. In Algeria, scorpionic envenomation occupies a prominent place in declarations. In 2016, 43000 cases were reported. The objective of our study is to describe the epidemiological, diagnostic, therapeutic and evolutionary characteristics of the scorpion sting in children.

Retrospective study of 07 cases of scorpionic envenomation hospitalized in the pediatric resuscitation department of the EHS Canastel ORAN conducted during the year 2016The inclusion criteria were the presence of traces with at least one locoregional or general clinical signs. The parameters studied-age, sex, city of origin, time of bite, time of management, initial first aid, time limit for admission to pediatric intensive care, and severity criteria. Results: 57% of these cases were boys and 43% girls. The mediane age 6.5 90% of the punctures occurred during the day, the site of the injection was the lower limb in 80% of the cases and 20 There were 9 bites scorpion cases in the west of Algeria and exactly in Oran and Tiaret.100 of the cases was the upper limb. The delay of the management was from 1 to 3 h for 30 100 of the cases who were classified in the third classed according to the clinical signs of gravity. The type of the scorpion was not identified. We can classify all the patients that we received in our service into three classes −43% in class I, with local signs such as pruritus, redness, abnormalities and local pain. EVA 6-7, calmed by the infusion of 15 mg kg iv of paracetamol and application of xylocaine cream at the site of the sting. Introduction: The residence of children in intensive care is most often due to the existence of one or more organ dysfunction which requires heavy treatment (intubation, ventilation, drainage, venous tract) and this in a hostile environment which amplifies the aggression organic.

The main objective of our work is to study the consequences of hospitalization of children in pediatric resuscitation. Patients and methods: This is a descriptive prospective study on the outpatient consultation file of Canastel's EHS Multipurpose Resuscitation. We studied 18 files and assessed memory, perception of contact and nuisance factors felt by sick children. Results: Out of 18 children seen in post resuscitation. The sex ratio is 1.25. The average age of children is 4 years (2 months-14 years). The average hospital stay is 13 days. The average GOS (Glasgow out scale) is 4. (2) (3) (4) (5) . The average duration of ventilation is 8 days. 60% of children had central vascular access. Three children describe a total memory of the stay, 2 some memory and 2 none. Three children have a good perception about the staff, one child dissatisfied and three others indifferent. The nuisance factors described by the children are pain (3), cold (2), noise (3), hunger (1) and light (1) . Conclusion: Consequences of psychological trauma, insufficiently evaluated especially by the staff, which result in the appearance of psychological disorders (nightmares and anxiety) with sometimes even severe post-traumatic neurosis. Hence the need to adapt the environment and mainly noise and respect for sleep. [3] [4] [5] [6] [7] [8] [9] . The median treatment duration time was at 120(87-180) minutes. Femoral vein was used as vascular access (93%) and most of PE procedures (78%) were performed with citrate anticoagulation. Median exchange volume was at 3500 [2796-4190] ml and renal replacement fluid was fresh frozen plasma (FFP) in 64%, 50% FFP and 50% human albumin 4% in 22% and human albumin only in 14% of procedures. Adverse effects were observed in less than 20% of procedures and 10% were lifethreathening including cardiac arrest, heart rhythm disorders, cerebral oedema and hemolysis. Other remaining complications were secondary infections 48%, hemorrhage 23%, and pulmonary oedema 14% in all patients. Twenty patients deceaded (ICU mortality 26%). ICU and hospital lenght of stay was at 19 ± 21 and 47 ± 33 days respectively. 2 3 of survived patients still underwent PE after their ICU discharge + 9 totally recovered whereas 49 (63%) were on partial remission. Conclusion: PE is a routine and feasible technique in ICU. This study showed that TPP was the most commonly indication of its use and that outcome was fair. Adverse effects frequently occured but most of them were not severe. Further studies would benefit form larger cohort to improve indications, delay of initiation and practice of this treatment. Renal replacement therapy was required in 46% of elderly versus 27% (p = 0.047). Frequency of TTP, HUS and aHUS was similar beetween groups. TMA was more frequently associated with ongoing cancer and drug use in elderly (39 vs. 8%, p < 0.01 and 23 vs. 6%, p < 0.01, respectively). Gastro-intestinal bleeding during ICU occurred more often among elderly (35 vs. 15% (p = 0.02)). ICU mortality rate was higher (19 vs. 7%, p = 0.049). No difference was found concerning plasma-exchange therapy, steroids use, and rescue treatments for refractory-TTP. Discussion: Increased complication and mortality rates in the elderly group might be ascribed to more cardiovascular morbidity in this population. The association between TMA and ongoing cancer suggests a routine oncological workup among elderly. Introduction: Neutropenia, defined by an absolute count of polymorphonuclear neutrophils less than < 1500 mm3, exposes patients to infectious complications that can lead to sepsis or septic shock. The mortality risk is higher. The French guidelines published in 2016 were formulated to homogenize the clinical practices and improve survival.

We performed a monocentric retrospective study including all consecutive patients admitted to the medical ICU of a tertiary hospital to a neutropenia with sepsis or septic shock, between the 30th of December 2012 and the 30th of December 2016. The study protocol was approved by the local Ethics Committee (2017. CE15) and published on clinical trial (NCT03217721). Results: 2235 patients were admitted in ICU during this period. 130 patients (17%) presented a neutropenia with sepsis or septic shock. Among these patients, 92% had hematologic malignancies and 5% had solid tumour. 78 patients (60%) was treated empirically with antipseudomonal beta-lactam or carbapenem and aminoglycoside. 129 (99%) skin or suspected catheter-related infections were treated with anti-MRSA (methicillin-resistant staphylococcus aureus), vancomycin or linezolid. Adequate antibiotics as described in guidelines was performed to 76 patients (58%). 76 patients (58%) received aminoglycoside (58 patients received initial dose in ICU, 18 patients complement dose) and 100 (77%) received anti-MRSA with antipseudomonal betalactam or cabapenem. 71 patients (55%) had microbiologically documented infections with, 59% of bacteria (16% of gram-posit cocci, 1% of gram-negative cocci, 39% of gram-negative bacillus), 8% of fungi and 3% of viral infection ( Table 3) . Among of them, 10% (13) of ESBL, 2% (2) of MRSA and 2% (2) of emerging highly resistant bacteria (BHRe). The ICU-mortality rate was 29% (37 130) with 28% of 28-day mortality (36 130). The curves of the cumulative incidence of death risk between D0 and D28 were no different according to adequate empirical antibiotic treatment as like French guidelines (Fig 1) . By multivariate analysis, independent factors of adequate antibiotic treatment were septic shock (OR, 0.38 + 95% CI 0.15-0.96) and febrile neutropenia > 7 days (OR, 0.42 + 95% CI 0.20-0.88) at ICU admission. Conclusion: According to the usual clinical practice, septic neutropenic patients was already treated empirically by bitherapy including antipseudomonal or anti-MRSA if there is a skin or suspected catheter-related infection. Adjunction of aminoglycoside in of the symptomatology in case of overdose, make the diagnosis difficult, especially since the drug in question is often unspecified and the toxicological analysis is not exhaustive. Introduction: Carbon monoxide intoxication is a public health problem in Tunisia and around the world. Currently, it is unclear the impact of this type of poisoning in our country for lack of declarations. We propose in our work to study the epidemiological characteristics of fatal carbon monoxide intoxications collected in the forensic Pathology department of the university hospital in Sfax, Tunisia, to describe the different steps used in forensic diagnosis of fatal carbon monoxide intoxication and to propose preventive measures to reduce the rate of these intoxications. Patients and methods: It is a retrospective study of 29 cases of fatal carbon monoxide intoxications collected in the Forensic Pathology Department of the University Hospital in Sfax, Tunisia during 06 years (1 January 2011 to 31 December 2016). Commemoratives were collected from medical and police records. A forensic autopsy and a toxicological analysis were carried out in all cases. Results: Fatal carbon monoxide intoxication is the leading cause of toxic death in Sfax during the period of our study. We notice a decrease in the incidence of this type of intoxication. The average age of deaths was 36 years and 2 months with male predominance. The peak frequency of intoxication was in cold season. The most frequent form of intoxication was accidental. The source of carbon monoxide was mainly the defective water heater often placed in poorly ventilated areas. The classic carmine red-color of lividity was found in the majority of cases. Myocardial distress, favored by hypoxia, has been reported in two subjects with a pathological coronary artery. The mean HbCO level was 51.59%. However, account must be taken of the survival time and the time elapsed between death and dosing of HbCO. The incidence of fatal carbon monoxide intoxication has decreased since 2011 and the victim profile has not changed too much.

The fatal carbon monoxide intoxication is still persists as a public health problem in Tunisia. The reduction of its frequency requires the implementation of a well-structured prevention plan based on epidemiological data from a national registry. The identification of these data requires mandatory reporting of this type of intoxication in Tunisia. Introduction: Olanzapine is an atypical antipsychotic drug frequently prescribed in the treatement of bipolar disorder and schizophrenia. Acute poisoning with this molecule is rarely reported. Through this study we aimed to evaluate the incidence and describe the different clinical features of acute olanzapine poisoning. Patients and methods: Retrospective analysis of all cases of olanzapine intoxication admitted in 12-bed teaching ICU between January 2013 and Decembre 2017. Inclusion criteria were patient age ≥ 14 year, acute olanzapine intoxication, the intoxication severity was assessed by the Poisoning Severity Score (PSS) of the European Association of Poison Centres and Clinical Toxicologists. The evaluation of electrocardiograms was performed in the first day of hospitalization. The durations of QRS and QTc was measured and arrhythmias and conduction disorders was identified. Results: 24 patients were included, the mean age was 35 ± 11 years. They were 11 males and 13 females. Long term treatment with olanzapine was noted in 19 patients (79%) who suffered from psychiatic desease. The supposed ingestion dose ranged from 25 to 600 mg. The mean consulting time was 5 ± 4 h after the ingestion. Olanzapine was co-ingested with others drugs in 16 patients (66%). Co-ingested drugs were-benzodiazepine (n = 5), levomepromazine (n = 5), serotonin recapture inhibitor (n = 3), amitriptilyne (n = 2) and biperiden (n = 1). The PSS was moderate in 9 cases (37.5%), severe in 14 cases (58%) and fatal in 1 case. The main clinical signs were tachycardia and miosis in 62% of cases each of them (n = 15), agitation in 33% of cases (n = 8). ECG abnormalities has been detected such as prolonged QTc in 5 cases with a mean duration of 460 ± 28 ms. In the group of monointoxication (8 patients) the PSS was moderate in 3 cases (37.5%), severe in 4 cases (50%) and fatal in one case. The Coma Glosgow Scale was < 12 Fig. 1 Kaplan-Meier survival between admission and 28-day according to adequate empirical antibiotic therapy guidelines (log rank, p = 0.53) in 14 cases. Mechanical ventilation was required in 58% of cases (n = 14%) with a mean duration of 23 ± 8 heures. The mean duration of ICU stay was of 50 ± 30 h. Twenty three patients recovered during the hospitalisation, one patient died with severe poisoning. Conclusion: As showed in this study, acute olazapine poisoning could be severe, and lead to death sometimes. Introduction: Voluntary drug intoxication (VDI) continues to be a major health problem in many developed and developing countries. In Algeria, this has become a worrying concern. Awareness-raising is launched to prevent the public from these dangers. VDI are intentional or rarely accidental and can be individual or collective and affect all age groups. The VDI represents the first reason for hospitalization in the Emergency Department University hospital of Oran.

In Algeria there is no national or regional register of voluntary intoxication. Knowledge of the causes of drug poisoning should therefore be extrapolated from foreign studies. To draw up an assessment of the IMVs, a retrospective study was carried out over the 2 years (2015-2016) . This survey consisted of collecting data on the nature of the drug, age, sex, major toxidromes, severe IMVs requiring hospitalization in ICU, mortality, E.T.C scores and GLASGO scores.

Results: 1650 cases of acute poisoning were collected, with a predominance in patients aged between 16 and 25, a percentage of 31.77%. In addition, most patients were female with 60.98%, a sex ratio of 1.56 with p < 0.05. The main toxidromes were-opioid syndrome in 27% of cases and anticholinergic syndrome in 23% of cases. ETC with a score of > 9% accounted for 93% of patients. Severe VDI requiring resuscitation hospitalization were 8%. Conclusion: Acute poisoning remains high and steady in the Oran region and the under-25 age group represents the most affected category. Awareness campaigns must be launched throughout the year to better conserve and store medicines, phytosanitary products and other chemicals. Improved socio-economic conditions would help to reduce voluntary intoxication. Introduction: Scorpionic envenomation is unevenly distributed throughout the world and is particularly frequent in some regions of the world, notably North Africa. The purpose of this work is to describe the epidemiological profile of the scorpionic envenomations admitted to the resuscitation department of Mahres. Patients and methods: A prospective study conducted at the Mahres intensive care unit over a period of 6 months (15 02 2017 until 15 08 2017), including all patients admitted for scorpion envenomation. Results: We collected 102 cases of patients admitted to the resuscitation department of Mahres from 15 02 2017 to 15 08 2017, including 10 cases of scorpionic envenomations, i.e. 0.098%. The median age was 43 years with extremes ranging from 20 to 78 years. The sex ratio was 4. Scorpion stings occurred at night in 80% of patients, 60% in the first half of the night (between 6 pm and 11-59 pm) and 20% in the second half of the night (0 to 5 h). Venom inoculation points were in the lower limbs in 80% of cases, followed by upper limbs (20%). The color of the incriminated scorpion was yellow in 80%, black in 10% and unspecified in 10% of the cases. For admission classes, there were 10% Class I, 80% Class II and 10% Class III. The traditional therapeutic gestures practiced by the patients or their entourage were the laying scarification (50%) and the suction (10%). All patients received anti-scorpion serum, an analgesic, serum and tetanus vaccine. The progression was favorable in all cases after an average hospital stay of 4 ± 1 days. Conclusion: Scorpionic envenomations are indeed a reality in Mahres with a non-negligible frequency despite under-reporting of cases treated by traditional medicine or in other hospitals. They mostly affect young people and the associated clinical manifestations often remain benign. Introduction: Severe pediatric poisoning is defined by the need for intensive care monitoring due to the nature, quantity of the substance and or clinical manifestations. It is one of the frequent reasons for admission to emergency and resuscitation. The purpose of this work is to identify poisoning in children admitted to pediatric intensive care units in order to assess the frequency, identify the products involved, and the clinical and evolutionary aspects. Patients and methods: This is a descriptive study over a 24-month period in the Canastel Oran multi-purpose pediatric intensive care unit from July 2016 to July 2017. We included all children aged 0-15 years admitted for ingestion and inhalation of products toxic. Results: 39 children admitted to pediatric intensive care, mean age was 5 years, 70% under 6 years with extremes of 02 months and 15 years, a female predominance of 60% was observed with a slight predominance of accidental poisoning (56%) Compared to voluntary poisoning (44%). In 87% the toxic is ingested orally. The most frequent toxicants were drugs with 19 cases (35%), mostly antidepressants and antiepileptics, followed by organophosphates with 10 cases (26%), CO 5 cases (12%), petroleum products and plants with 5 cases (12%). The main clinical signs were neurological signs (76%) with predominance of coma and convulsions in 19 cases (43%), respiratory distress was present in 6 cases (15%) and digestive signs 8 cases (20%). For therapeutic management gastric lavage, charcoal and antidotes were the most frequent treatments. The evolution was marked by a mortality of 2% or a death secondary to a poly-medicinal intoxication voluntary in a girl of 10 years. Mechanical ventilation in 5 cases (12%) and an average hospital stay of 2 days. Conclusion: Acute poisoning is a medical emergency that may require resuscitation. Young children are most exposed with drugs are the most frequently incriminated. We propose, as a preventive measure, companions of information on the dangers of toxic products and especially of medicines by the surveillance of the child and the regulation of certain products. Introduction: The place of neuron specific enolase (NSE) dosing remains uncertain as an indicator of neurological prognosis after a cardiac arrest, the threshold value for predicting an unfavorable evolution being variable from one study to another. Our objective was to determine a NSE cut-off value predictive of poor neurological outcome after a cardiac arrest. Patients and methods: We realized a monocentric prospective trial in a medical ICU of a French University hospital from January 1st 2016 to December 31th 2016. All patients over 18 years old hospitalized for a cardiac arrest in medical ICU were included. Patients who died during the first 24 h or admitted for cardiac arrest with a neurological cause were excluded. Serum NSE values (Elecsys NSE test, Cobas ® analyzer) were assessed at H24 and H72 after cardiac arrest. Somatosensory evoked potentials were recorded between H24 and H72. The primary endpoint was neurological outcome at 6 month using the cerebral performance category scale (CPCS). CPCS 1 or 2 was considered as favorable outcome and CPCS higher than 2 as poor outcome. Data were collected using cardiologic or neurologic consultations report, or by phone call to the patient. Using a ROC curve we determined the NSE value at H24 with higher specificity and acceptable sensitivity. Results: We included 48 patients. Average age was 62 years old. Noflow time and low-flow time were respectively 3.7 and 17 min. Hypothermia was performed in 30 (63%) patients. 27 patients (56%) died in the ICU. The 30-day and 6-months survival rates were respectively 44 and 42% with a favorable outcome of 35% at 6 months. On the ROC curve we found a cut-off value of 41 ng ml with specificity of 0.95 CI 95% (0.75-0.99) and a sensibility of 0.64 CI 95%(0.44-0.81). Area under curve was 0.828 CI 95% (0.713-0.942). 9 out of the 10 patients with a rising NSE between H24 and H72 had an unfavorable outcome. Among patients with NSE > 41 ng ml, the cortical N20 responses were bilaterally present in 4 of them. Conclusion: In our study NSE value over than 41 ng ml at H24 was predictive of poor neurological outcome after cardiac arrest. NSE may prove to be a useful marker in patients with present N20 responses, possibly limiting the duration of hospitalization by introducing therapeutic limitation or withdrawal of support.

Physicians assessment of prognosis in ICU patients with brain Introduction: Outcome prediction in ICU patients with severe brain damage is a difficult task with observed heterogeneity in physicians estimation. The aim of the survey was to evaluate the prognostic estimates and treatment recommendation of intensivists in real patients with various causes of severe brain damage. Patients and methods: A web anonymous survey including a summarized clinical report of four patients who stayed in the ICU was submitted to French intensivists. Patient 1 presented with prolonged hypoglycemic coma, patient 2 with intracerebral hemorrhage, patient 3 with central and extra pontine myelinolysis, patient 4 with a brainstem hemorrhage. All these patients received full treatment in the ICU and had a 6-month follow-up. Physicians were provided with the four clinical vignettes including clinical history, brain imaging and other relevant exams (CSF, EEG,…), evolution of symptoms within the first days of the ICU stay. They had to estimate 6-month outcome using modified Rankin scale (mRS) where a score from 0 to 3 was considered as a good outcome and 4 to 6 as a poor outcome. They had to provide a recommendation about care among the following-full treatment, care limitation, care withdrawal. Results: 109 physicians completed the survey. There were 37 (33.9%) female. 48 (44%) respondents were residents and 20 (18.3%) had a > 10-year of experience. Patients 1 and 2 had a good 6-month outcome with mRS 1 and mRS 2 respectively while patients 3 and 4 had a poor outcome, both with mRS 5. Correct prognosis estimations were 36 (33%), 31 (28.4%), 97 (89%) and 100 (91.7%) in patients 1 to 4 respectively. Care limitation or withdrawal was recommended by 70 (64.2%), 40 (36.7%), 73 (67%) and 73 (67%) respondents in patients 1 to 4 respectively. Of interest, care withdrawal was recommended by 2 (1.8%), 4 (3.7%), 19 (17.4%) and 25 (22.9%) respondents in patients 1 to 4 respectively. Univariate analysis did not display any factor related with a good prediction of prognosis. Conclusion: In this study, overall predictions were pessimistic with important variations among respondents. Although decisions to withdraw life sustaining care were relatively low with regard to estimated prognosis, both inappropriate care limitation leading to self-fulfilling prophecies and unreasonable prolonged life supportive care could result from these estimations. Introduction: Organ harvesting is a national priority because of the shortage of organs, responsible each year for the lengthening of transplant waiting lists. Among the identified potential donors, the main cause of non-harvesting is the refusal of organ donation (OD), which exceeds 30% in France and 40% in Paris area. Patients and methods: In a network of 6 hopitals, each procedure on a potential donor by the donor co-ordinator is recorded in a report. After selection of the reports with interviews with relatives about OD between 2012 and 2015, the data in the reports were collected and a multivariate logistic regression was performed to identify the factors associated with the refusal. Results: 571 reports with interviews about OD was found. The overall opposition rate is 43.3%. Among the 42 children (7.3% of cases) the opposition rate is 47.6%. Among adults, 147 (27.8%) expressed their will about OD during their lifetime, with an opposition rate of 43.5% and for the 382 (72.2%) of them who never expressed their will, the opposition rate is 42.9%. The factors associated with opposition in multivariate analysis are presented in Table 1 . When the deceased had never expressed their will, the reasons given by the relatives to justify the refusal are specified in 87.5% of the reports. These are religious grounds (20%), cultural grounds (12%), respect for physical integrity (15%). In 18% of the cases, relatives believe that the deceased would have been opposed, and in 16% of the cases, they choose to refuse because they do not know the deceased's opinion. Discussion: French law is based on presumed consent. Despite this, it is noted that when patients had never expressed their opinion about OD (and therefore had not refused it), the opposition rate reached 43.5% and was comparable to the patients who had expressed themselves. Conclusion: In our study, factors related to refusal of OD are mainly related to the characteristics of the deceased (religion, culture, history of ethylism) and those of relatives (disagreement, presence of a spouse), but little to the way of doing the interview. However, there is a trend for less opposition when the interview is conducted during the day (between 8-00 and 20-00). On the other hand, when relatives first address the issue of OD, the opposition rate is lower. Introduction: French intensive care society guidelines and the Claes-Leonnetti Law recommend that intensive care teams organize collegiate and multidisciplinary discussions regarding limitation and withdrawal of care decisions. These moments, coined ethical staffs in our unit, require freedom and safety of speech, which can be difficult to obtain when people are caught in hierarchical and or power relations. We sought to assess the representations, perceptions and opinions of ICU personnel regarding ethical staffs. Patients and methods: A questionnaire, developed by the ICU psychologist, was distributed to the entire unit (secretaries, nurses, nursing auxiliaries, doctors) over a period of 6 months. This 30-question questionnaire covered session organization and power relations between participants. Results: Among the 86 questionnaires distributed in the ICU, 76 were retrieved and analyzed. Medical function was associated by respondents with roles linked with power (leading, knowledge, decision, explanation) whereas paramedical function was associated with roles linked with care (perception, account, spokesperson) (Fig. 1) . Regarding representations of decision making, nurses were considered as decision makers in 48 cases (63%) and doctors in 76 cases (100%). Discussion: Although ethical staffs are presented as a place where each opinion counts, stereotypes representation appear in the different roles assigned-on one side doctors are in charge of explanation and decision, and on the other side, nurses are taking care of patient's feelings and assume a role of spokesperson. These stereotypes correspond to gender stereotypes assigning women to positions of care, empathy and relationship, and men to more intellectual and leading skills. These gender stereotypes attest a hierarchy internalized by each one, as highlighted by social sciences and gender studies. Conclusion: Our results highlight the existence of a global idea, shared by the majority-doctors are decision makers and therefore are in a power relation regarding paramedical staff. This hierarchical relationship persists in this moment wished egalitarian (each opinion would count equally). These is a linkage between professional power relations and gender power relations, which show an association between doctor and masculine "qualities" and caretakers and feminine "qualities". These power relations are rarely acknowledged but could have a significant impact on the decision process of these meetings, and should be further investigated.

results. Despite the diary, 33% had a QSPT score > 51, indicating a higher post traumatic disorders. 9 patients (25%) presented a anxiety score > 11 and 11 patients (30.5%) had a depression score > 11. These results underline the need of psychological support after the stay. Conclusion: Many survivors of intensive care unit reported a high level of psychological distress. It seems important offer at this patient a psychological support after an intensive care unit stay. Most patients needs return in intensive care unit to understand some elements of hospitalization. Actually, this support lack to screening and treatment this psychological morbidity.

Prevalence and description of the complications following a percutaneous coronary intervention for a myocardial infarction in non-cardiac critically ill patients: a retrospective single-center Introduction: Type 1 myocardial infarction (MI) is an emergency, which immediate invasive strategy by a percutaneous coronary intervention (PCI) is based on guidelines for cardiologic patients. Conversely, the invasive strategy remains uncertain for patients hospitalized in the intensive care unit (ICU) for a primary non-cardiac disease with MI as a complication, given the ischemic and hemorrhagic risks. We aimed to assess the prevalence of-and describe the major adverse cardiac and hemorrhagic events occurring in the ICU after an invasive strategy by PCI in this context.

We conducted a retrospective single-center 5-year (2012-2017) study. All the consecutive ICU patients with a suspected MI undergoing a coronarography were screened. Patients treated with an invasive strategy (PCI performed within 7 days of MI) were included. Patients hospitalized in ICU for cardiac disease were excluded. The major adverse cardiac events (MACE) were defined as post-procedure events occurring in the ICU, including death from cardiovascular causes, MI recurrence, need for emergent revascularization and stroke. The major adverse hemorrhagic events (MAHE) were defined as post-procedure events occurring in the ICU, according to the Bleeding Academic Research Consortium. Results: 60 ICU patients suspected of MI underwent a coronarography. 29 patients (48%) had significant coronary lesions. Twelve patients were excluded-tri-truncular coronary involvement (n = 12), delayed procedure (n = 4), cardiogenic shock (n = 1). 17 patients were included (11 men, 70 years [IQR 25-75-68-77], 9 patients mechanically ventilated, 9 patients with sepsis septic shock, median SOFA Score at the time of MI 8 [3] [4] [5] [6] [7] [8] [9] [10] ). A PCI was performed during the first day after diagnosis of MI in 9 patients (53%) (median time-0 day [IQR 25-75-0-2]). A MACE occurred in 3 patients (18%), including stroke (n = 2) and MI recurrence without revascularization (n = 1). No patients deceased from cardiovascular causes in the ICU, neither at 6 months post-procedure (Table 1) . A MAHE occurred in 3 patients (18%), 2 of whom had a MACE. Altogether, the prevalence of major adverse cardiovascular events combining MACE and MAHE was 0.24 (95% CI 0.01-0.46). There was no difference between septic and non septic patients regarding the prevalence of MACE or MAHE.

The prevalence of adverse cardiovascular events after an invasive strategy by PCI is high in non-cardiac critically ill patients with MI. Larger studies are needed to determine which patients may benefit from this procedure. Introduction: Resuscitated cardiac arrest (CA) lead to immune alteration including lymphopenia, decreased monocyte HLA-DR (mHLA-DR) expression and dysregulated production of cytokines. In a recent multicenter randomized clinical trial, we tested the hypothesis that Cyclosprine A (CsA) would limit organ failures following out-of-hospital cardiac arrest (OHCA). In a substudy, we aimed to determine the influence of CsA on OHCA-induced immune dysfunction.

This study is a predefined substudy of the randomized CYRUS trial (Cyclosporine in CA resuscitation). Patients with non-shockable OHCA randomly received either an intravenous bolus injection of CsA (2.5 mg kg) at the onset of advanced cardiovascular life support (CsA group) or no additional intervention (Control group). Patients from the coordinating center were sampled at admission (D0) and at 24 h (D1). Complete blood count, CD4 + lymphocytes count and mHLA-DR were evaluated by flow cytometry. Serum levels of IL-1, IL-6, IL-8, IL-10 and TNF&#945 + were measured by ELISA test on frozen samples. Results: A total of 33 patients were sampled-17 patients from the CsA group and 16 from the Control group. The characteristics of the patients, including resuscitation data, were also similar between the two groups at admission. The severity of organ failure as assessed by the SOFA score at admission was similar between groups. All patients Introduction: Critically ill patients experience major insults that lead to increased protein catabolism and a significant loss of lean body mass with an impact on weaning from the ventilator and muscle recovery. In critically ill patients, severe and persistent testosterone deficiency is very common after ICU admission. Administration of testosterone may induce skeletal muscle fiber hypertrophy and decreases protein breakdown. The aim of this work is to assess testosterone levels in critical ill patients and to evaluate the safety of testosterone gel administration.

This is a single center study realized in a university ICU of 10 beds. Total testosterone levels were measured in critical ill men with at least one organ dysfunction with SOFA > 3.

The study drug was Androgel, a formulation of 1% testosterone in an alcohol-water gel, approved by the ANSM for treatment of hypogonadism in men. AndroGel was applied to the abdomen, shoulders or upper arms once a day at the same time to dry and intact skin during ICU stay. The daily dose was 75 mg in men and 25 mg in women daily. Patients with history of prostate or breast cancer or PSA > 4 ng ml were excluded. Results: Total testosterone levels were measured in 19 men. Median length of stay at the time of measurement was 7 days in ICU and 11 days in the hospital. Plasma testosterone levels were low in all but 1 patient. Median testosterone level was 58 ng dl (normal values 270-780 ng dl). Testosterone levels were not correlated with score SOFA or length of ICU stay. We found a moderate positif correlation between testosterone levels and length of hospital stay (r = 0.5 =). Testosterone gel was administered in 12 men and in 6 women. In these 18 patients, the median score SOFA was 10, ICU death occurred in 3 patients (22% ICU mortality), median length of ventilation was 13 days and median length of stay in ICU 30 days. All patients received mechanical ventilation and vasoactive treatment. 9 patients needed renal replacement therapy. AndroGel was well tolerated. No ischemic cardiovascular events were described. There was no application site reaction or acne. Median length of testosterone gel administration was 12 days. Conclusion: Critical ill patients have low testosterone levels. Testosterone gel may be safely administered during the acute phase in ICU.

Randomized clinical trials are needed to evaluate the impact of testosterone gel on physical performance. Introduction: Stroke is the leading cause of physical disability and the second leading cause of death worldwide. Two thirds of all strokes occur in developing countries and is increasingly a public health problem. The aim of this study was to evaluate the epidemiology of strokes in Oran, Algeria in order to create a stroke registry. Patients and methods: A cross-sectional study was conducted on all patients admitted for stroke at the Oran CHU between January 2014 and September 2017. Sociodemographic data, modifiable and nomodifiable risk factors, type of stroke, degree of disability, Severity scores (GLASGOW and NIHSS) were studied. The SPSS 20 software, Log Rank test, was used for data analysis and statistical testing as well as kaplan-meier for survival studies.

Results: A total of 2305 stroke patients were enumerated, aged 20-99 years (mean ± SD = 68.33 ± 12.99), 74.2% had an ischemic stroke and 15% had a haemorrhagic stroke. 49% of the patients were men and 51% of the women. High blood pressure, diabetes, emboligenous heart disease and smoking were the most common risk factors. Intra-hospital mortality was 15.5% and the overall survival rate at 28 days was 77%. Conclusion: This epidemiological study demonstrates that strokes at Oran Hospital may be similar to other locations. However, it seems necessary and useful to design a continuous patient registration system. Introduction: The prevalence of hyperosmolar states and the relationship with mortality nevertheless remain unquantified and not objectively demonstrated. The aim of this work is to determine whether hyperosmolarity is a prognosis factor, and to assess the impact of hyperosmolarity on the evolution of patients. Patients and methods: This is a retrospective descriptive and analytical study performed at the medical intensive care unit at the university teaching hospital IBN RUSHD in Casablanca on the cases admitted during 1 year. We noted epidemiological, clinical, biological and evolutionary parameters of all the patients and divided them into two groups according to their osmolar states, the first non-hyperosmolar group with plasma osmolarity of less than 320 mOsm L, called the control group and the second hyperosmolar group, plasma osmolarity greater than or equal to 320 mOsm L. Results: 371 patients were included. The first group comprised 293 patients (79%) and the second comprised 78 patients (21%). The two groups did not differ significantly about sex and age. Hyperosmolar patients had more diabets 42.3%. Patients in the two groups did not show significant differences in clinical outcomes, including APACHE II and SAPS II scores. Significant differences are reported between the two groups, in natremia, creatinemia, liver transaminases. The plasma osmolarity was significantly different between the two groups with a mean in the control group of 269.77 ± 12.73 mol L while in the hyperosmolar group it was 346.95 ± 35.85 mosmol L (p = 0.046). The prevalence of hyperosmolar states in the study was 21% with 60% mortality.

In the control group 41% were intubated-ventilated + 21.2% received vasoactive drugs and 68.6% received antibiotic therapy. In the control group + 7%of the patients were complicated by nosocomial infection, 9.9% by septic shock and 1% diseased by thromboembolic complications. The deceased subgroup used intubation artificial ventilation in 89.36%, vasoactive drugs in 68%, and antibiotic therapy in 89.36%. In the surviving subgroup, 6.45% only contracted the nosocomial infection. In the subgroup died 51.1% are of mixed hyperosmolar type + 82.4% hyperglycemic hyperuremic + 55.6% hyperglycemic hypernatremic type. Conclusion: Hyperosmolar states are an independent a prognosis factor. Intubation and ventilation, vasoactive drugs and antibiotic therapy increases considerably in hyperosmolar states. Furthermore, it induced serious complications as nosocomial infections and septic shocks that further aggravate the prognosis even within hyperosmolar states. Introduction: Hyperthermia represents a major life-threatening medical emergency, and is also one of the leading causes of death in young athletes worldwide. Its incidence is rare and little understood, but its mortality is on the rise. The objective of this study was to describe the population of patients admitted for exertional hyperthermia in Martinique and Guadeloupe and to determine the prognostic factors. Patients and methods: Retrospective and prospective study, including all patients admitted for exertional hyperthermia in both emergency and resuscitation services in Martinique and Guadeloupe from January 2006 to June 2017. Results were expressed as mean ± SD or %. Results: In 10 years, 55 patients were observed (age-79 ± 18, 44 men and 11 women), the main antecedents of which were-2 hypertension, 2 chronic OH, 2 psychoses, 1 stress hyperthermia. 10 (18%) of the patients had seizures initially. The pre-hospital management was < 30 min. Nevertheless, 20 (36%) patients were admitted to ICU due to organ failure (neurologic 74%, hemodynamic 2%, liver 4%). The progression was favorable, 4 deaths, including 3 fulminant hepatitis and multi-visceral failure. The average length of stay in intensive care units was 5 days (± 6). Conclusion: Despite considerable preventive measures, stress hyperthermia represents a major problem within the military, soldiers and other athletes, with a mortality rate about 10% in most published series. The most effective method is immersion in ice water. There is an urgent need to provide the region with a clear preventive policy, including a relief action plan, training for doctors, athletes and other health professionals at risk of hyperthermia.

Chapoutot Anne-Gaëlle 1 , Leteurtre Stéphane 1 , Chamouine Abdourahim 2 (2008) . The University Hospital of Lille is a pediatric center including several IteCUs in its pediatric hematology or gastrology departments, and more recently in its pediatric surgical department. Moreover, there are 4-6 IteCU extra-beds within the 12-14 bed pediatric intensive care unit (IveCU). The Hospital of Mayotte has no pediatric IveCU but a polyvalent one for adults, which receives children when necessary, as well as a 4 bed IteCU. The aim of this study was to describe prospectively the pediatric population which was admitted in the IteCUs of Lille and Mayotte over a one-year period from June 2016 to May 2017. Patients and methods: In this twin-center, prospective and observational study, data were collected for each patient admitted during the test period in IteCUs of both Lille and Mayotte pediatric hospitalsgeneral information about the patient, characteristics of each stay, severity scores on admission, type of treatments implemented, the report of the stay and patient's evolution. A standard declaration was made with an authorization granted by the local Commission on Informatics and Liberty (French Commission Informatique et Liberté, CIL). Results: During the course of the study, about 450 children were admitted in each center. The collected data allow to describe and compare both populations in terms of severity of each patient's condition.

This study based on a very large cohort has permitted to compare the population of a regional hospital with that of a university hospital and to demonstrate that a health-care provision including a pediatric intensive care unit is needed on Mayotte Island. Introduction: Simulation in intensive care is an innovative method for teaching. Respiratory settings are responsible for some morbi-mortality of our patients. For this reason we develop a simulator of artificial ventilation (SimVA) and virtual patients. Mathematical model resolved differential equations of chest and lung movements in order to match with a clinical data base. The goal of this study was to evaluate and compare virtual patients respiratory mechanic with the results of 4 different protocols of ventilation from 2 large randomised controlled trial-Arma (1) and Express (2). Patients and methods: Virtual patients had ARDS, and were defined by different thoracic and pulmonar compliance, total resistance, lung volumes, pressure-volume relation, and pressure and volume recruitment coefficients. Ventilatory protocols were High versus Low VT (Arma study) and Max versus Min distension according to PEP (Express study). Each virtual patient was titrated on the simulator with the 4 protocols. Respiratory frequency was set around 28 cycles minute and adapted to protocols. Respiratory mechanic after titration was recorded and compared to results of the 2 studies. Results: Results are summarised in the table-the difference between virtual and real patients were not significant. Vm L/min 12.6 (4.5) 13.3 (1.7) 12.9 (3.6) 13.0 (2.0) 11. Ctp: tharacopulmanar compliance (ml/cmH 2 O) Discussion: Inspiratory plateau pressure and thoraco-pulmonary compliance were able to change according to PEP or VT settings within the same range as the 2 large RCT studies. Mathematical model of recruitment was adapted to create many different results while PEP was titrated according to respiratory mechanics with the Express protocol.

Conclusion: Simulation of artificial ventilation with a software can be realistic and might be an interesting pedagogical tool to teach interactively and repetidly ventilatory settings and respiratory mechanics interactions in ARDS without any risk for the patient in our units. Introduction: Expiratory flow limitation (EFL) has previously been investigated in ARDS patients on zero PEEP by using negative expiratory pressure (NEP) technique on tidal breath. In ARDS patients with EFL PEEP 10 improved oxygenation from intrinsic PEEP homogenization rather than lung recruitment. The NEP technique is no longer available. As EFL should reflect airway closure it is important to assess it. We described a new technique to assess EFL. Patients and methods: Thirty-nine ARDS patients (6 mild, 32 moderate, 1 severe) were investigated at PEEP5 and15. They were intubated, mechanically ventilated (Evita XL) in volume controlled mode (tidal volume 5 ± 1 ml kg predicted body weight) in the semi-recumbent position. Airway pressure and flow measured proximal the endotracheal tube were continuously recorded (Biopac150). We measured respiratory mechanics by the occlusion technique at each PEEP and recruited lung volume between PEEP15 and 5 by using low flow inflation method associated with measurement in change in end-expiratory lung volume. For the latter, patient was manually disconnected at the end of baseline tidal inflation downstream pneumotachograph to atmosphere til zero flow, then reconnected at previous settings. EFL was assessed offline by superimposing flow-volume loops of disconnected and baseline breath. EFL was defined if no change in flow occurred over all or part of the disconnected expiration as compared to the baseline breath and no EFL (NFL) if any increase in flow during the expiration was present (Fig. 1) . The percentage of the tidal volume involved in EFL was measured. Results: EFL was present in 7 patients (18%) over 80% of the tidal expiration. Patients with EFL had significant higher body mass index (34 ± 7 vs. 28 ± 6 kg m 2 , p < 0.05) and totalPEEP at PEEP5 (7 ± 1 vs. 6 ± 1cmH2O, p < 0.05) than NFL patients and tended to be more hypoxemic. At PEEP15 EFL patients had a significant better compliance (50 ± 21 vs. 30 ± 12 ml cm H 2 O, p < 0.05) with no change in recruited lung volume (393 ± 271 vs. 347 ± 203 ml) and tended to be more hypoxemic than NFL patients. Mortality at ICU discharge was 57% in EFL versus 28% in NFL (p = 0.19). Conclusion: Measurement of EFL is feasible without the NEP technique. At higher PEEP ARDS patients with EFL markedly improved compliance of the respiratory system not related to lung recruitment. Further studies are required to better understand EFL in ARDS patients and to assess its impact on patient outcome.

limiting factor being carbon dioxide accumulation and hypercapnic acidosis. Extra corporeal carbon dioxide removal (ECCO2R) intervenes by maintaining ph and PCO2 within physiological ranges. This combination is called ultra-protective ventilation. We report our experience with ECCO2R in ARDS and non ARDS patients with a focus on feasibility and safety. Patients and methods: From June 2014 to July 2017 all patients who have undergone ECCO2R in our ICU were included consecutively and prospectively. Venovenous ECCO2R was used through a dual lumen venous catheter (femoral or jugular). Results: Nineteen patients underwent ECCO2R for a total of 21 sessions. ECCO2R was implemented through a dual lumen venous catheter (femoral or jugular) with 3 different devices-Hemolung Respiratory Assist System ® (ALung) (n = 2), iLA activve ® (Novalung) (n = 5) and Prismalung ® (Prismaflex system) (n = 12). Sessions were 3 (IQR 2.5-4.0) days long. Catheter diameters were 13 Fr (n = 8), 15 Fr (n = 6), 24 Fr (n = 4) and 17 Fr (n = 1). Thirteen patients suffered from ARDS and 6 had non ARDS indications for ECCO2R, including ultraprotective ventilation. Tidal volume decreased during ECCO2R from 5.3 (IQR 4.3-5.8) to 3.4 (IQR 2.6-4.1) ml kg of predicted body weight (p < .001) while ECCO2R allowed maintaining of pH and PCO2 within acceptable range (Fig. 1 ). Driving pressure decreased from 17 (IQR 11-21) to 8 (IQR 6-14) cm H 2 O (p < .001). The main adverse effect was thrombocytopenia (8 patients). Six selected patients had no anticoagulation during ECCO2R because of high bleeding risk. Discussion: Ultra-protective ventilation was achieved with a decrease of tidal volumes (Vt < 4 ml kg) and positive pressures. Few data on ECCO2R are available in patients at high risk of hemorrhagic complications, we report here a subgroup of 6 patients who underwent efficiently ECCO2R without anticoagulation. Six patients underwent ECCO2R for non ARDS indications, 3 of them had no structural damages to the lungs which has never been reported and ECCOR allowed implementing ultra-protective ventilation with no major adverse effect.

We report our experience on ECCO2R for ARDS and non ARDS indications. Ultra-protective ventilation (Vt < 4 ml kg) was safe and feasible.

The impact of general practitioners consultation on ARDS complicating community acquired pneumonia Donval Ulysse 1 , Tadie Introduction: Community-acquired pneumonia (CAP) is a potentially severe infection that results in numerous general practitioner (GP) visits and hospital admissions each year. CAP is also the most frequent single cause of acute respiratory distress syndrome (ARDS). Risk factors for development of ARDS in the course of CAP are not clearly defined although prognostic factors associated with mortality have been extensively studied. GP visits, as an early diagnosis and earlier access to antibiotics prescription could significantly affect the course of CAP. The aim of the present study was to evaluate the impact of general practitioners consultation on ARDS complicating CAP admitted to our ICU. Patients and methods: We retrospectively reviewed the medical records of all patients aged over 18 years admitted between October 1, 2006 and December 31, 2015, for ARDS complicating community acquired pneumonia with a PaO2 FiO 2 ratio < 200 mmHg after at least 12 h of lung protective mechanical ventilation (MV). Ventilatory modalities for ARDS had been protocolized over the study period as our ICU was recruiting patients for two consecutive multicenter trials (Acurasys and Proseva). Consequently, the protective ventilatory strategy used in these two clinical trials was applied to every patient with ARDS. Patients were divided into two groups according to whether or not they visited a GP before ICU admission.

: 216 patients were admitted for ARDS complicating CAP. 114 patients (53%) had visited a GP before admission in ICU (GP +) and 102 did not (GP-). Analysis of demographic data, respiratory microbiology patterns, ARDS severity at admission did not show any differences between the two groups. SOFA score at admission was significantly higher in GP-compared to GP + patients (9.5 (8-13) vs. 8.5 (7-10) respectively + p = 0.003) although respiratory SOFA scores were not different (4 (3-4) vs. 4 (3-4) respectively + p = 0.31). 71 (70%) GP-(70%) and 60 (53%) GP + patients presented septic shock at ICU admission (p = 0.01). Multivariate analysis found that GP consultation (0.54 [0.29-0.98] + p = 0.04) with antibiotics prescription (0.46 [0.22-0.99] + p = 0.04) were associated with decreased mortality at day 28 ( Fig. 1) .

In patients admitted to our ICU for ARDS complicating community acquired pneumonia, GP visits prior to ICU admission was associated with a better outcome. The beneficial effect may be due to earlier antibiotic prescription which could significantly lowered severe infection and septic shock. Introduction: Optimal PEEP level during ARDS remains controversial because of its beneficial and adverse effects. The optimal level of recruitment and its effect on oxygenation are not well defined and no technique is currently validated. The aim of our study was to evaluate the correlation between the recruited pulmonary volume estimated by a new technique (CRF INview ® ) and the evolution of PaO2 as well as the respiratory and hemodynamic tolerance of the application of an increasing levels of PEEP . Patients and methods: A prospective, monocentric study that will last 3 years (January 2015-January 2018), taking place in the intensive care unit at the military teaching hospital of Tunis and including patients if they met standard criteria for ARDS (Berlin criteria). The main criterion for judgment was the correlation between the recruited pulmonary volume estimated by a new technique (CRF INview ® ) and the evolution of the PaO2 after application of three increasing levels of PEEP (5-10-15). The other secondary criteria were the respiratory and hemodynamic tolerance of the application of increasing levels of PEEP measured by the PiCCO ® technique. aimed to investigate the concordance between the onset of three VAE tiers and VALRTI, and their impact on outcomes.

We performed a retrospective analysis of prospectively collected data from patients requiring mechanical ventilation for more than 5 days in a 50-bed mixed ICU of a tertiary university teaching hospital, between January 1 and December 31, 2016. VAT and VAP episodes were assessed by prospective surveillance of nosocomial infections, according to the American Thoracic Society criteria. VAE were identified retrospectively, according to current CDC definitions. The agreement between VAC, IVAC, PVAP and VALRTI was assessed by k statistic. The impact of VAE and VALRTI on duration of mechanical ventilation, ICU and hospital length of stay and mortality was also assessed for the first episode of VAT and VAP. Results: We included 545 patients (7927 ventilator days). 126 VAP (15.9 per 1000 ventilator-days), 80 VAT (10.1 per 1000 ventilator-days) and 115 VAE (14.5 per 1000 ventilator-days) were diagnosed. There was no agreement between VAT and VAE and the agreement was poor between VAP and VAC (k = 0.12, 95% CI 0.03-0.20), VAP and IVAC (k = 0.23, 95% CI 0.14-0.32) or VAP and PVAP (k = 0.30, 95% CI 0.22-0.40). Patients who developed VAT, VAP or VAE had significantly longer duration of mechanical ventilation, ICU and hospital length of stay, compared to patients who did not, with similar mortality rates. Conclusion: VAE are not relevant for VAT diagnosis and have low agreement with VAP, despite their negative impact on ventilation duration, ICU and hospital length of stay ( Fig. 1) .

The Introduction: Post-Operative Pneumonia (POP) is a frequent and severe complication of major lung resection surgery. In 2002, we changed our surgical antibioprophylaxis protocol from cefamandole to amoxicillin-clavulanate and observed a significant decrease of POP incidence and mortality. In 2012, we additionally implemented in the respiratory intensive care unit (RICU) an antimicrobial stewardship program based on a local antimicrobial guideline and a weekly multidisciplinary review of all antibiotic therapies by RICU physicians, infectious diseases specialists and microbiologists. Our objectives were to describe our current epidemiology of severe POP and to assess the quality of antibiotic prescriptions. Patients and methods: All patients with severe POP occurring within 30 days after lung resection between January 2013 and December 2015 were included. We collected data on clinical presentation, results of microbiological investigations, antibiotic regimen and outcomes. The quality of antibiotic use was assessed using indicators previously validated in the literature. Results: Over 1555 patients who underwent major lung resection in our center, 91 matched criteria for severe POP and were included. Most were males (n = 71, 78%). The median age was 69 years (minimum-42 + maximum-84). Most patients had chronic obstructive pulmonary disease (n = 59, 65%) and 18 (20%) a history of non-pulmonary cancer. The resection consisted in lobectomy in 59% (n = 54). The median length of stay in RICU was 12 days (1 + 90), and 30-day mortality was 9% (n = 8). Respiratory microbiological samples were obtained in all patients, in most cases invasively per bronchoscopy (74%). Microorganisms were cultured at a significant level in 66 (73%) patients. Predominant species were Enterobacteriacae (58%), Haemophilus influenzae (14%), Staphylococcus aureus (11%) and Pseudomonas aeruginosa (10%). Microorganisms were sensitive to third generation cephalosporins in 52 (79%) and to piperacillin-tazobactam in 57 (86%). In patients treated empirically, antibiotics were prescribed according to the guideline in 80% (69 86). In documented POP, empiric antibiotics were active against documented micro-organisms in 53 62 (86%), and were correctly changed to pathogen-directed therapy in 46 62 (74%). The median duration of antibiotics was of 7 days (2 + 21). Conclusion: Ten years after implementation of amoxicillin-clavulanate as surgical antibioprophylaxis, the proportion of Enterobacteriacae increased. The 30-day postoperative mortality rate remained below 10%. We report high adherence to the guideline for the choice of empirical therapy and treatment duration. The rate of de-escalation to pathogen-directed therapy could however be improved considering the high rate of bacteriologically-documented POP. resistance of PA has reduced between both periods from 42% to 11% (p < 0.01) for ceftazidim, from 74% to 18% (p < 0.01) for cirpofloxacin and from 38% to 18% (p < 0.01) for imipenem. Nevertheless, among the cases, the P2 period did not change the risk of developing an infection (RR = 0.77, CI 95% 0.58-1.01), a VAP (RR = 0.99, CI 95% 0.76-1.28), a septicemia (RR = 1, CI 95% 0.66-1.51) or the mortality rates (RR = 1.04, CI 95% 0.81-1.33). Conclusion: Colonization and infection with PA are risk factors of increased mortality rates and ALOS in ICU. An antibiotic stewardship program allows to reduce the incidence of patients having a positive sample with PA, and the antibiotic resistance of PA strains, without reducing the infection rate of these patients.

Impact of a local care protocol on the duration of antibiotic therapy in community-acquired peritonitis: 10 years of experience Introduction: The use of antibiotics is a major public health, economic and ecological challenge. In 2011, a French national warning plan was created to manage the use of antibiotics. It advocates monitoring of the prescription of antibiotics and the implementation of measures to assess professional practices. The great majority of guidelines concerning the duration of antibiotic therapy in community-acquired peritonitis are based on studies with low level of evidence. The objective of this study is to evaluate the implementation of a Standardized Operational Report (SOR) with a local antibiotic protocol in the management of community-acquired peritonitis at our institution. Patients and methods: This is a monocentric, prospective cohort study-before and after the establishment of the SOR. The primary endpoint is duration of antibiotic therapy. Secondary endpoints are length of hospitalization, infectious complications, mortality, and changes in local bacterial ecology. We have also evaluated retrospectively these different criteria on cohort was constituted since 2005. Results: A total of 205 patients were enrolled from January 2011 to June 2013 and 231 patients from May 2014 to May 2016. The duration of antibiotic therapy was decreased by 7 to 3 days in localized peritonitis (p < 0.0001) and 9 to 7 days in generalized peritonitis (p < 0.0001) (Figure) . However, the compliance to the protocol was only 66%, which leads to an increase in the duration of antibiotic therapy and hospital stay when not used (p < 0.0001). The hospital stay decreased from 7 to 4 days in the localized peritonitis (p < 0.0001). Amoxicillin clavulanic acid (AMC) is the most used antibiotic with an efficiency of 77%. There was no impact on morbidity and mortality when AMC was inadequate. The bacterial ecology was not modified, the rate of extended-spectrum beta-lactamase (ESBL) producing enterobacteria (ESBLE) was 3%.

The use of a standardized antibiotic protocol reduced antibiotic therapy duration and hospital stay, particularly in localized peritonitis despite incomplete compliance to the protocol. To achieve full compliance, we need to continue the training of different physicians and continue the spread of the protocol. Introduction: Bacterial meningitis is an important public health problem because of its frequency and severity. They remain a major cause of mortality and morbidity in developing countries. The aim of our work is to establish the epidemiological characteristics and the prognostic factors . Patients and methods: we did a retrospective descriptive and analytical study and we included all the patients admitted for severe meningitis for 1 year in the medical intensive care unit of the university teaching hospital Ibn Rushd at Casablanca-Morocco. Results: 70 patients were included. The incidence of severe meningtis was 12.61%, the mean age was 44 years old and the sex ratio H F was 1,06.24,3% were pneumococcal meningitis and 20% were tuberculosis In univariate analysis, factors influencing mortality significantly-The male sex Patients with pulmonary tuberculosis as an antecedent.• A low glasgow score at admission. The presence of a neurological deficit 

Arterial pH, mean (SD)

Arterial lactate, mean (SD)

Kidney Disease-Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease-synopsis of the kidney disease-improving global outcomes 2012 clinical practice guideline

Dramatic increase in venous thromboembolism in children's hospitals in the United States from

Antithrombotic therapy in neonates and children

Acute childhood arterial ischemic and hemorrhagic stroke in the emergency department

Childhood hemorrhagic stroke-an important but understudied problem

Emergency management of deeply comatose children with acute rupture of a cerebral arteriovenous malformation

Goulmane Mourad -m.goulmane@hotmail.com Annals of Intensive Care

We recorded 91 episodes of nosocomial infections-pneumonia (n = 45, 49.5%), bacteremia (n = 26, 28.6%), catheter related infections CRI (n = 13, 14.3%) and urinary infections (n = 7, 7.6%). Pathogens isolated were largely dominated by non-fermentent Gram-negative bacilli (n = 55, 60.4%)-Acinetobacter Baumanii (n = 39, 42.8%) with 100% resistance to imipenem and tygecycline, Pseudomonas aeruginosa (n = 14, 15.4%) with 33.3% resistance to ceftazidim and stenotrophomonas maltophila (n = 2). Other Gram-negative bacilli were enterobacteries (n = 11), which were wide-spectrum betalactamase secreting (n = 6) and carbapenemase (n = 1). Gram-positive cocci were the second highest (n = 22, 24.2%)-coagulase negative Staphylococcus (n = 12) which were resistant to methicilline (75%), enterococcus (n = 7) which were resistant to vancomycin (n = 2, 28.6%), Staphylococcus aureus sensitive to methicilline (n = 2) and streptococcus (n = 1). Candida was incriminated in 2 cases of CRI

We report here that neonates had a reduction in HLA-DR expression after CPB, and those with prolonged decreased HLA-DR in the early postoperative period (Day 4) could represent a subpopulation at greatly increased risk of later NI. If confirmed in a larger cohort of patients, our findings could indicate that HLA-DR may be a useful biomarker of immunosuppression after CPB in neonates.

Non-traumatic hemorrhagic stroke (NTHS) in comatose children: epidemiological features and clinical presentation Conclusion: Compared to normobaric LTOT the FiO 2 is lower during NIV with the same O2 flow. Compensation for intentional and nonintentional leaks and so an increase of air flow despite a constant O2 input might explain this. In intermediate care the use of HV for NIV may be interesting alternative in which case the clinician must keep in mind that the FiO 2 decreases compared to standard oxygen therapy. Concerning home usage we hypothesize that this partial removal of O2 treatment could contribute to the poor results of NIV in chronic COPD. Introduction: In February 2016, we opened a 12 beds-post ICU rehabilitation center (Service de Rééducation Post Réanimation, «SRPR»), dedicated to weaning from mechanical ventilation and global post ICU rehabilitation. Objectives-description of the characteristics and main outcomes of the patients admitted over the first year of activity. Patients and methods: retrospective analysis of data extracted from the medical files. Results: 96 patients were admitted 100 times in the unit over its 1st year, from 34 different ICUs (median duration of stay in the ICU 38.5 days (IQR 29-61)). 86% were ventilated (11% with NIV). 85% had a tracheostomy. 64% had ICU acquired weakness + 5% were able to walk. An underlying chronic respiratory disease was present in 53% of cases. 18% were obese. Difficult weaning was found to have one or several respiratory components in 77% of cases (including 20 post surgery diaphragmatic paralysis), cardiac in 34%, neurologic in 18%. Significant complications occured in 60% of cases. Median duration of stay was 19.5 (12-29.5) days. Ten patients died in the unit, 13 patients were re-transferred in the ICU, where 6 of them died. Over half of the patients were discharged at home, in a rehabilitation unit (SSR) or in a hospital ward awaiting a rehabilitation bed. The remaining 24%, that still needed some form of medical or surgical care were discharged in the ward (Fig 1) . In intention to treat, successful weaning from invasive ventilation was obtained in 70% of patients. Of the patients discharged alive from the unit after completing the rehabilitation program (n = 74), 60% were completely weaned from mechanical ventilation, 35% were discharged with NIV or CPAP + 4 patients (5%) were considered not weanable from invasive ventilation + decanulation of tracheostomy was obtained in 82% of cases + 87% of the patients could walk. Conclusion: SRPRs offer a new concept of care for difficult to wean patients, with promising Results. Introduction: Scarce data about patients with prolonged weaning from the mechanical ventilation are available in the literature. Patients without successful weaning 7 days after their first weaning attempt were classified in the group 3 of the Weaning according New Definition (WIND) classification (1) . We here describe specific data concerning weaning and hospital evolution of group 3 patients included in this prospective cohort.

Among the 2709 patients included in the WIND study, 235 were classified in the group 3. Additional data concerning comorbidities, cause of weaning failure and hospital evolution were collected for 213 (91%) of these 235 patients. Results: These 213 patients had median [interquartile range] duration of invasive mechanical ventilation of 18 [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] days and 3 [2] [3] [4] separation attempts. Etiology of ICU hospitalization was medical in 171 (80%). They had a COPD in 49 (23%), hearth disease in 33 (15%) and immusoppression in 31 (15%). We noticed a mean SAPS II of 53 ± 18, a mean SOFA D1 of 8 ± 4 and D3 of 7 ± 4. Tracheostomy for weaning was performing in 55 (26%). At the end of their follow-up, 144 (68%) were still alive-44 (21%) were still tracheostomized, 4 still intubated and ventilated, 8 (4%) treated with VNI and 88 (41%) were extubated (or decannulated) and breathed without assistance. Among the 44 patients still tracheostomized at the end of the follow-up, 14 (32%) were still ventilated (permanently for 8 of them, and partially for 6) and 30 (68%) had spontaneous breathing through their tracheostomy. These patients had a total ICU length of stay of 30 days. The destination at discharge from the ICU is known for only 49 of the 144 survivors-24 (49%) in medical ward, 15 (31%) in intermediate care units, 4 (8%) in sub acute care, 3 (6%) in ICU and 3 in surgical ward. Conclusion: A third of the 213 patients of the WIND study classified in group 3 and with available additional data died in hospital in 2 months following intubation. At the end of the follow-up, 41% had spontaneous breathing without assistance, and 21% were still tracheostomized. Among these tracheostomized patients, one third still required mechanical ventilation. (1)-Béduneau, G., Pham, T. and co (2017) . Epidemiology of weaning outcome according to a new definition. The WIND study. AJRCCM, 195(6) , 772-783. Introduction: COPD patients have often polyglobulia because of associated hypoxemia especially in patients at the stage of chronic respiratory failure. We recently reported that anemia was present in 36% of patients with severe AECOPD admitted to ICU without impact on short-term prognosis. The aim of the present study was to assess the long-term impact of haemoglobin (Hb) levels on outcomes of AECOPD patients. Patients and methods: In a prospectively collected database including consecutive patients admitted between 2007 and 2015 for AECOPD in our ICU. Long-term status of patients following the first ICU admission (surviving or deceased) has been verified by consulting the civil status registers. Anemia was defined according to WHO criteria-Hb < 13 g dl in males + Hb < 12 g dl in females. Long-term survival was assessed by Kaplan-Meier curve. Results: The cohort included 213 patients (median age 67, median pH 7.30, 84.5% males, NIV as first ventilator mode in 87.4%). Anemia was observed in 77 of the 213 patients (36.2%) with median haemoglobin levels at 10.8 and 14.5 g dl, in patients with and without anemia, respectively. Anemia was associated with significantly lower 2 years survival (Log Rank p = 0.043) (Fig. 1 ). The final model included age, SAPS II score, comorbidities, home oxygen therapy, initial ventilatory mode, NIV failure and haemoglobin levels. Multivariate analysis identified age (OR 1.05 per year + IC 95% 1.01-1.10 + p = 0.028), home oxygen therapy prior to exacerbation (OR 2.38 + IC 95% 1.09-5.12 + p = 0.029), intubation at ICU admission (OR 6.97 + IC 95% 2.31-21.03 + p < 0.001), NIV failure (OR 11.5 + IC 95% 2.75-47.6 + p < 0.001), and haemoglobin (OR 1.20 per decrease of 1 g dl + IC 95% 1.01-1.44 + p = 0.034) as independently associated factors with 2 years mortality .

We conducted a prospective observational study including all patients who visited the SIS during the last 12 months. The collection of the usual anonymous demographic, medical and toxicological data was performed by the care-givers and social workers in charge of the drug users. Data were declarative and no analytical confirmation was available except for the patients admitted in the ICU. Results Discussion During 10 months, 818 drug users [F M sex ratio 0.13 + median age 37.8 years (21-69) + patients without resources (40%), without medical insurance (27%), unstable housing homelessness (52%)] visited the SIS for drug injection or inhalation, representing 50,060 drug use including 14,587 inhalations and 35,473 injections by 180 drug users day. Drug users had no addictology (48%) or sociomedical (27%) follow-up. They were infected by hepatitis virus C (44%) and or HIV (5%). They declared to continue injecting in the public space (52%), sharing material (13%), and needles syringes (47%). The injected inhaled drugs in the SIS were Skenan ® (morphine, 42.6%), crack (43% including 1 3 injections), methadone (6.3%), buprenorphine (6.1%), heroine (1.2%), and cocaine (0.89%). These drugs were self-administered by polydrug users declaring concomitantly consuming crack (72.0%), illicit morphine (68.5%), cocaine (34.8%), ethanol (33.7%), cannabis (33.4%), heroin (29.9%), illicit methadone (20.4%), benzodiazepines (13.6%) and illicit buprenorphine (9.5%). Forty-five patients required a paramedical intervention in the SIS resulting in 17 calls to the emergency department and 15 hospital admissions including 2 transfers to the ICU in relation to opioid overdose. No cardiac arrest and no death occurred. Conclusion: SIS visit for recreational drug self-administration rapidly becomes popular among drug users. Illicit morphine (Skenan ® ) Glycemia (mmol/l) 6.2 (5-7) 6.5 (5-8)Ketones in the effluent liquid (g/l) 0.15 (0.025-0.8) 0 (0-0) Patients and methods: Physiological tracings were recorded from the standard monitoring system (Intelliview MP70 Philips), using a dedicated network and extraction software (Synapse v1, LTSI INSERM U1099) that enables photoplethysmographic recordings from oximetry monitoring at a native resolution of 125 Hz. Raw data were subsequently stored on a dedicated local server, before anonymization and analysis. All consecutive patients were recorded for a 2-hours period during the 24-hours following ICU admission. All measurements were recorded with the patient laying supine, with a 30° bed head angulation. Physiological recordings were associated with metadata collection by a dedicated research assistant.HRV parameters defined in a previous study were derived using Kubios HRV premium ( Introduction: Preventing post liver transplantation (LT) hepatic artery and portal vein thrombosis is challenging and includes enoxaparin administration. Enoxaparin pharmacokinetics (PK) has not been investigated in children following LT. Between-subject variability and critical illness may alter PK, leading to the risk of subtherapeutic exposure. Patients and methods: Clinical, biological and kinetic data were retrospectively collected in a single Pediatric Intensive Care Unit center from January 2013 to July 2015. We described an enoxaparin PK model in 22 children the first week following the LT. Anti-Xa activity timecourses were analyzed using a non linear mixed effects approach with Monolix version 2016R. Results: Anti-Xa activity time-courses were well described by a one-compartment open model with first order absorption and elimination. Body weight prior the surgery (BWPREOP) and the related postoperative variation (BW(t)) were the main covariates explaining CL and V between subject variabilities. Parameter estimates were CLi = CLTYP*(BWPREOP 70)3 4 + Vi = VTYP*(BW(t) 70)1 + where typical clearance (CLTYP) and typical volume of distribution (VTYP) were 1.26 L h −1 and 16.9 L, respectively. Standard dosing regimens of 50 IU kg 12 h were insufficient to reach the target range of anti-Xa activity of 0.2 to 0.4 IU mL. Specifically, 7 children (32%) did never attain the target range during the whole period of treatment and all children were at least once under dosed. According to the final results, we simulated individualized dosing regimens within 4 h following the first administration. More than 100 IU kg 12 h are suggested to reach the target range of anti-Xa activity of 0.2 to 0.4 IU mL from the first day.

Standard enoxaparin dosing regimens is not appropriate to reach the target in pediatric liver transplantation patients. Enoxaparin PK modeling should help the physician to achieve the target range from the initial dose and during the maintenance doses. Higher dosing regimens, especially in youngest children are suggested to achieve the prophylactic target range.

Pharmacokinetic analysis of unfractionated heparin in critically ill children during extracorporeal membrane oxygenation: Do we achieve the target? Introduction: Preventing thrombosis in children under extracorporeal membrane oxygenation (ECMO) requiring unfractionated heparin administration. Unfractionated heparin pharmacokinetics (PK) has not been well investigated in children under ECMO. We described the unfractionated heparin dosing regimens and resulting anti-Xa activities in children with ECMO. Patients and methods: This is a single center retrospective study from March 2015 to September 2016. Were included children (< 18 years old age) who were under ECMO for refractory hemodynamic failure related to (i) myocarditis or (ii) septic shock. Anti-Xa activity timecourses were analyzed using a non linear mixed effects approach with Monolix version 2016R. Results: A total of 12 children were included (septic shock, n = 6 + myocarditis + n = 6 with a median age of 42 months (0-197), a median weight of 17.7 kg (4.9-69) and median admission PELOD-2 score of 11 (6-21). Bleeding occurred in 2 children and thrombosis in 4. An initial bolus of unfractionated heparin ranging from 30 to 85 IU kg was infused and then continued by continuous perfusion with an initial dosing ranging from 15 IU kg h to 215 IU kg h. A total of 214 Anti-Xa activity measurements were performed between 1 h empirically antibiotics for these patients with severe infection may be recommended. Introduction: Prognosis of allogeneic hematopoietic stem cell transplant (HSCT) recipients admitted to ICU has improved with advances in HSCT procedures and critical care management, but also with evolution in ICU triage policy. Our aim was to describe the outcome of HSCT recipients admitted to ICU according to a wide admission policy. Patients and methods: Retrospective multicenter study including all consecutive allogeneic hematopoietic stem cell transplant (HSCT) recipients admitted to Saint-Antoine hospital medical ICU, Paris, France from to January 2005 to April 2017. Admissions were identified through a systematic review of ICU database using ICD-10 codes Z948 and T860. Data were extracted from medical charts. Qualitative and quantitative values are expressed as number and percentage, and median and interquartile range, respectively. Comparisons between groups were performed using Fisher's exact test and Mann-Whitney test for qualitative and quantitative variables, respectively. A p-value < 0.05 was considered to be significant. Results: One hundred seventeen patients-77 men (65.8%), median age 53 [36-63] years-were included in the study. Underlying hematological malignancies were: acute myeloid leukemia (n = 51, 43.6%), myelodysplastic/myeloproliferative neoplasms (n = 22, 18.8%), acute lymphoid leukemia (n = 22, 18.8%), lymphoma (n = 11, 9.4%), other 11 (9.4%). Complete remission was achieved before HSCT in 61 (56%) patients. Forty-nine (46.2%) patients underwent myeloablative conditioning regimen and 23 (21.1%) received haploidentical grafts. Twenty-eight (23.9%) patients experienced disease relapse after HSCT and 48 (41%) graft versus host disease prior ICU admission. Median SAPS II was 49 and SOFA score at day one 9 [6-11]. The ICU, hospital and 90-day mortality rates were respectively 38.5, 54.9 and 57.5%. In univariate analysis, factors associated with 90-day mortality were: SAPS II (p = 0.0011), invasive mechanical ventilation (p < 0.0001), vasopressors (p = 0.0012) and renal replacement therapy (p = 0.045). Mechanical ventilation was the only independent factor of 90-day mortality (OR 2.5-16.4], p < 0.0001) with mortality rate reaching 76.9% and even 86.7% among patients with uncontrolled hematological disease. Conclusion: Prognosis of unselected HSCT recipients admitted to ICU remains poor, particurlaly among those receiving mechanical ventilation, and even more if hematological disease is not controlled. These results suggest that the implementation of an ICU triage policy determined both by intensivits and hematologists would be helpful to identify good candidates for ICU admission. Introduction: Acute respiratory failure (ARF) is a common event in patients with primary malignant brain tumors (PMBT). Even if many factors (corticosteroid therapy, swallowing disorders) suggest a specific etiologic spectrum, few data are available regarding its precipitating factors. Our first aim was to compare the causes of ARF between patients with PMBT and those with other type solid tumors. Our second aim was to identify, among PMBT, the factors influencing survival in ICU. Patients and methods: Bicentric case-control study from March 1996 to May 2014. Patients with PMBT (cases, primary central nervous system lymphoma included) admitted for ARF were compared to patients with other kind of solid tumors (controls). The reason for admission "ARF" as well as the causes of ARF was determined by three experienced respiratory physicians and were required for inclusion: a respiratory rate > 20 cycles/min and a PaO2/FiO 2 < 300 for patients in spontaneous breathing and only a PaO2/FiO 2 < 300 for patients under mechanical ventilation. In both groups were excluded patients with metastatic solid tumors, benign tumors or tumors with more than 5 years of complete remission, recent post-operative patients, and patients with other immunodeficiency. Results: A total of 84 cases and 133 controls were included. Main patients' characteristics are reported in the Table 1 . Acute infectious pneumonia was the leading cause of ARF in both groups but was more frequent among cases (77 vs. 36%, p < 0.001). Cardiogenic pulmonary edema and exacerbation of chronic respiratory diseases were more frequents in controls (10 vs. 37%, p < 0.001). Pulmonary embolism was similar between the two groups (10 vs. 4%, p = 0.143). Among acute infectious pneumonia, pneumocystis pneumonia (PCP) and aspiration pneumonia were more frequent in cases (19 vs. 2%, p < 0.001 and 19 vs. 8%, p < 0.001 respectively). In multivariate analysis cancer progression (OR-7.25 95%IC [1.13-46 .45], p = 0.034), need for intubation (OR-7.01 95%IC [1.29-38 .54], p = 0.022) and respiratory rate (OR-1.17 95% CI [1.05-1.30], p = 0.003) independently predicted ICU mortality of PMBT patients. Conclusion: In PMBT patients, the causes of ARF differ significantly from other cancer patients. Up to 30% of the admissions was related to preventable causes (pulmonary embolism, PCP) and a curable cause was identified in the majority of cases. Our results suggest that PMBT alone is not a relevant criterion for ICU recusal. Introduction: Drug intoxication is a common problem encountered in emergency departments. Poisoning remains a major cause of hospitalization for young people, and that of the elderly is constantly increasing. Objectives 1. Determine the epidemiological characteristics of addicted patients 2. Know the clinical manifestations of poisoning. Patients and methods: A retrospective study of cases of acute poisoning recorded at the University Hospital Center CHUOran between January 2013 and December 2015 was carried out. Seizure on data processing by epi-info version 3.5 Results: 808 cases of acute poisoning, with an age ranging from 16 to 90 years. Female patients predominated with 67%. People between the ages of 16 and 25 are the people most affected by poisoning. The nature of poisoning is varied. In this series, analgesics were found to be the leading cause of acute intoxication, with 81 cases, 31% followed by psychotropic drugs (24%), benzodiazepines (21%), neuroleptics (6%), antiepileptics%) and antihistamines (9%). The majority of acute intoxications were managed within an average time of 2.51 ± 3.03 h with an interval between 0.5 and 48 h. In 74% of cases the poisoning was asymptomatic, there were digestive manifestations in 10% of patients, 7% Neurological, 6% Cardiovascular and 3% respiratory. We deplore 1 death in this series secondary to many drug poisoning. Conclusion: Acute drug poisoning is a common reason for admission to the emergency department of Oran University Hospital. The large number of drug families offered for sale, as well as the heterogeneity Introduction: Selective serotonin reuptake inhibitors (SSRIs) have been considered for their low toxicity comparatively to antidepressant agents. The present study aims to describe clinical features and prognosis of poisoning SSRIs. Patients and methods: A retrospective study of patients admitted to our 12-bed teaching ICU for acute SSRIs poisoning over a period of 8 years from January 2009 to December 2016. SSRIs poisoning was retained on a history of over dose ingestion, clinical signs and positive urine samples for SSRIs. Results: Thirty seven patients were collected, the middle age was 32 ± 15 years with a female predominance (86.5%). A psychiatric history with depressive syndrome was noted in 67.6% and a history of suicide in 13.5%. Paroxetine was the main invoked drug (n = 20), followed by sertaline (n = 8), then fluoxetine (n = 6), venlafaxine (n = 1) citalopram (n = 1). The mean supposed ingestion dose was 342.9 mg. Intoxication was pure in 13 cases and associated with other drugs in 24 cases-benzodiazepines (n = 17), klippal (n = 2), amisulpride (n = 1), Non-steroidal anti-inflammatory drug (n = 1), prazin (n = 1) and promethazine (n = 1). Neurological examination found drowsiness and mydriasis in 46% of cases (n = 17), coma in 13.5% (n = 5), agitation (n = 5), tremor (n = 5), hyperreflexia (n = 2), hypersudation (n = 1), fever (n = 1) and diarrhea in one patient. The QT was lengthened in five cases. Treatment was symptomatic. Five patients (13.5%) required mechanical ventilation with average of ventilation duration of 21.2 h. All patients discharged alive the ICU. Conclusion: SSRIs poisoning is mainly manifested by serotonergic syndrome. Evolution is favorable in the majority of cases. Mechanical ventilation could be required.

Hemodynamic profile of shocks induced by dihydropyridine calcium channel blocker poisoning Khzouri Takoua Introduction: Acute Calcium Channel Blockers (CCB) poisoning remains infrequent despite their increasing use. In our country, dihydropiridines are the most prescribed ones. Very few works have studied the hemodynamic profile of acute dihydropyridines poisoning either by invasive means (right cardiac catheterization, transpulmonary thermodilution) or non-invasive (cardiac ultrasound). In this perspective, we carried out this study whose main objective was to illustrate the different hemodynamic profiles of shocks induced by dihydropyridine CCB Poisoning. Patients and methods: It was an observational retrospective study spread over 12 months from 1st January 2016 to 31th December 2016 in a teaching toxicological ICU, including all patients admitted for acute dihydropyridine CCB poisoning, who presented a shock and underwent right hemodynamic exploration.Results: During the study period, CCB poisoning accounted for 3.15% (n = 24) of all the acute poisoinings requiring hospitalization in our Intensive Care Unit. Among them, 21 had taken dihydropyridine which represents 87.5%. Four women aged of 29 [21, 47] were eligible. All the exposures were single-drug. The dihydropyridines involved were amlodipine in 2 cases with a median value of supposed ingested dose (SID) of 297.5 mg and nicardipine in the other two ones, the median SID was 1000 mg. The delay of consultation was of 2.25 ± 1 h after ingestion. Gastrointestinal decontamination was performed in one patient with activated charcoal. The 4 patients developed a shock within 3 h, treated by initial vascular filling on average 1000 ml of crystalloids, noradrenaline alone in 3 cases and with a combination of dobutamine in one patient. Other adjuvant treatments (high dose insulin, calcium salts) have been used in all patients. Their hemodynamic profile evaluation by right-handed catheterization Swan-Ganz was in favour of vasoplegia in 3 cases with median values of systemic vascular resistances (SVR) of 224 dynes.s.cm-5, of cardiac Output (CO) of 14 (L min), and of the arteriovenous oxygen difference of 4.76. The fourth patient's shock had mixed nature with SVR of 507 dynes.s.cm-5 and CO of 3.7 (L min). All patients were discharged from the ICU with a mean length of stay of 14 days. Conclusion: The dihydropyridine calcium channel blockers poisoning exposes to the shock risk due to several mechanisms. The clinician must be warned to look for signs of severity and understand its mechanisms by using the hemodynamic study in order to improve its management.

Goulmane Mourad 1 , Alachaher Djamel 1 , Djebli Houria 1 Introduction: In daily practice, admission to the intensive care unit (ICU) usually does not raise any major ethical problems. Difficulties arise mainly in acute situations requiring intensive care that have not been anticipated and therefore, not adequately prepared and discussed. We hypothesized that non-admission of a patient to the ICU must occur in the following circumstances-(1) with the patient's agreement, expressed either directly or through advance directives (AD), or as relayed by a surrogate or the family + (2) according to a collegial decision-making process (if the patient is decisionally incapacitated) + and (3) after seeking the opinion of an external consultant. The decision-making process must be documented in the patient's medical file. Patients and methods: Prospective, observational study in two hospitals (one large university hospital, one regional non-acamedic hospital) over a period of 2 months. Inclusion criteria were-patients aged ≥ 18 years presenting with failure of at least 1 organ that was directly life-threatening and requiring life-sustaining therapies. Complete data collection was performed for each patient. Results: A total of 31 patients were included (61% from the emergency department and 39% from medical wards). The decision not to admit the patient to the ICU was taken-(1) during night duty for 19 patients (61%) + (2) by a senior physician in 100%, and (3) after clinical examination in 25 (80%). The main reasons justifying the decision not to admit to the ICU were-(1) metastatic cancer in 8 patients (26%) + (2) total loss of autonomy in 8 (26%) + (3) severe cognitive impairment in 4 (13%) + (4) premorbid state in 1 (3%) + (5) chronic organ failure for 2 (5%) + and (6) presence of AD (written or oral) specifying that the patient did not wish to be admitted to the ICU in 8 (26%). This study raises several points concerning the decision-making process for patients requiring intensive care. First, collegiality is observed in almost all situations of non-admission (97%). Second, an outside consultant was contacted in around 30% of cases. Third, 26% of patients had AD. Fourth, the family or entourage were consulted in less than 40% of cases and finally, in around 75% of cases, the decision-making process was documented. Conclusion: This study shows that in emergency situations, it is more difficult to take adequately structured decisions regarding ICU admission than, for example, decisions regarding limitation or withdrawal of treatment in the ICU. Introduction: As known, tracheostomy is performed to improve quality of life (QOL) in patients requiring prolonged mechanical ventilation. It is indicated to facilitate care of critically ill patients, in order to minimize risks of oro-tracheal intubation, and enhance recovery, allowing early discharge from ICU with home ventilation. We aimed by this study to evaluate long-term survival and QOL in Tunisian patients discharged from the ICU with tracheostomy, as well as related burden assumed by their relatives. Patients and methods: Patients who were admitted to the ICU between 2015 and 2017 were eligible for inclusion in this retrospective cohort if they had a tracheostomy during their ICU stay, and were discharged at home with a tracheostomy canula. For survivors, we used the Short Form Health survey (SF12) to assess their QOL at home. We estimated the degree of autonomy using the ADL scale. To assess burden assumed by caregivers (family members most of the time) we used the short version of Zarit burden interview. Exclusion criteria were refusal of the interview or unavailability on the phone call. Results: Fourteen patients were discharged at home with a tracheostomy canula. Only twelve responded to the phone call. Four patients died 1 month later. Amoung the 8 survivors, the removal of the tracheostomy canula was successful in 3 patients after a mean duration of 30 days. Main findings are summarized in Table 1 . Conclusion: Tracheostomy shows good acceptance and acceptable QOL. It allowed shorter length of stay in the ICU and long-term survival after discharge from the ICU, and should be encouraged for Tunisian patients. In contrast, the QOL of patients' relatives was more affected, with significant burden and work load. Introduction: Intensive care survivors present often some psychological disorders linked with experience memory loss or nightmares. The use of patient diaries has been developed and implemented by clinical staff to improve the quality of life after intensive care. Patients received their diaries at ICU discharge. This study was conducted in order to understand the potential benefits for patients the diary on prevalence anxiety, depression and post traumatic disorders during recovery. Patients and methods: A structured interview study was administered to adult critical illness survivors who received ≥ 48 h of mechanical ventilation in a medical and surgical Intensive care unit. After 6 months, this patients answered at two questionnaire-Hospital Anxiety and Depression Scale (HAD) and a screening instrument for PTSD (QSPT). Results: From the survivors at 6 months, 36 patients answered the questionnaires. We have two groups-18 patients had a diary and 18 patients no diary. But these group are so low currently to compare Introduction: In ARDS patients under ECMO common ventilator strategy aims at resting the lung by lowering tidal volume (VT) in the 1-4 ml kg predicted body weight range found in the literature analysis. We tested on the bench the not previously explored hypothesis that VT was not delivered in the 10% accuracy by most of ICU ventilators in this low range. Patients and methods: Pneumatic test lung set at 20 ml/cmH2O compliance and 20 cm H 2 O/L/s resistance was attached to any of 5 ICU ventilators (V 500 (Drager), Carescape R 860 (GE Healthcare), Servo U (Maquet), PB980 (Covidien) and G5 (Hamilton)) equipped with Heated humidifier (Fisher-Paykel MR 850) set off and adult ventilator circuit (RT 380 EVAQUA Fisher Paykel). Each ICU ventilator was set in BTPS condition, at PEEP 12 cm H 2 O and FIO2 0.21. Airway pressure and airflow (Hans-Rudolph pneumotachograph) were measured (Biopac M150) proximal to the lung model. For each ventilator a series of VT ranging from 100 to 280 ml was delivered for 10 breaths each, at 30 then at 15 breaths/min respiratory rate (RR). The relationship of VT measured to VT set was assessed by linear regression over the 5 ICU ventilators for each circuit-RR combination. In each model, the change from the mean effect was assessed for each ventilator. For each model we obtained the mean effect of the 5 ventilators then we compared the effect of each ventilator to the mean effect. Results: For each combination of f and circuit, the mean slope was significantly lower than 1 indicating that, on average, the set VT was under delivered (Table) . There were differences in change in slope from the mean across the ventilators with interaction between ventilators and combinations. As an example, for the adult circuit f 15, Carestation, PB980 and Servo U performed better than G5 and V500. Across the combinations, V500 had consistent negative (greater underestimation than average) slopes and Servo U consistent positive (lower underestimation than average) slopes whilst the slope sign in the three others changed direction. biomarkers. Yet, HLA-DR expression on alveolar monocytes was lower in ARDS than in controls, consistent with sepsis-induced immunosuppression at the alveolar level. Functional differences observed between ARDS and controls suggested a tolerogenic profile of ARDS monocytes. Introduction: Despite their recommendation in the prevention of ventilator-associated pneumonia, oral care is not still clearly standardized. It generally includes a time for oropharyngeal and tracheal suctions which can induce a cough reflex in non-paralyzed patients leading to the mobilization of the endotracheal tube and a consecutively increased risk of tracheal microaspirations. During the oral care procedure, drainage of subglottic secretions at particular times before oro-tracheal suctions is expected to reduce microaspiration. The aim of this study is to assess whether this "optimized" oral care including subglottic drainage can reduce microaspirations.

This is an open prospective study, including ICU ventilated patients. Two procedures have been compared in two randomized cross-over consecutive periods of one day each (3 oral cares a day)-on 1 day, they received routine oral care (oral care (O) then tracheal suction (T)) and on the other day they received optimized oral care (subglottic suction (SG1) then O then SG2 then T). The amylase enzymatic activity has been measured in O, T, SG1 and SG2 suctions as a surrogate for the oropharyngeal content. If present in T suctions, it defines microaspiration. Since the amylase O content is not similar from a patient to another, the primary outcome was the median amylaseT O ratio after routine versus optimized oral care. Results: After informed consent, 24 patients were included. 21 were analyzed due to incomplete follow-up in 3 patients. Patients (SAPSII 51 ± 16) were ventilated since 4.5 ± 4.3 days for a majority of respiratory indications. At day 1, 10 and 11 patients received routine oral or optimized oral car respectively without significant baseline difference. A trend in the reduction (− 35%) of Amylase T O median ratio was observed after optimized versus routine oral care (2.3% [0.6-6 vs. 1.5% [0.7-16], p = 0.16. Conclusion: Despite protection of trachea by the cuff of the endotracheal tube, amylase has been found in tracheal suctions (which represents the last step of oral care). In this pilot study with a limited sample of patients, a trend in the reduction of microaspirations was observed when subglottic suctions were interleaved between oral and tracheal suctions. An increased sample power could show more significant results, but we cannot eliminate that this weak effect could also be due to the inability of subglottic suctions to prevent microaspiration of the oral content. The study has been founded by Teleflex. Introduction: Although necessary, mechanical ventilation can lead to ventilator-induced lung injury (VILI) even when using protective ventilation strategies that combine low tidal volume (Vt)(6 ml kg predicted body weight) and plateau pressure (Pplat) <= 30cmH20. Lower positive pressures and tidal volumes could enhance lung protection + the HLA-DR and PD-L1 expressions were higher on alveolar than on blood monocytes in both ARDS patients and controls (Figure) . Yet, HLA-DR expression on alveolar monocytes was higher in controls compared to ARDS patients (p = 0.004). Circulating monocytes had a higher phagocytic activity than alveolar monocytes (p < 0.001), but no significant difference was observed between ARDS patients and controls. An LPS challenge increased the phagocytic activity of monocytes in controls (p = 0.03) but not in ARDS monocytes (p = 0.88). TNF-α intracellular synthesis was increased after LPS exposure in circulating and alveolar monocytes of controls (p < 0.05) but only tended to do so in ARDS (p = 0.08).

Conclusion: Differences in the phenotype of alveolar and circulating monocytes were observed in ARDS but also in controls, suggesting a physiological lung blood gradient in the expression of these Results: Until 31 03 2016, ten patients were included and analyzed for the study. There was a significant difference between the volumes recruited at the three PEEP levels (p = 0.002). The recruitment evaluated was not correlated with PaO2. There is a significant decrease in cardiac index and PAM caused by the increase in PEEP. Conclusion: Preliminary results from our study suggest that the estimated recruited lung volume estimated by CRF INview ® technology appears to be poorly correlated with measured PaO2. The hemodynamic repercussions observed should also be considered in order to propose an optimal strategy for the optimal adjustment of PEEP. were compliant with the re-evaluation. 191 (85%) patients received carbapenems according to the recommendations. A compliant prescription had no impact on hospital or ICU length of stay and no impact on duration of mechanical ventilation but seemed associated with increase mortality (p = 0.04). Discussion: The high rate of compliant prescriptions can be explained by the broad indications of carbapenems in the ICU, especially in patients with septic shock. The increase mortality of patients with a compliant prescription is probably due to the severity of the infections. In order to achieve 100% compliance, we could suggested regularly updating the knowledge of carbapenems prescriptions, collaborating with bacteriology and infectiology teams, and establishing a computerized or paper prescription with feedback control. Conclusion: The prescription of carbapenems appears most often in accordance with the recommendations in this ICU. However, there is a need for improvement. Introduction: Bacterial infections are frequent triggers for diabetic ketoacidosis and a significant increase in morbimortality is observed in case of delayed antibiotic treatment. However the unnecessary administration of antimicrobial therapy can also lead to bacterial resistance. Early sepsis markers are thus particularly useful for patients admitted in ICU for diabetic ketoacidosis. Patients and methods: We retrospectively studied cases of patients admitted in ICU at Avicenne French Universitary hospital for ketoacidosis defined by pH < 7.3 and glycemia > 13.75 mmol L. Clinical and biological data were analyzed at admission (D0) and on day 2 (D2). Results: Between 2010 and 2016, among 93 patients admitted for diabetic ketoacidosis, 69 were included. Twelve out of 69 were infected (5 urosepsis, 5 pneumonia, 2 others). Demographic data and comorbidities did not significantly differ between the infected and non infected group (IG and NIG). Antibiotics were administered to 33 patients-12 12 (100%) in the infected group versus 21 57 (36.8%) in the non infected group. On D0, there was no difference for-pH, temperature, leukocytes, neutrophils-to-lymphocytes count ratio and PCT (Table 1) . On D2, temperature, leukocytes, neutrophils-to-lymphocytes count ratio and PCT were significantly higher in the IG. In the IG, the biological markers did not vary between D0 and D2, whereas in the NIG, leukocytes (p < 0.0001), PNN (p < 0.0001) and neutrophils-to-lymphocytes count ratio (p < 0.0001) significantly decreased. Surprisingly average PCT levels seem to be particularly high in the NIG on DO as well as on D2. Conclusion: At admission, PCT as well as other usual markers do not appear to be useful to differentiate infected from non infected patients admitted for ketoacidosis. However, on day 2, two different patterns can be drawn and help detecting non-infected patients and thus reduce exposure to antibiotics. These results should be confirmed by a prospective study, including a larger number of patients. Ventilator-associated events (VAE), reflecting worsening oxygenation, are defined as a persistent and significant increase in FiO 2 or PEEP level after a period of stability on the ventilator. VAE definition includes ventilator-associated conditions (VAC), infection-related ventilatorassociated complications (IVAC) and probable ventilator-associated pneumonia (PVAP). The relevance of VAE for ventilator-associated pneumonia (VAP) is low. However, the correlation between the three VAC, IVAC, and PVAP, and the onset of ventilator-associated low respiratory tract infection (VALRTI), including ventilator-associated tracheobronchitis (VAT) and pneumonia (VAP), has never been studied yet. We on clinical examination. Gravity scores-APACHE II and SAPS II. For lumbar puncture data, there is the proteinuria, glycorrhaphy Resuscitation measures-drug intake and intubationIn multivariate analysis, the factors of pejorative evolution-The male sex Presence of meningeal syndrome. High proteinorachia. Taking vasoactive drugs. The SAPS II score. Conclusion: According to this work, many factors influence the prognosis of acute meningitis in our population such as severity general scores, hemodynamic state and initial lumbar puncture data. We will need more investigations and prospective multicentric study to have more discrimination parameters. Introduction: The emergence of ATB-resistant bacteria has become an important public health problem, particularly in resuscitation environments, surveillance and monitoring of ATB consumption is essential to combat this threat ecologically and economically. The aim of this work was to evaluate the consumption of ATB in surgical resuscitation, to establish the cost, and to list the risk factors for bacterial resistance. Patients and methods: It is a retrospective analytical study spread over 1 year, studying 225 patients who have received antibiotic therapy, the data on the consumption of ATB were collected from the patient's medical records, the delivered doses were converted into DDD, according to The WHO standards and the end result is expressed in DDD 1000 days of hospitalization. The statistical analysis was carried out by the SPSS 16 software. Results: In our study, the mean age was 43.15 ± 5.5, with male predominance + Sex ratio 1.71, traumatic pathology is the most common reason for admission, pneumopathy was the most frequent infection. Overall ATB consumption was 1236.11 DDD 1000DH, dominated by the class of Betalactamins (cephalosporins 166.89 DDD 1000DH, carbapenemes 179.68 DDD 1000DH), the direct cost of ATBs rises to 0.33 million dirhams, these are accounting for a large part of the pharmaceutical budget of the Ibn Rochd University Hospital. Bacteria found in order of frequency were Acinetobacter baummanii, beta-lactamaseproducing enterobacteria, S. aureus and P. aeruginosa. Acinetobacter baumannii showed the highest resistance rate. Several risk factors for bacterial resistance were studied, notably the correlation between the use of ATB and the emergence of resistant strains, only piperacillintazobactam was associated with the emergence of resistant strains of EBLSE, as well as 2 other factors that were retained as significantly related to bacterial resistance by multivariate analysis-duration of hospitalization and perfusion of albumin. Discussion: Despite the limited number of studies done on ATB consumption, it seemed that our results were similar to other national and foreign studies, the consumption of ATBs is increased in hospital giving rise to the appearance of many multi-resistant bacteria. Conclusion: In conclusion, resistance to antibiotics is a serious threat to public health both nationally and globally. It is therefore crucial to implement measures to counter this phenomenon + this is only possible through the proper use of ATBs and gaits to prevent nosocomial infections. Introduction: Ventilaor-associated pneumonia (VAP), the leading cause of infection in resuscitation, is also the main respiratory complication in cranial trauma. The aim of this study is to determine the specific risk factors for the occurrence of VAP in this type of patient in an intensive care unit. Patients and methods: We performed a retrospective study in our intensive care unit for an 18-month period (January 2016, June 2017). All patients admitted for cranial trauma were included in the study and ventilated more than 48 h in intensive care. VAP is defined as late as of the 5th day of occurrence. The quantitative and qualitative variables studied were recorded at admission and during hospitalization. A univariate and multivariate analysis using the Fischer and Mann-Whitney tests was performed. p is said to be significant if it is < 0.05. Results: Our study included 50 traumatic brain injury in older adults, of whom 22 (44%) had one or more episodes of VAP during their resuscitation. Late VAP accounted for almost 2 3 of the cases (33 patients). Four independent variables were significantly related to the occurrence of VAP-advanced age (p = 0.04), Glasgow score (GCS) at admission < 8 (p = 0.01), diabetes (p = 0, 03), and the use of Proton Pump Inhibitors for the prevention of stress ulcers (p = 0.04). The duration of intubation (18 ± 6 vs. 11 ± 3 days) and on intensive care (28 ± 16 vs. 15 ± 3 days) are significantly longer in the case of VAP. Mortality was significantly higher in VAP-45 versus 28% (p = 0.01). The majority of early VAP were due to both Strepococcus ppneumoniae and Haemophilus influenzae. The ecology of late VAP was dominated by Klebsiella pneumoniae, Pseudomonas aeruginosa and acinetobacter baumanii. Conclusion: Of the four independent risk factors found in our study, glycemic balance and rapid airway safety by orotracheal intubation in the case of initial GCS < 8 represent the 2 relevant prevention axes of VAP in traumatic brain injury in older adults. Unfortunately, it is accompanied by a significant increase in bacterial resistance to antibiotics, leading to an increase in morbidity and mortality in intensive care units. Patients and methods: This is a retrospective study carried out in our intensive care unit, covering all patients hospitalized between January 2010 and June 2014 and having contracted a nosocomial urinary infection. Patients whose hospital stay was less than 48 h and those Fig. 1 Agreement between VAE and LRTI diagnostic with a nosocomial urinary tract infection acquired in another service were excluded. Results: The study of resistance of the germs responsible for nosocomial urinary tract infection showed that-Escherichia-coli was resistant to Third generation cephalosporins in 21% of cases, at imipenem in 8% of cases, and without resistance to ertapenem and amikacin. Pseudomonas was resistant to ceftazidime in 61% of cases, to imipenem in 64% of cases and to amikacin in 44% of cases. Acinetobacter baumannii was resistant to imipenem in 87% of cases and to amikacin in 85% of cases. Enterococcus faecalis had no resistance to vancomycin and ampicillin. Staphylococcus aureus was resistant to methicillin in 25% of cases and without any resistance to vancomycin. Mortality directly associated with nosocomial urinary tract infection was 11%.

The comparison with previous studies has shown a significant increase in the bacterial resistance responsible for nosocomial urinary tract infection, which is of interest in monitoring the ecology of intensive care units and the resistance profile as well as the improvement of the management of antibiotics. Introduction: Nosocomial enterococcus infections are a constant concern in intensive care units due to their increasing frequency and the emergence of resistant strains to vancomycin. The aim of our study was to compare outcome findings of patients with nosocomial enterococcus infections according to their sensibility to vancomycin, and then to investigate predictive factors of mortality. Patients and methods: It was a retrospective descriptive study, including all hospitalized patients in intensive care, between January 1st, 2013 and April 1st, 2017, with nosocomial enterococcus infections. We recorded demographic and clinical findings, severity scores IGS II, APACHE II, initial SOFA and SOFA at the time of infection, microbiological, therapeutic and outcome data. Patients infected with vancomycin-susceptible enterococcus (VSE) were compared to those having vancomycin-resistant enterococcus (VRE) + then we searched for independent risk factors for VRE. Finally, a multivariate logistic regression was conducted to investigate independent predictive mortality factors. Results: During the study period (4 years and 3 months), 35 patients presented a nosocomial enterococcus infection with a median age of 63 years [25-87] and a sex-ratio of 2.18. At admission, 31 patients (83.3%) had respiratory distress. The median scores of IGS II, APACHE II, initial SOFA and SOFA at the time of infection were respectively 45 + 16 + 6 and 6. The infection sites were-urinary infection (n = 17, 48.6%), bacteremia (n = 15, 42.9%) and central line associated infection (n = 3, 8.5%).16 patients had a VRE nosocomial infections and 19 VSE. A septic shock complicated enterococcus infection in 13 cases including 7 cases of VRE and 6 cases of VSE (p = 0.458). VRE nosocomial infections were significantly related to arterial (p = 0.006) and venous (p = 0.009) femoral catheterization, to a duration of venous femoral catheterization > 3 days (p = 0.035) and to E. faecium species (p < 10-3). No independent risk factor of VRE was found. The median duration of hospitalization was 34 days and the overall mortality rate was 68.6%. Multivariate analysis identified 2 independent predictive factors of attributable mortality-patients in coma (OR 30.44 + IC 95% = 1.99-465.39 + p = 0.014) and the occurrence of septic shock (OR 14.4 + IC 95% = 1.45-137.72 + p = 0.023). Conclusion: Attributable mortality to nosocomial enterococcus infections was high and independent of the susceptibility of the strain to vancomycin. Mortality was independently associated to septic schock occurrence and neurologic dysfonction. Introduction: Ventilator-Associated Pneumonia (VAP) is defined by a lung infection contracted 48 h after the putting under mechanically assisted breathing. Risk factors predisposing to the development of VAP among mechanically ventilated patients are many. Some are related to the patient as age, history of COPD, presence of an altered state of consciousness + others are related to care providing. Patients and methods: A prospective nested case control study was conducted from Marsh 2014 through April 2015. All ICU patients mechanically ventilated for more than 48 h with endotracheal intubation or tracheostomy were included. Cases of community-acquired pneumonia, non-mechanical ventilated hospital-acquired pneumonia, end-life patients and those aged less than 18 years were excluded. The included patients with VAP and those without VAP were matched based on the age, the severity score and the comorbidities. For all patients included, preventive measures as assessed by the recent guidelines for preventing VAP were applied after an education period of all medical and paramedical staff of the ICU. The collected data are-age, comorbidities, admission severity scores, time to onset of VAP, prior antibiotic therapy at the onset of VAP, need for tracheostomy, duration of mechanical ventilation, length of stay in ICU and become. Results: During the study period, 71 patients were mechanically ventilated. VAP was observed in 42% of cases. VAP was observed in 27 cases with an incidence of 38% and incidence density of 21 per 1000 patient-days of mechanical ventilation (MV). In univariate analysis, significant difference was found between the group with VAP and the group without VAP regarding admission for poly trauma, acute respiratory failure, the concept of prior antibiotic therapy, the need tracheostomy, the number of days alive without antibiotics and without MV, the duration of mechanical ventilation, length of stay and mortality. Multivariate analysis showed that prior antibiotic therapy and the use of tracheotomy were independent factors for developing VAP. Prolonged duration of mechanical ventilation was an independent predictor of mortality in multivariate analysis with OR 1.773 + 95% [1.202 to 2.616], p = 0.04. The occurrence of VAP was not an independent predictor to mortality. Conclusion: The incidence of VAP found in our study is similar to that found in the literature. An active strategy of rationalizing the prescription of antibiotics in intensive care units and a well-defined protocol of weaning from mechanical ventilation may reduce the incidence of VAP and over-all morbidity and mortality. Introduction: Hyperoxemia is common in critically ill patients. Hyperoxic acute lung injury (HALI), reduced bacterial clearance, atelectasis and higher mortality rates were reported in mechanically ventilated patients with hyperoxemia. The aim of our study was to determine the relationship between hyperoxemia and mortality in patients with ventilator-associated pneumonia (VAP).

This retrospective observational single center study was performed in a 50-bed mixed intensive care unit (ICU) during a 1-year period, from January 2016 to January 2017. All patients with VAP were included. VAP was defined using clinical, radiological and quantitative microbiological criteria. Hyperoxemia was defined as peripheral capillary oxygen saturation-SpO2 ≥ 98%. SpO2 was hourly collected in all study patients during the whole period of mechanical ventilation. The daily percentage of time spent with hyperoxemia was calculated as the number of hours with hyperoxemia divided by 24. Results: Among the 547 patients receiving invasive mechanical ventilation (MV) > 48 h during the study period, the incidence rate of VAP was 11.7 VAP per 1000 ventilator-days. 93 patients developed VAP and were all included in this study. 30 (32%) VAP patients died in the ICU. The mean daily time spent with hyperoxemia was 45%. No significant difference was found in mean percentage of time spent with hyperoxemia between survivors and nonsurvivors at ICU admission, before, after or at the VAP diagnosis. Age, and sequential organ dysfunction assessment (SOFA) at the day of VAP occurrence were independently associated with ICU mortality (OR 1.04 [1.007-1.075 ] per year, p = 0.02 + 1.19 [1.064-1.339 ] per point, p = 0.003 + respectively). No significant impact was found of time spent with hyperoxemia before VAP occurrence, on MV free days, or ICU length of stay (Fig. 1 ). Discussion: Several potential explanations could be provided for the absence of negative impact on mortality of hyperoxemia. First, the definition used for hyperoxemia could be debated, as no consensus exists. However, the definition used in our study was rather stringent and the mean daily time spent with hyperoxemia was in line with that reported by studies. Second, the impact of hyperoxemia on mortality could have been confounded by a large number of patients included with pulmonary lesions at admission. Third, the number of included patients was small. Conclusion: Our study found no significant impact of hyperoxemia at ICU admission, or during ICU stay, on ICU mortality in VAP patient. Results: 128 patients collected during this period. 228 distal protected specimens were performed in patients suspected of VAP. The diagnosis of this infection was made. In 55 of them with other diagnostic criteria (43%) which represents an incidence density of 8.2 per 1,000 days.80% of PAVM are due to gram negative bacilli. The first germ involved in our series and pseudomonas (30%) followed by klebsielles (15%) followed by acintobacter baumanii (8%) enterobacteries representing the rest.12% lung infection with Gram-positive cocci (principally sensitive methicillin) pseudomonas was imipenem resistant in 18.4%, baumanii was imipenem resistant in 55%.

The resistance profile of the recovered germs (baumanii and pseudomonas) encourages the utmost rigor in the management of these patients, prevention is better attitude to adopt. Introduction: The ventilator associated pneumonia (VAP) appear in the second rank of the infections acquired in hospital after the urinary infections. The diagnosis is based on a beam of clinical, biological, radiological and bacteriological arguments. This work consisted of an epidemiologic analysis of the VAP and aimed at evaluating of it the frequency, the risk factors, the antibioresistance of the isolated bacteria and the mortality factors. Patients and methods: This retrospective study related to 906 patients hospitalized in ICU during a period of 3 years from January 2014 to December 2016. The study included all patients over 18 years and ventilated more than 48 h and developing VAP. Results: BGN predominant and represent 80.16% of identified germs, the Acinetobacter baumanni leads with 33.88%, followed by klebsiella pneumonia (13.22%), followed by Pseudomonas aeruginosa (9.92%), followed by E. coli (6.61%), followed by Enterobacter cloacae (3.31%) and citrobacter frendi (1.65%). The cocci gram positive (CGP) constitue 18.19% of isolated germs of witch 14.88% Staphylococcus aureus, 0.83% of non aureus staphylococci, 2.48% Streptococcus sp. The polymicrobism was found in 33% cases. The isolated germs were multiresistants. In this study, we find a very high mortality and a major additional morbidity of the NP by prolongation of hospitalization, of mechanical ventilation and a major additional cost.Conclusion: It appears in the light of this work that a strategy of prevention based on the strict application of hygiene measurements, the maintenance of the material of ventilation and the respect of care procedures prove to be urgent in our context. Introduction: Burns induce modification of distribution volume, increased clearance of drugs and decrease of protein binding. Amikacin pharmacokinetics (PK) was altered with subthera-peutic serum concentrations. The aim of our study was to assess the PK of amikacin in burns after a loading dose given once a day according to this equation-Dose(mg kg) = 30*Pi(30*0,4*Dp1) + (30*0,4* Dp2). Threshold for therapeutic efficacy was a ratio of ≥ 8 between the concentration achieved 1 h after beginning the infusion (C peak) and the minimal inhibitory concentration (MIC) of the isolated pathogen. Patients and methods: This study was conducted in burn center in Tunis. Patients with documented and or suspected infections were included. Were excluded pregnant women and patients with renal failure. Enrolled patients received amikacin at a loading dose in 1 h infusion. Blood samples for PK analysis were assessed during 5 days (total duration of amikacin)-immediately after the end of the first infusion (T1) and 30 min after (T2) at day 1. For the 2nd, 3rd, 4th and 5th day, blood samples were taken before the infusion (T0), at the end (T1) and 30 min after the end of it (T2). Results: 18 burned patients were included. The mean age was 40 ± 15 years with a body weight of 78 ± 15 kg. The mean dose of amikacin was 26 mg kg day [20-35 mg kg day]. A peak between 60 and 80 μg/ml was reached in 55% of cases, corresponding to 8 times the MIC, break-points for Enterobactericeae and Pseudomonas Aeuroginosa. Total volume of distribution was 0.55 L kg (0.28-1.32) L kg, half-life time (t1 2) was 4.70 h [1.42-8 h] and the amikacin clearance was 6.4 L h. A correlation was found between Cpeak At day 1 and Cpeak at day 5 (r = 0.45). Conclusion: Our study shows that an early achievement of an optimal Cpeak MIC ratio of amikacin was reached in half of cases with a correlation between Cpeak in the beginning and at the end of treatment. So, initial Cpeak was useful tu adjuste AMK therapy in burns and predicts treatment efficacy. *Pi-ideal weight + Dp1-admission weight-ideal weight + Dp2-actuel weight-admission weight.

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