key: cord-355038-o2hr5mox
authors: nan
title: Proceedings of Réanimation 2020, the French Intensive Care Society International Congress
date: 2020-02-11
journal: Ann Intensive Care
DOI: 10.1186/s13613-020-0623-7
sha: 
doc_id: 355038
cord_uid: o2hr5mox

nan

Rationale: Expiratory muscles has recently been stated as the «neglected component» in mechanically ventilated patient. Several authors stated these muscles importance in cough capacity, contractile efficiency of the diaphragm or reduction of hyperinflation. However, few studies reported potential factors leading to expiratory muscle weakness and its importance on weaning success or survival after mechanical ventilation. Patients and methods: This study is a secondary analysis of our previously described cohort of 124 patients ventilated for at least 24 h assessed for respiratory muscles function. Maximal expiratory pressure (MEP) measurement was carried out during spontaneous breathing trial using a manometer with an unidirectional valve. MEP diagnostic accuracy to predict ICU-AW (ICU acquired weakness), weaning success and sursvival within 30 days were assessed using expiratory muscle strength as absolute values (cmH 2 O), as %predicted values and as %lower limit of normal. Results: Due to the paucity of data reporting threshold value for expiratory muscle weakness, we considered our median value (47 cmH 2 O (IQR 44)) as the threshold value for expiratory muscle weakness group (MEP ≤ 47 cmH 2 O) and normal expiratory muscle group (MEP > 47 cmH 2 O). Patients with low MEP received more catecholamines (p = 0.04) and a higher duration of mechanical ventilation (p = 0.001). Inversely, higher body mass index was associated with higher MEP. Patients with low MEP presented more ICU-AW compared to normal MEP patients (64% vs. 35%; p = 0.003). No other outcomes were different between groups. MEP was statistically able to predict ICU-AW but area under (AUC) receiving operating curves showed weak predictive ability (AUC: 0.66 (95% IC 0.55-0.77; p < 0.01) for a threshold value ≤ 49 cmH 2 O. Expiratory muscle weakness was unable to predict critical outcomes when adjusting MEP to the %predicted or lower limit of normal. Discussion: Possible explanation is that contrary to inspiratory muscle weakness, cough inefficacy after weaning from mechanical ventilation could be managed with cough supplementation techniques (i.e. mechanical in-exsufflation). Conclusion: In our cohort, MEP was not associated with mechanical ventilation weaning or death. Despite our results, different clinical techniques for quantifying expiratory muscle weakness may provide more beneficial results. Compliance with ethics regulations: Yes Rationale: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to support tissue perfusion during extracorporeal cardiopulmonary resuscitation (e-CPR). Shock, resuscitation and the extracorporeal circuit may trigger a capillary leakage and a vasoplegic shock. Currently, in these situations, high doses of Norepinephrine (NE) are required. Because high NE doses may have significant cardiovascular side effects, alternative options to support arterial blood pressure are needed. In recent years, several approaches to decrease the administration of high NE doses have been tested, one of them is the administration of Vasopressin (AVP). Randomized trials have shown that AVP infusion increases arterial pressure and systemic vascular resistance, decreases catecholamine requirements in patients with or at high risk of vasoplegic syndrome and attenuates vascular dysfunction. Currently, no data are available for the study of the effects of AVP in shock state in post refractory cardiac arrest. Patients and methods: 20 pigs were randomized into two groups, in order to receive AVP or NE. A refractory cardiac arrest of ischemic origin was surgically created and VA-ECMO was started after a 30 min period of cardio-pulmonary resuscitation. Then, resuscitation lasted 6 h in each randomization group. The evolution of the consequences of the shock was evaluated by lactatemia and microcirculation (SDF and NIRS) at baseline hour, H0 (when ECMO starts), H3 and H6. Renal and hepatic functions were assessed. Results: Experimental conditions were met for 16 animals (AVP, n = 8; NE, n = 8). The groups were comparable on the shock impact and its severity. No significant differences were found between populations for ECMO flow and MAP. There was a significant difference on fluid volume resuscitation amount (14000 [11.250-15.250 ] mL in the NE group versus 3500 mL in the AVP group, p < 0.05) (Fig. 1 ). No significant difference between the NE and AVP groups for lactate clearance between H0 and H6 (25.6 [− 7.31 to 35.34]% vs 47.84 [13.42-82.73 ]%, p = 0.686). We did not find any significant for sublingual microcirculation indices and NIRS values. Renal and liver function evolution were similar in the two groups during the protocol. Conclusion: AVP administration in refractory cardiac arrest resuscitated by VA-ECMO when compared to NE is associated with less fluid volume for similar global and regional hemodynamic effects. Compliance with ethics regulations: Yes. Patients and methods: A single-center prospective study. Patients younger than 6 months with severe bronchiolitis and supported by NIV or HFNC were included. NIV/HFNC was discontinued according to the local practices and no protocol existed. Exceptt the principal investigator, the attending team was blinded to the study. Weaning failure was defined as the need to reinstate NIV/HFNC in the 48 h after discontinuation. Ethical approval was not necessary for this study in accordance with the French data protection autority methodology reference number MR-004. Results: A total of 95 patients (median age 47 days, 53 (56%) males) were included. Respectively, 72 (76%) and 23 patients (24%) were supported by NIV and HFNC at admission (Fig. 1) . Regarding the mode of NIV, a bilevel mode was used in 46 patients (48%) (Fig. 1 ). In patients supported by HFNC, the ventilatory support was discontinued progressively by decreasing air flow in 9 patients (39%) while it was stopped abruptly in 5 (22%). In patients supported by NIV, the respiratory support was stopped abruptly in 5 (19%) of them while HFNC was used as a weaning method for 17 (65%) patients. A total of 22 (23%) patients experienced a weaning failure. Patients supported by NIV/ HFNC who experienced a prompt weaning had a lower Pediatric Intensive Care Unit (PICU) length of stay as compared to patients in whom HFNC was used as a weaning method (78 ± 27 h versus 112 ± 112 h, p = 0.01). However, the hospital length of stay was similar according to the weaning method (6 ± 3 days versus 7 ± 3 days for prompt and progressive methods respectively, p = 0.07). The duration of the weaning process did not differ according to the bed-availability in PICU.

In patients with severe bronchiolitis, a prompt weaning from NIV/HFNC was associated with a lower length of stay in PICU. However, the hospital length of stay was similar according to the weaning method. We suggest that a prompt weaning should be preferred in order to reduce the risk of PICU related complications. Compliance with ethics regulations: Yes. information and incitation to open a Twitter account and to follow critical care journal feeds) or group 3 (control group). ICT were interrogated on their recent medical literature knowledge at 3 and 6 month on 5 trials published in pre-selected journals. Results: During the study period, on the 969 French ICT contacted, 77 agree to participate: 16 were already on Twitter, 31 were randomized to Twitter incitation and 30 to control group. At 3 month, there were 62 who answered electronic questionnaire. Self-declaration of article knowledge was not different between 3 groups (P = 0.85). Knowledge of primary outcome of each trial was not significantly better in 3 groups (P = 0.09). In per-protocol analysis of ICT on Twitter or not, knowledge of article and primary outcome were also not significantly different (respectively P = 0.57 and P = 0.17).

Short incitation to open a Twitter account and follow major medical journals with specific focus on cardiac arrest did not improve knowledge of medical literature by intensive care trainees at 3 month. Further trials are needed to better imply intensive care trainees in scientific medical literature. Compliance with ethics regulations: Yes. 1-1.1] ; P = .07) as independently associated with in-hospital mortality ( Fig. 1 ). Discussion: Triple therapy is the recommended first-line treatment of CAPS. However, herein, it was not significantly associated with better survival in critically ill, thrombotic APS patients. For the subgroup of "definite/probable CAPS" patients, double and triple regimens were associated with survival. But the bivariable analyses including the day-0 SAPS II showed that survival was linked to in-ICU anticoagulation and corticosteroids-not IVIg or plasmapheresis. Our findings indicate that corticosteroids should probably be added to in-ICU anticoagulation to treat "definite/probable CAPS". Frequent fever and elevated C-reactive protein in all thrombotic APS patients suggest a marked inflammatory state that could explain corticosteroid efficacy. Neither plasmapheresis nor IVIg impacted the prognosis of "definite/ probable CAPS", but that finding could be explained by a lack of power compared to CAPS Registry data. Conclusion: In-ICU anticoagulation was the only APS-specific treatment independently associated with survival for all patients. Doublebut not triple-therapy was independently associated with better survival of "definite/probable CAPS" patients. In these patients, double therapy should be used as first-line therapy while the role of triple therapy requires further evaluation. Compliance with ethics regulations: Yes. Motor deficiency 0 (0%) 2 (11%) 4 (15%) 0.021

Cognitive impairment 0 (0%) 2 (11%) 7 (26%) 0.001

Intra-individual relationships between ΔPdi and TFdi for mechanically ventilated (MV) patients (A) and healthy subjects (C). Relationships between ΔPdi and TFdi when breathing cycles were averaged for all participants during each condition for MV patients (B) and healthy subjects (D). − 25%: initial settings minus 25% inspiratory help, + 25%: initial settings plus 25% more inspiratory help, PEP 0: zero positive end-expiratory pressure, SBT: spontaneous breathing trial. Healthy subjects performed spontaneousbreathing (SB) and ventilation against inspiratory threshold at 10, 20, 30, 40 and 50% of maximal inspiratorypressure (MIP) groups. Airway closure occurrence increased with BMI (22%, 38% and 58%, p = 0.04). When present, airway opening pressure was 9.6 cmH2O (8. 5-13.2) and similar between the 3 groups. With increasing BMI, total PEEP increased from 6.0 to 9.0 cmH2O between groups (p = 0.02). All values of esophageal pressure increased with BMI. Endexpiratory esophageal pressure was strongly correlated with BMI (rho = 0.71, p < 0.001), as illustrated in Fig. 1 . Consequently end-expiratory transpulmonary pressure decreased from − 2.7 to − 9.3 cm H2O with increasing BMI (p = 0.008). The ratio of EELV to predicted functional residual capacity was negatively correlated with end-expiratory pressure (Rho = − 0.39, p = 0.01), but not with BMI. Driving pressure and elastance of the respiratory system, chest wall and lung were similar across all ranges of BMI. Likewise, EELV was similar between groups. Conclusion: In ARDS, increasing BMI is associated with increased occurrence of airway closure and increased values of esophageal pressure. Conversely, chest wall elastance is not influenced by BMI, as well as lung elastance. Including BMI in interpreting respiratory mechanics in ARDS patients can provide additional information for the clinical management.

Compliance with ethics regulations: Yes. Rationale: Low tidal volume is the cornerstone of protective ventilation inthe initial phase of ARDS (1) . Whether such low tidal volume can still be achieved when the patient is allowed to breathe spontaneously under pressure support ventilation (PSV) is unknown. In moderate-tosevere ARDS patients receiving neuromuscular blockade, we assessed the tidal volume and its potential association with the outcome during the "transition period" following neuromuscular blockade. Patients and methods: Retrospective observational study in two university intensive care units. Patients fulfilling moderate-to-severe ARDS criteria less than 72 h after intubation and receiving neuromuscular blockers were included upon entry in the "transition period". We defined the "transition period" as the 72 h following neuromuscular blockers cessation. Ventilatory and hemodynamic parameters were recorded every 3 h during the "transition period". Primary outcome was the association between mean tidal volume under pressure support ventilation (PSV) during the "transition period" and the 28-day mortality after adjustment for confounding factors. Data are reported as median [1st-3rd quartile] or number (percentage). Results: One hundred nine patients were included, with a PaO2/FiO2 ratio of 100 mmHg at intubation and 194 mmHg at inclusion and a SOFA score at 7 [4.5-10] . Patients had been ventilated 2 days [1-3.8 ] before inclusion. During the "transition period", 88 patients (80.7%) were switched to PSV. The median duration of PSV was 42 h . The mean tidal volume under PSV was significantly lower in survivors than in non survivors at day 28 (7.1 ml/kg [6.3-7 .9] vs. 7.8 ml/kg [6.8-9.4 ] respectively, p = 0.007). By multivariate analysis (Cox proportional hazards regression model), mean tidal volume during PSV remained independently associated with the 28-day mortality after adjusting for SOFA score and immunosuppression. Patients with a mean tidal volume above 8 mL/kg under PSV during the "transition period" had a lower cumulative probability of survival at day 28 as compared with others (Log rank test, p = 0.008) (Fig. 1) . Conclusion: In patients with moderate-to-severe ARDS, a higher tidal volume under PSV within the 72 h following neuromuscular blockers cessation is independently associated with the 28-day mortality.Compliance with ethics regulations: Yes.

Kaplan-Meier estimate of the cumulative probability of survival according to the mean tidal volume (Vt)-lower of higher than 8 ml/ kg-under pressure support ventilation (PSV) during the "transition period" transfusion is associated with adverse events, and equipoise remains on the optimal transfusion strategy in oncologic patients in surgical setting. Patients and methods: This is a retrospective, single center study. All adults admitted to the intensive care unit (ICU) after oncologic surgery from January 2017 to December 2018 were eligible. The following types of surgery for cancer or metastasis resection with a high risk of bleeding were eligible: thoracic, abdominal, neurosurgery, gynecologic, urologic, otorhinolaryngology or spinal surgery. The primary outcome was a composite outcome including post-operative complications (respiratory, cardiac, renal, thromboembolic, infectious and/or hemorrhagic) and/or hospital mortality. Results: Of the 287 patients included, 142 patients (49.5%) had anemia (based on the WHO definition: hemoglobin level 10-11.9 g/dl for female; hemoglobin level 10-12.9 g/dl for male), 69 patients (24%) had moderate anemia (hemoglobin level: 8-9.9 g/dl) and 32 patients (12.5%) severe anemia (hemoglobin level < 8 g/dl). Fifty-six patients (19.6%) received at least one RBC transfusion during their hospital stay. Patients exposed to moderate and severe anemia required more often renal replacement therapy (RRT) for acute kidney injury (AKI) (1.1% vs. 10 .9%; p = 0.003), had more surgery-related infections (7.6% vs. 22.8%; p = 0.004). Patients who received RBC had more often AKI with RRT (0.9% vs. 19.6%; p < 0.001), thromboembolic events (2.2% vs. 8.9%; p = 0.039), sepsis (4.3% vs. 16.1%; p = 0.004), pneumonia (4.8% vs. 14.3%; p = 0.024), surgical site infections (8.7% vs. 30.4; p < 0.001) and second surgery for infection (3% vs. 16.1%; p = 0.001). The multivariate analysis found an association between moderate and severe anemia (moderate anemia: OR 15.03 [2.73-282.3] ; severe anemia: OR 16.65 [2.71-325.7 ]; p = 0.011) and severe post-operative complications (Fig. A) . There was also an association between RBC transfusion and severe post-operative complications ]; p < 0.001) (Fig.  B) . Conclusion: Anemia was frequent in oncologic surgical patients. Anemia, including moderate anemia, was independently associated to patient outcomes; however, RBC transfusion also negatively impacts on patients' prognosis. Our study highlights the need for further research to identify the optimal hemoglobin threshold for RBC transfusion in surgical oncologic patients. Compliance with ethics regulations: Yes. Rationale: Right ventricular (RV) failure is a common complication in moderate to severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO2 removal (ECCO2R) might allow ultraprotective mechanical ventilation strategy with a low tidal volume (VT) and plateau pressure (Pplat). This study investigated if ECCO2R therapy could have beneficial effects on RV function. Patients and methods: This prospective monocentric pilot study was conducted in a French ICU from January 2017 to March 2019. Patients with moderate to severe ARDS with PaO2/FiO2 ratio between 80 to 150 mmHg were enrolled. Ventilation parameters, arterial blood gases, echocardiographic parameters performed by transthoracic echocardiography (TTE), low-flow ECCO2R system operational characteristics, outcomes and adverse events were collected during the protocol. Primary end point was evolution of RV echocardiographic parameters with ultraprotective ventilation strategy at 4 mL/Kg PBW during the 24-h following the start of ECCO2R. Results: Eighteen patients were included. Efficacy of ECCO2R allowed an ultraprotective strategy in all patients. We observed a significant improvement of RV systolic function parameters assessed by TTE (Fig. 1 ). Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S') also increased after 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement of aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed. There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP). When patients were separated in two groups according to baseline PaCO2 level above or under 50 mmHg, we showed the deleterious effect of hypercapnia on RV function, and observed in both groups a beneficial impact of an ultraprotective ventilation strategy on TAPSE. No severe adverse events directly related to ECCO2R were observed in our small cohort. Conclusion: The low-flow ECCO2R allows ultraprotective ventilation strategy and improve RV function in moderate to severe ARDS patients. Similarly to prone positioning, ECCO2R could become a strategy that enables to reconcile lung protective approach with RV protective approach in ARDS patients. Large-scale clinical studies, including patients with severe RV dysfunction, will be required to confirm these results and to assess the overall benefits, in particular the best timing of beginning ECCO2R in ARDS patients. Compliance with ethics regulations: Yes.

Rationale: Bronchoalveolar lavage (BAL) is usually deemed to allow the diagnosis of a large array of pulmonary diseases and is usually considered as well tolerated in intensive care unit (ICU) patients. However, recent data suggest that the diagnostic yield of BAL could be rather low (1) , and may question its innocuity (2) . The present study aimed at assessing the benefit-to-risk balance of BAL in ICU patients. Patients and methods: The study was approved by the appropriate Ethics Committee and registered with clinicaltrials.gov (NCT03098888). In 16 ICUs, from April 2017 to October 2018, we prospectively collected adverse events (AE) during or within 24 h after BAL and assessed the BAL input for decision-making in consecutive adult patients. AEs were categorized in 5 grades of increasing severity. The occurrence of a clinical AE at least of grade 3, i.e. sufficiently severe to need therapeutic action (s), including modification (s) in respiratory support, defined poor BAL tolerance. The BAL input for decision-making was declared satisfactory if it allowed to interrupt or initiate one or several treatments. Results: We included 483 BAL in 483 patients (age 63 yrs ; female gender: 162 [33.5%]; Simplified Acute Physiology Score II: 48 ; immunosuppression 244 [50.5%], chronic pulmonary disease [163/483 (33.7%)]). BAL was performed either in non-intubated patients receiving standard O2 therapy (n = 56 [11.6%]), or noninvasive ventilation (n = 4 [0.8%]), or high-flow nasal cannula O2 therapy (45 [9.3%]), or in patients under invasive mechanical ventilation (n = 378 [78.3%]). A total of 710 AEs were observed in 415 (85.9%) patients. Sixty-seven (13.9%) patients reached the grade 3 of AE or higher. The main predictor of poor BAL tolerance identified by logistic regression was the association of a BAL performed by a non-experienced physician (non-pulmonologist, or intensivist with less than 10 years in the specialty or less than 50 BAL performed) in non-intubated patients (OR: 31.8 [95% confidence interval 11. 6-87.6] ; P < 0.0001). Ordinal regression also showed that when BAL was performed by a non-experienced physician in a non-intubated patient, this was associated with an increased risk of AE of any grade (OR: 12.66 [6.27-25.57 ]). A satisfactory BAL input for decision-making was observed in 227 (47.0%) cases and was not predictable using logistic regression. Conclusion: Adverse events related to BAL in ICU patients are frequent, and sometimes serious. Our findings call for an extreme caution when envisaging a BAL in ICU patients and for a mandatory accompaniment of the less experienced physicians. Compliance with ethics regulations: Yes.

Meningitis is a rare complication of critically ill patients with severe pneumococcal community-acquired pneumonia Paul Jaubert, Julien Charpentier, Jean-Daniel Chiche, Frédéric Pene, Alain Cariou, Guillaume Savary, Marine Paul, Jean-Paul Mira, Mathieu Jozwiak Cochin, Paris, France; 2 Mignot, Versailles, France Correspondence: Paul Jaubert (paul.jaubert@gmail.com) Ann. Intensive Care 2020, 10 (Suppl 1): Rationale: Severe pneumococcal community-acquired pneumonia (PCAP) is a frequent infection requiring intensive care unit (ICU) admission. Pneumococcal meningitis associated with PCAP has been reported and could worsen the prognosis of patients. However, this complication is difficult to predict and lumbar puncture is not systematically performed, regardless the severity of PCAP. Thus, we investigated the characteristics of patients with PCAP associated with pneumococcal meningitis. Patients and methods: We retrospectively included all patients admitted for PCAP in our ICU between 2006 (inception of our electronic medical sheet) and the end of 2018. Community-acquired pneumonia was defined according to the criteria of the American Thoracic Society. We excluded all patients admitted in ICU with initial suspicion of meningitis. Variables regarding epidemiology, clinical and microbiological characteristics, management and prognosis of these patients were collected and analyzed. Results: Among the 264 patients admitted for PCAP (62 ± 17 years old, SAPS II 55 ± 22, 59% of men), 59% of the patients required mechanical ventilation and 29% vasopressors infusion. The ICU mortality was 16%. S. pneumoniae was documented by a positive antigen test in 81% of the patient and/or by a positive sputum smear, tracheal aspirate or distal protected airway specimen in 54% of the patients, and/or by pleural aspirate in 5% of the patients and/or by positive blood culture in 32% (n = 84) of the patients. A lumbar puncture was performed in 39% (n = 33) of the patients with bacteriemia and in 30% (n = 54) of the patients without bacteriemia, with a median delay of 12 h [interquartile range: after the onset of antibiotherapy. Alllumbar punctures (n = 87) were performed for neurological signs: 50% of coma, 46% of confusion and 1% of seizures. When a lumbar puncture was performed, meningitis was diagnosed in 24% (n = 8) of the patients with bacteriemia and in 2% (n = 1) of the patients without bacteriemia (p < 0.05). The ICU mortality (22% vs. 16%, respectively), age (58 ± 19 vs. 63 ± 17 years old, respectively), SAPS II (65 ± 27 vs. 54 ± 22, respectively) or ICU length of stay (17 ± 24 vs. 11 ± 16 days, respectively) were not different between patients with and without meningitis (each p = NS). Conclusion: Meningitis is a rare complication of PCAP and is more frequent in patients with bacteriemia. Suprisingly, meningitis is not associated with higher ICU mortality. Further analyses are ongoing to identify independent risk factors of meningitis in patients with PCAP. Compliance with ethics regulations: Yes.

Rationale: Shock is the clinical expression of a circulatory failure that results in inadequate cellular oxygen utilization. Whereas the host response to septic shock has been extensively described, knowledge of the pathogenesis of non-septic shocks remains limited. We aimed to characterize the systemic host response in shock related to non-septic conditions (NSsh) as compared with septic shock (Ssh). Patients and methods: We performed a prospective study in two intensive care units (ICUs) in patients admitted for Ssh (n = 931) or NSsh (n = 1338). Immune responses were determined upon ICU admission by measuring 17 plasma biomarkers reflecting host response pathways implicated in the pathogenesis of critical illness (in 573 Ssh and 287 NSsh patients), and by applying genome-wide blood mRNA expression profiling (in 267 Ssh and 136 NSsh patients). Results: Compared with NSsh, patients with Ssh had more chronic comorbidities, greater disease severity (APACHE IV score 89 vs. 71 , p < 0.001) and worse outcomes resulting in higher mortality rates up to one year after ICU admission (53.8% vs. 38.8%, p < 0.001). Plasma biomarker analysis revealed severely disturbed host responses in both Ssh and NSsh patients. However, Ssh patients displayed more prominent inflammatory responses, endothelial cell activation, loss of vascular integrity and a more pro-coagulant state relative to NSsh patients. Blood leukocyte genomic responses were more than 80% common between Ssh and NSsh patients relative to health (Fig. 1A) , comprising overexpression of innate pro-and anti-inflammatory pathways, and underexpression of lymphocyte and antigen-presentation gene sets. Direct comparison of Ssh to NSsh patients matched for severity (Fig. 1B) showed overexpression of genes involved in mitochondrial dysfunction and specific metabolic pathways, and underexpression of lymphocyte, NF-κB and cytokine pathways. Conclusion: Patients with Ssh and NSsh present with largely similar host response aberrations at ICU admission; however, patients with septic shock show more dysregulated inflammatory and vascular host responses, as well as specific leukocyte transcriptome alterations consistent with greatermetabolic reprogrammingand more severe immune suppression. Compliance with ethics regulations: Yes. Rationale: AKI is associated with short and long term mortality and morbidity. Although recovery has been demonstrated to be associated with outcome of critically ill patients, interpretation of available data is limited by time dependent nature of recovery and by competing risks. Our objective was to describe renal recovery, pattern of recovery according to ADQI definitions and risk factor of this later.

Monocenter retrospective cohort study. Adult patients admitted in our ICU from July 2018 to December 2018 were included. AKI was defined according to KDIGO criteria and recovery according to ADQI definition. Incidence of recovery at each time point was depicted using competing risk survival analysis. Risk of transition between AKI and no-AKI was assessed by a semi-Markov model. Last, a trajectoire analysis was performed to depict most frequent recovery patterns. Results are reported as n (%) or median (IQR). Results: 350 patients were included with a median age of 57 (45-72).

Median SOFA score at admission was 4 [2] [3] [4] [5] [6] [7] . At ICU admission, 85 patients (24.2%) had an AKI stage 1, 44 patients (12.6%) an AKI stage 2 and 37 patients (10.6%) an AKI stage 3. According to ADQI criteria, AKI was defined as rapidly reversed in 42 patients (25.3% of AKI patients), persistent AKI in 16 patients (9.7%) and as acute kidney disease (AKD) in 64 patients (38.6%), remaining patients couldn't be classified (n = 44). Risk of recovery was of 9% per day until day 7 then 15% per day (Fig. 1a) . Fine and Gray model, taking into account death as competing risk, identified 3 risk factors negatively associated with renal recovery, namely SOFA score (sHR = 0.94 per point; 95% IC = [0.89-0.99]), preexisting hypertension (sHR = 0.56; 95% IC = [0.32-0.98]) and AKI severity (stage 3 vs. stage 1 sHR = 0.17; 95% IC = [0.06-0.56]). Risk of de novo AKI was maximal during the first 7 days and ranged from 25 to 36% per day. Trajectoire model identified 3 clusters of patients ( Fig. 1b) , closely associated with patients' outcome: a) low patients' severity and no or mild AKI (n = 251; hospital mortality: 8%); b) moderate to severe AKI but little associated organ dysfunction (n = 70, hospital mortality: 12.9%); c) severe AKI and multiple organ failure (n = 29; hospital mortality: 89.7%).

Conclusion: This study, assessing AKI recovery patterns, is the first to our knowledge using ADQI definition. Despite the high rate of early recovery and of rapidly reversed AKI, up to 40% of AKI patients had not recovered at day 7 and could therefore be classified has having AKD. Compliance with ethics regulations: Yes.

Rationale: Sepsis is the most frequent cause of acute kidney injury (AKI). The "Acute Disease Quality Initiative Workgroup" recently proposed new definitions for AKI, classifying it as transient or persistent. We aimed to determine the incidence, attributable mortality and host response characteristics of transient and persistent AKI in patients with sepsis. Patients and methods: We performed a prospective observational study comprising consecutive admissions for sepsis in 2 intensive care units (ICUs) in the Netherlands, stratified according to the presence and evolution of AKI. Attributable mortality fraction (excess risk for dying with persistent AKI relative to transient AKI) was determined using a logistic regression model adjusting for confounding variables.

In a subset of 866 sepsis patients, 16 plasma biomarkers indicative of major pathways involved in sepsis pathogenesis were measured. In a second subset of 392 patients, whole-genome blood-leukocyte transcriptomes were analyzed. Results: 1545 sepsis patients were included. AKI occurred in 37.7% (n = 577), of which 18.4% (n = 106) was transient and 81.6% (n = 471) persistent. Patients with persistent AKI had higher disease severity scores on admission than patients with transient AKI or without AKI and more frequently had severe (Injury of Failure) RIFLE AKI-stages on admission (n = 322, 68.4%) than transient AKI patients (n = 33, 31.1%, P < .001). Persistent AKI, but not transient AKI, was associated with increased mortality by day-30 (adjusted OR 2.42, 95% CI 1.28-4.58; P = .006) ( Figure) and up to 1-year (adjusted OR 2.10, 95% CI 1.12-3.92;P = .020). The attributable mortality of persistent relative to transient AKI by day-30 was 14.0% (95% CI 3.7-24.2%). Persistent AKI was associated with enhanced and sustained inflammatory and procoagulant responses during the first 4 days, and a more severe loss of vascular integrity compared with transient AKI. Baseline blood gene expression showed minimal differences with respect to the presence or evolution of AKI. Conclusion: Persistent AKI is associated with higher sepsis severity, sustained inflammatory and procoagulant responses, and loss of vascular integrity as compared with transient AKI, and independently contributes to sepsis mortality. Compliance with ethics regulations: Yes. Rationale: To address the paucity of data on the epidemiology of patients admitted to intensive care units (ICUs) with in-hospital cardiac arrest (IHCA), we examined key features, mortality and trends in mortality in a large cohort of patients admitted in 33 French ICUs over the past 18 years. Patients and methods: From 1997 to 2015 database of the Collège des Utilisateurs de Bases de données en Réanimation (CUB-Réa), we determined temporal trends in the characteristics of IHCA, patients' outcomes and predictors of ICU mortality. Results: Of the 376 325 ICU admissions, 33 126 (8.8%) were cardiac arrests and 15 324 were IHCA (4.1%). During the study period, the age of IHCA patients increased by 0.7 years (P = 0.04) and patients presented more comorbidities (chronic heart disease, chronic kidney disease and cancer). Patients were also more critically ill over the period as reflected by the increase of SAPS-II by 2.3% (P < 0.001). Paradoxically, in-hospital management became lighter through the time with reduced respiratory support (p < 0.001), renal support (p < 0.001) and use of vasoactive drugs (p < 0.001). Crude in-ICU mortality decreased from 78% to 62.5% over the past eighteen years (P < 0.001), Fig. 1 Rationale: In surgery, prophylaxis antibiotic aims at preventing the occurrence of post-operative infections. For adults, it is currently recommended to only use prophylactic antibiotic therapy during the time of the intervention. But in pediatric cardiac surgery, there is no consensus around the optimal duration of use of antibiotic prophylaxis. The protocol was modified in 2018 in the ICU and its time reduced to 24 h. We aimed to determine whether 24 h of post-sternotomy antibiotic prophylaxis was not less effective than 48 h treatment to help prevent care-associated infections. Patients and methods: After agreement of the ethics committee of our institution, we performed a retrospective non inferiority study, with an inferiority margin to 10%. The primary objective is to compare the incidence of care-related infections between a second-generation cephalosporin (C2G) antibiotic prophylaxis during 48 h and a 24-h protocols. The secondary objectives are to determine the infection's incidence, to identify the risk factors for nosocomial infections and to compare the incidence of multidrug-resistant infections. Results: Between January 2013 and July 2019, 402 children underwent cardiac surgeries with sternal opening. 299 received 48 h of C2G antibiotic prophylaxis and 103 received 24 h of C2G treatment. Five previously infected children have been excluded. Both groups were demographically and surgically similar. The median age was 7 months (range a few hours of life to 14.5 years old) and the median weight was 6.7 kg. In the intent-to-treat analysis, incidence of care-related infections is at 10.03% in the C2G-48 h group and 10.68% in the C2G-24 h group. A multivariate analysis shows that the shorter 24-h time antibiotic prophylaxis is not inferior regarding infection prevention compared to 48 h of antibiotic prophylaxis, p = 0.046. As in the per protocole analysis, the C2G-48 h group rate was 9.1% and 6.6% for the G2G-24 h group. Conclusion: It demonstrates that shortening the antibiotic prophylaxis treatment time to 24 h does not affect or increase the rate of infections after a pediatric sternotomy surgery compared to 48-h protocole. Prophylaxis in pediatric cardiac surgery should be short-lived. A multicenter prospective study would allow a consensus and confirm this decision. Compliance with ethics regulations: Yes. Rationale: The use of "big data" is getting increasingly popular in the medical field, especially in intensive care where large amounts of data are continuously generated. However, big data can be misleading when essential clinical data are missing. The adequate adjustment for potential confounding factors (e.g., severity of respiratory distress) should be the key procedure in the big data analyses; however, it is challenging to capture the clinical severity within large electronic databases. Bronchiolitis is one main reason for admission to pediatric intensive care unit (PICU). The modified Wood's clinical asthma score (mWCAS) is widely used to assess the severity of bronchiolitis. The objective of the study is to build an automated mWCAS (A-mWCAS) to continuously assess the severity of respiratory distress in critically ill children.

This retrospective study included all infants < 2 years old with a clinical diagnosis of bronchiolitis, ventilated with non-invasive neurally adjusted ventilatory assist, in a Canadian PICU, between October 2016 and June 2018. We developed an algorithm, using Python 3.7, which was directly connected to the electronic medical record. The components of the score were collected using structured query language (SQL) queries and processed to derive the A-mWCAS. For validation, the A-mWCAS score was compared to the mWCAS manually computed by a clinical expert (M-mWCAS) .

Results: Sixty-four infants were included in the study, for which 256 of A-mWCAS and M-mWCAS were generated respectively. The Cohen's Kappa coefficient was applied to estimate the agreement between the two scores which was 0.71 (95% confidence Interval) ( Table 1 ) which corresponds to 78.5% of complete agreement. 17.5% of the A-mWCAS scores were within ± 0.5 of the M-mWCAS. The Kappa coefficient for the each score component were: 0.91 for the oxygen saturation, 0.79 for the expiratory wheezing, 0.91 for the inspiratory breath sounds, 0.89 for the use of accessories muscles and 0.51 for the mental status, respectively. Discussion: The largest discrepancy was observed in the mental status, which clinical evaluation is relatively subjective and varies among care team members (doctor, nurse, respiratory therapist…). The automated score likely decreases this variability by consistently using the same source (respiratory therapist), but its validity should be confirmed in a prospective study.

The A-mWCAS provides a valid estimation of the mWCAS that is fast and robust. After external prospective validation, it may help to add some clinical sense within large electronic databases, with improved assessment of the respiratory distress. Compliance with ethics regulations: Yes. Rationale: In paediatric intensive care units (PICU), survival rates have dramatically improved. This has been accompanied by increased morbidity, including psychological morbidity. These new impairments, that can affect the survivors and their families have been conceptualized under the frame of post-intensive care syndrome (PICS) and PICSfamily. The aim of this study was to explore the experience of critically ill children parent's during the stay in PICU, and its impact on the family. Patients and methods: We planned a prospective, single centre study for 3 months. We collected qualitative written data from parents whose child had been admitted to the PICU for the first time, for at least two nights. Results: Fifty-seven questionnaires were analysed from thirty-seven admissions. PICU admissions were mostly unplanned. Among parents 40% experienced very painful memories during admission and 61% have feared for their child's life. During the stay, noise has bothered 30% of parents, and many have described difficulties to rest at night. 81% had the sensation that their child was suffering, mostly from pain, tiredness, anxiety or fear. During PICU stay, 75% of parents had to stop working, and siblings schooling was impacted in 25% of cases, 77% of parents considered themselves to be useful for their child and 81% have participated to nursing care. More than 70% were satisfied about information given and communication, 77% appreciated empathy and support from care givers. Parents received support from family, friends, and also from other parents of hospitalized children. Parents expressed relief (46%) and serenity (38%) to leave PICU, 58% of them were in demand to meet PICU staff again after discharge. Conclusion: PICU parent's experience is tough, and the impact on family is clear. These are known risks factors for PICS. On a very positive note, parents seemed to be satisfied by family-centred care, and were able to preserve their parental role. However, there is still room for improvement of practices. Compliance with ethics regulations: Yes.

The Gut has been suspected to be involved in multiple organs dysfunction syndrome (MODS) in the Intensive Care Unit (ICU). Studies suggested a link between gastrointestinal dysfunction (GID) and outcomes. But these studies included very few patients and most of them were retrospective. Patients and methods: This study is a secondary analysis of data from a previous study that included patients from 44 French ICUs. GID is defined as the association of vomiting and constipation or diarrhea during the first week after ICU admission. Patients included were treated with vasopressors and mechanical ventilation. The first goal was to determine if GID is a risk factor of 28-day mortality in this population. Secondary goals were to assess the impact of GID on nosocomial infections. Results: Among 2410 included patients, 238 (9.9%) had GID. By day-28, 76 (32%) of the 238 patients with GID and 780 (36%) of the 2172 patients without GID had died (Odds Ratio 0.84 [0.96-1.01]; p = 0.25).

Multivariable regression model did not show any association between gastrointestinal dysfunction and increased risk of 28-day mortality in patients (Odds Ratio 0.76 [0.56-1.04], p = 0.083). Gastrointestinal dysfunction was strongly associated with other secondary outcomes ( Table 1 ). Patients with GID had longer ventilation duration, ICU length of stay and hospital length of stay. They also had more nosocomial infections, in particularly ventilator-associated pneumonia. This association still existed in a multivariable regression model for prediction of nosocomial infection including the same variables than the previous model (Odds Ratio 1.68 [1.19-2.37 ], p = 0.0028). No association with day-90 mortality was observed. Conclusion: Gastrointestinal dysfunction was not a risk factor of day-28 mortality but was associated with an increased risk of nosocomial infection and an increased length of stay. This study is observational and no causality link can be done. However, our data suggest further studies on strategies aimed to limit GID. Compliance with ethics regulations: Yes. 

Rationale: Acute cholangitis (AC), a bacterial infection related to an obstruction of the biliary tree, may be responsible for life-threatening organ failure. However, little is known about the outcome and the predictive factors of mortality of critically ill patients admitted in ICU for acute cholangitis. We aimed to describe characteristics of patients admitted in ICU for AC and to analyze predictive factors of in-hospital mortality including the time to biliary drainage procedure. Patients and methods: Retrospective study of all cases of acute cholangitis admitted in 11 French ICUs (5 tertiary hospitals and 6 non-ter- 1 [5.3; 54.8 ] µg/L. 63% of patients (n = 252) have positive blood culture, mostly Gram negative bacilli (86%) and 14% producing extended spectrum beta lactamase Enterobacteriaecae. At ICU admission, persisting obstruction was frequent (79%) and therapeutic endoscopic retrograde cholangiopancreatography was performed in 76% of them.

In a multivariable analysis, at ICU admission, several factors were significantly associated with in-hospital mortality: SOFA score (OR = 1.14 [95% IC 1.05; 1.24] by point, p = 0.001), arterial lactate (OR = 1.21 [1.08; 1.36 ] by 1 mmol/L, p < 0.001), total serum bilirubin (OR = 1.26 [1.12; 1.41] by 50 umol/L, p < 0.001), obstruction nonrelated to gallstones (P < 0.05) and AC complications (liver abcess and/or pancreatitis) (OR = 2.74 [1.45; 5 .17] p = 0.002). In addition, time > 48 h between ICU admission and biliary drainage was associated to in-hospital mortality (adjusted OR = 2.73 [1.30; 6.22 ] p = 0.02). Conclusion: Acute cholangitis is responsible for high mortality in ICU. Organ failure severity, causes and local complications of cholangitis are predictive factors of mortality as well as delayed biliary drainage. Compliance with ethics regulations: Yes.

the United Kingdom) were included (n = 152). Predictors of one-year mortality were retrospectively screened and tested on a single center training cohort. A predictive score was developed and tested on an independent multicenter cohort. Results: Four independent pre-transplantation risk factors were associated with one-year mortality after transplantation in the training cohort: age ≥ 53 years (OR = 5.79, 95% CI = 1.05-32.04, p = 0.044), pre-transplantation arterial lactate level ≥ 4mml/l (OR = 9.99, 95% CI = 1.62-61.46, p = 0.013), mechanical ventilation with PaO2/ FiO2 ≤ 200 mmHg (OR = 8.60, 95% CI = 1.30-56.88, p = 0.026) and pretransplantation leukocyte count ≤ 10G/l (OR = 12.91, 95% CI = 2.26-73.87, p = 0.004). A simplified version of the model was derived by assigning 1 point to each risk factor: the Transplantation for ACLF-3 Model (TAM) score. A cut-off at 2 points distinguished a high-risk group (score > 2) from a low-risk group (score ≤ 2) with one-year survival of 8.3% vs. 83.9% respectively (p < 0.001). The model and its simplified version were validated on the independent multicenter cohort. There was a significant difference between the high-risk and low-risk group with one-year survival of 10% vs. 71.9% respectively (p < 0.001). Conclusion: Liver transplantation can be an effective treatment for critically ill cirrhotic patients with hepatic and extra hepatic organ failure provided patients are carefully selected and that they are transplanted at the optimal time in the intensive care. The TAM score can help stratify post-transplantation survival and assist clinicians in the transplantation decision-making process at the bedside of ACLF-3 patients.

Compliance with ethics regulations: Yes. Rationale: Trans-thoracic echocardiography (TTE) is commonly used in the initial management of patients with shock in ICU. There is little published evidence for any mortality benefit. We compared the effect of echocardiography protocol versus standard care for survival and clinical outcomes. Patients and methods: This randomized controlled trial included selected shocked patients (systolic blood pressure < 90 mm Hg and signs of organ hypoperfusion) randomized to early TTE plus standard care versus standard care without TTE. The primary outcome measure was survivalto 28 days. Secondary outcome measures included initial treatment and vasopressor weaning. Results: 202 consecutive subjects with circulatory shock (low systolic arterial blood pressure (SAP) and signs of organ hypoperfusion) at the time of ICU admission are included in the study. In the TTE group: fluid prescription during the first 24 h was significantly lower Rationale: Both the negative prognostic value and reversibility of left ventricular (LV) diastolic dysfunction in septic patients remain debated. The excess of mortality in septic shock patients with hyperdynamic profile has only been reported by small-size studies. Accordingly, the primary objective of the PRODIASYS study was to assess the impact of LV diastolic dysfunction (and its severity) and of LV hyperkinesia echocardiographically identified during the initial phase of septic shock on 28-day survival. The secondary objective was to assess the potential link between LV diastolic dysfunction, cumulative water balance (on day 4), and outcome. Patients and methods: This was a multicenter, prospective, observational, cohort study. Patients older than 18 years hospitalized in ICU for septic shock (Sepsis-3 definition) were eligible. Exclusion criteria were administration of inotropes, severe left valvular disease, constrictive pericarditis and moribund patients. In each patient, echocardiography was first performed within 12 h after the diagnosis of septic shock and then daily until Day 3, after vasopressor discontinuation, at ICU discharge and on Day 28 or at hospital discharge, whichever occurred first. Vital and biological parameters usually monitored for septic shock management were collected at each echocardiographic assessment. Vital status was collected on Day 28. Associations between LV diastolic dysfunction or LV hyperkinesia and Day-28 mortality were analyzed using a Chi2 test. Adjusted analyses were performed using logistic regression models, including variables known to be linked with the prognosis of septic shock (e.g., severity scores, delay of antibiotherapy). The relationship between the grade (I to III) of LV diastolic dysfunction and 28-day survival were analyzed using a logistic regression model. The relationship between the presence of LV diastolic dysfunction and cumulated water balance on Day 4 were analyzed using a linear regression model adjusted on the body weight on admission. The relationship between the grade of LV diastolic dysfunction and cumulated water balance on Day 4 were analyzed using a linear regression model.

Diaphragm dysfunction and weaning induced pulmonary edema are two frequent causes of weaning failure but their coexistence and interaction have been poorly investigated. We hypothesized that diaphragm dysfunction may not induce a sufficient decrease in intra-thoracic pressure to increase venous return and generate a weaning induced pulmonary edema. We therefore investigated whether weaning induced pulmonary edema and diaphragm dysfunction are or not associated and evaluated the effect of diaphragm dysfunction on cardiac function and lung aeration during a spontaneous breathing trial (SBT). Patients and methods: Patients with readiness to wean criteria who had failed a first SBT were eligible. Before and after a second SBT, diaphragm function was assessed by measuring the change in tracheal pressure induced by a bilateral phrenic nerve stimulation (Ptr, stim), cardiac function (cardiac output, systolic pulmonary arterial pressure) was evaluated with echocardiography and lung aeration was estimated from the lung ultrasound score (LUS). Plasma protein concentration and hemoglobin were also sampled before and after the SBT. Diaphragm dysfunction was defined by Ptr, stim < − 7 cmH2O and weaning induced pulmonary edema was diagnosed in case of SBT failure associated with 1) increase in plasma protein concentration or hemoglobin > 5% during the spontaneous breathing trial and/or 2) early (E) over late peak diastolic velocity ratio > 0.95 or E over peak diastolic velocity ratio > 8.5. Results: Fifty-three patients were included and 31/53 (58%) failed the SBT. Diaphragm dysfunction was present in 20/24 (83%) of patients with weaning induced pulmonary edema, in 11/22 (50%) patients with SBT success and in 2/7 (29%) patients with other causes of SBT failure (p < 0.01). During the SBT, diaphragm dysfunction induced a significant increase in systolic pulmonary arterial pressure but no change in cardiac output. Patients with diaphragm dysfunction had a higher LUS as compared to their counterparts (10 ± 9 vs. 3 ± 4, respectively, p < 0.01). Conclusion: Diaphragm dysfunction induces a loss of lung recruitment and a significant increase in systolic pulmonary arterial pressure during the SBT. Coexistence of diaphragm dysfunction and weaning induced pulmonary edema is common in case of SBT failure but weaning induced pulmonary edema appears more likely to be involved than diaphragm dysfunction. Compliance with ethics regulations: Yes.

Rationale: Diaphragmatic weakness in the Intensive Care Unit (ICU) is associated with poor outcome. Prolonged mechanical ventilation is associated either with a decrease (atrophy) or an increase (supposed injury) in diaphragmatic thickness, both associated with prolonged weaning. Shear wave elastography is a non-invasive technique that measures diaphragm shear modulus (SM), a surrogate of its mechanical properties. The aim of this study was to describe the diaphragm shear modulus during the ICU stay and to describe its relation with diaphragm thickness. Patients and methods: This prospective and monocentric study included all consecutive critically ill patients. Ultrasound examination of the diaphragm (Aixplorer; SuperSonic-Imagine, Aix-en-Provence, France) was obtained by two investigatorsevery other day until ICU discharge. Demographics, diaphragm thickness, SM and outcomes were collected. A mixed model regression was used to study the relation between SM and diaphragm thickness. Results: We enrolled 102 patients from 2017 December 1st to 2018 June 1st, 88 being invasively mechanically ventilated during the stay. Diaphragm ultrasound evaluation was feasible in 94/102 (96%) patients. The duration of mechanical ventilation during the ICU stay was 7 [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] days with 3 [1] [2] [3] [4] [5] days spent on controlled mechanical ventilation. SM was 14.3 ± 4.3 kPa and diaphragm end-expiratory thickness was 0.20 ± 0.05 cm upon ICU admission. Increase and decrease ≥ 10% during ICU stay occured in 37 and 49 percent of the patients respectively for diaphragmatic thickness, and in 51 and 41 percent of the patients respectively for diaphragmatic SM. Diaphragm thickness over time was inversely correlated with diaphragm SM and with time spent under mechanical ventilation (Table) . Diaphragm SM over time was correlated with time spent under pressure support ventilation or under spontaneous breathing (compared to controlled ventilation) and with time spent under deep sedation. Diaphragm SM was inversely correlated with age, sepsis, exposition to steroids (Table) . No association was found between diaphragm SM and outcomes. Discussion: Our results are in line with the myotrauma concept, suggesting alteration in diaphragm mechanical properties associated with increased diaphragm thickness in critically ill patients. We hypothesize that this observation most likely reflects muscle injury and tissue infiltration with edema and inflammatory cells. Conclusion: Shear wave ultrasound elastography suggests that in critically ill patients, the increase in diaphragmatic mass is associated with an alteration in diaphragm mechanical properties as measured by SM. Compliance with ethics regulations: Yes. Rationale: Diaphragm dysfunction and intensive care unit (ICU) acquired weakness (ICU-AW) are associated with poor outcomes in the ICU but their long term impact on prognosis and health-related quality of life (HRQOL) is poorly established. This study sought to determine whether diaphragm dysfunction is associated with negative long-term outcomes and whether the coexistence of diaphragm dysfunction and ICU-AW has a particular impact on two-year survival and HRQOL. Patients and methods: We used a previous cohort study conducted in our institution to follow up mechanically ventilated patients in whom diaphragm and limb muscle functions were investigated at the time of liberation from mechanical ventilation. Diaphragm dysfunction was defined by tracheal pressure generated by phrenic nerve stimulation < 11 cmH2O and ICU-acquired weakness was defined by Medical Research Council (MRC) score < 48. HRQOL was evaluated with the SF-36 questionnaire. Results: Sixty-nine of the 76 patients enrolled in the original study were included in the survival analysis and 40 were interviewed. Overall two-year survival was 67% (46/69): 62% (28/45) in patients with diaphragm dysfunction, 71% (17/24) in patients without diaphragm dysfunction, 46% (11/24) in patients with ICU-acquired weakness and 76% (34/45) in patients without ICU-acquired weakness. Patients with concomitant diaphragm dysfunction and ICU-acquired weakness had a poorer outcome with a 2-year survival rate of 36% (5/14) compared to patients without diaphragm function and ICU-acquired weakness (79% (11/14) (p < 0.01)). HRQOL was not influenced by the presence of ICU-acquired weakness, diaphragm dysfunction or their coexistence. Conclusion: ICU-acquired weakness but not diaphragm dysfunction has a strong negative impact on two-year survival of critically ill patients. The presence of diaphragm dysfunction appears more likely to be a determinant of early prognosis and does not appear to have a significant impact on long-term survival. Compliance with ethics regulations: Yes.

Rationale: Influenza can lead to severe condition with acute respiratory failure and acute respiratory distress syndrome due to a massive pulmonary inflammatory in response to the viral invasion. Lung bacteriobiota has been described to be associated with pulmonary inflammation in chronic respiratory diseases such as chronic obstructive pulmonary disease or cystic fibrosis. Lung mycobiota has been poorly investigated despite the well-known role for fungi in numerous respiratory diseases. The aim of our study was to assess the prognostic value of lung bacteriobiota and mycobiota among critically ill influenza patients. Patients and methods: We prospectively included influenza patients admitted to ICU. Sputum were stored a -80 °C. Bacterial and fungal DNA were extracted thanks to QIAamp ® PowerFecal ® Pro DNA Kit. 16S rRNA gene V3-V4 regions and ITS2 regions were amplified by PCR and sequenced on Illumina MiSeq ® . Taxonomic assignation was obtained by DADA2 pipeline and microbiota analysis were performed according to day-28 mortality by the mean of Phyloseq package on R 3.6.0 software. Results: Thirty-nine patients were admitted to ICU for influenza with 23 sputa available and finally 18 DNA samples available after extraction. Bacteriobiota alpha diversity was significantly lower among non-survivors than survivors when expressed by the mean of Shannon index, Simpson index or Evenness (respectively p = 0.01, p = 0.02, p = 0.01). Area under the curve to predict day-28 mortality was 0.91, 95CI [0.77; 1.00] for Shannon index, 0.8995CI [0.74; 1.00] for Simpson index and 0.91 95CI [0.77; 1.00] for evenness. β-diversity analysis also demonstrated significant differences between survivors and non-survivors (adjusted permutational multivariate ANOVA, p = 0.01). Nonsurvivors had a higher abundance of Staphylococcus, Haemophilus, Streptococcus and Moraxella. None of the fungal alpha-diversity index nor beta-diversity were significantively different between survivors and non-survivors. Non-survivors had a higher proportion of Candida albicans and Malassezia but not of Aspergillus. Conclusion: The lung bacteriobiota profile, but not the mycobiota one, of critically ill influenza patients is associated with day-28 mortality and may be used to identify subjects with a poor prognosis at the time of admission. Compliance with ethics regulations: Yes.

that takes into account the interaction between multiple cellular pathways. The pathway profiles between moderate and severe influenza were then compared to delineate the biological mechanisms underpinning the progression from moderate to severe influenza. Results: 107 patients (44 severe and 63 moderate influenza patients) and 52 healthy control subjects were included in the study. Severe influenza was associated with upregulation in several neutrophilrelated pathways, including pathways involved in neutrophil differentiation, migration, degranulation and neutrophil extracellular trap (NET) formation. The degree of upregulation in neutrophil-related pathways was significantly higher in severely infected patients compared to moderately infected patients. Severe influenza was also associated with downregulation in immune response pathways, including pathways involved in antigen presentation, CD4+ T-cell co-stimulation, CD8+ T cell and Natural Killer (NK) cells effector functions. Apoptosis pathways were also downregulated in severe influenza patients compared to moderate and healthy controls. Conclusion: These findings showed that there are changes in gene expression profile that may highlight distinct pathogenic mechanisms associated with progression from moderate to severe influenza infection. Compliance with ethics regulations: Yes. Rationale: Herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ARDS). However, few is known about Herpes Simplex Virus (HSV) and Cytomegalovirus (CMV) reactivation occurring in patients with severe ARDS under venovenous ExtraCorporeal Membrane Oxygenation (ECMO). We tried to determine the frequency of herpesviridae reactivation and its impact on patients'prognosis during ECMO for severe ARDS. Patients and methods: We conducted an observational, retrospective study in a medical ICU (ARDS and ECMO referee center) between 2011 and 2017. Patients with a severe ARDS requiring a venovenous ECMO for 2 days or more were included. HSV and/or CMV reactivation occurring after ECMO insertion was screened for these patients. Patients with immunosuppression, antiviral therapy against HSV and/ or CMV prior to inclusion, or HSV/CMV reactivation known at the time of ECMO insertion were excluded. HSV reactivation was defined by a positive qualitative throat sample (Virocult ® ) PCR or positive bronchoalveolar lavage (BAL) PCR. CMV reactivation was defined by a positive quantitative blood or BAL PCR. Results: During a five-year period, 123 non-immunocompromised patients with a severe ARDS necessitating a veno-venous ECMO were included. Sixty-seven (54%) experienced HSV and/or CMV reactivation during ECMO course (20 viral co-infection, 40 HSV alone and 7 CMV alone). HSV reactivation occurred earlier than CMV after the beginning of MV (10 (6-15) vs. 19 (13-29) days; p < 0.01) and after ECMO implementation (4 (2-8) vs. 14 (10-20) days; p < 0.01). In univariate analysis, HSV/CMV reactivation was associated with a longer duration of mechanical ventilation (34 (22-52.5) vs. 17.5 (9-28) days; p < 0.01), a longer duration of .5) vs. 9 (5-14) days;p < 0.01), and a prolonged vs. 16 (9-30) days; p < 0.01) and hospital stay (44 (29-63.5) vs. 24 (11-43) days; p < 0.01). However, in multivariate analysis, viral reactivation remained associated with prolonged MV only. When comparing patients having CMV (alone or combined with HSV) vs. HSV reactivation alone, CMV positive patients had a longer mechanical ventilation duration and fewer ventilator-free days at day-28 and a longer ICU and hospital length of stay. Conclusion: Herpesviridae reactivation is frequent among patients with sevre ARDS under veno-venous ECMO and is associated with a longer duration of mechanical ventilation. CMV seems to have a proper negative role on pulmonary fiunction as compared to HSV alone. HSV and CMV deserve to be researched in severe ARDS patients under ECMO. Compliance with ethics regulations: Yes.

Charlotte Vandueren 1 , Benjamin Zuber 2 , Eve Garrigues 3 , Antoine Gros 4 , Nicolas Epaillard 5 , Guillaume Voiriot 6 , Yacine Tandjaoui Rationale: Respiratory syncytial virus (RSV) is a common cause of pediatric bronchiolitis and influenza-like illness in adults. Its involvement in severe infections in adults remains unclear. The CAPTIF study aimed at comparing characteristics and prognosis of ICU patients infected with RSV and influenza, assuming that, based on the limited evidence, the mortality of RSV infection would be lower than the influenza related one. Patients and methods: Multicenter Franco-Belgian retrospective study. Adults admitted to 18 ICUs between 1/Nov/2011 and 30/ Apr/2017 with respiratory RSV infection were included and matched 1:1 to influenza patients on center and ICU admission date. Patients' characteristics, clinical presentation, and outcome were compared between groups using univariate and multivariable analyses. Results: We report here the results for the first 470 cases among 650 included patients. Mean age was 65.5 (16.7) years and SAPS-2 score was 42 (17), not different between groups. Compared to influenza patients, RSV patients more frequently had chronic respiratory failure (61% vs 39%, p < 0.001) or immune suppression (36 vs 26%, p = 0.03). Frequencies of cardiac, renal and hepatic chronic diseases were similar. Almost all patients had respiratory symptoms (> 95%), extrarespiratory symptoms were more frequent in influenza patients (9 vs 15%, = 0.04). RSV patients more frequently had bronchospasm (51 vs 36%, p = 0.001). Clinical presentation such as ARDS (20%), shock (30%) and pulmonary coinfection (32%) were similar, however SOFA score was higher in RSV patients (4.6 (3.4) vs 5.6 (4), p = 0.004). The P/F ratio was around 210 mmHg in both groups, PaCO 2 was higher in RSV patients (55 vs 47 mmHg, < 0.001). Respiratory assistance at diagnosis tended to differ (p = 0.06), RSV patients receiving more non invasive ventilation (29 vs 19%) and less high flow oxygen therapy (10 vs 14%) but invasive ventilation was required similarly (36 vs 33%). During ICU stay, ARDS was more frequent in RSV patients (21 vs 30%, p = 0.03), accordingly prone position (1.3 vs 4.3%) and ECMO (2.5 vs 9.1%) were more frequently needed. Length of mechanical ventilation (2 days (0-8) ) and ICU LOS (5 days (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) ) were not different. ICU mortality was similar in RSV and influenza patients (18.4% and 21.3%), the multivariate analysis did not find an association between type of virus and mortality. Conclusion: RSV infection is frequent in adult ICU patients. It presents more frequently than influenza as an acute on chronic respiratory failure with bronchospasm. Despite difference in case mix and clinical presentation, VRS severity and burden appear similar to influenza justifying effort to prevent and treat it. Compliance with ethics regulations: Yes.

Rationale: Mortality in acute stroke patients requiring mechanical ventilation ranges from 60 to 90% at 1 year. Studies evaluating indicators of outcome in these patients have limitations, including singlecenter, retrospective designs and no adjustment for withholding/ withdrawal of life-sustaining treatments (WLST). Our objective was to identify factors associated with 1-year survival in acute stroke patients requiring mechanical ventilation. Patients and methods: Retrospective analysis of a prospective multicenter database between 1997 and 2016. ICU stroke patients entered in the database and requiring mechanical ventilation within 24 h were included. Were excluded patients with stroke of traumatic origin, subdural hematoma or venous cerebral thrombosis. Factors associated with 1-year survival were identified using a Cox model stratified on inclusion center, adjusted on WFLST occurring during the first 48 h. Data are presented as median [Q1-Q3] or percentages. Cox model results are presented as hazard ratios (HR) and 95% confidence intervals (CI). Results: We identified 419 patients from 14 ICUs, aged 68 [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] years and 60% males. On admission, the Glasgow coma score (GCS) was 4 [3] [4] [5] [6] [7] [8] and the SAPS 2 score was 58 . Types of strokes were ischemic (46%), hemorrhagic (42%) and subarachnoid hemorrhage (SAH) (12%). Ischemic stroke patients received thrombolysis or thromboaspiration in 35/191 (18%) cases, and hemorrhagic stroke/ SAH patients received neurosurgery or embolization in 35/228 (15%) cases. Reasons for endotracheal intubation were coma (72%), acute respiratory failure (12%), seizures (8%), cardiac arrest (5%) and elective procedure (3%). Sixty-five (16%) patients received a decision of WFLST in the first 48 h. One-year survival year was 23%. Variables independently associated with 1-year survival were stroke type (ischemic as reference, hemorrhagic HR 0. (Fig. 1) . Inclusion period (1996 Inclusion period ( -2002 Inclusion period ( /2003 Inclusion period ( -2009 Inclusion period ( /2010 Inclusion period ( -2016 or having a stroke unit on site was not associated with 1-year survival. Conclusion: In acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive a specific stroke therapy are independently associated with long-term survival. These variables should be integrated in the decision process regarding initiation of MV in acute stroke patients. Compliance with ethics regulations: Yes. Rationale: International guidelines recommend targeted temperature management (TTM) between 32° and 36 °C for out-of-hospital cardiac arrest (CA) patients. However, it is unknown if this treatment is effective whatever the severity of the insult. We aimed to examine the association between TTM and long-term neurological outcome according to the risk evaluated at time of admission in intensive care unit (ICU) using a dedicated and validated score. Patients and methods: We used data prospectively collected in the Sudden Death Expert Center (SDEC) registry (Great Paris area, France) between May 2011 and December 2017 and in the Resuscitation Outcome Consortium-Continuous Chest Compression (ROC-CCC) between June 2011 and May 2015. We used a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score to assess the risk of poor outcome at ICU admission in each of 2 datasets. We finally studied the association between TTM use and long-term neurological prognosis according to mCAHP score at ICU admission divided into tertiles of severity in each of the 2 datasets. Results: There were 2723 patients analyzed in the French dataset and 4202 in the North-American dataset. The mCAHP identified 3 categories: low risk (score < 80 points, 40% of unfavourable outcome), medium risk (80 ≤ score < 105, 80% of unfavourable outcome) and high-risk group (score > 105, 95% of unfavourable outcome). According to the mCAHP score at ICU admission, TTM was associated with a better long-term neurological prognosis in patients with low risk (aOR = 1.62 [1.15-2.30 Rationale: Acute ischaemic stroke is associated with a high risk of mortality, morbidity and healthcare-related costs. Over the last decades new treatments, such as thrombolysis and thrombectomy, have been introduced. Because of their further improvement, complications have been decreasing. This also led to extending indications for treatment to patients who were previously not eligible. The impact of this evolution on long-term outcome and cost-effectiveness has mainly been assessed in clinical trials and simulation studies. Patients and methods: This single-centre retrospective study included 564 patients treated for stroke between January 2017 and February 2019. Functional outcome at 90 days was assessed by the modified Rankin Scale (mRS). Cost data were retrieved from individual invoices of 538 patients. Undiscounted total healthcare costs were calculated for the index hospital stay, capped at 90 days. Contribution of 6 cost categories to total costs was analysed. mRS at 90 days was used as a proxy for utilities to define Quality-Adjusted Life Years (QALYs). Multivariate analysis was done for gender, age, Charlson comorbidity index, pre-stroke mRS, stroke severity (NIHSS) and treatment modality (thrombectomy, thrombolysis, thrombectomy + thrombolysis, no intervention). Incremental Cost-Effectiveness Ratios (ICERs), associated to each treatment modality, were calculated. Results: No intervention was done in 328 patients (61.0%). 93 patients (17.3%) required thrombolysis, 64 (11.9%) thrombectomy and 53 (9.9%) the combination. Total costs were mean 15,787 EUR 177) . Hospitalisation costs (mean 11,275 EUR, IQR 2066-12,428) represented 71% of total costs, compared with drug costs (341 EUR, IQR 118-330), procedural costs (3283 EUR, IQR 652-2981), honoraria (290 EUR, IQR 111-395), lab (123 EUR, IQR 22-116) and imaging (475 EUR, IQR 334-539). Mean total costs differed between treatment modalities: 12,553 (IQR 3080-12,947) EUR for no intervention, 11,820 197) EUR for thrombolysis, 26, 103 (IQR 12, 893) EUR for thrombectomy and 30,301 (IQR 12, 488 ) EUR for the combination (p < 0.0001). Drivers for total costs were treatment modality (p < 0.017) and NIHSS-stroke severity (p < 0.0001). Utility scores were 0.65 Rationale: Emergency endotracheal intubation (ETI) in the Intensive Care Unit (ICU) often concerns hypoxemic patients with hemodynamic instability. A cardiovascular collapse (CVC) after ETI is a life-threatening complication. 2018 French guidelines suggested systematic fluid loading prior to ETI. Our study aimed to predict CVC after ETI, while using echocardiography, and to evaluate the impact of fluid loading. Patients and methods: A prospective study of 70 consecutive intubations was performed from June 2017 to November 2018 in three ICUs. Patients were selected if mean blood pressure measurements ≥ 60 mmHg before ETI. CVC was defined as mean blood pressure < 60 mmHg within 15 min following ETI. Four echocardiographic examinations were performed: 1-30 min before and 2-30 min after ETI (or when a CVC occurred); 3-after passive leg raising; 4-3 h following ETI. Patients were classified as fluid responders when the left ventricular outflow tract velocity-time integral increased by at least 10% compared with baseline. Results: 269 echocardiographic examinations were performed. CVC occurred in 32/70 procedures (46%). In CVC group, mean dose of Diprivan, used for fast sequence induction, was higher (2.8 ± 1 mg/kg vs 1.3 ± 0.7 mg/kg, p = 0.02). In the CVC group, fluid responsiveness was considered in 44% patients and left ventricular (LV) systolic dysfunction 13%. LV diastolic dysfunction did not concern any patient in the CVC group. Systolic blood pressure (SBP) < 120 mmHg was the sole independent risk factor for CVC occurrence in multivariate analysis: OR 5.9 CI 95% 1.7-21.2, p = 0.02. Fluid responsiveness independent risk factors for CVC patients was SBP < 120 mmHg (OR 8.7, CI 95% 1. Rationale: The autonomic nervous system 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 autonomic nervous system activity and a relation between HRV and outcome has been proposed in various types of patients. We attempted to evaluate the best determinants of such variation in survival prediction using a physiological data-warehousing program (ReaSTOC ClinicalTrials identifier NCT 02893462). Patients and methods: Physiological tracings were recorded at 125 Hz from the standard monitoring system (Intelliview Philips MP70) using the Synapse Software (LTSI INSERM UMR 1099), for a 2 h period, during the 24 h following ICU admission. All measurements were recorded while patients were laying in bed, with the head at 30° and without any medical intervention. Physiological data were associated with metadata collection by a dedicated research assistant. HRV was derived using Kubios HRV, in either temporal ( (SDNN), (RMSSD) and triangular index (TI)), frequency ( (LF), (HF)), non-linear domains (Poincaré plotting) and entropy. Results: 540 consecutive patients were recorded between May 2014 and April 2019. A lower LF/HF (< 0.9) and SD2/SD1 (< 1.3) ratios on admission were associated with a higher ICU mortality. Multivariate analysis enabled to develop a mortality predictive model (BICUS) associating SpO2/FiO2 and HRV parameters (LF/HF and Shannon entropy) with an AUC = 0.73 (p < 0.0001) for a BICUS value > 1 (Fig. 1) . Conclusion: HRV measured on admission enables to predict prognosis in the ICU, independently of the admission diagnosis, treatment and MV requirements. BICUS may help predict prognosis on a real time basis, using parameters derived from standard routine monitoring. Compliance with ethics regulations: Yes. Rationale: Stroke, in the context of type 2 diabetes (T2D) is associated with a worse outcome than in non-diabetic conditions, reflected by an increased ischemic volume and more intracerebral hemorrhage. An unbalanced diet is one of major risk for developing T2D. We aimed at creating a reproducible mouse model of stroke in impaired glucose tolerance condition induced by high fat diet. Patients and methods: Adult C57BL6mice (28 male and 28 female) were fed for 2 months with either High Fat Diet (HFD, 43% lipids, 21% proteins, 35% carbohydrates) or a normal diet (ND, 8.4% lipids, 19.3% proteins, 72.4% carbohydrates) . We used a model of Middle Cerebral Artery Occlusion (MCAO) by a monofilament for 90 min. Oral Glucose Tolerance Test and Insulin Tolerance Test were used for evaluating the pre-diabetic state. Mice were euthanized 20 h after reperfusion. Systemic inflammation, cerebral infarct volume and hemorrhagic transformation were determined. Results: HFD was associated with an increased glycaemia following the Oral Glucose Tolerance Test. Plasma leptinlevels in stroke conditions were significantly higher in HFD vs ND group. The HFD group presented a significant increase of infarct volume (HFD: 51.86 ± 4.46 mm 3 vs ND: 33.23 ± 4.29 mm 3 p = 0.016) and hemorrhagic transformation (HFD: 2.67 ± 0.66 vs ND: 0.73 ± 0.28 p = 0.012) (Fig. 1 ) compared to ND group. Discussion: In humans, one of the mechanisms leading to insulin resistance is low-grade inflammation. HFD increases gut permeability, which leads microbiota dysbiosis, thereby promoting metabolic endotoxaemia and a low-grade inflammation state. Experimental mouse models available for diabetes studies use leptin receptor deficient mice which develop T2D or destruction of pancreatic beta cells by streptozotocine injection (T1D). Studies using diet-induced insulin resistance models generally feed the mice for 12 weeks or more. However, metabolic disorders could appear earlier such as increase inflammatory markers. In our model, a short exposition to HFD (8 weeks) leads to an increase of the pro-inflammatory markers as plasma leptin and a more severe stroke status (infarct and hemorrhagic transformation). Conclusion: Two months of HFD in adult mice altered hyperglycemia control. This metabolic disorder was associated with significantly higher leptin production, increased infarct volume and hemorrhagic complications than in normal-fed mice. This new model is particularly relevant to study stroke under pre-diabetic conditions induced by HFD. Compliance with ethics regulations: Yes.

Eight weeks of HFD increase ischemic volume and hemorrhagic transformation. (A)-Infarct volume (V) 24 h after reperfusion, all value are mean ± SEM, HFD: V = 51.66 ± 4.46 mm 3 , n = 14, ND: V = 33.23 ± 4.26 mm 3 , n = 7, *p = 0.016 (B)-Hemorrhage Transformation (HT) score 24 h after MCAO. All value are mean ± SEM HFD: HT score = 2.67 ± 0.66, n = 15, ND: HT score = 0.73 +/+ 0.28, n = 15 *p = 0.012 Rationale: Cardiac arrest (CA), as massive ischemia reperfusion (IR), is an universal health issue. Medication taken at the time of the CA could have prognosis consequences. No medication has proven its benefit on CA prognosis. Pharmacological pre-or postconditioning aims to reduce IR injury but with disappointing results. Metformin (MET) is a worldwide-prescribed antidiabetic drug, and several clinical reports plead for a potential protective effect in various settings of sterile and non sterile inflammation, including IR. Our hypothesis is that MET act as a preconditioning drug against CA-induced IR. Patients and methods: Retrospective single academic medical center survival study (French West Indies) on resuscitated CA in ICU (institutional ethical committee approval). Data were extracted from medical charts, PMSI, and laboratory DBSYNERGY ™ software. Anonymized data were entered on a Excel ™ and transferred to IBM ® -SPSS ® software (v 24.0.0.0) for analysis. Univariate study (Chi-2, Fisher exact tests, Student-t test, Mann-Whitney U-test if required) was followed by a multivariate model (Odd ratio OR and 95% IC: Kaplan-Meier estimator and non parametric Logrank test-Mantel Cox model). Assuming an overall in-hospital mortality for CA in ICU of 80% with an expected mortality decrease of 15% by MET, the number of patients to be included is 510. Results: The inclusion period was 2012 to 2018, with 555 included patients (202 diabetic patients among whom 62 took MET). The D28 mortality was 67% in MET+ patients (n = 62) versus 82% in NoMET patients (n = 493), p < 0.01. Comparing alive (n = 115) versus deceased (n = 440) at D28 in univariate then multivariate analysis, asystole on the first EKG, number of iterative cardiac arrest,SOFA, No-Flow, lactate, Low-flow and SAPSII appear as independent criteria associated with D28mortality.Conversely, MET intake showed up as a protective criterion (OR 0.477, CI95 0.237-0.957). The survival curve, including strata of Low-Flow duration at the cut-off 20 min, is reported on the Fig. 1 . Among diabetic patients (n = 202), the mortality of patients in the MET+ (n = 62) was 67% versus 80% in the NoMET (n = 140), p = 0.04. Conclusion: In diabetic patients suffering of massive IR related to resuscitated CA, a current treatment by MET is associated with a better survival. These results support a protective effect of MET and are important to initiate prospective evaluations, because of millions diabetic people around the world and the potential benefit of MET. The potential benefit in non diabetic patients and in sterile as well as non sterile inflammation should be addressed. Compliance with ethics regulations: Yes. Rationale: During systemic inflammation, the accumulation of misfolded proteins in the endoplasmic reticulum (ER) induces ER stress (ERS). In animal models, the inhibition of ERS reduces inflammatory response and organ failure. Cardiopulmonary bypass (CPB) induces a significant systemic inflammatory response but ERS expression has never been described in cardiac surgery patients. Our objective was to describe the variations of the Glucose Related Protein of 78 kDa (GRP78), the final effector of the ERS, during CPB. Patients and methods: We conducted a prospective monocenter study including patients undergoing cardiac surgery with CPB. Two samples (PAXGene ® tube + EDTA tube) were taken at three times: before CPB, 2 h after the end of CPB (H2-CPB) and 24 h after (H24-CPB).

After RNA isolation and reverse transcription, we performed a quantitative polymerase chain reaction to evaluate the expression of gene encoding for GRP78 and determined the plasma level of GRP78 using Enzyme-Linked Immunosorbent Assay. Our main objective was to study the variation of GRP78 between pre-CPB and H2-CPB samples. Our secondary objectives were to evaluate the association of ERS with morbi-mortality: organ failure at 24 h (catecholamines and/or invasive ventilation and/or acute renal failure), troponinemia and PaO2/FiO2 ratio (lung damage control). Fig. 1 ). We found an inverse correlation between GRP78 plasma level and troponinemia at H2 (r = − 0.31; 95% CI[− 0.56; − 0.10]; p = 0.037) and a correlation between the PaO2/FiO2 ratio and GRP78 plasma level at H2 (r = 0.37; 95% CI[0.10; 0.59]; p = 0.0064).

We showed a significant relationship between the variation in plasma concentration of GRP78 and post-operative organ failure after CPB. Further studies are needed to better understand the molecular mechanisms of ERS in acute inflammatory organ failure in humans. Compliance with ethics regulations: Yes. Patients and methods: In a retrospective monocentric study (01/2013-01/2017) conducted in cardio-vascular surgical intensive care unit (ICU) in Henri Mondor teaching hospital, all consecutive adult patients who underwent peripheral VA-ECMO were included, with exclusion of those dying in the first 24 h. Diagnosis of acute mesenteric ischemia was performed using digestive endoscopy, abdominal CT-scan or fist-line laparotomy. Significative results in the univariate analysis were analyzed in a multivariate analysis using logistic regression. Results: 150 VA-ECMO were implanted. Median age was 58 (48-69) years and median . VA-ECMO was implanted after a cardiotomy in 43% of the cases and for a medical reason in 57% of the cases including 26% of refractory cardiac arrest. Patients characteristics are reported in the table. Acute mesenteric ischemia was suspected in 38 patients, with a delay of 4 (2-7) days after ECMO implantation. Digestive endoscopy was performed in 33 patients, CTscan in five patients and first-line laparotomy in three patients. Acute mesenteric ischemia was confirmed in 14 patients, i.e. an incidence of 9%. Laparotomy was performed in six of the 14 patients, two having a stage I colitis ischemitis with stable conditions and 6 being considered too severe to undergo futile surgery. Overall mortality was 56%. All the patients with acute mesenteric ischemia died in the ICU. Independent risk factors of developing acute mesenteric ischemia were renal replacement therapy , p = 0.02)) and onset of a second shock state within the first 5 days of ICU stay (OR 7.8 (95% IC 1.5-41.3, p = 0.02)). Conversely, early enteral nutrition was negatively associated with acute mesenteric ischemia (OR 0.15 (95% IC 0.03-0.69), p 0.02). Conclusion: Acute mesenteric ischemia is a relatively frequent condition among patients under VA-ECMO for cardiogenic shock. Its extremely poor prognosis requires low threshold of suspicion. Compliance with ethics regulations: Yes. (1). It allows the computation of trans-pulmonary pressure (2) and can be used to set positive end-expiratory pressure (PEEP) (3.4) . Prone position(PP) can reduce mortality in patients with acute respiratory distress syndrome (ARDS), but PEEP selection in PP is controversial. In human ARDS end-expiratory Pes at zero flow (PEEPt,es) was not different between supine (SP) and PP at same PEEP (5). As no study measured Ppl in SP and PP in ARDS we aimed at comparing PEEPt,es and end-expiratory Ppl at zero flow (PEEPt,Ppl) in this condition. Our hypothesis was that PEEPt,es was close to dorsal PEEPt,Ppl (PEEPt,Ppldorsal) in SP and to ventral PEEPt,Ppl (PEEPt,Pplventral) in PP.

In eight female pigs of 40 kgs intubated, sedated, paralyzed and mechanically ventilated, ARDS was induced by repeated saline lavage until PaO2/FIO2 < 100 mmHg under FIO2 1 and PEEP 5cmH2O. Pes was measured by Nutrivent catheter. Ppl was measured by custom-made pouch sensors inserted surgically into the right anterior and posterior sixth intercostal space. Ppl sensors were filled with air. After ARDS induction animals were randomly assigned to SP or PP. In each position, a recruitment manoeuver was performed and PEEP decreased from 20 to 5 cmH2O by steps of 5cmH2O lasting 10 min each, then the animals were crossed over into the alternate position where the same procedure was done. At the end of each step nonstressed volume and correct position (Baydur maneuver) were determined for Pes and Ppl sensors, then a 3-s end-expiratory occlusion was performed and Pes and Ppl recorded. Linear mixed model was used to compare the value of Pes and Ppl at each PEEP and position. Results: Box-and-whisker plots of Pes and Ppl in SP and PP are shown in Fig. 1 . There is marked dorsal-to-ventral gradient in Ppl at each PEEP in SP, which is reverted in PP at PEEP 10 and 15 only. There was no interaction between pressures and PEEP or position. With increasing PEEP Pes increased significantly from PEEP 5 in SP and PP. PEEPt,PplVentral was significantly lower than PEEPt,es in SP but not in PP. (Medtronic) , Carescape 860 (GE)) were set in pressure support 0 cmH2O, PEEP 4 cmH2O, FIO2 21% and equipped with the same double limb ventilator circuit (Intersurgical) without any humidification device. ASL 5000 bench model was set with 3 inspiratory/expiratory resistance (R) and compliance (C) combinations: R13/12-C54, R12/14-C39 and R22/18-C59 mimicking normal, ARDS and COPD conditions, respectively (1) . Inspiratory effort generated by ASL 5000 consisted of 30 consecutive breaths obtained from the esophageal pressure in a real patient at the time of a spontaneous breathing trial. For each ICU ventilator and RC combination, two steps were performed: in the first, ATC was not activated and ventilator attached to ASL 5000 without ETT (ATC-ETT-); in the second, ATC was set on at 100% compensation for an ETT 8 mm ID and such an ETT (Shiley Hi contour, Covidien) joined ICU ventilator to ASL 5000 (ATC+ ETT+). The null hypothesis is that VTATC+ ETT+ minus VTATC-ETT-is 0. Primary end point was the breath by breath paired difference betwen ATC+ ETT+ and ATC-ETT-. It was tested to zero for each ventilator in each RC condition. Results: Median VT was 213 ml. Table 1 displays mean (± SD) difference in VT (ml) between ATC+ ETT+ and ATC-ETT-: a negative value means that ATC under delivers and a positive value that ATC over delivers VT for a given patient's inspiratory effort and RC. In four ventilators (C6, S1, Elisa 800 and 980) ATC almost systematically under delivered VT. In several instances under compensation was greater than 10% median VT. By contrast ATC performed better with the other three ventilators (Evita XL, V500 and Carescape 860). Conclusion: ATC tended to under deliver VT. Furthermore, there were marked differences between ICU ventilators the clinician should be aware of when using the ATC option. Compliance with ethics regulations: NA. Rationale: During the last decades, identification of factors associated with ventilation-induced lung injury has led to improved survival in patients with ARDS. The mechanical power of ventilation is the total energy transmitted from the ventilator to the respiratory system per unit of time and comprises three different components: elastic related to PEEP, elastic related to tidal volume and resistive. This integrative variable has been recently proposed as an useful predictor of ventilationinduced lung injury and death among ventilated patients. Our goal was to determine the respective impact of the total mechanical power and its three components on the outcome of patients with ARDS. Patients and methods: We performed a post hoc analysis of a randomized, controlled study of patients with ARDS with a PaO2/FiO2 ratio < 150. Themechanical power at inclusion and averaged on the first 2 days after inclusion (total and its three different components) was computed according to the following equation: PowerRS (J/ min) = 0.098 Respiratory Rate Tidal Volume [PEEP (1) + ½ Driving Pressure (2) + (Peak Pressure-Plateau Pressure) (3)], where the (1), (2) and (3) parts correspond respectively to the elastic related to PEEP, elastic related to tidal volume and resistive components. The association between each of these four types of mechanical power evaluated during the first 2 days after inclusion and mortality at D90 was assessed one after the other through multiple logistic regression, allowing control for potential confounding variables at inclusion (age, IGS score without age, group of randomization, PaO2/FiO2, arterial pH). Results: Data from 339 patients were analyzed, among which 115 (33.9%) died before D90. There was no difference concerning the mechanical power at inclusion between survivors and non survivors (either total or its three components). Among the four different types of mechanical power tested during the first 2 days after inclusion, the elastic component related to tidal volume was the only one that was independently associated with mortality at D90 (OR 1.030; 95% CI 1.003-1.058; p = 0.03) (Figure) . Conclusion: Our study shows that only the elastic component of the mechanical power related to tidal volume independently predicted mortality at D90 among patients with ARDS, whereas the total mechanical power, its elastic component related to PEEP and its resistive component did not. Further studies are needed to better define how the mechanical power of ventilation could be useful to synthetize the risk of ventilation-induced lung injury. Compliance with ethics regulations: Yes.

Probability of death at D90 as a factor of mean value (on D1-D2) of the elastic component related to tidal volume of the mechanical power.

To examine the effect of early-stage mechanical ventilation (MV) on diaphragmatic contractility. In the 2nd step, if a diaphragmatic dysfunction was detected, we assessed its influence on the weaning from ventilator. Patients and methods: We measured prospectively the ultrasounddiaphragmatic thickening fraction (DTF) between 2 groups: a study group versus a control group (n = 30 for each). The study group included all adult patients receiving MV, in whom, the DTF was measured within a minimum of 48 h and a maximum of 5 days of MV. For the control group, were enrolled after their approval for participation, adult volunteers in spontaneous ventilation (SV). Patients with factors affecting the diaphragmatic contractility (neuromuscular disease, severe obesity, and neuromuscular blockers…) were excluded. The ultrasound measurements were obtained at the zone of apposition of the right hemithorax. Teleinspiratory and telexpiratory diameters (tid/ ted) were taken on the 3 medio-axillary lines: posterior, median and anterior. The DTF was calculated as following: DTF = (tid-ted/ted) x 100. At the 1st step, the DTFs were compared and at the 2nd step: the relationship between DTF and weaning was analysed. Results: Our 2 groups were comparable in corpulence and co morbidities. The SV group was younger (35 vs. 47 years, p < 0.05) with a predominant female composition. The diaphragmatic exploration concluded that in the MV group, the mean tid tended to be higher but without significant difference (29.1 + 7 versus 26.1 + 5 mm, p = 0.09), the mean ted was significantly higher (20.9 + 6 versus 17.6 + 3.2 mm, p = 0.01) and DTF was significantly lower (39.9 + 12.5% versus 49 + 20.5%, p = 0.043). The ventilation mode had no effect on DTF (40.2 + 13% for control volume vs. 38.6 + 9% for PSV mode, p = 0.8). Fourteen among 30 ventilated patients had a successful weaning with a mean duration of 6 days. A negative correlation was found close to significance between DTF and weaning duration (Rho = − 0.464 and p = 0.08). A DTF value > 33% wasassociated with weaning success (OR = 2, 95% CI = [1.07-3.7] and p = 0.058) with sensitivity = 85.7%, Specificity = 50%, PPV = 60% and NPV = 80%. Conclusion: The diaphragmatic contractile function was altered from the first days of MV. Weaning duration seemed to be negatively correlated with DTF, and a DTF at the first 5 days of MV greater than 33% was predictive of weaning success. Compliance with ethics regulations: Yes. Rationale: Mechanical ventilation is a life-saving treatment that is however associated with lung injury and/or diaphragm dysfunction. The optimal ventilator settings to provide lung protective ventilation while maintaining safe diaphragm activity are difficult to determine. A noninvasive and bedside evaluation of the diaphragm activity could be helpful in this context. The present study investigated whether changes in diaphragm shear modulus (i.e. stiffness, ΔSMdi) assessed by ultrasound shear wave elastography (SWE) may be used as a surrogate of changes in transdiaphragmatic pressure (ΔPdi) in mechanically ventilated patients. Patients and methods: Patients had to be ventilated for at least 24 h without contraindications for the placement of an oeso-gastric catheter. Pdi was monitored continuously and SMdi was measured at the zone of apposition of the right hemi-diaphragm, at 2 Hz sampling rate. Measurements were performed twice under initial ventilator settings and at the end of a weaning trial. Pearson correlation coefficients (r) were computed to determine within-individual correlations between Pdi and SMdi and changes in Pdi and in SMdi occurring between initial ventilator settings and the end of the SBT were compared by a paired test. Results: Twenty-five patients were enrolled and 8 displayed a significant correlation between ΔSMdi and ΔPdi (mean r = 0.73, range = 0.62-0.88, all p < 0.05) (Fig. 1A ). Compared to their counterparts, patients with significant within correlations had a lower respiratory rate (16.8 ± 4.7 vs 23.9 ± 6.2breath/min. respectively; p < 0.01) and a significant increase in ΔSMdi (7.3 ± 5.5 kPa vs 13.4 ± 9.0 kPa. p < 0.01) between initial ventilator settings and the SBT. Patients without ΔSMdi-ΔPdi correlation only displayed an increase in ΔPdi (7.9 ± 5.9 vs 14.9 ± 7.9 cmH 2 O, p < 0.01) at the end of the SBT with no concomitant significant increase in ΔSMdi (7.6 ± 3.8 kPa vs 7.9 ± 5.3 kPa, p > 0.05). (Fig. 1B) . Conclusion: SMdi obtained by SWE appears as a promising technique to assess diaphragm activity in mechanically ventilated patients but technological improvements are necessary to increase SWE sampling rate before enabling its generalization in the ICU. Compliance with ethics regulations: Yes. Rationale: End-inspiratory (EIP) and end-expiratory (EEP) pauses are commonly used during volume assist control ventilation to assess plateau pressure and total positive end-expiratory pressure (PEEPtot). They can also be used during assisted ventilation (AV) for muscle pressure assessment. It requires ventilators able to perform EIP during AV. Plateau pressure (Pplat) usually increases in AV during EIP due to "hidden" inspiratory effort. Pressure muscular index (PMI) is equal to Pplat minus the sum of PEEPtot (measured during an EEP) and set pressure support (PS); it theoretically reflects patient's effort without esophageal pressure (Pes) monitoring. Pes is the gold standard method to assess inspiratory muscle pressure (Pmus, difference of Pes drop at neural end-inspiration and correction factor for chest wall elastance and tidal volume). We aimed to illustrate the feasibility of measuring PMI using a standard ICU ventilator at the bedside and study the correlation between Pmus and PMI. Patients and methods: Measurements were recorded in 4 ICU patients. Pes was measured using an nasogastric probe (equipped with an esophageal balloon) inserted for advanced monitoring (severe acute respiratory distress syndrome-ARDS) or for a study protocol (difficult weaning after COPD exacerbation). Recorded EIP, EEP and Pes were used for post hoc analyses. Results reported as ranges and median [IQR] . Correlation between Pmus and PMI tested with Spearman correlation test. Results: 25 out of 28 EIP and EEP duos could be analyzed (2-esophageal spasm/1-calibration error). Ventilator mode was pressure support ventilation (PS 0-12 cmH2O). cmH2O, Pmus = 3.5 [1.7-9 .5] cmH2O, PMI = 4.5 [2.4-7.8 ]. For all recordings, Spearman r coefficient between Pmus and PMI was 0.438 (p = 0.028). Conclusion: Muscular effort can be assessed in AV using EIP and EEP using ICU ventilators. However, recordings can be influenced by expiratory muscles contraction. Patient's ability to follow directions during the maneuvers is an important factor to obtain reliable values. There seem to be a correlation in our small sample between muscular pressure assessed without and with Pes. Compliance with ethics regulations: Yes. Rationale: Severe pneumonia can culminate in acute respiratory distress syndrome (ARDS). An uncontrolled inflammatory response is a key feature favoring transition towards ARDS. However, the underlying mechanisms remain poorly understood. In this context, the contribution of "innate T cells" (ITC) -a family of non-peptide reactive T cells comprising NKT cells, Mucosal Associated Invariant T (MAIT) cells and γδT cells-has never been explored. ITC have emerged as key players in orchestration of the host response during infections and inflammation processes. For these reasons, these cells are already seen as potential therapeutic targets in other medical fields (especially oncology). Here, we hypothesized that a tight regulation of their functions could be paramount to control the inflammatory response and to prevent ARDS development. Patients and methods: To explore this, we combined a murinemodel of influenza A virus (IAV) infection mimicking ARDSsymptoms and a clinical study recruiting patients admitted in ICU for severe pneumonia. Using flow-cytometry approaches, we investigated (1) the abundance and dynamics of ITC in various compartments, (2) their pattern of activation/regulation markers (respectively CD69 and PD-1) and (3) their cytokine production. Results: During experimental IAV pneumonia, ITC were transiently recruited into the airways. Unlike γδT and NKT, MAIT cells phenotype was largely changed, displaying a progressive CD69 overexpression and increased IL-17A production. During the resolution phase, up to 90% of pulmonary MAITs expressed PD-1 (versus < 10% in controls), which can suggest emergence of regulatory functions. Last, using gene-targeted mice, we suggested that MAIT cells confer a protective effect during pneumonia. In the ongoing clinical study, the proportion of circulating MAIT cells in patients was markedly decreased compared to controls (1.0 ± 1.0% versus 5.7 ± 2.8% of T cells), but not for NKT or γδT cells. Notably, some patients with severe ARDS presented detectable levels of MAITs in their respiratory fluids. In addition, circulating MAIT cells in patients overexpressed CD69 and PD-1 (56.5% and 55% respectively), but with a reduced proportion able to produce IL-17 and IFNγ, compared to healthy controls. Lastly, proportion of activated (CD69 +) MAIT cells significantly decreased with clinical improvement. Conclusion: This translational approach combining in vivo animal experiments and clinical samples with ex vivo experiments indicates a preferential modulation in MAIT cells functions during severe pneumonia. These data justify an in-depth analysis of MAIT cells activation mechanisms and functions in this context, in order to further explore a potential use as a disease-progression marker and -in a long term perspective-as a potential therapeutic target. Compliance with ethics regulations: Yes.

Representative flow-cytometry dot-plots of MAIT cells labelling using fluorophore-conjugated MR1 tetramers loaded with 5-OP-RU from lungs of an infected mouse (A) and blood sample of a patient with pneumonia (B). C: frequency of MAIT cells, proportion of CD69 and PD-1 + MAIT cells in bronchoalveolar lavage during experimental murine pneumonia. D: blood frequency of MAIT cells in patients with pneumonia compared with healthy controls (as % of total T cells) Rationale: Immune paralysis following hyperinflammatory states increases the risk of secondary infections and death. Reversing T-cells exhaustion using recombinant IL7 or immune checkpoints inhibitors may improve the prognosis of patients with sepsis admitted to the ICU. However, there is an unmet need to better characterize the state of T-cells exhaustion in these patients, its reproducibility and its correlation with the outcomes before implementing immunotherapy in the therapeutic armamentarium against sepsis. Patients and methods: Prospective observational cohort study performed in two tertiary-care ICUs in a university hospital. Peripheral blood mononuclear cells were collected at day 1 in 80 adult patients with sepsis admitted to the ICU. The level of CD4+ and CD8+ T-cells exhaustion was quantified using multi-color flux cytometry targeting the following exhaustion markers: PD-1, 2B4 and CD160. CD4+ regulatory T-cells (CD3+ CD4+ CD25hi CD127Lo cells) were also assessed. Results: The 80 patients included in the study could be split in five clusters according to their dominant pattern of exhaustion markers on CD8+ T-cell (i.e. no markers, PD-1+, 2B4+, 2B4+ CD160+ and 2B4+ PD-1+) and independently of their underlying morbidities. No patients harbored a fully exhausted triple-positive pattern. By multivariate analysis, SAPS2 gravity score at day 1 (p = 0.007), a dominant 2B4 and/or PD-1 CD8+ pattern (p = 0.04) and lung sepsis (p = 0.02) where associated with the risk of death at day 28, whereas hemoglobin level was associated with survival (p = 0.04). No CD4+ or CD8+ exhaustion pattern independently predicted the risk of secondary infections. Neither the level of CD4+ regulatory T-cells nor the dominant CD4+ exhaustion pattern was associated with the outcomes. Rationale: There is growing use of multiplex polymerase chain reaction (mPCR) for respiratory virus testing in patients with communityacquired pneumonia (CAP). Data on one-year outcomes in patients with severe CAP of bacterial, viral and unidentified etiology are scarce. Patients and methods: A single-center retrospective study was performed in 123 intensive care unit (ICU) patients with known one-year survival status who had undergone respiratory virus testing for CAP by mPCR. One year after ICU admission, mortality rates and functional status were compared in patients with CAP of bacterial, viral or unidentified etiology. Results: There were 19 (15.4%) patients in the bacterial group, 37 (30.1%) in the viral group and 67 (54.5%) with unidentified etiology.

One-year mortality was 57.9% (n = 11/19), 27% (n = 10/37) and 28.4% (n = 19/67), respectively (p = 0.046). In multivariate analysis, one-year mortality was higher in the bacterial group than in the viral group (HR 2.92, 95% IC 1.71-7.28, p = 0.02), had a trend to be higher in the bacterial group compared to the unidentified etiology group (HR 2.07, 95% IC 0.96-4.45, p = 0.06) and was not different between the viral and unidentified etiology groups (HR 0.71, 95% IC 0.30-1.65, p = 0.43). Severe dyspnea (mMRC score = 4 or death), major adverse respiratory events (new homecare ventilatory support or death) and severe autonomy deficiencies (ADL Katz score ≤ 2 ordeath) were observed in 52/104 (50.0%), 65/104 (62.5%) and 47/104 (45.2%) patients, respectively, with no difference between groups. Conclusion: CAP of bacterial origin was associated with a poorer prognosis than viral or unidentified etiology. Impaired functional status was observed in a substantial proportion at one-year, irrespective of the causative microorganisms involved. Compliance with ethics regulations: Yes.

Interest of UNYVERO multiplex PCR (CURETIS) for BAL rapid microbiologic and antibiotic susceptibility documentations in immunocompromised patients under antibiotic therapy Jean-Luc Baudel 1 , Jacques Tankovic 2 , Redouane Dahoumane 2 , Salah Gallah 2 , Laurent Benzerara 2 , Jean-Remy Lavillegrand 1 , Razach Abdallah 1 , Geoffroy Hariri 1 , Naike Bige 1 , Hafid Ait-Oufella 1 , Nicolas Veziris 2 , Eric Maury 1 , Bertrand Guidet 1 Rationale: Our aim was to evaluate the interest of the Unyvero rapid (4.5 h) multiplex PCR assay (performed on bronchoalveolar lavage [BAL] samples) for the management of immunocompromised patients already treated with antibiotics and diagnosed with pneumonia (according to clinical and radiological findings). We thus performed an observational study that compared the results (and the length of time to obtain them) of routine microbiological evaluation and Unyvero assay. Patients and methods: From July 2018 to January 2019 and from April to August 2019, we examined BAL samples from immunocompromised patients (coming from hematology, oncology, hepatology, gastroenterology, internal medicine, and neurology units) diagnosed with pneumonia (based on clinical and radiological findings), and already receiving antibiotic treatment. The following data were collected: age, gender, SAPS2 score, lung CT scan (92%) or X-ray (8%) results, duration and content of prior antibiotic therapy, direct examination, culture, antibiogram and Unyvero results, secondary confirmation of pneumonia or not, possible changes in antibiotic therapy that could have been made after obtention of Unyvero results. Informed consent was obtained from all patients. Results: 40 BAL samples were analyzed in 38 immunocompromised patients (m/f ratio 2.17, SAPS2 51.5 ± 6.8) mostly with hematologic (76%) or oncologic (13%) diseases. The patients received either corticosteroids (47%), or chemotherapy (37%), or immunotherapy (8%). 40% of the patients were under mechanical ventilation, 15% under Optiflow. 32% presented a shock, 22% had aplasia or neutropenia, 24% were allografted, 16% were autografted. The duration of prior antibiotic therapy at the time of BAL were 9.3 ± 5.6 days. Direct examination was positive in 22.5% of the cases, culture (both above and under the classical threshold of 104 CFU/ml) in 60%, Unyvero in 47.5%. A retrospective analysis of all the cases confirmed the initial diagnosis of pneumonia in only 50% of the cases. Compared to culture, the sensitivity of Unyvero was 81%, its specificity 94%. Unyvero could permit to rapidly deescalate antibiotic therapy in 42% of the cases and to rapidly stop it in 32%.

The Unyvero assay on BAL samples is useful in this specific population for rapid obtention of microbiological results and also for confirmation of the negativity of cultures and thus permits a better management of antibiotic therapy, leading to a reduction of antibiotic resistance selection pressure in the ICU. Compliance with ethics regulations: Yes.

Do not underestimate RSV pneumonia among critically ill patients Erwan Begot 1 , Suzanne Champion 1 , Charline Sazio 1 , Benjamin Clouzeau 1 , Alexandre Boyer 1 , Hoang-Nam Bui 1 , Marie-Edith Lafon 2 , Camille Ciccone 2 , Julia Dina 3 , Didier Gruson 1 , Renaud Prével 1 1 CHU Bordeaux, Medical intensive care unit, Bordeaux, France; 2 CHU Bordeaux, Virology laboratory, Bordeaux, France; 3 National Reference Center for Measles Mumps and Rubella, CHU de Caen, Caen, France Correspondence: Erwan Begot (erwan.begot@chu-bordeaux.fr) Ann. Intensive Care 2020, 10 (Suppl 1):F-019 Rationale: Respiratory syncitial virus (RSV) is a well-known cause of respiratory failure among neonates but its pathogenicity in adults is now emerging as a potential cause of viral pneumonia. Data are limited with conflicting results regarding RSV pneumonia severity in adults. Data are lacking about critically ill RSV patients' characteristics and outcomes. The aim of this study is to compare RSV patients' characteristics, care and outcomes to influenza patients' ones. Patients and methods: Patients diagnosed with RSV and influenza pneumonia admitted to our medical ICU were included. Data were retrospectively recorded. Quantitative data are expressed by median and interquartile range and compared by use of Mann-Whitney test. Qualitative data are expressed by number and percentages and compared by use of Fischer exact t-test. RSV strains were prospectively collected. Results: Eighteen critically ill patients with RSV pneumonia and 95 with influenza pneumonia were included. RSV and influenza patients had the same characteristics at admission except for age (respectively 71yo [62; 81] and acute respiratory distress syndrome rates (respectively 7/18 (39%) vs 47/95 (49%), p = 0.44). They received similar treatment as suggested by oro-tracheal intubation rates (respectively 6/18 (33%) vs 52/95 (54%), p: 0.12) and antibiotics prescription (respectively 16/18 (89%) vs 88/95 (93%), p: 0.63). RSV and influenza patients also had the same rates of bacterial co-infections (4/18 (22%) vs 28 (29%), p: 0.78). Invasive aspergillosis remained a rare event but also occurred among RSV patients (1/18 (6%) vs 3/95 (3%), p: 0.51). Acute coronary syndromes were as frequent in both groups (respectively 2/18 (12%) vs 9/95 (10%), p = 1.00). Day-28 mortality was similar between RSV and influenza patients (respectively 3/18 (19%) Rationale: Respiratory distress from seawater drowning is commonly considered multifactorial. Etiologies are debatable and include heart failure, infection and acute respiratory distress syndrome (ARDS). Documented bacterial infections seems mostly related to the site of drowning. Data in this regard are scarce with prospective studies lacking. The objective of our study was to describe prospectively the characteristics and determinants of respiratory distress from Seawater Drowning. Patients and methods: All patients admitted for seawater drowning to seven intensive care units (ICU) on the French Riviera in the summers of 2017 and 2018 were prospectively included. Recorded data included clinical features on examination, personal history, chest X-rays, echocardiography and biological results obtained within the first 48 h. A paired Student's t-test was used to study statistical differences between quantitative variables on admission and during early evaluation (i.e. first 48 h). Results: Forty-eight patients were admitted to seven centers of which 45 (94%) were diagnosed as having ARDS, 31 (65%) early pneumonia and 4 (8%) acute cardiogenic pulmonary edema. Twenty-one (44%) respiratory samples were collected but bacterial culture was positive in only 5 cases. Multidrug-resistant bacteria were not observed, and amoxicillin-clavulanate as first-line treatment was effective in all cases. Echocardiography performed in 38 (75%) patients was normal and unable to identify specific patient profiles. The median Clinical Pulmonary Infection Score (CPIS) on admission was 6 (IQR, 5-7) and decreased rapidly and significantly (p < 0.0001) within 24 h to 3 (IQR, 2-3) (Fig. 1) . Conclusion: Data from this multicenter cohort suggest that respiratory distress following seawater drowning can mimic bacterial pneumonia during the first 24 h with subsequent rapid clinical improvement in patients admitted to the ICU. Probabilistic antibacterial therapy should therefore be limited to the most severe patients. Isolate ARDS is often the only etiology found and is resolutive within 24 h. This prospective cohort is the largest of its kind and gives a better insight into the limited impact of cardiogenic and infectious processes on sea drowning-related respiratory distress. Compliance with ethics regulations: Yes. Rationale: Patients treated with "ExtraCorporeal Membrane Oxygenation" (ECMO) are at a higher risk of developing nosocomial infections and they are consequently often treated with beta-lactams. French guidelines recommend obtaining beta-lactam trough concentrations above four times the minimal inhibitory concentration (MIC) of the causative bacteria. The ECMO device may alter the pharmacokinetics of these medications, which may result in underexposure to beta-lactam antibiotics. Patients and methods: This observational, prospective, multicenter, case-control study was performed in the intensive care units of two tertiary care hospitals in France. ECMO Patients with sepsis treated with piperacillin-tazobactam were enrolled. Control patients were matched according to SOFA score and creatinine clearance. The pharmacokinetics of piperacillin was described based on a population pharmacokinetic model, allowing to calculate the time spent above 4 × the MIC breakpoint for Pseudomonas aeruginosa susceptibility after the first dose and at steady state between two piperacillin infusions. Results: Forty-two patients were included. The median age was 60 years [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] , the SOFA score was 11 [9] [10] [11] [12] [13] [14] , and median creatinine clearance was 47 mL/min . There was no significant difference in the time above 4 x MIC in patients treated with ECMO and controls during the first administration (p = 0.184) and at steady state (p = 0.309). There was no significant difference between the trough at steady state (p = 0.535), with 18/42 patients (43%) exhibiting concentrations of piperacillin lower than 4 x MIC. ECMO support was not associated with a steady state trough concentration below 4 x MIC (OR = 0.5 [0.1-2.1], p = 0.378). The only variable independently associated with this risk was a creatinine clearance ≥ 40 mL/min, (OR = 4.3 [1.1-17.7 ], p = 0.043). Conclusion: ECMO support has no significant impact on piperacillin exposure. Intensive care unit patients with sepsis are, however, frequently underexposed with piperacillin, which suggest that therapeutic drug monitoring should be strongly recommended for severe infections. 

Impact of a visual support dedicated to prognosis of patients on symptoms of stress of family members Rationale: Family members commonly have inaccurate expectations of patient's prognosis. Adding to classic oral information a visual support, depicting day by day the evolution of the condition of the patient, improves the concordance in prognosis estimate between physicians and family members. The objective of this study was to evaluate the impact of this support on symptoms of anxiety/depression of family members. Patients and methods: We conducted a bi-center prospective beforeafter study. All consecutive patients admitted in the two ICUs were eligible. In the before period (3 months), family members received classic oral information. In the after period (3 months) , in addition to classic oral information, the visual support ( Fig. 1) was available for family members in the patient's room from the day of admission until discharge from the ICU. At day 5 and 90 from admission, symptoms of anxiety/depression of referent family member were evaluated by Hospital Anxiety and Depression Scale (HADS). Results: 140 patients and their referent family members were included (77 in period before and 63 after). Characteristics of patients of the two groups were similar regarding age, reason for admission, SAPS II at admission and SOFA score at day 5. Also characteristics of referent family members were comparable in terms of age, sex ratio, type of relationship with the patient and number of visits since admission. At day 5, total HAD score was 17 [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] in the group before without the support and 15 [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] in the group after with the support (p = 0.43). The prevalence of symptoms of anxiety (HAD-A score > 7) and depression (HAD-D score > 7) was similar in the two groups (respectively 66.2% and 49.4% in the group before, and 68.3% and 36.5% in the group after (NS)). At day 90, total HAD score was 11 in the group before [7-16] and 9 [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] in the group after (p = 0.38). By multivariate analysis the following factors were significantly associated with total HAD score > 12 at day 5: age of patient ]), number of visits of referent ) and previous or current treatment of referent for anxiety or depression .06]). Conclusion: In this study, the use of a visual support dedicated to prognosis of patients did not modify the level of stress of family members. Compliance with ethics regulations: Yes. Rationale: The use of sedation and opioids at the end of life is a topic of considerable ethical debate. Incidence of discomfort during the end-of-life of ICU patients and impact of sedation on discomfort are poorly known. Patients and methods: Post-hoc analysis of an observational prospective multicenter study comparing terminal weaning vs. immediate extubation for end-of-life in ICU patients, aimed at assessing the incidence of discomfort events according to levels of sedation. Discomforts including gasps, significant bronchial obstruction or high behavioral pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation Sedation Scale (RASS). Results: Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and less frequently had deep sedation (RASS -5) than patients without discomfort (59% vs 79%, p < 0.001). After multivariate logistic regression, immediate extubation was the only factor associated with discomfort whereas deep sedation and administrations of vasoactive drugs were two factors independently associated with no discomfort. Death occurred less rapidly in patient with discomfort than in those without discomfort (7.3 h [1.9-25.0] vs 1.6 [0.3-6.0], P < 0.0001) (Figure) . Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. Discussion: Despite the theoretically expected anticipatory titrated doses of opioids and benzodiazepines to alleviate any discomfort after withdrawal of mechanical ventilation, half of the patients did not receive sedation or opiate when the decision to withdraw mechanical ventilation was taken. A major point that could interfere with the continuous deep sedation practice until death is the fear of potentially hastening death, and there is much controversy regarding its proper use in end-of-life care. Conclusion: Discomfort was frequent during end-of-life of ICU patients and was mainly associated with terminal extubation and less profound sedation. Compliance with ethics regulations: Yes. Rationale: Bereavement in Intensive Care Unit (ICU) is associated with psychiatric disorders on relatives called Post-Intensive Care Syndrome Family (PICS-F). No isolated intervention (such as condolence letter) has shown a positive effect on these disorders, despite a well acceptance by relatives. We thought that a more integrated bereavement program should be considered. The goal of this study is to evaluate a combined psychologist-physician post-death meeting (PDM) in a bereavement program to evaluate needs and adhesion of relatives, and the effect on symptoms of anxiety and depression. Patients and methods: Monocentric, prospective study focused on relatives of patient admitted > 48 h and deceased in ICU. During patient's stay, relatives' presence was allowed on a 24 h-basis and they could meet a clinician psychologist. Formal meeting between relatives and the staff was realized at patient's admission and after important decision-making treatment. Two weeks after patient's death, the psychologist called relatives to offer emotional support and to invite to a PDM. PDM occurs 3 weeks after patient's death with the psychologist and the physician in charge of the patient. The objectives of the meeting were to provide emotional support, to answer medical question, and to detect symptoms of anxiety and/or depression with the Hospital Anxiety and Depression Scale (HADS). We hypothesized that PMD would be able to alleviate PICS-F at 3 months. We aimed to enroll 70 families to detect a 20% lowering of HADS. Results: The rate of PDM acceptance was lower than expected. After 53 inclusions, only 12 relatives accepted the PDM, whereas the phone call was well perceived (86%). Main association with acceptance of PMD was a short duration of ICU stay (4.3 days [2-5.3] vs 7.3 days [3.7-10.9] P = 0.027) and ICU admission for acute respiratory failure (66.7% vs 19.5%, P = 0.003) ( Table 1) . We found no relation between the number of in ICU meeting (psychologist of medical staff) and PMD acceptance. For relatives who accept PMD we found a high proportion of symptoms of anxiety and depression (92% and 83%) with a HADS at 28.5 [22-34.5] (Median, IQR). No evaluation was performed at 3 months. Conclusion: Post death contact appears well perceived by relatives but PMD quite useless. This result may be explained by the inclusion of only late death (> 48 h) where psychologist and medical staff had the opportunity to support relatives. Further study should focus on early death (< 48 h). Compliance with ethics regulations: Yes. Rationale: Pediatric intensivists frequently question themselves on the issue of limitation or termination of life-sustaining treatments (LLST) carried out on children. Such a decision comes under the Claeys-Leonetti Law which forbids doctors from applying unreasonable treatment However, every so often, parents oppose themselves to a collegial LLST decision that the medical and paramedical team had taken. Such cases can even end up in Court. In order to sort out this problem, this study focused on the factors that underlie the disagreement and the solution brought forward by pediatricians whenever parents demand to persue treatments although considered as unreasonable obstinacy. Patients and methods: We carried out a qualitative study involving three multipurpose pediatric critical care unit. All pediatricians operating within these units were contacted. Those who volonteered were met individually for a semi-directed interview. Every interview was recorded and entitled to a complete hand-written retranscription. The interviews were analysed following the phenomenological interpretive analysis method and were subject to dual listing. Results: 16 pediatricians out of 30 took part in the study. 8/16 claimed they would increase treatments or carry out cardiopulmonary resuscitation acts if asked to do so by parents, even if this went against the initial collegial decision. 8/16 claimed they would persue treatments although not beyond the current level. 2/16 said they would oppose themselves to parents concerning blood transfusion for comfort reasons. Several key factors were identified as leading a doctor to the non-application of a LLST decision: the certainty regarding the child's death on a short or mid-term basis (16/16), the litigiousness risk (14/16), the apprehension of mediatic pressure (14/16), the fear of a violent reaction from parents (13/16), other self-interest positions within the medical team (12/16), empathy towards parents (11/16), the uncertainty concerning the neurological prognosis (5/16), the lapse of time needed to fully accept the application in force of a decision (5/16). 12 pediatricians out of 16 admitted their own-suffering when confronted to the situation. Conclusion: This study points out that pediatricians tend to follow parents' position when confronted to parental opposition. In such situations, pediatricians go against their own decision in order to safeguard the parental alliance even if it leads to unreasonable obstinacy, thus conflicting with medical deontological Code obligations. Compliance with ethics regulations: Yes. Rationale: End-of-life management strategies are clearly a worldwide issue of major importance that intensivists have to deal with on a daily basis. Advance directives may be the solution sought to guide physicians to take such difficult decisions. Yet, health care directives are not legislated in Tunisia. The objective of this project was to draw a general descriptive overview to assess patients' wishes in Tunisia. Patients and methods: Data were collected from a 39-item-questionnaire based on the French Intensive Care Society's form for advance directives which was filled by 101 people of general population in Tunisia, including doctors and paramedics, from May to mid-September 2019. All people included were 18 or older and well informed of the form's utility. Results: A total of 101 participants were included. The mean age was 34.6 ± 13.5 years with extremes of 18 and 76 and a sex ratio of 1.7. Fourty-one (36.6%) were either doctors or nurses and 3 (3%) did suffer from a severe medical condition. Among all the participants, 30 (29.7%) thought that end-of-life decisions were up to the doctor. For the rest, they willingly chose to be hospitalized in an ICU, to undergo cardiopulmonary rescuscitation and to have ventilation support with orotracheal intubation or tracheostomy respectively in 63 (87.5%), 60 (83.3%) and 67 (93.1%) of the cases. Only 4 (5.6%) refused temporary dialysis. When asked about sequelae they can live with, participants accepted hemiplegia in 63.9% and paraplegia in58.3% of the cases. On the contrary, 68 (94.4%) refused to live in permanent coma and 55 (79.9%) disagreed to undergo tracheostomy and ventilation for life. Moreover, 31 (43.1%) found that serious un aesthetic sequelae was a fatal consequence they could not survive. As well, only 7 (9.7%) consented to live with deep intellectual deficiency. Regarding palliative care, 53 (73.6%) participants wished to be profoundly sedated until death, 65 (90.3%) prefered to die home over 2 (2.8%) in hospital. Sixtytwo (84.9%) desired to see a representative of their religion. Furthermore, 65 (89%) were for organ donnation. Gender, being a health care professional and age under 30 versus equal or over30 were not significant in dependent factors (p > 0.05). Conclusion: It is our duty ashealth care professionals to spread advance directives awareness and education. Nevertheless, the law should keep the pace with ethics evolution. Compliance with ethics regulations: Yes. Rationale: Adapted organ support techniques are needed to enhance reliability of preclinical animal experiments in the intensive care setting (Guillon, Annals of Intensive Care-2019). A few renal replacement therapy (RRT) models have already been developed in rats, mostly hemodialysis in chronic kidney disease models or hemofiltration techniques in sepsis experiments. Mounting evidence from clinical (Gaudry, NEJM-2016) and histopathological studies suggest that RRT for acute kidney injury (AKI) could impair renal recovery by acting as a 'second hit' leading to a maladaptive repair of tubular epithelium. We aimed to study this hypothesis in a hemodialysis model in rats with septic AKI. Patients and methods: On day 1, Sprague-Dawley rats were injected with lipopolysaccharide or placebo (NaCl 0.9%) intraperitoneally. On day 2, anesthetized rats underwent femoral artery catheterization for hemodynamic parameters monitoring. At the same time, one femoral vein and one carotid artery were catheterized for arterio-venous sterile extracorporeal circulation with or without passing through a miniature sterile Polyester Sulfone hemodialyzer (20 cm2 surface, 50 kDa pores, MicroKros ® ) filled with dialyzate liquid in the outer compartment (Table 1) . Vessels were ligated after the procedure and rats allowed to awaken. On day 3, rats were sacrificed. Results: All rats injected with lipopolysaccharides O127:B8 10 mg/kg survived at day 2. Anesthesia was much challenging: Ketamine + Xylazine and Tiletamine-Zolazepam + Xylazine required induction and maintenance intraperitoneal injections. These medications induced important hemodynamic parameters fluctuations and high mortality. Isoflurane gas inhalation enabled better stability, less hypothermia and quick awakening. Adequate temperature was controlled with a heating pad during the procedure and an incubator after. Supine position was maintained. The whole circuit was anticoagulated with 1 ml of heparinized saline 100 UI/ml, since clots occurred in the absence of anticoagulation and bleeding when higher dosing was used. Circuit (< 1.5 ml including dialyzer) was filled with saline solution before initiation, and total restitution of blood at the end of the experiment prevented any blood transfusion requirement. Hematocrit was determined at beginning (50%) and end of experiment (40%). A peristaltic pump provided a blood flow rate of 1.0 mL/min, (higher rate was not tolerated) for 2 h. Of note, rats who underwent sham procedure (vessels ligature only) survived and did not display AKI. Circulation of a counterflow dialysate in the dialyzer is planned but has not been performed yet. Conclusion: This hemodialysis system for rats is feasible at a reasonable price and might help research involving RRT in either CKD or AKI. Compliance with ethics regulations: Yes. There were no significant relationship between RRI and past medical history or severity score. We observed a significant negative correlation between RRI and diastolic arterial pressure (p = 0.004) and heart rate (p = 0.004) as it could be expected by RRI formula. An increased RRI was associated with higher potassium (p = 0.019) and higher creatinine levels (p = 0.042).

Although not significant, we found a higher rate of subsequent RRT in the high RRI group (23% vs 6%, p = 0.146). Over the first 3 days, fluid balance was significantly different between groups (2217 ml vs -1314 ml respectively for low and high RRI group, p = 0.017). Since standard of care were similar, this suggests different fluid volume status between the two groups. In the low RRI group, the cause of AKI could predominantly be prerenal since positive fluid balance was not explained by more severe AKI with refractory oliguria as shown by the low RRT rate. Nevertheless, we did not observed any relationship between RRI and the evolution of serum urea or creatinine levels, nor with the presumed aetiology of AKI. Conclusion: When focussing on the first RRI measurement once stage 2 AKI was reached, RRI ≤ 0.7 seems to be in favour of prerenal and transient renal dysfunction even if this is not supported by creatinine serum evolution. Compliance with ethics regulations: Yes. Rationale: Critically ill patients are at higher risk of bleeding but also dialysis filter clotting (inflammatory state). Intermittent hemodialysis with calcium-free citrate-containing (0.8 mmol/L) dialysate (CafCit-IHD) recently emerged as a new safe and simple alternative to continuous renal replacement therapy allowing heparin-free extended dialysis sessions (> 5 h). In this study, we aimed to answer to two issues still unresolved: (i) can citrate contained in the dialysate accumulate and lead to citrate intoxication in patients with liver disorders, and (ii) can citrate be avoided using citrate-and calcium-free dialysate (CCF-IHD)? Patients and methods: Monocentric retrospective study. Among the 450 sessions performed with CafCit-IHD, the 20 IHD sessions (18 critically ill patients) with citrate measurement available before and after the dialysis filter were reviewed. Estimation of the liver clearance was performed using the Picco Lemon ® system (Pulsion). In addition, 8 sessions performed using CCF-IHD were reviewed. Results: All the patients had liver disorders (post-liver transplantation period n = 2; cirrhosis with Child > A6). Among the eighteen CafCit-IHD patients, fifteen (75%) and six (30%) received mechanical ventilation or vasopressive drugs, respectively. The median time of the dialysis session was 5 h [2] [3] [4] [5] , with hourly ultrafiltration rate of 400 mL (one premature termination not related to dysfunctional catheter). In all patients, ionized calcium (iCa) decreased below 0.40 mmol/L after the filter, whereas post-filter calcium reinjection according to ionic dialysance led to a stable pre-filter (i.e. patient) iCa. Median citrate concentrations were all below 0.8 mmol/L after the filter (minimal concentration to obtain anticoagulation 3 mmol/L) and all except one below the normal value (< 125 µmol/L) before the filter. During all the sessions, ionized to total calcium ratio was below 2.1 and the strong ionized gap decreased. When available (n = 7), no correlation could be identified between serum citrate concentration and liver clearance. Last, in 8 CCF-IHD sessions performed in critically ill patients, no premature termination occurred (median time of the sessions 5 h) and post-filter iCa also decreased below 0.45 mmol/L.

No citrate accumulation could be identified in critically ill patients (even with liver disorders) and receiving extended dialysis sessions (5 h or more) using calcium-free citrate containing-IHD. Interestingly, we demonstrated that citrate is not required to obtain optimal regional anticoagulation (i.e. post-filter iCa < 0.45 mmol/L), and a citrate-and calcium-free dialysate could be a safe alternative. Compliance with ethics regulations: Yes. Rationale: Ventilator induced diaphragmatic dysfunction is highly prevalent in adult critical care and associated with worse outcomes. Specificities in pediatric respiratory physiology suggest that critically ill children may be at high risk of developing this complication, but no study has described the evolution of diaphragmatic function in critically ill children undergoing mechanical ventilation. This study aims to validate a method to quantify diaphragmatic function in mechanically ventilated children.

In this prospective single-center observational study, 10 children between 1 week and 18 years old intubated for elective ENT surgery and without pre-existing neuromuscular disease or recent muscle paralysis were recruited. Immediately after intubation, diaphragmatic function was evaluated using brief airway occlusion maneuvers during which airway pressure at the endotracheal tube (Paw) and electrical activity of the diaphragm (EAdi) were simultaneously measured for 5 consecutive spontaneous breaths, while the endotracheal tube was occluded with a specific valve. Occlusion maneuvers were repeated 3 times. In order to account for central respiratory drive and sedation use, we recorded the neuromechanical efficiency ratio (NME, Paw/EAdi), in addition to the maximal inspiratory force (MIF). In order to determine the optimal measure of NME during an occlusion, the variability over the three occlusion maneuvers of different variables (first breath, last breath, breath with maximal Paw deflection, breath with maximal NME value, and median NME value) was assessed using coefficients of variation and repeatability coefficients.

Results: Patients had a median age of 4.9 years (interquartile range 3.9-5.5), a median weight of 18 kg (14-23), and 5 were male (50%). The median evolution of Paw, EAdi, and NME ratio over the 5 occluded breaths are represented on Fig. 1 . NME values corresponding to the last breath and the breath with maximal Paw deflection were the least variable, with median coefficient of variation of 23% and 23% and repeatability coefficients of 3.44 and 3.44, respectively. Conclusion: Brief airway occlusions can be used to assess diaphragmatic function in intubated children through both MIF and NME ratio, and the latter should ideally be computed on the last breath or the breath with the largest pressure deflection to improve repeatability and decrease variation. Compliance with ethics regulations: Yes. Epidemiology is poorly understood due to the rare use of validated diagnostic tools. The main objective of the study was to determine, by systematically calculating the WAT-1 score, the incidence of WS in our surgical PICU. The secondary objective was to analyze the risk factors, consequences and management modalities of WS. Patients and methods: Following Institutional Review Board approval, we conducted a prospective monocentric study between July 2018 and January 2019. All consecutive mechanically ventilated children admitted in our surgical PICU with sedation/analgesia by continuous intra-venous (IV) benzodiazepines (BZD) and/or opioids for at least 48 h were included. As soon as sedation was decreased and during 72 h following their total discontinuation, WAT-1 score was assessed twice a day. WS was defined by a WAT-1 score > 3. The search for risk factors and consequences associated with WS was performed by univariate analysis (Mann-Whitney and Chi2 test). Ethical standards were satisfied and the lack of opposition from patients and their parents was systematically checked. Results: The incidence of WS was 50% among the 46 patients of our cohort including 54% of children admitted postoperatively and 35% after severe traumatic brain injury (TBI). Significant results are reported in Table 1 . Our results show that even for sedation time less than 5 days, children could develop WS (11/23 patients). On the other hand, age, severity (PELOD 2 score), number of previous surgeries and severe TBI were not associated with WS. Our study also demonstrated that cessation of sedation and prevention of WS was not uniform in our unit.

The high incidence of withdrawal syndrome in our study, even in children sedated for less than 5 days, and its consequences require thinking about prevention. We suggest a systematic monitoring of the occurrence of this adverse event using a validated score, from 3 days of continuous IV sedation/analgesia. Compliance with ethics regulations: Yes. Rationale: Severe traumatic brain injury (TBI) is a major healthcare problem. Amplitude and duration of intracranial hypertension is highly associated with patient outcome. The intracranial pressure (ICP) is therefore one key parameter to monitor in the acute phase. When ICP is monitored with an external ventricular drain, the pressure recorded by the monitor does not always correspond to the real ICP, depending on the status (open/closed) of the 3-way tap. Misleading values could therefore be sent to the patient medical record. Our hypothesis is that a machine-learning algorithm will be able to identify automatically and in real time the reliable and non-reliable values of the ICP signal.

We retrospectively studied pediatric patients having an external ventricular drain between July 2018 and July 2019, in a single pediatric intensive care unit. The ICP signals were extracted from a high-frequency database (128 Hz) and pre-processed adequately. To train the algorithms, an annotated database was manually created with two classes: reliable ICP vs. non-reliable ICP (drain system opened to allow cerebrospinal fluid removal). Eleven signal characteristics were compared between the two classes (Mann-Whitney test), and significantly differing variables were tested in the algorithms. We compared the performance of two machine-learning algorithms: the K-Nearest Neighbors (KNN) and the Support Vector Machine (SVM).

Using 10-fold cross-validation method, 75% of the data was used to train the algorithms and 25% was used for testing. The best classifier was further validated by simulating a real-time ICP analysis, using a 15 s sliding-window approach with 50% overlap. The study was approved by the localresearch ethics committee. Results: Sixteen patients were included in the study. The training database created from 14 patients, contained 320 segments (of 15 s duration) per class and per patient. Eight signal variables were identified and kept to define the segments. The KNN algorithm, with k = 3, led to the best performance, with a mean of 98% (mean ± SD: 98% ± 0.29%). The KNN was then visually validated on ICP signals from the remaining two patients ( Figure) . By simulating a real-time ICP extraction, our algorithm was able to efficiently identify the reliable ICP segments, and to display a mean value only for valid segments. University Hospital PICU (Paris). All consecutive children (1 month-18 years) admitted for acute encephalitis were included and diagnosis was confirmed using the 2013 consensus conference criteria's. Data regarding clinical, biological and radiological presentations were collected as well as data on the therapeutics used and outcomes at discharge and at the last medical consultation. Results: 106 patients were included with a mean age of 6.2 years (range 0.1 to 17 years old). Infectious causes were identified in 45% (n = 48), autoimmune causes in 8% (n = 8) and acute demyelinating encephalomyelitis in 4% (n = 4) of cases. Etiology remained undetermined in 43% of cases (n = 46). The most common pathogens were, in order of frequency, Influenzae virus, Mycoplasma pneumoniae and Epstein-bar virus. The main clinical features were fever (88% n = 93); epileptic seizures (80% n = 85) and coma (46% n = 49). Regarding therapeutics, 52% of patients required mechanical ventilation and 20% of patients required hemodynamic support. 47% received corticosteroids, 17% intravenous immunoglobulins and 12% plasmatic exchanges. The use of these specific treatments was heterogeneous, especially in infectious and undetermined encephalitis, where respectively 48% and 38% received boluses of corticoids. The mean length of stay in PICU was 10.7 days (range 1-155 days). The mortality rate was 10% and the overall rate of sequelae at discharge was 76% and 61% at distance, with 21% considered as severe (GOSE-PED score > 5). The use of mechanical ventilation and young age at diagnosis were risk factors associated with poor prognosis at discharge.

The etiology of acute encephalitis remains indeterminate in more than 40% cases with a clear predominance of infectious causes when an etiology is found. This is a severe pathology responsible for significant mortality and morbidity requiring long-term follow-up. Compliance with ethics regulations: Yes. Rationale: Preserving neurological outcome of children under Extracorporeal Membrane Oxygenation (ECMO) remains challenging. Acute Brain Injury (ABI) is a frequent complication of ECMO that could be prevented by continuous neuromonitoring. Cerebral Near InfraRed Spectroscopy (NIRS) is routinely used for detecting cerebral complications of cardiac surgery. In adults and infants under prolonged ECMO, cerebral hypoxia is associated with poor neurological outcome. The aim of this study was to assess the value of an impaired cerebral oxygenation on mortality and occurrence of an ABI in children under ECMO. Patients and methods: Children under 18 years old were included in this observational retrospective monocentric study if they needed veno-venous (V-V) or veno-arterial (V-A) ECMO for respiratory and/ or circulatory failure and had concomittant NIRS monitoring. Cerebral desaturation was defined as a rScO 2 value under 50% or under 20% from the baseline; cerebral hyperoxia was defined as a rScO 2 value above 80%. Proportion of time in cerebral desaturation and hyperoxia were recorded. Neurological lesions were identified on imaging (MRI or scan) by blinded radiologist and classified as major or minor. ABI was defined as any hemorragic or ischemic lesion on cerebral imaging, including brain death. Results: 63 patients were included. ECMO duration was 9 [5; 13] days. The mortality rate was 32 (50.8%), and the proportion of ABI was 34 (54%) including 5 brain deaths, 10 (15.9%) major lesions, and 19 (30.2%) minor lesions. Mean rScO 2 was 73 ± 9% in the right hemisphere, and 75 ± 9% in the left hemisphere. There was no significant difference in cerebral hypoxia between survivors and non survivors, and between patients with and without an ABI. Cerebral hyperoxia was associated with a better survival (p = 0.03 in the right hemisphere, and p = 0.02 in the left hemisphere). In V-V ECMO and at the right Conclusion: In our study, cerebral hypoxia was not associated with poor neurological outcome, but cerebral hyperoxia seems to be protective especially in V-V ECMO. This is the first study assessing the value of cerebral oxymetry in all age ranges pediatric ECMO. In this population, multimodal monitoring might be better than NIRS alone to predict neurological impairment. Further prospective studies are needed to assess first the feasibility, then the impact of such a monitoring. Compliance with ethics regulations: Yes.

Cerebral autoregulation impairment is associated with acute neurological events during pediatric extracorporeal membrane Rationale: Children supported by extracorporeal membrane oxygenation (ECMO) present a high risk of adverse neurological complications. As some animal studies have shown, cerebral autoregulation (CA) impairment after exposure to ECMO, may be a key factor. Our main objective was to investigate the feasibility of CA continuous monitoring during ECMO treatment. The second objective was to analyze the relationship between CA impairment and neurological outcome. Patients and methods: An observational prospective study including children treated by ECMO in 2 centers was conducted. A correlation coefficient between the variations of regional cerebral oxygen saturation (rScO 2 ) and the variations of mean arterial blood pressure(MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx) during ECMO. A COx > 0.3 was considered as indicative for dysautoregulation. COx values were averaged inside 2 mmHg-MAP bins, allowing determining optimal MAP (MAPopt) and lower (LLA) and upper (ULA) limits of autoregulation in 8-h periods. Neurological outcome was assessed by the onset of an acute neurologic event (ANE) defined by occurrence of hemorrhagic or ischemic stroke and/ or clinical or electrical seizure and/or brain death during the ECMO treatment. Rationale: Myocardial ischemia reperfusion (IR) injury is the leading cause of perioperative morbi-mortality. Protective effect of pharmacologic preconditioning such as anesthetic preconditioning (APC) with sevoflurane (SEV) has been widely demonstrated in animal and human models. APC seems to protect myocardial cells from apoptosis, a programmed process of cell death tightly controlled by Bcl-2 family proteins. However, the involved mechanisms in APC have yet to be characterized. We hypothesized that APC protects against myocardial apoptotic cell death by regulating Bcl-2 anti-apoptotic members.

To study the SEV-induced APC mechanisms against myocardial IR, we used a validated in vitro model reproducing IR injury. Rat cardiomyoblast cells H9c2 were cultivated in 0.1% O2 hypoxia in the presence of ischemia-mimicking medium. After 90 min of ischemia, the reperfusion injuries are induced by replacing the culture medium with a Krebs-Henseleit normoxic medium for 60 min. APC was performed by adding SEV directly into the culture medium at an initial concentration of 20 mM, prior to ischemia, for 60 min. We then used another preconditioning agent, metformin (MET), to explore the same signaling pathways. Apoptotic cell death was measured by caspase activity assay and western blotting (expression of cleaved caspase 3) under IR and APC conditions. Results: Our model faithfully reproduced the protective effect of APC which results in a significant decreased apoptosis under IR (50% reduction of the Caspase 3 enzymatic activity, correlated with a decrease of Caspase 3 cleavage). We showed that SEV induces overexpression of the anti-apoptotic protein Bcl-xL, which is responsible for the protective effect of APC. Furthermore, these observations were confirmed in vivo in mouse heart lysates. We demonstrated that Bcl-xL overexpression was due to the activation of the protein kinase Akt. Interestingly, we were able to show that preconditioning with MET reproduces the protective effect of SEV by inducing an Akt-dependent Bcl-xL overexpression. Indeed, SEV and MET, which are both complex 1 inhibitors of mitochondrial respiratory chain, seem to share a common Reactive Oxygenated Species-dependent protective mechanism responsible for Bcl-xL protein regulation. Rationale: Despite early endovascular treatment with successful recanalization, 50% of acute ischemic stroke (AIS) patients experience a poor functional outcome after a large vessel occlusion. Sepsis is frequent at the acute phase of stroke and is associated with poorer short and long term outcomes. We aimed to investigate the cerebral consequences of sepsis after recanalized AIS and explore possible mechanisms involved. Patients and methods: Male C57Bl6 mice were randomly assigned to a 2x2 factorial plan to one of the 4 following groups: 1) a 60-minute middle cerebral artery (t-MCAO) transient occlusion under inhaled general anesthesia, followed 5 min after recanalization by intraperitoneal (I.P.) sepsis (LPS, 10 µg/g diluted in 100µL of NaCl0.9%), (tMCAO/ LPS group); 2) t-MCAO followed by I.P. placebo (100µL of NaCl0.9%) (tMCAO/placebo group); 3) Sham operation (cervicotomy without carotid catheterization) followed by I.P. LPS. (Sham/LPS group); 4) Sham operation followed by I.P. placebo, (Sham/placebo group). In all groups, animals received subcutaneous fluid resuscitation (200µL NaCl 0.9%) immediately after the procedure and 1 h later. Twenty-four hours after recanalization, animals were scored for sepsis features and neurological deficit (on the modified neurological severity scale), (mNSS) before sacrifice. The primary outcome measurement was a composite of death and hemorrhagic transformation at 24 h. Secondary outcome measurements included neurological deficit, sepsis features, neutrophil activation reflected by plasmatic myeloperoxydase (MPO) levels, stroke volume, and microglial activation in brain parenchyma (infarct core, perilesional area, controlateral hemisphere). Results: t-MCAO/LPS animals had higher mNSS (1.7 fold, p = 0.02) and sepsis (6 fold, p = 0.0018) scores at 24 h with increased plasma MPO levels at 1 h (2.8 fold, p < 0.01) and 24 h (5.9 fold, p < 0.0001), as well as, lower temperature (3.0 °C reduction, p = 0.01) and glycemia (0.9 g/l reduction, p = 0.01) as compared to tMCAO/placebo animals. t-MCAO/LPS animals had a higher risk of unfavorable outcome at 24 h (4-group comparison: p = 0.03; 2x2 analysis: t-MCAO/LPS, 6/12 − 50%vs. t-MCAO/placebo 1/17-6%-, p < 0.01), whereas stroke volumes were not significantly different between groups. Detailed results are presented in Table 1 . Compared to t-MCAO/placebo group, t-MCAO/ LPS animals had 1.3 fold increase (p = 0.05) in the mean number of microglial cells in the hemisphere controlateral to t-MCAO, whereas no significant difference was observed in infarct core or peri-infarct parenchyma. Conclusion: Early sepsis after experimental AIS worsens outcome and neurological deficit, without impacting stroke volume. Early sepsisinduced systemic activation of neutrophils and increased microglial activation in the hemisphere contralateral to ischemia may have an important role on neurological outcomes observed in this setting. Compliance with ethics regulations: Yes. Rationale: Extracellular vesicles (EVs) regulate diverse cellular and biological processes via facilitating intercellular cross-talk. Several studies have suggested an association between lung injury and the generation of EVs derived from platelets, neutrophils, monocytes, lymphocytes, red blood cells, endothelial cells, and epithelial cells.

Every year more than 25,000 patients require cardiac surgery with cardiopulmonary bypass (CPB). This CPB allows a substitution of the heart pump function and an oxygenation of the blood permitting a stop of the mechanical ventilation (MV). Stopping MV during CPB is responsible for lung damage, leading to postoperative systemic inflammation while maintaining MV with positive expiratory pressure (PEEP) diminished the occurrence of atelectasis and the postoperative inflammatory response. In addition, this surgery is marked by immune dysfunction, leading to real immunosuppression of patients in postoperative care. A link between pulmonary injury and postoperative immunosuppression has been established, however, the mechanisms underlying this association are not fully known and EVs may have a role in this post-operative immunosuppression. The purpose of this study is to investigate whether lung injury induced during cardiac surgery with CPB lead to the emergence of EVs. The effect of MV during CPB on the production of these EVs has also been studied. Patients and methods: Patients were prospectively divided into two groups: without MV during CPB and dead space MV with positive end-expiratory pressure during CPB. PaO 2 (arterial oxygen tension)/ FIO 2 (inspired oxygen fraction) ratio, biological markers of lung injury (CXCL10, CCL2, TNF-α, IL-1β, IL-10, RAGE, IL-8) and blood cell count were collected before, 24 h and 7 days after surgery. The quantification of plasma EVs was performed using Turnable Resistive Pulse Sensing and characterization of EVS was performed using flow cytometry before, 24 h and 7 days after surgery. Rationale: The benefit of prone positioning (PP) during moderate to severe acute respiratory distress syndrome (ARDS) may be related to its impact on the inflammatory response to ventilator-induced lung injuries.

[11C]-PK11195 is a positron emission tomography (PET) radiotracer that allows the non-invasive quantification of macrophages. We aimed to evaluate the effects of PP on [11C]-PK11195 lung uptake in animals with experimental ARDS. Patients and methods: Experimental ARDS (by hydrochloric acid) was induced in 10 pigs in supine position (SP), to obtain a PaO 2 / FiO 2 < 300 mmHg. Animals were under general anesthesia, neuromuscular blockade, and ventilated with a 6 ml kg −1 tidal volume, and 5 cmH 2 O of positive end-expiratory pressure (PEEP). Immediately after experimental ARDS, animals were randomized to be prone positioned, or to remain in SP. PET and computerized tomography (CT) were acquired 4 h after randomization (H4).

[11C]-PK11195 uptake was measured on the whole lungs, and by dividing the lungs into 8 regions or slices-of-interest (SOI) along the ventro-dorsal axis, and was quantified by the standardized uptake value (SUV), corrected for lung tissue density. Results: PP was performed in 6 animals, and SP in 4. After ARDS induction, PaO 2 /FiO 2 was 107 [IQR, [1.2-1.7] in SP animals (p = 0.61). In PP animals, [11C]-PK11195 SUV was significantly lower in ventral SOI, compared to SP, and significantly increased in dorsal SOI ( Fig. 1 , *: p < 0.01 between groups in a given SOI). In univariate analysis, [11C]-PK11195 regional SUV was positively associated with regional CT-measured PEEP-related increase in gas volume, and negatively with PEEP-related lung recruitment, but not with regional tidal volume. Conclusion: During experimental ARDS, PP redistributed lung macrophage recruitment estimated by [11C]-PK11195 uptake from ventral lung regions to dorsal regions, without affecting global macrophage influx. The intensity of macrophage recruitment was associated with PEEP-related lung inflation. Compliance with ethics regulations: Yes. Rationale: Acute respiratory distress syndrome (ARDS) is a pleiomorphic disease characterized by a severe respiratory failure associated with an increased mortality. Nowadays, predicting clinical outcome of patients suffering from ARDS remains difficult. Therefore, identifying new biomarkers to predict patient outcome, to evaluate response to therapy and to identify new potential pathways of interest are highly needed. Exosomes are extracellular vesicles involved in cell-cell communication by transferring microRNAs (miRNAs) from donor to recipient cells. Thus, exosomal miRNAs can significantly affect biological pathways within recipient cells resulting in alterations of cellular function and the development of a pathological state. As biomarkers are highly needed in the particular field of ARDS, we realized a monocentric and prospective study to identify a new potential biomarker of interest. Therefore, a prospective plasma sampling at the diagnosis of moderate to severe ARDS according to the definition of "Berlin" has been performed. We analysed miRNA content of exosomes from plasma ARDS patients compared to healthy subjects (HS) in order to identify new potential predictive biomarkers in ARDS.

During one-year period, patients hospitalized in the ICU of CHU Sart Tilman suffering from infectious moderate-to-severe ARDS have been included. The ethical committee review boards of the hospital approved the research protocol (B707201422832, ref: 2014/302), and informed consents were obtained. Exosomes were isolated from plasma samples of 10 ARDS patients and 10 HS with standard ultracentrifugation protocol. Exosomal miRNA content was analyzed using small RNA sequencing method, and diseases/biological processes associated to altered miRs were determined by bioinformatic analysis. Results: For the first time, exosomal miRNA expression modifications were studied in patients with moderate-to-severe infectious ARDS. We identified a new signature statistically significant composed of three up-regulated miRNAs (miR-122, miR-23a and miR-126) and one downregulated (miR-Let-7b). Conclusion: We identified potential biomarkers for ARDS from plasma exosomes. Our findings may thus lead to predict ARDS outcome but also a better understanding about the roles of these miRs in the pathogenesis of ARDS and thus open new avenues for therapeutic approaches. In particular, exploit and develop the pro-fibrotic pathway induced by down-expression of miR-Let-7b. But also confirm in the future the current interest about miR-126 in its ability to restore pulmonary integrity after trauma. Compliance with ethics regulations: Yes. Rationale: Diabetic ketoacidosis (DKA) is a life-threatening emergency. Microvascular hyporeactivity was reported in these patients and was completely reversibly when pH was corrected with treatment: aggressive rehydration, electrolyte replacement and insulin therapy (1) . Red blood cell (RBC), a component of the microcirculation, showed alterations oftheir shape in diabetic patients (2) but no data were available concerning the time course of the RBC deformability during treatment for DKA. We aimed to assess the RBC deformability during DKA treatment in ICU patients. Patients and methods: After approval by the ethics committee, RBCs deformability was assessed, in all ICU patients admitted for DKA and without infection, by ektacytometry technique (Laser-assisted Optical Rotational Red Cell Analyzer-LORRCA): at ICU admission, +8 h, +24 h and at the end of the ICU stay (36-48 h). Elongation index (EI) was defined as (L − W)/(L + W), where L is the length and W is the width. At 37 °C, EI values were determined in the function of shear stress (SS) in a range of 0.5-50 Pa, based upon the laser diffraction pattern changes. A higher EI indicates greater RBC deformation. RBC deformability from patients with DKA was compared at ICU admission to healthy volunteers (V) and to diabetic patients followed in consultation (D). We also studied the evolution of deformability during treatment. Results: 15 ICU DKA patients compared to 31 D and 20 V were studied. As expected, glycemia and glycated hemoglobin were significantly higher in DKA compared to D (respectively: glycemia: 549 (444-872) vs 139 (92-181) mg/dL and 11.7% (9.4-13.4) vs 7.8 (7.3-8.2); all p < 0.001). DKA patients received 6279 (5482-8308) ml of fluids and 2.24 UI/ Kg BW (1.71-2.42 ) of insulin during their first 24 h of ICU stay. RBCs deformability from DKA patients was significantly more altered at ICU admission compared to others groups ( Fig. 1 ) and these alterations persists despite treatment. No correlations were observed between these alterations and quantity of fluids or insulin received, glycemia, glycated hemoglobin, pH, natremia, age or length of diabetes history. Conclusion: In contrast of reversible microvascular hyporeactivity, RBC deformability from DKA patients was already altered at ICU admission and remains altered despite treatment. These alterations could contribute to the blood flow abnormalities observed in these patients. Compliance with ethics regulations: Yes. Rationale: Sepsis remains the first cause of acute circulatory failure in the Emergency Department (ED). Standardized fluid resuscitation may not be adapted in certain patients, especially those with early sepsisinduced cardiac dysfunction in whom excessive fluid administration could be deleterious. Information on early hemodynamic profile of septic patients in the ED are scarce. Accordingly, we aimed at describing hemodynamic profiles encountered in septic patients assessed shortly after their ED admission using focused echocardiography. Patients and methods: We prospectively enrolled adult patients with sepsis (qSOFA score ≥ 2) from January 2017 to July 2019 in the ED (NCT02974790). Focused echocardiography were performed by emergency physicians previously trained to ECMU 1 level. Each patient was evaluated according to a standardized protocol based on a limited number of simple binary clinical questions. Investigators interpreted on-line the echocardiographic examination, determined the hemodynamic profile based on simple yet robust criteria (hypovolemia, left ventricular [LV] or right ventricular [RV] failure, vasoplegia with hyperdynamic state, tamponade, severe mitral or aortic regurgitation, or apparently normal profile), and recorded any substantial change in planned therapeutic management (Surviving Sepsis Campaign 2016). Data were digitally stored and validated off-line by an expert in critical care echocardiography. Results: Focused echocardiography were performed in 81 patients (mean age: 70 ± 15 years; men: 58%; source of infection: pulmonary 37%, urinary 25%, abdominal 25%) after a median fluid loading of 500 mL (IQR: 500-1500 mL). According to Sepsis-3 definition, 44 patients had sepsis and 37 sustained septic shock. Mean SOFA score was 5.3 ± 2.9 (hemodynamic failure 85%, respiratory failure 72%, renal failure 67%), mean lactate reached 4.7 ± 4.3 mmol/L, ICU admission involved 38% of patients and overall 28-day mortality reached 35%. Hemodynamic profile was hypovolemia in 54 patients (67%), vasoplegia in 26 patients (32%), cardiac failure in 21 patients (26%) (LV failure: n = 15; RV failure: n = 6) and without relevant hemodynamic abnormality in 9 patients (11%). Ongoing therapy was altered based on early echocardiographic assessment in 26% of cases. Mortality rate was not significantly different between groups (p = 0.46). Conclusion: Although hypovolemia was predominantly identified in patients presenting to the ED with sepsis during hemodynamic assessment, early ventricular dysfunction involved one-quarter of patients. These results suggest that early focused echocardiographic assessment promises to help the front-line physician tailoring the therapeutic management of septic patients in ED, especially regarding fluid resuscitation. Compliance with ethics regulations: Yes.

Right ventricular failure in septic shock Characterization, incidence and impact on fluid-responsiveness Guillaume Geri 1 , Amélie Prigent 2 , Xavier Repessé 2 , Marine Goudelin 3 , Gwenael Prat 4 , Bruno Evrard 3 , Cyril Charron 1 , Philippe Vignon 3 , Antoine Vieillard-Baron 1 1 Ambroise Paré Hospital, Boulogne-Billancourt, France; 2 Ambroise Paré Hospital, medical ICU, APHP, Boulogne-Billancourt, France; 3 CHU Limoges, Limoges, France; 4 CHU Brest, Brest, France Correspondence: Guillaume Geri (guillaume.geri@aphp.fr) Ann. Intensive Care 2020, 10 (Suppl 1):F-049 Rationale: Right ventricular (RV) failure was defined by RV dilatation with systemic congestion. Tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. Patients and methods: Ancillary study of the HEMOPRED prospective multicenter study including patients under mechanical ventilation with circulatory failure. 282 with septic shock were analyzed. Patients were classified in 3 groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/ LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Passive leg raising (PLR) was performed. Results: 41% of patients were in group 1, 17% in group 2 and 42% in group 3. In group 2 and 3, RV/LV EDA was higher than in group 1, 0.7 [0.7; 0.9] versus 0.5 [0.4; 0.5]. CVP was 12 [10; 14.5] mmHg in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to PLR (Figure) . A large overlap of TAPSE values was observed between the 3 groups. 36.5% of patients with RV failure had an abnormal TAPSE. Conclusion: RV failure is frequent in septic shock and alters fluid responsiveness. TAPSE was not accurate enough to diagnose RV failure. Compliance with ethics regulations: Yes. Rationale: Weaning-induced pulmonary oedema (WIPO) is a leading cause of weaning failure in high-risk patients (heart failure, COPD, obesity). We hypothesized that hypervolemia associated with positive fluid balance facilitates WIPO in high-risk patients. Patients and methods: In this prospective, observational, singlecenter study, patients with COPD and/or heart failure with reduced ejection fraction (< 40%) were studied. Exclusion criteria were nonsinus rhythm, severe mitral valve disease and inability to obtain adequate echocardiographic views. Echocardiography was performed immediately before and during spontaneous breathing trial (SBT, 30-min T-tube). Patients who failed SBT were treated according to echocardiographic results before undergoing a second SBT. Fluid balance and body weight were collected at each SBT. shows interesting performance to predict fluid responsiveness in spontaneously breathing patients. Nevertheless, measurement sites of inferior vena cava (IVC) diameters remain controversial for that purpose. The aim of the study was to test the accuracy of different measurement sites of cIVC to predict fluid responsiveness in spontaneously breathingpatients.

This study is a post hoc analysis of two prospective cohorts. We included spontaneously breathing patients without mechanical ventilation presenting with sepsis-related acute circulatory failure and considered for volume expansion (VE). We assessed hemodynamic status at baseline and after a fluid challenge (FC) induced by a 30 min-infusion of 500 mL-gelatin 4%. The IVC diameters were measured off-line with ultrasonography using the bi-dimensional mode on a subcostal long-axis view. The cIVC was calculated as [ (expiratory-inspiratory)/expiratory] diameters during standardized (cIVC-st) and unstandardized breathing (cIVC-ns) conditions. Breathing standardization consisted of a deep inspiration with concomitant control of buccal pressures and passive exhalation.

Patients were referred to be responders to FC (i.e. fluid responsive) when the stroke volume increased by ≥ 10%. Results: Among the 81 patients included in the study, 41 (51%) were responders to FC. The accuracy of cIVC-st and cIVC-ns before FC to predict fluid responsiveness differed significantly by measurement sites (interaction p value < 0.0001 and < 0.001, respectively). Measuring IVC diameters 4 cm from the junction of the IVC and the right atrium provided the best accuracy to predict fluid responsiveness ( Fig. 1 ). At 4 cm caudal to the right atrium, cIVC-st was significantly better than cIVCns to predict fluid responsiveness: area under ROC curve 0.98 (95% CI 0.97-1.0) versus 0.84 (95% CI 0.78-0.94), p < 0.001. At 4 cm, a cIVCst ≥ 44% and a cIVC-ns ≥ 33% predicted fluid responsiveness with sensitivity of 93% and 66%, and specificity of 98% and 92%, respectively. Conclusion: Accuracy of cIVC to predict fluid responsiveness in spontaneously breathing patients depends on both measurement sites of IVC diameters and breathing conditions. Measuring IVC diameters during a standardized inspiration maneuver at 4 cm caudal to the right atrium is the most relevant mean to optimize cIVC performance to guide VE. Compliance with ethics regulations: Yes. Rationale: Intermittent hemodialysis (IHD) is increasingly used in patients admitted to intensive care unit (ICU) with acute kidney injury (AKI) requiring renal replacement therapy (RRT). However, this technique is associated with nearly 20% of episodes of perdialytic hemodynamic instability (HI), a common cause of increased morbidity and mortality. At the same time, trans-thoracic echocardiography (TTE) has become widely used in intensive care units and is now one of the hemodynamic monitoring methods used daily in the ICU setting. Patients and methods: Search for one or more pre-dialysis TTE criteria predictive of perdialytic HI, defined by a systolic blood pressure (SBP) lesser than 90 mmHg or a suddain decrease in SBP of more than 40 mmHg. Prospective, observational study of standard care in a medical ICU. Collection of demographic, clinical and pre-dialysis echocardiographic data from included patients. Results: Twenty-five patients with a total of 98 sessions of IHD between November 2017 and November 2018 were included in the study. TTE was performed for each patient before each IHD session. HI occurred in 31 hemodialysis sessions. In univariate analysis, the existence of prior heart disease (38% vs 0%, p = 0.04), a greater diameter of the left atrium (4.2 vs 3.6 cm, p = 0.0001), a lower cardiac output (5.8 vs 6.6 l/min, p = 0.04), a right dysfunction assessed by lowered TAPSE and S-wave (16 vs 24 mm, p < 0.0001 and 12.8 vs 15.7 cm/s, p = 0.002, respectively) and an increase in PAPS (45 vs 34 mmHg, p = 0.003) were significantly associated with the occurrence of perdialytic HI (Fig. 1 Rationale: Several transthoracic echocardiography (TTE) parameters of left (LV) and right ventricular (RV) systolic function are available. We compared the ability of these different parameters to track changes in LV or RV systolic function and to detect LV or RV systolic dysfunction in critically-ill patients.

In 20 patients (15 mechanically ventilated and 2 with atrial fibrillation), TTE examinations were performed before and after i) infusion of 500-mL of saline (n = 10), ii) changes in norepinephrine (n = 8), iii) or in dobutamine (n = 2) dosage. For the LV systolic function, we compared the mitral annular plane systolic excursion (MAPSE), the systolic (s') peak velocity of the lateral mitral annulus and the global longitudinal strain (GLSLV) to the LV ejection fraction (LVEF), considered as the gold standard. For the RV systolic function, we compared the tricuspid annular plane systolic excursion (TAPSE), the systolic peak (S) velocity of the tricuspid annulus and the global longitudinal strain (GLSRV) to the RV fractional area change (FAC), considered as the gold standard. Results: After pooling all values, LVEF (55 ± 12% at baseline) was better correlated to GLSLV (r 2 = 0.71) than to MAPSE (r 2 = 0.25) and s' wave (r 2 = 0.13) (each p < 0.05). The concordance rate between changes (in %) in LVEF and in the other parameters of LV systolic function was 87% for GLSLV, 72% for MAPSE and 67% for s' wave. Both MAPSE and s' wave could not reliably detect moderate (30% ≤ LVEF ≤ 40%) or severe (LVEF < 30%) LV dysfunction. Conversely, a GLSLV > − 12% predicted moderate LV dysfunction with a sensitivity of 100% (95% IC: 29-100%) and a specificity of 89% (95% IC: 71-98%) and a GLSLV > − 9.5% predicted severe LV dysfunction with a sensitivity of 100% (95% IC: 16-100%) and a specificity of 96% (95% IC: 82-100%). After pooling all values, FAC (32 ± 11% at baseline) was better correlated to GLSRV (r 2 = 0.57) than to TAPSE (r 2 = 0.31) and S wave (r 2 = 0.24) (each p < 0.05). The concordance rate between changes (in %) in FAC and in the other parameters of RV systolic function was 81% for GLSRV, 72% for TAPSE and 50% for S wave.Both TAPSE and S wave could detect RV dysfunction (FAC ≤ 35%) with moderate reliability only. Conversely, a GLSRV > − 12% detected RV dysfunction with a sensitivity of 56% (95% IC: 30-80%) and a specificity of 100% (95% IC: 77-100%).

In critically-ill patients, GLSLV and GLSRV seem to be the best TTE parameters of LV and RV systolic function. Enrolments are still ongoing, which may allow further analysis. Compliance with ethics regulations: Yes. Rationale: Passive leg raising (PLR), pulse pressure variation (PPV), and the 15-second end-expiratory occlusion test (EEXPO) are frequently used to assess preload responsiveness. However, there are conditions in which they are not valid or feasible, which may preclude their applicability in the daily clinical practice. The aim of this study was to estimate the prevalence of such conditions in critically ill patients with acute circulatory failure.

Between January and April 2019, all patients of a 25-bed medical ICU were daily screened and those with acute circulatory failure, defined by norepinephrine infusion or fluid therapy > 1L during the previous 24 h, were included. In each of them, we screened the criteria of validity/feasibility of PPV, PLR and EEXPO. Results: Eighty-four patients (78% with septic shock, 8% with cardiogenic shock, 8% with hypovolemic shock, 6% with non-septic vasoplegic shock) were enrolled in the study. Among them, norepinephrine infusion was ongoing at the time of enrolment in 95% of the patients whilst 69% were under mechanical ventilation, and 30% with acute respiratory distress syndrome. PLR was not applicable in 37% of cases. This was mainly due to venous compression stocking (17% of cases), intra-abdominal hypertension (11% of cases), and either an absence of cardiac output monitoring or impossibility to perform echocardiography (9% of cases). Among the 58 intubated patients, PPV was applicable in 16% of cases, including cases with high PPV under conditions generating false negatives (low tidal volume or lung compliance) or low PPV values under conditions generating false positives (spontaneous breathing, cardiac arrythmias). However, PPV was not interpretable in 84% of cases. This was mainly due to low tidal volume ventilation (27% of cases), spontaneous breathing activity (12% of cases), while the remaining non-interpretable cases (51%) had more than one reason. In the 58 intubated patients, EEXPO was not applicable in 21% of cases. This was due to impossibility for patients to sustain a 15-s hold of mechanical ventilation in 58% of cases, and either an absence of cardiac output monitoring or the impossibility to perform echocardiography in 42% of cases. PLR and EEXPO were both valid and feasible in 35% of the patients, and the three tests were all feasible in only 4% of patients. Rationale: Comorbid association between chronic respiratory diseases and sleep apnea syndrome (SAS) revealed frequent with systematic search in ICU following ICU stay. This association carries prognosis impact depending whether specific treatment is implemented or not. NoSAS and Stop Bang scores are proposed for screening of SAS in general population. The aim of the present study is to report the prevalence of SAS in ICU patients admitted for hypercapnic respiratory failure and compare association of NoSAS and Stop Bang score with SAS severity.

The study was conducted between January 2016 and September 2018. Patients consecutively admitted in the ICU for hypercapnic respiratory failure had calculation of a no SAS and STOP Bang scores at admission. In survivors nocturnal polygraphic records was performed 3 to 4 weeks following ICU discharge. The association between the number of apnea-hypopnea episodes, BMI, and clinical variables suggestive of SAS, was tested by POISSON regression model. Results: During the study-period, 65 patients (mean age: 69 ± 9 years, pH 7.29 ± 0.03, PaCO 2 75 ± 16) were admitted for hypercapnic respiratory failure. Non invasive ventilation was used in 85% and death occurred in six patients. Polygraphic records were performed in 45 (9 lost to follow-up) Mean apnea-hypopnea index was 40 ± 15 with a minimum of 7 and a maximum of 62. Poisson logistic regression showed that No SAS (p = 0.006) but not Stop Bang (p = 0.1) was associated with the level of apnea-hypopnea index. Rationale: Patients with severe acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) may benefit from high-flow nasal oxygen regarding its physiological effects and good tolerance. Bronchodilator vibrating mesh nebulization through high-flow nasal oxygen circuit has been described to induce similar effect to standard facial mask jet nebulization in stable COPD patients. We aim to evaluate whether vibrating mesh nebulization of salbutamol through highflow nasal oxygen circuit is efficient in unstable patients with COPD. Patients and methods: We conducted a monocenter non-randomized physiological prospective cross-over study, between January and September 2019, including ICU patients with severe acute exacerbation of COPD and respiratory acidosis treated by salbutamol nebulization. Spirometry and airway resistances records were performed after a 3-h wash-out period without bronchodilator, before and after vibrating mesh nebulization of 5 mg salbutamol through high-flow nasal oxygen circuit. The primary endpoint was Forced Expiratory Volume in 1 s after salbutamol nebulization. Secondary endpoints included other spirometry parameters, clinical parameters, dyspnea assessed by a Borg scale. Results: Fourteen consecutive patients were included, Forced Expiratory Volume in 1 s increased significantly after salbutamol nebulization through high-flow nasal oxygen (91 ± 111 mL, p = 0.005), as well as Forced Vital Capacity (190 mL ± 193, p = 0.005). Airway resistances were not significantly changed after nebulization (− 0.73 ± 1.67, p = 0.08) as well as Peak Expiratory Flow (+ 231 mL ± 439, p = 0.09). No difference was observed on Borg scale (p = 0.06) and respiratory rate (p = 0.18) after salbutamol nebulization, while heart rate increased significantly (p = 0.01). Discussion: Salbutamol nebulization using vibrating mesh nebuliser placed on high-flow nasal oxygen circuit induces a significant but moderate bronchodilation in patients with severe acute exacerbation of COPD. Moreover, improvement of Forced Vital Capacity after salbutamol nebulization suggests a reduction of dynamic hyperinflation. Conclusion: Salbutamol vibrating mesh nebulization through highflow nasal oxygen circuit increases significantly Forced Expiratory Volume in 1 s. Compliance with ethics regulations: Yes.

T-piece versus sub-therapeutic pressure support for weaning from invasive mechanical ventilation in patients with chronic obstructive pulmonary disease: a comparative prospective study Amira Jamoussi, Fatma Jarraya, Samia Ayed, Takoua Merhabene, Jalila Ben Khelil, Mohamed Besbes Abderrahmen Mami Hospital, Tunis, Tunisia Correspondence: Amira Jamoussi (dr.amira.jamoussi@gmail.com) Ann. Intensive Care 2020, 10 (Suppl 1):F-058

Rationale: The best weaning strategy for patients with chronic obstructive pulmonary disease (COPD) remains unknown. The spontaneous breathing trial (SBT) represents a crucial step of weaning, but the choice between the T-piece (SV-Tube) or the sub-therapeutic setting of the level of pressure support without positive expiratory pressure (PSV) is still a matter of debate. We aimed to compare the success of extubation between two groups of COPD patients according to the SBT type (VS-Tube vs PSV). Patients and methods: It was a prospective and comparative study, from April 2017 to March 2019, at the Abderrahmen Mami hospital's intensive care unit (ICU). COPD patients who underwent invasive mechanical ventilation (MV) for at least 24 h and met the criteria for weaning were included and randomized to SV-Tube or PSV. A multivariate analysis was performed to determine the association between the SBT modality and the success of extubation (no re-intubation during the 48 h following extubation). Results: During the two years' study, 32 patients were included. The mean age was 66 ± 10 years, the sex-ratio was 4.33. Weaning process was simple in 16 patients (50%), difficult in 10 patients (31%) and prolonged in 6 patients (19%). Fifteen and 17 patients were respectively randomized to the SV-Tube and PSV groups. The mean duration of MV before randomization was comparable between the 2 groups (SV-tube 6.87 ± 4.3 days vs PSV 6.06 ± 4.8 days, p = 0.622). Mean weaning time (days) was 3.73 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] for the SV-Tube group and 4.35 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] for the PSV group. The mean total MV duration (days) was higher in the SV-Tube group than in the PSV group (15.13 vs 7.65, p = 0.105).

The number of re-intubated patients within 48 h following extubation was higher in the PSV group (7/17 vs 1/15, p = 0.024) as well as the overall reintubation rate (64.7% vs 20%, p = 0.011). In multivariate analysis, the SBT's trial was independently associated to the success of extubation (OR = 0.081, IC [0.008-0.865], p = 0.037) in favor of SV-tube' modality. The median length of stay in intensive care was 16 days [10; 26]. The mortality was higher in the PSV group (7/17 vs 2/15, p = 0.08). Extubation failure was a factor associated with mortality (OR = 8.333, CI [1.392, 49 .872], p = 0.02). Conclusion: Ventilation weaning was easy in 50% of intubated COPD patients. SV-Tube as SBT modality was associated to success of extubation in patients with COPD. Mortality in intensive care was significantly higher in re-intubated patients. Compliance with ethics regulations: Yes. Rationale: Non-invasive ventilation has become the mainstay in hypercapnic respiratory failure. Delaying intubation and invasive ventilation is associated with a worse outcome in these patients. Although a predictive score of NIV failure has been validated for hypoxemic respiratory failure no such score exists in hypercapnic respiratory failure. The aim of our study is to compare the performance of two scores in the predictive NIV failure hypercapnic respiratory failure. Patients and methods: Consecutive patients admitted between January 2017 and July 2019 for hypercapnic respiratory failure, were included. HACOR score and ROX score were calculated in each patient at admission. In patients ventilated non-invasively, the outcome (NIV success or failure) was noted. The area under curve (AUC) and operative characteristics were computed for both scores. Results: During the study-period, 107 out of 133 patients admitted for hypercapnic respiratory failure received NIV as the primary ventilatory mode. These patients were mainly men (77/30), had a mean age of 66.7 ± 10 years and had the following pulmonary disease: COPD exacerbation 50.5%, obesity-hypoventilation syndrome 18.7%, bronchiectasis 15.9%, and other diseases: 8.4%. NIV failure occurred in 39 patients (36.4%) and ICU mortality in 18.7%. Mean HACOR score and ROX score were 5.8 ± 3.6 and 18.3 ± 2, respectively. The AUC under ROC was higher for HACOR than ROX (0.91 and 0.76 respectively) ( Fig. 1 ). The HACOR score (cut-off 6) had a sensitivity of 0.93 and specificity of 0.85. Conclusion: HACOR score seems more accurate in predicting NIV failure in hypercapnic respiratory failure. Further prospective validation is needed. Compliance with ethics regulations: NA. Rationale: Published data on outcomes in respiratory weaning centers are limited and seem to depend on the organisation of healthcare systems and patient case-mix. The weaning center of our university hospital (Post intensive care rehabilitation unit) admits for weaning and rehabilitation patients from medical and surgical intensive care units without severe neurological pathologies. The aim of this study was to describe patient's characteristics and outcome (weaning outcomes and survival) and to compare in subgroups according to the initial medical, surgical or cardiac surgical context. Patients and methods: We conducted a monocentric retrospective observational study between 01/02/2016 and 30/06/2018. «Successful outcome» was defined by the association of survival and weaning from invasive ventilation. Factors associated with evolution were investigated by uni-and multivariate analysis. Survival after discharge was analysed according to the initial context and according to the type of ventilation at discharge. Results: Among 215 patients included, 167 (77.6%) had a successful outcome with high use of non-invasive ventilation (NIV) (37%). Respiratory history (p = 0.02), female gender (p < 0.001), IGS2 score at admission to the SRPR (p = 0.001) and non-cardiac surgical setting (p < 0.012) were associated with an adverse course. The 6-month survival rate was 84% in discharged patients. The outcome was not different in the tree subgroups. NIV rate at discharge was high in the subgroup of cardiac surgery patients.

A multidisciplinary and personalised approach by a specialized weaning unit can provide a successful service model for patients who require liberation from prolonged invasive mechanical ventilation. Compliance with ethics regulations: Yes. Rationale: High-dose Insulin Euglycemic Therapy (HIET) is recommended as first line therapy for calcium channel blockers (CCBs) poisoning because of its inotropic effect. Our first objective was to study its hemodynamic impact.

We performed a retrospective cohort study of all consecutive patients admitted for CCBs poisoning treated with HIET, in one ICU at the University Hospital of Lille between January 2013 and July 2018. The hemodynamic impact was studied through mean arterial pressure (MAP), Vasoactive-Inotropic Score (VIS) and MAP/VIS ratio during the 24 h following HIET initiation. Metabolic parameters were also collected. Results: 104 patients admitted for CCBs poisoning. 43 patients treated with HIET in ICU (7 patients without circulatory shock, 5 patients with shock after HIET and 31 patients with shock at baseline before HIET). Among shocked patients at baseline (n = 31), no hemodynamic improvement was found except an increased MAP/VIS ratio at H24 (p < 0.05). On the contrary, an initial worsening of VIS (137 [ Rationale: Ketamine is used in the induction and maintenance of general anesthesia. Recently, there were concerns regarding its liver toxicity. We conducted a study to investigate the link between Ketamine use and Liver Dysfunction (LD) in Intensive Care Unit (ICU) patients. Patients and methods: Data were extracted from the [anonymized] study, a randomized controlled trial designed to evaluate the effect of Cisatracurium on 90-day mortality rate in moderate and severe Acute Respiratory Distress Syndrome (ARDS) patients. The main endpoint was the occurrence of a LD defined as a total serum bilirubin superior or equal to 33 micromol/l. A matched case-control cohort was created: cases, receiving at least 1 day of continuous Ketamine infusion, were paired 1 for 1 with controls according to treatment with Cisatracurium, hepatic and cardiovascular SOFA sub-score, total serum bilirubin level at the time of inclusion, age, sex, ARDS from septic origin, shock anytime after inclusion. An analysis was also made on the whole cohort comparing the patients receiving at least 1 day of continuous Ketamine infusion to all patients who did not fulfill this criterion. Results: 66 cases were identified and matched to 66 controls. In the Ketamine group, the median Ketamine duration was 5 (3-8) days, and median total cumulative dose 18.6 (9.6-42.5) g. The occurrence of LD was higher in the Ketamine group than in the matched control group (53.8% versus 28.6%, p = 0.002, Fig. 1 ). The Hazard ratio (HR) for LD in the Ketamine group was 2.03 (95% CI 1.15-3.59, p = 0.015). There was an increased risk of LD of 5.9% per day of exposure to Ketamine (HR 1.06, 95% CI 1.02-1.1 p = 0.003) and of 0.8% per gram of Ketamine infused (HR 1.01, 95% CI 1.00-1.01, p = 0.006), with a risk starting to be statistically significant after 4 days and 18gr. In multivariate analysis on the whole cohort, Ketamine exposure (HR 2.49, 95% CI 1.40-4.44, p = 0.02), cumulative dose in gram (HR: 1.02, 95% IC: 1.01-1.04, p = 0.002) and ketamine exposure in days (HR: 1.16, 95% IC: 1.07-1.25, p < 0.001) remained independent risk factors for LD occurrence. Conclusion: Ketamine use in critically ill patients treated for ARDS is associated to a higher risk of liver dysfunction, assessed by total serum bilirubin. This risk is dose-dependent and increases with duration of treatment. The prescription of high doses or prolonged treatment with Ketamine should probably be avoided in critically ill patients. Compliance with ethics regulations: Yes. Rationale: Ciguatera is one of the most common cases of marine poisoning associated with fish consumption in the world. The incidence of this intoxication is largely unreported. In Martinique, the incidence of this intoxication seems constantly increasing. During the last 3 years, numerous cases of large collective poisonings have been reported in Martinique, especially during summer. The spectrum of clinical manifestations is large including gastrointestinal, neurological andcardiovascular symptoms. Ciguatoxin, the toxin responsible for ciguatera fish poisoning is considered as a sodium channel agonist with cholinergic and adrenergic activity. It is rarely fatal and management of poisoned patients is essentially based on supportive care. The objective of this study was to describe the clinical characteristics and complications of ciguatera poisoning in Martinique, focusing on the cardiovascular ones.

Observational, retrospective, single-center study covering six-year period from October 2012 to September 2018, including all patients admitted to the Emergency Department of the University Hospital of Martinique (CHU), and all patients who were declared to the Regional Health agency (ARS) for ciguatera intoxication. Results: One hundred and forty-nine patients (149) who were ciguatera-affected were included. The incidence rate found was to be 0.67 cases per 10.000 patient-years in Martinique over the period. About 90% of patients had gastrointestinal symptoms such as nausea, vomiting, diarrhea, or abdominal pain; 83% neurological disorders and 42% cardiovascular symptoms including, bradycardia, hypotension and interventricular block. Ingestion of Carangue fish was related to a major risk of chronic signs. Conclusion: The incidence of ciguatera in Martinique is increasing, with 0.67 cases/10.000 patient-years. The clinical presentation is defined mainly by digestive signs, followed by peripheral neurological disorders and cardiovascular symptoms. Ciguatera fish poisoning in Martinique presents similar clinical presentation to that of the other Caribbean Islands. There is no specific treatment. Acute ciguatera poisoning is responsible for significant cardiovascular complications. Physicians should be aware of the potential cardiovascular risk of ciguatera poisoning. Compliance with ethics regulations: Yes. Rationale: Pesticides have represented the most incriminated products in severe acute poisonings, in the developing countries, due to the availability of these products. Organophosphate poisoning accounts for 3 million poisonings/year worldwide. Organophosphate (OP) pesticides are used mainly as insecticides in agriculture. the Moroccan anti-poison and pharmacovigilance centrer shows that OP poisoning are responsible for 13% of all poisonings combined. The aim of our study: epidemiological, clinical, management and prognostic factors. Patients and methods: A retrospective study was conducted on patients with OP poisoning admitted to our nine-bed medical intensive care unit between January 2018 and December 2018. inclusion criteria were: all patients over 16 years of age and the exlusion criteria were: pesticide poisoning other than OP, alcohol poisoning, drug poisoning, scorpionic poisoning and snake bites. statistical analysis was performed with SPSS software. Results: Forty patients were admitted for acute OP poisoning. In Morocco, organophosphores are available over-the-counter in several forms: Rodentocides, Malathion, Cockroach trap, Baygon Insecticide ( Fig. 1 ). The average age was 26 years with a female prévalence of 74.1%. The intoxications were mostly intentional (85%). The symptomatology was determined by the three syndromes: central syndrome in 50%, muscarinic syndrome in 69%, nicotinic syndrome in 10%. Rhythm disorders in 8%, and cardiovascular collapse in 9%. The symptomatic treatment was applied to all patients, antidotic treatment was administered in 80% of patients. The average length of hospitalization was 06 days. Conclusion: Acute OP poisoning is a real public health problem. Its associated symptomatic treatment (respiratory and neurological resuscitation) and antidotic treatment. The mortality remains high in our context, therefore, we must attach great importance to the prevention.

Compliance with ethics regulations: Yes. (1). Over an 8-month period, health officials in Guadeloupe and Martinique reported more than 12.000 such cases. Assault of these brown algae represents not only an environmental and economic disaster, but also a threat for human health. After 48 h on seashore, large amounts of toxic gas are produced by matter decomposition, including hydrogen sulfide (H2S) and ammoniac (NH3). The acute effects on humans after exposure to high concentrations of H2S are well described and of increasing severity with concentration, leading to potentially fatal hypoxic pulmonary, neurological and cardiovascular injuries (Table 1) ; however, the association of long-term exposure to Sargassum and health events is unknown. Although less documented, long term exposures may result in conjunctiva and upper airways irritation, headaches, vestibular syndrome, memory loss, and modification of learning abilities. In the absence of any available antidote, management of H2S intoxication relies on supportive care and prevention using individual protection. The objective of this study was to evaluate the clinical characteristics and consequences of long-term exposure to Sargassum among the local population.

We conducted a prospective observational cohort study including all patients admitted to the emergency department at the University hospital of Martinique from March 2018 to December 2018 due to exposure to sargassum. Patients were managed according to the protocol established by the Research Group on Sargassum in Martinique. We assessed the patients exposure to Sargassum and air pollutants using 14 monitor located near of the patient's residence. Demographics and clinical data (including cardiovascular, neurological and respiratory events) were collected. Data are presented as mean ± SD or %.Comparisons were performed using univariate analysis. Results: In 8 months, 160 patients were included (age: 48 ± 20 years, 54 M/146 W, past history: hypertension (N = 25), diabetes (N = 29), asthma (14). Patients arrived with referral letter from their general practitioner (80%) and presented headaches (76%), developed gastrointestinal disturbances (79%), dizziness (54%), skin lesions (30%), cough (44%) and conjunctivitis (33%). Not all patients were clinically symptomatic. In the patients presented in June (14%), symptoms more frequently occurred in the workplace or at home (p < 0.05). Initial lung function tests were normal (50%). Three patients were admitted in intensive care unit. Conclusion: Our study indicates that the magnitude of health effects following long-term exposure to Sargassum may be larger than previously recognized. Efforts to limit long-term exposure are mandatory. Compliance with ethics regulations: Yes. Rationale: Liver consequences of out-of-hospital cardiac arrest (OHCA) have been poorly studied. The aim of this study was to describe the characteristics of OHCA-induced acute liver dysfunction and its association with outcomes.

We analyzed all consecutive OHCA patients admitted to two academic centers between 2007 and 2017. Patients treated with vitamin K antagonist were not included. Acute hepatocellular insufficiency (AHI), liver failure (LF) and hypoxic hepatitis (HH) were defined as a prothrombin (PT) ratio < 50%, a hepatic SOFA sub-score > 2 and an increase in transaminases > 20 times the normal values, respectively. Indocyanine green (ICG) clearance was used as the reference measure of liver function in a subset of patients. Multivariate logistic regression was used to identify potential risk factors for day 28 mortality. Rationale: Neuron-specific-enolase (NSE) is commonly used as a biomarker reflecting the extent of brain injury in different settings. In post-cardiac arrest patients, previous clinical studies reported that an increase in NSE was predictive of a poor outcome but did not specifically focused on neurological outcome. In this prospective study, we aimed to determine the NSE performance for prediction of severe brain damage in post-cardiac arrest patients. Patients and methods: All consecutive patients admitted in our ICU after cardiac arrest between January 2017 and February 2019 that were still comatose at H48 and had at least one measurement of serum NSE were included. Blood samples for NSE measurement were serially collected at 48 (H48) and 72 h (H72) after cardiac arrest and serum NSE levels were measured within 4 h. We used the following criteria for the definition of severe brain damage (primary endpoint): Cerebral Performance Categories (CPC) 3 or 4 level at discharge, brain death or withdrawal of life-sustaining treatments (WLST) based on neurological status. We also assessed the predictive value of serum NSE using allcause mortality as a secondary endpoint. Results: During the study period, 155 patients were available for the analysis. They were mostly male (66.9%), with an age of 60.6 years. Among these patients, 83 (50.3%) had a good neurologic outcome (CPC 1-2) and 68 patients were classified as having a severe brain damage (52 WLST based on neurological status, 11 brain deaths and 5 survivors with . In univariate analysis, patients with severe brain damage less frequently received bystander CPR, had longer duration of no-flow, less initial shockable rhythm, more post-resuscitation shock and higher NSE values: mean at H48 were 217.3 versus 26.2; and 270.1 versus 21.4 at H72 (p < 0.001). NSE levels at H48 and H72 were strong predictors of severe brain damage (AUC of 0.948 and 0.972 respectively, Figure 1 ) and also predicted all-cause mortality (AUC of 0.896 and 0.931 respectively). To predict severe brain damage with 100% specificity, best NSE cutoff values at H48 and H72 were 52.3 and 53.2 µg/l, with a sensitivity of 77.6 and 82.9% respectively. Conclusion: A high serum NSE measured at H48 and H72 after cardiac arrest accurately predicted severe brain damage with a high specificity. Our results support the use of NSE for neuroprognostication after cardiac arrest, in combination with other predictors. Compliance with ethics regulations: Yes. Rationale: The psychological care of patients, their relatives and of healthcare workers is a major issue in the intensive care unit (ICU). Psychologists may provide emotional support during trying times. The intervention of a psychologist may alleviate long term mental health issues such as post-traumatic stress disorder. The main objective of our study was to describe the availability of psychologists in French-speaking ICUs. Patients and methods: Internet survey conducted between March and May 2019 using SurveyMonkey (San Mateo, USA). Survey consisting of 20 questions sent to subscribers of the SRLF mailing list via MailChimp software (Atlanta, USA). Frequencies and percentages were determined for categorical variables and median and interquartile range for continuous variables. The ICUs with or without psychologist were compared using nonparametric Fisher exact test. STATA 14 used (Lakeway Drive, TE, USA). Results: 263 responses were obtained from 197 unique ICUs in France (n = 182), Belgium (n = 6), Switzerland (n = 5), Algeria (n = 2), Morocco (n = 1) and Tunisia (n = 1). 164 (82%) ICUs were part of public hospitals, 33 (18%) of private facilities. 187 (94%) ICUs cared for adult patients, 10 (6%) for children. The median number of beds was 20 [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] . 79 (40%) ICUs were open to visitors 24/7, 46 (23%), to visitors > 8 h/day and 72 (37%) to visitors < 8 h/day. Psychological consults were established in 89 (45%) wards (2 ICUs did not answer). Pediatric ICUs employed more psychologists than adult ICUs (P = 0.006). Comparison of ICUs based on the presence or not of a psychologist appears in Table 1 . In ICUs where a consulting psychologist is available, their effective availability is 0.5 [0.2-1] full time equivalent. Consults are delivered to: patients (100%), families (100%) or healthcare workers (60%). Out of the 106 ICUs without a psychological consult, responders from 5 (2.5%) ICUs believe that a psychological consult is undesirable. Out of the 106 ICUs without psychological consult, 24 (22%) responders cannot obtain a psychological consult, whatever the circumstances, 41 (39%) can require an outside psychological consult when needed, while 41 (39%) can require assistance from a psychologist working in another unit (several answers possible for each respondent). Conclusion: Psychologists consult in only half of adult ICUs but in almost all pediatric ICUs. 22% of ICUs are unable to provide a psychological consult. Psychological consults are delivered in similar proportions to patients, their family and to a lesser extent to healthcare workers.

Responders from 2.5% ICUs without an established psychological consult believe that the availability of a psychologist is undesirable. Compliance with ethics regulations: NA. Rationale: Comfort of patients in Intensive Care Unit (ICU) is now a real concern for the healthcare teams. Perceived patient discomfort assessment is a daily practice for our staff. The primary objective of our study was to assess whether the overall discomfort score reported by patients hospitalized in a separate intermediate care unit differs from that reported by patients hospitalized in ICU.

A tailored multicomponent program consisting of assessment of ICU-related self-perceived discomforts with a 18-item questionnaire, immediate and monthly feedback to healthcare teams and site-specific tailored interventions, was applied in our department, located in a general hospital, and comprising a 12-bed ICU and a separate 6-bed intermediate care unit Rationale: The transition period surrounding the discharge from ICU to hospital ward is a critical period in the course of the patient.

Handoff of complex patients is at high risk for communication failures between providers, inaccurate cares and ICU readmission. A transition program including a post ICU follow-up has been proposed to improve handoff quality. Post ICU consults by ICU team represent, also, an opportunity for improving feedback on the quality of ICU cares. The goal of the present study is to assess the feasibility and the impact of a systematic early post-ICU consult (EPICUC) program on handoff quality in a 14 bed mixed ICU. Patients and methods: Before the development of the EPICUC program, standardized handoffs were already applied including identified day and hour of discharge and both verbally communicate and written medical and nurse information for receiving team. From 1st March to 30th October 2019, all patients who were discharged to the ward of our hospital were candidates for EPICUC. EPICUC were performed by ICU staff (at least one ICU physician) within the 3 days following discharge. The EPICUC consisted of a face-to-face discussion with the receiver team to assess the accuracy, completeness and understanding of passing information and of a patient visit. A standardized form was used for collecting data. The impact of EPICUC on handoff quality was assessed by the number of communication failures and the number of patients in whom EPICUC resulted in a management change.

Personal feeling of EPICUC providers on its usefulness was assessed by a 0-10 rating scale. Results: Among the 209 candidates for EPICUC, 4 were dead and 74 already discharged alive from hospital at EPICUC time. EPICUC were performed in 131 patients (63%) within 4 ± 3 days after ICU discharge. 85 EPICUC (65%) were performed by both, nurse and ICU physician. 111 (85%) patients and 84 receiver teams (64%) were available at EPI-CUC time. EPICUC duration was 11 ± 4 min. A communication failure was identified in 38 EPICUC (29%), either a rectification of passing information (n = 30; 23%) and/or a change in patient management (n = 19; 15%). The usefulness of the EPICUC was rated at 4 ± 3 and 5 ± 3 by ICU physicians and nurses, respectively. Conclusion: The time spent for EPICUC appears reasonable. EPI-CUC identified a communication failure in one-third of handoffs and allowed care readjustment in one quarter of patients. Factors associated with handoff failures will be presented during the congress. Compliance with ethics regulations: Yes. Rationale: Surviving a critical illness is a challenging condition for patients and relatives. The psychological aspects are directly affected by physical status and performance. Patients can feel depressed or anxious facing difficulties during recovery time. The aim of this study was to correlate patients' perceptions of his health status and his clinical performance measured after ICU discharge. Patients and methods: This is a prospective pilot study of an ICU follow-up clinic conducted in a single center from January 2018 to July 2019. This clinic is multidisciplinary and includes two visits at 3 and 6 months after ICU discharge. Patients with more than 5 days of ICU LOS were eligible. All patients at 3 and 6-m visit were evaluated with SF-36, 6MWT, MRC and time-up-and-go test. We conducted an analysis comparing clinical performance data and qualitative data between 3 and 6 months after ICU discharge.

The investigation included 90 patients who had at least 5 days of ICU length of stay. 50 patients attended the consult at 3-m and 28 patients attended the consult both times. The median age (IQR) was 63 (54-71) and 56% were men. 48%, 30% and 22% of patients had medical, scheduled surgical and emergency surgical admission causes respectively, with median (IQR) SAPS III score 53 (44-73). 38%, 14% and 80% of patients had sepsis, delirium and mechanical ventilation as a support. The physical status was progressively increased overtime likewise the physical capacity assessed by SF-36 score with p-value 0.007 between 3 and 6-m. However, no significant difference between the subjective dimension of SF-36, which analyses the perception of the patient about his physical capacity, assessed at 3-m and at 6-m was demonstrated (p 0.35).

In this pilot-phase of following a cohort of critically ill patients, the natural physical improvement does not seem to change the patient's perception of their performances. This paradigm rouses a different perspective that should take into account when setting up rehabilitation programs. Compliance with ethics regulations: Yes.

Post-traumatic stress disorder after discharge from an acute medical unit Basma lahmer 1 , naoufel madani 1,2 , jihane belayachi 1,2 , redouane abouqal Rationale: Post-Traumatic Stress Disorder (PTSD) occurs after exposure to a traumatic event and comprises of symptoms of repeated re-experiencing of the said event, avoidance of reminders, emotional numbing and persistent hyperarousal. In individuals exposed to "medical stress", various studies found evidence of PTSD occurring after the onset, diagnosis, or treatment of physical illness. Our study aims to determine PTSD's risk factors in patients of an acute medical unit (AMU) after their discharge. Patients and methods: It was a prospective, analytical study conducted over a period of 2 months at an acute medical unit. We collected sociodemographic and clinical data, patients' medical history, and evaluated the symptoms of anxiety and depression during their stay using the Hospital Anxiety and Depression Scale (HADS). The prevalence of severe PTSD symptoms was assessed with the Impact of Events Scale-Revised (IES-R) at 6 weeks and 3 months using a cutoff of 33. Associations between PTSD as evaluated by IES-R at 3 months and patients' characteristics, including HADS scores at admission were investigated using unadjusted linear regression, for univariate and multivariate regression analysis. Statistical analyses were carried out using SPSS for Windows (SPSS, Inc., Chicago, IL, USA).

We included 141 patients in our study with a mean age of 49.74 ± 17.8. In our population, 20.8% of patients scored higher than a 33 IES-R cutoff at 6 weeks compared to 17.6% at 3 months. The mean HADS-Anxiety score is 7.8 ± 6 and that of the HADS-Depression score is 7.1 ± 6.3. On one hand, higher HADS-anxiety Score during the stay in the AMU was linked to higher IES-R scores at 3 months β: Rationale: Objective of critical care includes restoration of functional capacities. Prompt identification of muscle acquired weakness (ICU-AW) is crucial to target efficient rehabilitation. In published literature, data of quadriceps strength (QS) cannot be compared because of insufficient standardization of measurement protocols. We recently validated a highly standardized protocol of QS measurement. In order to build basic and comparable knowledge and to identify the weakest patients, this study aimed to describe QS of critically ill (CI) patients during their short-term evolution, and to compare them to surgical (S) and healthy (H) subjects. Patients and methods: This observational study included CI patients who spent at least 2 days in ICU, patients scheduled for elective colorectal surgery (S) and young healthy volunteers (H). Maximal isometric QS was assessed using a handheld dynamometer (MicroFet2 ® ) and expressed in Newton/kg (N/kg). Dominant leg was tested in supine position using a highly standardized procedure. CI and S patients were tested at T0 (as soon as collaborative in ICU) and 1 month after discharge (M1 Rationale: The post intensive care syndrome (PICS) gathers various disabilities, associated with a substantial healthcare use. However, patients' comorbidities and active medical conditions prior to intensive care unit (ICU) admission may partly drive healthcare use after ICU discharge. To delineate the relative contribution of critical illness and PICS per se to post-critical illness increased healthcare use, as opposed to pre-existing comorbidities, we conducted a population-based evaluation of patients' healthcare use trajectories. Patients and methods: Using discharge databases in a 2.5-million-people region in France, we retrieved, over three years, all adult patients admitted in ICU for septic shock or acute respiratory distress syndrome (ARDS), intubated at least 5 days and discharged alive from hospital. Healthcare use (days spent in healthcare facilities) was analyzed two years before and two years after ICU admission. Healthcare trajectories were next explored at individual level: patients were assembled according to their individual pre-ICU healthcare use trajectory by clusterization with the K-Means method.

Results: Eight-hundred and eighty-two (882) patients were included. Median duration of mechanical ventilation was 11 days (interquartile ranges [IQR] 8; 20), mean SAPS2 was 49, and median hospital length of stay was 42 days (IQR 29; 64). Prior to ICU admission, we observed, at the scale of the whole study population, a progressive increase in healthcare use. However, clusterization of individual according to pre-ICU healthcare trajectories identified patients with elevated and increasing healthcare use (n = 126), and two main groups with low (n = 476) or no (n = 251) pre-ICU healthcare use. Patients with high healthcare use had significantly more comorbidities than those with low healthcare use. In ICU, however, SAPS2, duration of mechanical ventilation and length of stay were not different across the groups. Interestingly, analysis of post-ICU healthcare trajectories for each group revealed that patients with low or no pre-ICU healthcare (which represented 83% of the population) switched to a persistent and elevated healthcare use during the two years post-ICU. Conclusion: For 83% of ARDS/septic shock survivors, critical illness appears to have a pivotal role in healthcare trajectories, with a switch from a low and stable healthcare use prior to ICU, to a sustained higher healthcare recourse two-years after ICU discharge. This underpins the hypothesis of long-term critical illness and PICS-related quantifiable consequences in healthcare use, measurable at a population level. Compliance with ethics regulations: Yes. (1) to describe the pre-hospital grading protocol developed by the Northern French Alps Emergency Network (TRENAU) for children, (2) to evaluate its quality to detect the most severe trauma patients and (3) to assess the accuracy of this procedure to perform an adequate triage. Patients and methods: Our regional trauma system included 13 hospitals categorized as Level I, II or III pediatric trauma centers. Eachpatient was graded A, B or C by an emergency physician, according to the seriousness of their injuries at presentation on scene. The triage was performed according to this grading and the categorization of centers. This study is a registry analysis of an 8-year period (2009 to 2017). Results: A total of 1142 children (mean age 10 years, 65% were boys) with severe trauma were included in the cohort. Fifty-seven, 22% and 21% of patients were admitted to a level I, II and III, respectively. Road accident was the main mechanism of injury (35% of patients). Thirtysix percent of patients had a severe trauma, defined as an Injury Severity Score (ISS) higher than 15. One quarter of patients had at least 2 severe lesions and one-third of patients had a trauma brain injury. The pre-hospital gradation was closely related with injury severity score (ISS) and intra-hospital mortality rate. The triage protocol had a sensitivity of 78% and a specificity of 33% to predict adequate admission of patients with ISS more than 15. Using a specific trauma score (including occurrence of death, an admission in Intensive Care Unit and the need for urgent surgery), sensitivity and specificity reached 91 and 41%, respectively. Fourty-six percent of patients were not graded at the scene (Non-graded group). Undertriage rate was significantly reduced in the Graded group compared with the Non-graded group, (22% versus 45%), without significant modification of the overtriage rate (43% versus 45%). Overall, mortality at discharge from hospital was 2%, but 33% in Grade A patients. Conclusion: Implementation of a regional pediatric trauma system with a specific pre-hospital triage procedure was effective in detecting severe pediatric trauma patients and in lowering the rate of prehospital undertriage. Compliance with ethics regulations: Yes. Rationale: Critically ill children suffer from pathophysiological changes, leading to large between-subject variability in drug clearance. Since piperacillin is eliminated mainly via the kidney, changes in renal function go along with a modified elimination, and possible subtherapeutic or toxic drug concentrations. We aimed to determine the most accurate glomerular filtration rate (GFR) estimation formula for assessing piperacillin clearance in critically-ill children. Patients and methods: All children hospitalized in pediatric intensive care unit and receiving piperacillin were included. Piperacillin was quantified by high performance liquid chromatography. Pharmacokinetics were described using the non-linear mixed effect modeling software MONOLIX. In the initial pharmacokinetics model, GFR was estimated according to the Schwartz 1976 formula. In the study, GFR was estimated with 11 additional formulas, developed with plasma creatinine and/or cystatin C. Biases, precisions, Spearman's rank correlation coefficient and normalized prediction distribution error (NPDE) were used to assess the models. Results: We included 20 children with a median (range) postnatal age of 1.9 (0.1-19) years, body weight of 12.5 (3.5-69) kg and estimated GFR according to the Schwartz 1976 formula of 160.5 (38-315) mL min-1.1.73 m 2 . Piperacillin concentrations were best predicted with the model using the creatinine clearance. The correlations were most accurate: r2 = 0.7 between the population-predicted and the observed concentrations, r2 = 0.0004 and r2 = 0.04 for the NPDE versus population-predicted concentrations and time, respectively. Concerning the individual predicted concentrations, bias and precision were respectively − 4.1 mg L −1 and 14.7 mg L −1 . GFR estimations based on serum creatinine were higher than those based on cystatin C (p = 0.02). Conclusion: In summary, the 12-h creatinine clearance is the best predictor of piperacillin clearance and this could be investigated for drugs with renal elimination. As a whole, literature and our findings strongly suggest using creatinine clearance to also estimate GFR in critically ill children. The gap between the GFR estimations is large depending on the formulas, with higher estimations with equations based on serum creatinine. Compliance with ethics regulations: Yes. Rationale: Acute pancreatitis (AP) incidence have increased dramatically over the past years. New guidelines in 2018 were recently published in order to standardize the definition and management of AP. The aim of this study is to describe the management of children that were diagnosed with AP from the pediatric intensive care unit (PICU) in two French hospitals. Patients and methods: This retrospective cohort study included children aged under 18 years old, who were admitted to the PICU of Robert-Debré hospital and Trousseau from 2006 to 2018 with a discharge diagnosis of AP. Data collected included management, severity and outcomes. We have also obtained data on clinical, biological and radiological presentation. Results: Sixty patients were included, the median age was 8 years (5-14) and 75% had a co-morbidity mainly hematologic (26/60). Most of the AP were moderate (52%) or severe (45%). Hemodynamic failure was the main reason for PICU admission requiring a median fluid resuscitation 56 ml/kg complemented by a median intravenous fluid therapy of 4 ml/kg/h (2-5) during the first 24 h. Twenty patients (37%) required mechanical ventilation. Fasting has been instituted in 59 patients (98%) for a median of 4 days (1-6), whereas 54 patients (90%) received parenteral nutrition, only 18 patients (30%) received enteral nutrition. Antibiotic therapy was given to 53 patients (88%) including 13% for curative therapy. The median length of stay in PICU was 4 days (2) (3) (4) (5) (6) . The mortality rate was 13%. Conclusion: This is the first French study which precisely described the management of patients with AP in PICU. It highlighted the differences withthe new international guidelines. This study could improve the management of PA in PICU and open research perspectives. Compliance with ethics regulations: Yes. Rationale: Apheresis and Therapeutic plasma exchange (TPE) for children diseases has been poorly investigated in mostly small-uncontrolled studies. The purpose of this study is to describe indications and safety of TPE in children. Patients and methods: In this single center and retrospective study, we included 94 patients who underwent TPE with an age < 18 years old in the pediatric center of Necker-Enfants-Malades hospital from January 2005 to December 2014. Data were retrospectively collected in an electronic case report form via a web-based data collection system. Results: 78 patients with a median age of 9.8 years [range 0.53; 17.93] were selected. They achieved a total number of 731 procedures. Indications were antibody-mediated rejection (n = 33; 42%) or desensitization therapy (n = 5; 6%) for solid organ or hematopoietic transplantations; microangiopathy (n = 17; 22%); renal diseases (n = 6; 8%) and pediatric inflammatory diseases (n = 16; 21%); or hyperviscosity syndrome (n = 1; 1%). Each patient had an average of 6 procedures for the first session [range 1; 19] with a median volume of 1834 ml [range 500; 5000 ml] corresponding to a median (rang) total plasma volume (TPV) equivalent of 1.39 l/m2 [0.58-2.1]. Within 15 days since the beginning of sessions, 72 patients (92%) present a total of 311 Adverse Events (AEs) potentially related to TPE. There was a median (range) of 5 AEs/patients [0-24]. There was no association between AEs and diseases, severity of patients, venous access, plasma substitute and body weight. Few of AEs (n = 23 for 72 patients) were potentially life-threatening and concerned mostly critically ill children. Allergic reactions represented only 20 AEs for 14 patients (grade I n = 18; grade II n = 1; grade III n = 1). At the 12 months endpoint, 15 (19%) patients died and 10 (13%) patients had severe persistent disease. No death had been related to the TPE process.

We describe one of the largest retrospective pediatric cohort updated to the last international recommendations. TPE in children is performed for specific and potentially refractory disease. It is feasible without a major risk of life threatening adverse events. Compliance with ethics regulations: Yes.

Yacine Benhocine University hospital nedir mohamed, Tizi-Ouzou, ALGERIA Correspondence: Yacine Benhocine (yacine001@yahoo.fr) Ann. Intensive Care 2020, 10 (Suppl 1):F-080

Rationale: Although analysis of literature data shows that implantable chamber catheters (ICCs) are less at risk of infectious complications than other central venous catheters, these complications can be serious, which may differ from ongoing treatments such as chemotherapy, and may lead to the removal of the implanted device. The literature on preventing these infections is quite disparate, as practices. Purpose: to evaluate the incidence of infections, to identify responsible germs and to measure the impact of preventive measures. Patients and methods: Prospective, descriptive, mono-centric study, from January 2012 to January 2019. All patients under the age of 15 who have benefited from an implantable chamber catheter, whose insertion procedure is as follows: local anesthesia, surgical asepsis (polyvidone iodine) in an operating room, double disinfection, no antibiotic prophylaxis, routes used: subclavian (89%), internal jugular (11%) by anatomic registration. The main criteria of judgment are: the incidence of local and general infections, their time of onset, responsible microorganisms. Statistical analysis used the Statistical Package for the Social Sciences software. Results: 4480 patients were included, the average incidence density of early infection is 0.61/1000 day-catheters. The time of onset of infection is essentially between the 2nd and 3rd week post-exposure, of which 20% is general infection. Ablation involved 52% of infected catheters. The causative organisms are mainly Gram-positive cocci (67.99%), Gram-negative bacilli are less involved (23.33%), with a significant number of candida infections (8%). Discussion: Higher incidence of data from the literature. To remedy this requires the implementation of additional hygiene measures: antiseptic showers preoperatively, Chlorhexidine??, and practice changes: echo guidance, antibiotic prophylaxis or locks? Second generation catheters? Our practices are disparate especially since the recommendations specifically concerning the prevention of infectious risk associated with internationally published ICCs are rare. Conclusion: At the end of this work, our perspectives are to: update the procedure, highlight risk factors on which it is possible to act, the adhesion of the different staff to the protocols. Compliance with ethics regulations: Yes. Rationale: The 2014 sepsis and septic shock pediatric guidelines advise to treat patients using care bundles. In the first hour, the «Resuscitation bundle» contains an appropriate fluid resuscitation, a broad-spectrum antibiotics administration after blood cultures, and initiation of inotrope if needed. The objectives were to evaluate the Resuscitation bundle compliance in a cohort of septic children with cardiovascular dysfunction, and to analyze the effect on severity and outcome in pediatric intensive care unit (PICU). Patients and methods: Retrospective analysis of the DIABACT III study. This study analyzed the care course of children with severe community-acquired bacterial infection, hospitalized in PICUs in France's west departments, between August 2009 and January 2014. Children with severe sepsis and cardiovascular dysfunction were retrospectively included. Results: We included 92 children of whom 6 (6.5%) had compliant bundled care. The severity scores at PICU's admission were similar between groups (p = 0.55 for the PRISM score and 0.58 for the PELOD 2). There was the same proportion of fluid-refractory shock (p = 0.65), mechanical ventilation (p = 1.0), neurological dysfunction (p = 1.0) and cardiac arrest (p = 0.39). In the «Resuscitation bundle compliant» group, 33.3% died versus 15.1% in the other group (p = 0.46). We highlighted a severity bias: the sickest patients were more likely to receive compliant bundled care. Conclusion: In our cohort, the Resuscitation bundle's compliance was low. We did not show some effect on morbidity nor mortality. However, this study helps understand the factors associated with Resuscitation bundle's compliance. Rationale: Nosocomial infections with extended-spectrum β-lactamase (ESBL) producing gram-negative bacilli (GNB) are an important cause of hospital morbidity and mortality. The objective of this study was to determine the incidence and risk factors of nosocomial ESBL-producing GNB infections in a paediatric intensive care unit (PICU). Patients and methods: A prospective surveillance study was performed from January 2015 through March 2019 in a PICU. All patients hospitalized for more than 48 h were included. Centers for Disease Control and Prevention criteria were applied for the diagnosis of nosocomial infection. Results: During the study period, 1783 patients (median age: 12 ± 434 days) were included. The average length of stay was 9 ± 11 days with a total of 15,980 days of hospitalization. Newborns accounted for 61.8% of patients. Sixty-two per cent of patients were colonized with multi drug resistant Gram-negative rods, on admission or during their stay in the PICU. One hundred and nineteen bacterial infectious episodes were registered (7.4/1000 patient days). One hundred infectious episodes were caused by a GNB and 44 (36.9%) by ESBLs producing GNB with an incidence of 2.7/1000 patient days (bloodstream infections: 21 episodes, ventilator acquired pneumonia: 16 episodes). ESBLs producing GNB infection had a specific incidence of 10.9 per 1000 catheter-days, and 2.3 per 1000 mechanical ventilation-days. Fifty-nine percent of patients infected with ESBLs producing GNB had a prior digestive colonization with a multidrug-resistant GNB. Forty-one episodes (93%) occurred in patients with central venous catheters. Klebsiella Pneumoniae was the most frequently isolated bacteria (45.4%). Mortality in the ESBLs producing GNB group was high (29.5%). Associated factors of nosocomial ESBLs producing GNB infection were mechanical vrntilation (p < 0.001), central venous catheterization (p < 0.001) and colonization with multiple drug-resistant Gram-negative bacteria (p < 0.001). Conclusion: Nosocomial ESBL-producing GNB infection had an incidence of 2.7 per 1000 patient days in our unit and seems to increase the mortality rate. Factors associated with this infection were identified.

Marie Lemerle 1 , Aline Schmidt 2 , Valérie Thepot-Seegers 3 , Achille Kouatchet 1 , Valérie Moal 4 , Mélina Raimbault 5 , Corentin Orvain 2 , Jean-Francois Augusto 6 , Julien Demiselle 1 1 CHU Angers, Médecine intensive réanimation, Angers, France; 2 CHU Angers, Maladie du sang, Angers, France; 3 CHU Angers-ICO, Angers, France; 4 CHU Angers, Pharmacie, Angers, France; 5 CHU Angers, LABORA-TOIRE de Biochimie, Angers, France; 6 CHU Angers, néphrologie dialyse transplantation, Angers, France Correspondence: Marie Lemerle (marielemerle@yahoo.fr) Ann. Intensive Care 2020, 10 (Suppl 1):F-083

Rationale: Acute kidney injury (AKI) is associated with high morbidity and mortality in the setting of tumor lysis syndrome (TLS). Thus, strategies aimed at preventing AKI occurrence represent a major goal to improve prognosis of patients with TLS. The role of hyperphosphatemia as a risk factor of TLS has been poorly analyzed. The aim of this study was to study the association between hyperphosphatemia and AKI, and to determine whether a cut-off value of phosphatemia or phosphatemia's variation was associated with AKI development during TLS. Patients and methods: In this retrospective and monocentric study, we included all patients with TLS and whithout AKI at admission, admitted to hematology, nephrology and intensive care units of the University Hospital of Angers between 01/01/2007 and 31/12/2017. Results: One hundred and thirty TLS episodes were identified in 120 patients. AKI developed during 56 episodes of TLS (43%). Hospital mortality was much higher in AKI patients (26.8% versus 10.8%, p = 0.018). Phosphate maximal values (2.2 ± 0.7 versus 1.9 ± 0.3) and LDH maximal values (4337.5 ± 4511.9 versus 2437.7 ± 2937.0) were higher in TLS with AKI, before AKI occurrence (p = 0.006 and p = 0.009, respectively). We found no association between the other biological parameters of TLS and AKI (serum calcium, uric acid and potassium). After adjustment for cofounders, there was a strong association between a rise in phosphate level of 0.1 mmol/L (HR 1.31 IC 95% [1.19-1.42 ], p < 0.0001), exposure to platinum salts (HR 3.66 IC 95% [1.74-7.71 ], p = 0.0006) and increasing maximal LDH value (HR per 1000UI/L increase 1.10 IC 95% [1.03-1.17], p = 0.030) with AKI. Conclusion: This study highlights the utmost importance of serum phosphate in the setting of TLS: phosphate is an early relevant biomarker for the risk of AKI development. Further studies are needed to assess whether aggressive prophylactic treatment to control serum phosphate concentration, such as renal replacement therapy before AKI onset, constitutes a valuable approach. Compliance with ethics regulations: Yes.

Retrospective cohort of patients admitted to the medical ICU of university affiliated hospital after CARTs treatment between August 2018 and August 2019. Results: Of the 20 patients treated by CARTs in the haematology department, 7 (35%) were subsequently admitted to ICU. Median age was 66 [50.5-68.5] years, and 5 (71.4%) were female. CARTs were indicated for R/R lymphoma. The median time between CARTs injection and ICU admission was 5 [3.5-5.75 ] days. All patients had Cytokine Release Syndrome (CRS), and 6 (85.7%) developed CAR-related encephalopathy syndrome (CRES). Median SOFA score and SAPS 2 were 4 [2-4.5] and 45 [40.5-49 .5], respectively. Four (57.1%) patients had hypotension treated by fluid bolus (n = 3) or vasopressors (n = 2), and 2 (28.6%) had acuterespiratory failure requiring oxygen therapy (n = 1) or mechanical ventilation (n = 1). Six (85.7%) patients had neurological symptoms (impaired consciousness n = 4, confusion n = 2, transient aphasia n = 1), of whom one developed refractory convulsive status epilepticus afterwards. All patients received broad spectrum antibiotics, of whom 2 (28.6%) had documented infections. Six (85.7%) patients received interleukin-6 inhibitor (single dose n = 2, multiple doses n = 4), and 5 (71.4%) received intravenous dexamethasone. One patient died in the ICU from septic shock. Median ICU and hospital length of stays were 4 [4] [5] [6] [7] [8] [9] [10] [11] [12] and 24 [21.5-28.75] days, respectively. Two (28.6%) patients died from relapsing malignancy before hospital discharge. Three months after ICU admission, four (57.1%) patients were alive in complete remission. Conclusion: More than 30% of patients treated with CARTs required ICU admission for the management of a CRS or a CRES. Early ICU admission, close collaboration between haematologists and intensivists, and prompt administration of appropriate therapy (IL-6 inhibitor and/or dexamethasone) and supportive care resulted in a good prognosis. Compliance with ethics regulations: Yes. Rationale: Tisagenlecleucel (CTL019) is a chimeric antigen receptor T cell therapy that reprograms autologous T cells to target CD19 + leukemia cells, approved in the US since August 2017 and in the EU since August 2018 for children and young adult (< 25 years old) with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL). This study reports the experience of PICU management of CTL019 toxicity in patients treated in Robert-Debré University Hospitals. Patients and methods: All patients (age < 18 years old) treated by Tisagenlecleucel infusions between March 1, 2016 and September 15, 2019, included in sponsored-clinical trials or treated within the French compassionate program or with the commercial product, were retrospectively analyzed. Results: Twenty-four patients were infused and 8 patients (33%) were managed in PICU for 11 stays. (2 stays: n = 1 and 3 stays: n = 1). Median age at PICU admission was 11.5 years old [10.9; 13.2] with a median delay after CAR-T cells infusions of 5 days [4.5; 6] . The median length of stay in PICU was 2 days [1.5; 3] with a max at 25 days. Cytokine release syndrome (CRS) was the main indication of PICU hospitalization (37.5%, n = 9) with grade 2 (n = 5) and grade 3 (n = 4) according to American Society for Transplantation and Cellular Therapy (ASTCT) consensus grading system and treated by corticosteroid (n = .9) and Tocilizumab (n = 5, only one infusion). Norepinephrine was the only vasopressor used. The median Vaso-Inotrope Score (VIS) for grade 3 was 20 [17.5; 22 .5] with a maximum at 30. Neurologic toxicity was observed in 2 patients with a grade 4 (status epilepticus) and grade 3 (focal edema on neuroimaging with depressed level of consciousness) according to Immune effector Cell-associated Neurotoxicity Syndrome (ICANS) grading system from ASTCT consensus. The status epilepticus was managed with anti-epileptic drugs without mechanical ventilation. The focal edema was related to HHV6 and toxoplasmosis encephalitis. Evolution was positive with foscavir and ganciclovir and 14 days of mechanical ventilation. One patient was hospitalized for septic shock secondary to gram-negative central line bloodstream infection in aplasia, with a VIS score at 20. Evolution was favorable with antibiotics and central line removal. No death in PICU from severe Tisagenlecleucel toxicity was observed since the beginning of the CAR-T cells program. Conclusion: Toxicity profile of Tisagenlecleucel required frequent and early PICU hospitalization after infusions for severe CRS and ICANS management. Compliance with ethics regulations: Yes. Rationale: CAR-T cell (chimeric antigen receptor T) therapy is a promising treatment in refractory acute lymphoid leukemia (ALL) and diffuse large B cell lymphoma (DLBCL). The main complication consists in a cytokine release syndrome (CRS) leading to an inflammatory state that can be very severe with life-threatening organ failure. Neurological toxicity is also reported. We aim to describe CAR-T cells-related complications in ICU patients. Patients and methods: this is a single-center prospective study conducted between July 2017 and August 2019. All the patients who have received CAR-T cells and who required ICU admission were included. CRS grading was defined according to the most recent classification of the ASBMT and neurological toxicity was assessed with the CARTOX scale. Each admission is considered independent and therefore corresponds to one patient. Results: 48 admissions, representing 41 patients (27 men and 14 women), were considered. The median age was 56 years . Twothirds of the patients have been diagnosed with DLBCL (n = 34, 71%) and one-third with ALL (n = 14, 29%), 31 months [23-59] ago. They had received 4 lines [3] [4] of chemotherapy and had a high tumor burden (65% of lymphomas classified stage IV). The majority of the patients was admitted because of hemodynamic failure (n = 23, 48%) or respiratory failure (n = 9, 19%), 5 days [3] [4] [5] [6] [7] after CAR-T cells infusion. SOFA at admission was 4 [2] [3] [4] [5] [6] . All the patients presented at least one complication ( Figure) , the most common being CRS (n = 39, 81%) with a median grade of 2 [1] [2] . Neurological toxicity was reported in 17 (35%) patients (worst grade at 3 [2] [3] [4] ). Documented bacterial infection involved 29% of the patients and consisted in catheter-related infections for half of the cases. In the ICU patients were managed with fluid resuscitation (n = 27, 56%) during the first day, vasopressors (n = 14, 29%) and broad spectrum antibiotics (98%). A single patient required mechanical ventilation and two patients underwent dialysis. Tocilizumab (anti-IL6 receptor) was given to 34 patients (87% of CRS) in a median time of 5.5 h [2.1-21.5 ] after ICU admission. 30 patients (61%) received corticosteroids. The median ICU length of stay was 4.5 days [3] [4] [5] [6] . 3 patients (6%) died in the ICU and hospital mortality was 14%.

The 5-Fluorouracil (5-FU)-induced hyperammonemic encephalopathy is a rare but serious 5-FU adverse drug reaction, which could require the admission of patients in intensive care unit (ICU). Given the paucity of data regarding this 5-FU adverse drug reaction, we performed a retrospective national survey from the French pharmacovigilance database to better characterize 5-FU-induced hyperammonemic encephalopathy and its management. Patients and methods: Since the inception of the French pharmacovigilance database, we identified all patients that experienced 5-FU-induced encephalopathy. Variables regarding epidemiology, characteristics, management and prognosis of these patients were collected and analyzed. Results: From 1985 From to 2018 years-old, 43% of women) were included. Overall mortality was 17% (n = 5) and 57% (n = 17) of patients were admitted in ICU. The 5-FU-induced hyperammonemic encephalopathy started 2 [1] [2] [3] [4] days after the onset of 5-FU infusion. The most common neurological disorders were consciousness impairment, confusion and seizures. Abnormalities in CT scan, MRI, electroencephalogram and lumbar puncture were found in 9%, 65%, 77% and 16% of the whole population respectively, similar in ICU and non-ICU patients. Ammonemia was dosed in 50% of the whole population and in 65% of ICU patients. Hyperammonemia tended to be higher in ICU than in non-ICU patients (250[133-522] vs. 139[68-220] µmol/L, respectively, p = NS) and in patients with the lowest Glasgow outcome scale, but was not different between survivors and non-survivors. Among ICU patients, 70% required mechanical ventilation and 47% anti-epileptic drugs administration. Besides 5-FU discontinuation, lactulose intake, renal replacement therapy or ammonium chelators were used to decrease hyperammonemia in 17%, 27% and 7% of patients respectively. A complete neurological recovery was observed in up to 70% of ICU and non-ICU patients within a delay of 5[2-10] days. A dihydropyrimidine deshydrogenase (DPD) deficiency was found in 21% of tested patients. A 5-FU rechallenge was considered in 47% (n = 14) of patients with complete neurological recovery, including a patient with a partial DPD deficiency, within a delay of 19[18-28] days after recovery. A 5-FU-induced hyperammonemic encephalopathy relapse was observed in 57% of patients with 5-FU rechallenge. No relapse was observed when 5-FU rechallenge was performed with a decreased 5-FU dosage. Conclusion: We report the first national survey and the largest cohort of patients with 5-FU-induced hyperammonemic encephalopathy so far. This serious 5-FU adverse drug reaction must be known by intensivists, since more than half of patients are admitted in ICU and specific treatments are available. Compliance with ethics regulations: Yes.

Immune related adverse events: a retrospective look into the future of oncology in the intensive care unit Adrien Joseph 1 , Annabelle Stoclin 2 , Antoine Vieillard-Baron 3 , Guillaume Geri 3 , Jean-Marie Michot 4 Rationale: Immune checkpoint inhibitors (ICI) represent a paradigmatic shift in oncology. With their new position as a mainstay in cancer treatment, new toxicities called immune related adverse events (irAEs) have emerged. Patients and methods: Retrospective study including patients admitted in the ICU within 60 days after treatment with an ICI in 3 French hospitals. Patients were classified into 3 groups according to the reason for admission: irAE, intercurrent adverse event (intAE) or event related to tumor progression (TumProg). Results: 84 patients were admitted during the course of an ICI treatment, including 21 irAE, 25 intAE and 38 TumProg, with a significant increase between 2013 (n = 1) and 2018 (n = 24 patients, p for trend < 0.001). irAE included 5 pneumonitis, 4 colitis, 4 diabetes complications, 2 hypophysitis, nephritis, myocarditis and cardiac disorders, hepatitis or allergic reaction and 1 meningitis. The immune related nature of the complication was known before admission in only 4 (18%) cases. Mean age was 61 (± 14) years and 73% had a performance status of 0-1. Primary tumors were melanomas (14, 67%), non-small cell lung cancers (4, 19%) , urothelial carcinomas (2, 10%) and Hodgkin lymphomas (1, 5%) . ICI at the time of admission included anti-CTLA4 (5, 24%), anti-PD1/PDL1 (10, 48%) and anti-CTLA4/anti-PD1 combination in 6 (29%) patients. Mean duration of stay in the ICU was 6.5 (± 9) days. Three patients required vasopressor therapy alone, 2 with mechanical ventilation and one with extracorporeal membrane oxygenation. Three patients required non-invasive ventilation and 2 renal replacement therapy alone. Six required only endocrine or electrolytic equilibration and 4 others did not receive any form of organ support. ICU mortality was 14%. Compared with other admissions, anti-CTLA4 or anti-CTLA4/anti-PD1 combination treatments were associated with irAE diagnosis (OR = 6.1 [1.1-43.4] , p = 0.021 for anti-CTLA4 and 5.7 [1.2-31.4] for anti-CTLA4/anti-PD1, p = 0.014) and so was the diagnosis of melanoma (5.7 [1.8-20.1] , p = 0.001). There was no difference in terms of ICU and post-ICU survival between irAE (median post-ICU survival 14 months [7-NA]), intAE (20.9 [9.5-NA]) and ). Six patients admitted for an irAE were rechallenged with the same ICI after ICU discharge and 3 achieved complete response. Conclusion: We conducted the first study describing patients admitted in the ICU for irAEs. Their specific and heterogeneous profile, along with the expected increase in the number of admissions, underlines the need for an in-depth knowledge for ICU physicians in order to take part in the multidisciplinary care required by these patients. Compliance with ethics regulations: Yes. Rationale: Patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (ICU). In this context, acute respiratory failure due to cancer involvement is the worst situation. In the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the ICU. Unlike cytotoxic chemotherapy, the fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for ICU patients. We sought to investigate the outcomes of patients with lung cancer involvement responsible for acute respiratory failure and who received Tyrosine Kinase inhibitor during ICU stay. Patients and methods: We performed a national multicentric retrospective study with the participation of the GRRROH (Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie). All patients with non-small-cell lung cancer admitted to the ICU for acute respiratory failure between 2009 and 2019 were included in the study if a Tyrosine Kinase Inhibitor was initiated during ICU stay. Cases were identified using hospital-pharmacies records. We collected demographic and clinical data in ICU charts. Vital status was assessed at the time of study completion (August 2019). The primary outcome was overall survival 90 days after ICU admission. Results: Twenty-nine patients (age: 60 ± 14 years old) admitted to a total of 14 ICUs throughout France were included. Seventeen patients (59%) were nonsmoker. The most frequent histological type was adenocarcinoma (n = 20, 69%) and a majority had metastatic cancer (n = 21, 72%). Epithelial Growth Factor Receptor mutation was the most common oncologic driver identified (n = 15, 52%). During the ICU stay, 16 (55%) patients required invasive mechanical ventilation, 12 (41%) catecholamine infusion, 3 (10%) renal replacement therapy and one (3%) extracorporeal membrane oxygenation. In addition to Tyrosine Kinase Inhibitor, 20 (69%) patients received steroids (beyond 0.5 mg/Kg/day) and 3 (10%) cytotoxic chemotherapy during ICU stay. Seventeen patients (59%) were discharged alive from ICU and 9 (31%) were still alive after 90 days (see Kaplan-Meier curve Figure) . Moreover, 5 patients (17%) were alive one year after ICU discharge. Conclusion: Despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of Tyrosine Kinase Inhibitor should not be refrained in patients with severe condition in ICU. Compliance with ethics regulations: Yes. Rationale: Acute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients and the need for invasive mechanical ventilation has become a major clinical end-point in randomized controlled trials (RCT). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs. Patients and methods: Hierarchical models and permutation procedures for testing multiple random effects were applied on both data from observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers. Results: The crude intubation rate varied across ICUs from 29% to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p-value = 0.013, Median OR 1.48 [1.30-1.72 ]; RCT: p-value:0.004, Median OR 1.51 [1.36-1.68 ]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation. Conclusion: Invasive mechanical ventilation has become an important endpoint in immunocompromised patients with acute respiratory failure. However, we found significant variation in intubation risk across ICU in both an observational cohort and a randomized controlled trial. Our results highlight the need to take into account center effect in analysis because it could be an important confounder. Reasons for heterogeneity are various (case-mix differences, center practices). This gives opportunities to future improvement in care management and study design. Compliance with ethics regulations: Yes. Rationale: Influenza virus (IV) infection is a major cause of ARDS that has been the focus of attention since the pandemic 2009 H1N1 (H1N1pdm2009) IV. Although IV-mediated damage of the airway has beenextensively studied emphasizing specificity compared to other causes of ARDS, the impact of IV infection on the prognosis of ARDS patients, compared to the other causes of ARDS, has been few assessed. Patients and methods: Systematic detection of IV in times of epidemic using RT-PCR in respiratory specimen is routine practice in our ICU along with prospective data collection of patients admitted to our ICU for ARDS with PaO 2 /FiO 2 ratio ≤ 150 mmHg. All patients received lung-protective ventilation, the Sequential Organ Failure Assessment (SOFA) score was calculated on the first 3 days of mechanical ventilation. The primary endpoint compared the 28-day survival from the diagnosis of ARDS between patients with and without IV infection. Results: From October, 2009 to May, 2019, 509 patients (pts) [median SAPS II score = 59 (33-67); age 58 years (47-68); PaO 2 / FiO 2 ≤ 100 mmHg, n = 308 (61%)] were admitted to our ICU for ARDS with PaO 2 /FiO 2 ratio ≤ 150 mm/Hg, including 100 pts (20%) with IV infection (H1N1pdm2009 IV A, n = 45; H3N2 A virus, n = 45; B virus, n = 10; associated bacteria, n = 46). Other main causes of ARDS were bacterial pneumonia without IV (39%), aspiration (15%), non-pulmonary sepsis (18%). 221 (42%) received prone positioning, and 47 (9%) extra-corporeal membrane oxygenation. The overall mortality rate at day-28 for the entire population was 33% (22 pts (22%) with IV infection versus 148 pts (36%) without IV infection, p = 0.007). Kaplan-Meier survival curves showed that survival was significantly higher in patients with IV infection than in those without IV infection. IV infection remained independently associated with a better prognosis at day-28 when entered as dichotomous variable (IV infection, yes/no) (adjusted hazard ratio (HR) = 0.60, 95% CI 0.37-0.98, p = 0.04) and when IV infection only was distinguished from other causes of ARDS including mixed infection IV plus bacteria (adjusted HR = 0.37, 95% CI 0.19-0.72, p = 0.003). Of note, within the first 3 days of mechanical ventilation, non-pulmonary SOFA scores were significantly lower in IV patients although similar pulmonary SOFA scores. Conclusion: Our results suggest that patients with IV related ARDS have less severe non-pulmonary organ dysfunctions than those with ARDS from other and a lower mortality at day-28 despite similar ARDS severity. Compliance with ethics regulations: Yes. Rationale: Acute Respiratory Distress Syndrome (ARDS) remains frequent in intensive care unit (ICU) with 20% to 40% mortality. According to Joint Theater Trauma System, ARDS occurs among 30% of war casualties: direct lung trauma, blast lesions, burn, massive transfusion and systemic inflammatory response syndrome lead to ARDS development. However, there is no data reporting ARDS among French evacuated casualties from forward environment. Our study's aim is to describe ARDS incidence and its severity concerning medical evacuations from War Theater. Patients and methods: This is an observational retrospective multicentric study analyzing all evacuated patient from War Theater and admitted in ICU. All patients developing ARDS according to Berlin definition have been included. Study has been approved by local ethic committee. Primary study endpoint was ARDS developing. Second study endpoints were ARDS severity, duration of invasive ventilation, ARDS treatments, ICU length of stay and mortality. Results: 141 patients have been admitted in ICU between 2003 and 2018. 5 have been excluded. A total of 136 patients have been analyzed. 84% (n = 48) were military aged 30 (25-36) years. 42% (n = 57) developed ARDS. We found 57% (n = 32) war casualties, 30% (n = 17) trauma not related to war and 14% (n = 8) medical patients. Among severe trauma, median ISS was 34 (27-44), AIS thorax 3 (2) (3) (4) , and 71% benefited from surgery on forward environment and 37% (n = 18) received massive transfusion. 22% (n = 13) suffered from mild ARDS, 42% (n = 24) moderate ARDS and 36% (n = 20) severe ARDS. Evacuation time was 26 (24-48) h. At admission in ICU, PaO 2 /FiO 2 ratio was 241 (144-296) (Fig. 1 ). All patients were intubated. ARDS treatments used were curarization (76%, n = 43), prone position (16%, n = 9), inhaled nitric oxide (NOi) (10%, n = 6), almitrine (7%, n = 7) and extracorporeal life support (ECLS) (4%, n = 2). Invasive ventilation duration was 13 (7-27) days, length of stay 18 (9-33) days, and 3-month mortality 21% (n = 12). Conclusion: According to our study, ARDS among French evacuated patients from war theaters remains frequent: it occurs on 42% among ICU admitted patients. 36% suffer from severe ARDS with 21% global mortality. Those datas are consistent with US studies. Also, we wonder if we must adapt our treatment capacities on forward environment for the most severe patients. In US army, a specialized team (Acute Lung Rescue Team) is trained to care the most hypoxemic war casualties with more treatment options as NOi, ECLS. Compliance with ethics regulations: Yes. Rationale : We recently reported that septic shock patients with pneumonia exhibit a high risk of ICU-acquired pneumonia, suggesting that a primary pulmonary insult may drive profound alterations in lung defence towards secondary infections (1) . Given their importance in lung immune surveillance, alveolar macrophages (AM) are likely to play a pivotal role in this setting. The objective of this experimental study is to address the impact of primary pulmonary or non-pulmonary infectious insults on lung immunity. Patients and methods: We established relevant double-hit experimental models that mimic common clinical situations. C57BL/6 J mice were first subjected either to polymicrobial peritonitis induced by caecal ligation and puncture (CLP), or to bacterial pneumonia induced by intra-tracheal instillation of Staphylococcus aureus or Escherichia coli. Respective control mice were subjected to sham laparotomy or intratracheal instillation of phosphate-buffered saline. Seven days later, mice that survived the primary insult were subjected to intra-tracheal instillation of Pseudomonas aeruginosa (PAO1 strain). We assessed survival and pulmonary bacterial clearance of post-septic animals subjected to P. aeruginosa pneumonia, as well as the distribution and functional changes in alveolar macrophages. Results: When compared to sham-operated mice, post-CLP animals exhibited increased susceptibility to secondary P. aeruginosa pneumonia as demonstrated by defective lung bacterial clearance and increased mortality rate (50% vs. 0%, p < 0.05). In contrast, all postpneumonia mice survived and even exhibited improved bacterial clearance as compared to their control counterparts. When addressing whole-lung immune cell distribution at the time of second hit (day 7), amounts of AM were decreased in post-CLP mice while preserved or even increased in post-pneumonia mice. Antigen-presenting functions of AM appeared similar in all conditions. Percentages of apoptotic (AnnexinV + ) and necrotic (7-AAD + ) AM were comparable at day 1 and day 7 after the first hit. Interestingly, both Ly6C high and Ly6C low monocytes were sustainably increased in the lungs of post-CLP mice, while only transiently expanded following pneumonia, suggesting that differences in AM counts could be related to modulated turnover from precursor monocytes. Conclusion: Using clinically relevant double-hit experimental models, a primary pulmonary infection conferred resistance to secondary bacterial pneumonia. Ongoing investigations are aimed at addressing the antibacterial AM functions, as well as the turnover-driving mechanisms.Compliance with ethics regulations: Yes. Rationale: Little is known on the role of exit-site signs in predicting intravascular catheter infections. The current study aimed to describe the association between local signs at the exit-site and catheter-related bloodstream infection (CRBSI), which factors substantially influenced local signs and which clinical conditions may predict CRB-SIs if inflammation at insertion site is present. Patients and methods: We used individual data from 4 multicenter randomized-controlled trials in intensive care units (ICUs) that evaluated various prevention strategies regarding colonization and CRBSI in central venous and arterial catheters. We used univariate and multivariate logistic regression stratifying by center in order to identify variables associated with redness, pain, non-purulent discharge, purulent discharge and ≥ 1 local sign and subsequently evaluate the association between CRBSI and local signs. Moreover, weevaluated the role of thedifferent local signs for developing CRBSI in subgroups of clinically relevant conditions. Results: A total of 6976 patients, 14,590 catheters (101,182 catheterdays) and 114 CRBSI (0.8%) from 25 ICUs withdescribed local signs were included. Redness, pain, non-purulent discharge, purulent discharge and ≥ 1 local signs at removal were observed in 1633 (11.2%), 59 (0.4%), 251 (1.7%), 102 (0.7%) and 1938 (13.3%) episodes, respectively. The sensitivity of ≥ 1 local sign for CRBSI was by 40.4%, whereas the highest specificities were observed for pain (99.6%) and purulent discharge (98.4%). Positive predictive value (PPV) was low for redness (2%), pain (3%), non-purulent discharge (3%) and ≥ 1 local sign (2%), but increased for purulent discharge (12.7%). Negative predictive values were high for all local signs. After adjusting on confounders, CRBSI was associated with redness, non-purulent discharge, purulent discharge and ≥ 1 local sign (Fig. 1 ). Conditions independently associated with ≥ 1 local sign were age ≤ 75 years old (OR 1.23, 95% CI 1.07-1.40, p < 0.01), SOFA score (SOFA < 8 OR 1.45, 95% CI 1.23-1.71, p < 0.01), non-immunosuppression (OR 1.38, 95% CI 1.12-1.68, p < 0.01), catheter maintenance > 7 days (OR 3.36, 95% CI 3.03-3.73, p < 0.01) and insertion site (OR for subclavian site 1.63, 95% CI 1.37-1.93, p < 0.01). However, the presence of ≥ 1 local sign was more predictive for CRBSI in the first 7 days of catheter maintenance (OR 6.30, 95% CI 3.53-11.24 vs. > 7 catheter-days OR 2.61, 95% CI 1.58-4.32, p heterogeneity = 0.02). Conclusion: This post hoc analysis showed that local signs were related to CRBSIs in the ICU. Local signs were independently associated with specific patient's and catheter's conditions. In the first 7 days of catheter maintenance, local signs were predictive for CRBSI. Compliance with ethics regulations: Yes. Rationale: Pneumococcal meningitis (PM) is the leading cause of bacterial meningitis in adult patients requiring ICU admission and is associated with a high case fatality rate (CFR), ranging from 15 to more than 33% (1) (2) (3) . Patients with PM may develop sepsis or septic shock that may impact management and outcomes. We aim to describe the epidemiology and outcomes of PM associated with sepsis in adult patients in France.

We analysed the occurrence of PM with sepsis from 2010 to 2015 in adult patients, using the national French hospital Database PMSI (Programme de Médicalisation des Systèmes d'Information). For all analyses, only the first hospital admission was considered. Cases were identified using a combination of a diagnosis code for PM plus a diagnosis code for sepsis (either a code for organ failure or a procedure code for organ support). Data recorded included comorbidities (4), characteristics of the hospital stay, severity of the patients including major intracranial complications and characteristics of the infection. Costs and endpoints were determined at the end of all the hospital stays related to the first admission for PM with sepsis. Standardized incidence, hospital mortality, and CFR were estimated. Temporal trends were assessed using Cochran Armitage tests of trends and linear trend analyses. Results: A total of 1236 PM with sepsis aged ≥ 18 years were hospitalized in France during 2010-2015. The incidence of PM decreased from 3.7 to 2.6 per 1 M inhabitants (p < 0.02) (Fig. 1) . Most of them came from home (94%), were admitted in an academic institution (93%) and benefited from ICU (93%). Their median age was 62 [51; 73] years. Twothird of them had at least one comorbidity. The initial neurological presentations included coma (58%), focal signs (15%), seizures (12%) and brain stem involvements (16%). The SAPS II score was 57 [44; 69] points. The main neurological complications were cerebrovascular complications (6%), cerebral abscess (4%) and hydrocephaly (2%). PM was associated with pneumococcal septicaemia or pneumococcal pneumonia in 30% and 23% of cases respectively. The length of ICU and hospital stays were 10 [4; 21] and 22 [10; 41] days respectively and only ICU length of stay decreased over time (p < 0.01). The prognosis was poor since only 27.6% of the patients were discharged to home. Indeed, 42.6% of them died and 18% were transferred to rehabilitation units. No temporal trends could be observed for these outcomes. The average hospital costs per case were 21, 717€ [13.198; 34.232] . Conclusion: PM with sepsis in adult in France remained a real burden associated with a high mortality rate, and disability.

Compliance with ethics regulations: NA. Rationale: Mucormycosis is an emerging fungal infection, especially in patients with hematological malignancies. Although this infection may lead to multi organ failure, no study has been dedicated to critically ill patients with hematological malignancy. The primary objective was to assess outcome in this setting. The secondary objective was to assess prognostic factors. Patients and methods: This retrospective cohort study was performed in 5 ICUs. Critically ill adult patients with hematological malignancies and mucormycosis were included between 2002 and 2018. Mucormycosiswas classified as "probable"or "proven" regarding EORTC criteria. Variables are reported as median [IQR] or number (%). Adjusted analysis was performed using Cox Model. Results: Twenty-six patients were included with a median age of 38 years [IQR, . Acute leukemia was the most frequent underlying disease (n = 13, 50%). Nine patients (35%) were allogeneic stem cell transplantation (SCT) recipients. Nineteen patients (73%) had neutropenia and 16 patients (62%) had received steroids. The main reason for admission was acute respiratory failure (n = 14, 54%) followed by shock (n = 5, 19%). The median SOFA score at admission was 7 [IQR, 5-8] points. Only 3 patients (11%) had received prior anti-fungal prophylaxis effective against mucorales. Mucormycosis was "proven" in 14 patients and "probable" in 12 patients. Diagnosis was made by histopathologic examination in 14 patients, direct microscopy or culture in 5, and polymerase chain reaction in 7. Rhizopus and Mucor were the most frequent documented species. Seven patients (27%) had concurrent Aspergillus infection. Mucormycosis was diagnosed 1 day [− 4 to + 6] after ICU admission. Ten patients (38%) had pulmonary involvement whereas five patients (19%) had rhino-cerebral involvement. Infection was disseminated in eight patients (31%). Twenty-two patients (85%) were treated with liposomal amphotericin B. Twelve patients (46%) received antifungal combination including posaconazole in 7. Eight patients (31%) underwent curative surgery. Multiple organ failure was frequent, 21 patients (81%) requiring invasive mechanical ventilation (IMV), 19 (69%) vasopressors, and 9 (35%) renal replacement therapy. ICU and hospital mortality rates were 77% and 88%, respectively. Only two patients were alive at day 90. Three variables were associated with mortality in a Cox model including allogeneic SCT .32]; figure), SOFA score (HR 1.19 [95% IC 1.02-1.39]) and dual therapy (HR 3.02 [95% IC 1.18-7.72]) (Fig. 1) . Conclusion: Mucormycosis is associated with a high mortality rate in patients with hematological malignancies, especially in allogeneic SCT recipients. Futility of ICU management in these patients is to be considered and strategies aiming to improve these patients' outcome are urgently needed. Compliance with ethics regulations: Yes. Rationale: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Several mediators, alone or in combination, were proposed to characterize individual response, but none was proven to have good external validity. The aim of this work was to establish whether some combinations are linked to clinical phenotypes in patients with presumed sepsis, using the data collected in the Captain multicenter cohort which methods and first results were previously published (Parlato, ICM 2018). Patients and methods: 279 patients were prospectively included at the time of sepsis criteria, 188 (67%) of whom with a secondary confirmed infection. Community acquired pneumonia was causal in 70% of infections. SAPS2 score = 55 points [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] , age = 65 years , male sex = 64%. 203 patients were followed for more than 3 days, in whom usual ICU clinical and biological parameters were collected, as well as 29 plasma biomarkers and 10 leucocyte associated RNAs. Patients were clinically classified according to their acute severity (SOFA score, serum lactate), confirmed initial infection, outcome (secondary infection occurrence, ICU survival). Non-supervised principal component analysis of the maximal values of biomarkers assessed on first 2 days of sepsis, and Varimax rotation technique of the selected components using SAS software. Results: 203 patients, med SOFA day1 = 5 pts, med serum lactates day 1 = 1.5 mEq/L, bacterial infection = 141 (69%), Enterobacteriaceae infection = 45 (22%), VAP and/or bacteremia after day 5 = 30 (15%), alive at ICU d/c = 146 (72%). Five components explain 57% of the variance of the biomarkers. The first component (26% of the variance) was not linked to the clinical predetermined phenotypes. The second component (11% of the variance) was principally made of HLA-DR RNA, CD74 RNA and CX3CR1 RNA, and linked to a lower initial severity (r = − 0.32, p = 0.0001), a less frequent confirmation of initial infection (p = 0.0001), a lower occurrence of pneumonia or bacteremia (p = 0.02) or death (p = 0.008). Conclusion: In our cohort, using non supervised analysis, we could separate a biomarker association linked to lower initial severity, lower rate of a bacterial cause to sepsis, and better outcome. The markers found are among those which are regularly considered as describers of the peripheral alteration of the immune system observed during sepsis (Pachot, CCM 2005; Friggeri, CC 2016; Peronnet ICM 2017) . Compliance with ethics regulations: Yes. (1) compared a standard of care to a procalcitonin (PCT) oriented use of antimicrobials for sepsis in 8 iCUs. Serial blood samples were biobanked in 4/87 ICUs (455/621 patients enrolled for pro-adrenomedullin (ProADM) and PCT concentrations). Patients and methods: The aim of the study was to evaluate the respective impact of serial PCT and proADM measurements in predicting relapse or superinfection and death on day 28*. Relapse was defined as the growth of one or more of the initial causative bacterial strains (i.e., same genus, species) from a second sample taken from the same infection site at 48 h or more after stopping of antibiotics, combined with clinical signs or symptoms of infection. Superinfection was defined as the isolation from the same or another site of one or more pathogens different from that identified during the first infectious episode, together with clinical signs or symptoms of infection [4] [5] [6] [7] [8] [9] [10] [11] points at amission, medical admission: 427 (95%), immunocompromised: 81 (18%), on mechanical ventilation 306 (67%), PCT and ProADM at inclusion were 2 [0. 6-9.3] ng/mL and 1.5 [0.4-2.7 ] nM/L respectively. 173 (38%) patients developed a first episode of recurrence or supereinfection after a median delay of 11 days [8] [9] [10] [11] [12] [13] [14] [15] [16] and 98 (22%) died before d28. The HR maximization process proposed an optimal cut point of 1 ng/mL for PCT and 2 nM/L for Pro ADM to predict d28 death. In the multivariate Cox model, both PCT and ProADM were associated with death but not with relapse or superinfection (Table 1) . Conclusion: Conclusion: Both serial measurements of PCT and ProADM are independent predictors of death in patients treated for sepsis in ICU. Our study confirmed the use of 2 nM/L as a good prognosis cut point for ProADM. 1. Compliance with ethics regulations: Yes. Rationale: The performance of serum (1-3)-β-d-glucan (BDG) and its evolution to predict the occurrence of invasive fungal infection (IFI) in a high risk non immunocompromized population remains to be determined (1). In a post hoc analysis of the EMPIRICUS Randomized Clinical Trial (2), we aimed to assess the prognostic value of repeated measures of BDG on the occurrence of invasive fungal infections. Patients and methods: Non-neutropenic, non-transplanted, critically ill patients with ICU-acquired sepsis, multiple Candida colonization, multiple organ failure, exposed to broad-spectrum antibacterial agents, and enrolled between July 2012 and February 2015 in 19 French ICUs were included. BDG were collected in ICU at day 0, 3, 7, 14 and 28 after inclusion. A value Time 0 of more than 80 pg/ mL, 250 pg/mL and an increase by more than 24% from the previous measurement (threshold of measurement error) were assessed at baseline and overtime. For that purpose, we conducted cause specific hazard models with death as a competing risk. We also planned subgroup analyses on the placebo and the micafungin groups. Cumulative risk (CumRisk) of IFI at day 28 were derived from models. [4.7; 5.2] ). Neither a BDG > 250 pg/mL, nor an increase by 24% of BDG over time were associated with the occurrence of IFI. Similar results were found in the placebo subgroup. Conclusion: Among high risk patients, a first measurement of BDG over 80 pg/mL was highly associated with the occurrence of IFI. Neither a cut-off of 250 pg/mL, nor repeated measurements of BDG over time seemed to be useful to predict the occurrence of IFI. The cumulative risk of IFI in the placebo group if BDG > 80 pg/ml is 25.39% questioning about the potential interest of empirical therapy in this subgroup. Compliance with ethics regulations: Yes. Rationale: Since the 2016 Sepsis-3 conference, the distinction between sepsis and septic shock is based on blood lactate value. Septic shock may be encountered in the pre-hospital setting. In order to reduce the mortality, the precocity of treatments implementation has been emphasized, particularly early antibiotic administration. Prior antibiotic administration, and blood culture drawing must be performed. The aim of this survey was to clarify the capabilities of French prehospital emergency service (PEMS) to measure blood lactate and to draw blood culture prior to hospital admission for septic shock. Patients and methods: We performed an electronic survey of 26 auto-questions addressed to the deputy chair of the French PEMS in 2018. Results: Sixty PEMS (60%) participated in the survey. Twenty-five percent are able to measure blood lactate and 45% are able to draw blood culture in the prehospital setting. Ninety-five percent declared lactate measurement is helpful in assessing severity. Ninety percent claimed that the lactate value influences the hospital facility, emergency department vs. intensive care unit. Twenty-eight percent believe that the impossibility to draw blood culture precludes prehospital antibiotic administration. Sixty-three percent estimate that a protocol for septic shock management would be beneficial. Conclusion: Few French PEMS are able to measure lactate and draw blood culture in the prehospital setting. The impact of blood lactate measurement and blood culture drawing by PEMS on septic shock outcome requires further studies. Compliance with ethics regulations: Yes. Rationale: Head injury is a common cause of morbidity and mortality in the first four decades of life, accounting for approximately 200,000 annual hospital admissions in the United Kingdom. The majority of patients recover without intervention, however some may develop a long-term disability or even die. The early detection of pathology is therefore absolutely critical in determining patients' prognosis, helping to provide appropriate timely management. The National Institute for Health and Care Excellence (NICE) adult head injury guidelines, recommend that head injuries with specific risk factors should have a CT scan within 1 h of risk factors being identified. Furthermore the provisional report should be made available within 1 h of the scan. This audit assessed the compliance of staff to the NICE adult head injury guidelines. Patients and methods: The previous 40 adult CT head scans, requested due to head injury, from the Emergency Department (ED) at London North West Healthcare NHS Trust were analysed for compliance to the NICE guidelines. The standards measured were: (1) Time from request of scan to completion of scan should be within 1 h; (2) Time from completion of scan to publication of provisional report should be within 1 h. The locally agreed target for both standards was 100%. Results: On review of the 40 CT scans, 32 (80%) were completed within 1 h of request. From the 8 scans (20%) not completed within the hour, 4 were due to porter unavailability, 1 due to an uncooperative patient and the remaining 3 reasons were not clear from documentation. Following completion of the scan, 38 scans (95%) were provisionally reported within 1 h. Conclusion: This study highlighted a good compliance by hospital staff in ensuring patients with head injuries are managed appropriately, following detection of risk factors indicating a CT head scan. Having said that, the locally agreed targets were just short of being met. One factor resulting in delayed scans was porter availability. An intervention recently introduced is the use of the "e-portering" application, which will endeavour to save time for referrers requesting porters and allow patient tracking. It is also worth educating porters, via email bulletins, on the importance of priority scans, such as CT head following injury. Furthermore, the findings of the audit were relayed to the radiology department to help improve reporting times and to the ED to re-emphasize prompt requesting of CT head scans when clinically indicated. Compliance with ethics regulations: Yes. Rationale: Continuous insufflation of oxygen (CIO) performed with specific endotracheal tube during cardiopulmonary resuscitation (CPR) is as effective as intermittent ventilation on endotracheal tube. Experimental data suggest that CIO improves the efficacy of external cardiac massage and reduces gastric dilatation. As endotracheal intubation is a cause of CPR interruption and requires skilled staff, a specific device has been developed to perform CIO without intubation. This device has been implemented progressively in our fire department since 2015. We evaluated this practice. Patients and methods: Longitudinal study comparing the patients with out-of-hospital cardiac arrest managed by our fire department with CIO or bag-valve ventilation between January 2015 and April 2019. Patients who received mechanical chest compression were excluded. The main outcome was hospital survival. Secondary outcomes were the return of spontaneous circulation (ROSC) and CPR quality. Univariate and multivariate analysis was performed in the whole cohort and in the sub-groups of patient with shockable and non-shockable rhythms to take into account factors associated with survival (shockable rhythm, witness, age). Results: Among the 793 patients included, 262 have been ventilated with CIO and 531 with valve-bag. The mortality was similar in the two groups (CIO: 85.1% valve-bag: 88.1% p 0.23). Mortality and ROSC were not associated with CIO in the multivariate analysis (odds ratio OR 1.19 95%-confidence interval CI95 [0.75-1.9] and 0.97 [0.59-1.6], respectively). CPR quality was better with CIO than with valve-bag regarding CPR fraction (ratio of duration of chest compressions on total duration of CPR, 84 versus 76% p < 0.0001) and adequacy to the guidelines of the rhythm and depth of chest compressions (70% vs 50% p < 0.0001 and 47% vs 38% p < 0.0001, respectively). In both subgroups of patients, CPR quality was still better with CIO than with valve-bag. In the subgroup of patients with shockable rhythm, univariate analysis showed a lower mortality among the 59 patients with CIO than among the 140 patients with valve-bag (57.6% vs 82.9% p < 0.001) but this difference was not confirmed by the multivariate analysis (OR 0.4 CI95 [0.10-1.03], p 0.06). Conclusion: CIO without intubation is associated with an improvement of CPR quality but neither with mortality nor return of spontaneous circulation in case of out-of-hospital cardiac arrest. Compliance with ethics regulations: Yes. Rationale: Cardiovascular accidents are a leading cause of death. A cardiopulmonary resuscitation (CPR) of quality has well shown that can reduce the mortality; despite this, survival rate has not changed significantly during last years. The aim of this study is to test a new wearable glove to provide lay people with instructions during out-ofhospital CPR. Patients and methods: We performed a blinded, controlled trial on an electronic mannequin AmbuMan to test the performance of adult volunteers, non-healthcare professionals performing a simulated CPR both, without and with glove, following the glove instructions. The group without glove, also called "no-glove" is intended as control group. Each compression performed on the electronic mannequin AmbuMan was recorded by a connected laptop computer, drawing a depth frequency curve over the time. Primary outcome was to compare the accuracy of the two simulated CPR sessions in terms of depth and frequency of chest compressions performed by the same lay volunteers. Secondary outcome was to compare the decay of performance and percentage of time in which the candidate performed accurate CPR. Finally, the participants were asked if the glove was useful for CPR maneuvers. The difference between the two groups in regard to change in chest compression depth over time due to fatigue, defined as decay were also analyzed. Results: 571 chest compressions were included: 293 in control group, 278 in glove group (Table 1) . Mean depth of compression in the control group was 55.17 mm versus 52.11 mm in the glove-group (p = 0.000016). Compressions with an appropriate depth were not statistically different (81.9% vs 73.6%, p = 0.017). Mean frequency of compressions in the group with glove was 117.67 rpm vs 103.02 rpm in the control group (p < 0.00001). The percentage of compression cycles with an appropriate rate (> 100 rpm) was 92.4% in the group with the glove versus 71% in the control group, with an observed difference of 21.4% between the two groups, which was statistically significant (p < 0.0001,CI = 95%). A mean reduction over time of compressions depth of 5.3 mm (SD 10.28) was observed in the control group versus a mean reduction of 0.83 mm in the group wearing the glove (SD 9.91), but this mean difference in the decay of compressions delivery was not statistically significant (f-ratio = 5.680, SS = 579.61, df = 1, MS = 579.61, p = 0.018). Conclusion: The visual and acoustic feedbacks provided by the device were useful in dictating the correct rhythm for non-healthcare professionals, translating in a significantly more accurate CPR. Compliance with ethics regulations: Yes. Rationale: Neuroprognostication after cardiac arrest (CA) is a crucial issue and current guidelines recommend delayed multimodal approach. We aimed to describe reasons for death in a prospective cohort of CA patients and evaluate the diagnostic accuracy of early combined neurological prognostication tools such as automated pupillometry (AP), continuous amplitude electroencephalography (aEEG) and Cardiac Arrest Hospital Prognosis (CAHP) score performed 24 h after return of spontaneous circulation (ROSC).

We set up a monocentric prospective cohort of adult CA patients admitted in ICU after sustained ROSC and collected data according to Utstein style recommendations. Reasons for death were described under recently proposed classification: withdrawal of life-sustaining therapies (WLST) for neurological reasons, WLST due to comorbidities, refractory shock or recurrence of sudden CA or respiratory failure. For patients who kept abnormal neurologic state after ROSC with Glasgow Coma Scale < 15, we analysed accuracy of early neuroprognostication tools (AP, aEEG and CAHP score) to predict poor neurological outcome, i.e. Cerebral Performance Category (CPC) > 2 at hospital discharge. Results: 144 patients were admitted after sustained ROSC from CA during the period (31.08.2018 to 10.07.2019). In-hospital mortality was 51%. Neurological WLST was the first reason for death (62%). Exhaustive early neuroprognostication with AP, aEEG and CAHP score was available for 75 patients. Among them, poor neurological outcome at hospital discharge (CPC > 2) was observed for 39 patients (52% (Fig. 1) . This strategy would falsely misclassificate 4% of patients in a good neurologic outcome category. Other survivors (24%) should then be investigated with further classical delayed neuroprognostication tools. Compliance with ethics regulations: Yes. Rationale: Management delay is one of the determining factors in the assessment of emergency department quality of care. Asking for a specialized advice seems to increase the time of delay. Our study aimed at measuring the delays in obtaining specialized advice and identify their major causes. Patients and methods: We conducted a prospective study over the period of 1 month. We included all adult patients presenting to the emergency department who required specialized advice. Data of all patients was collected. Waiting times and influencing factors were studied. Results: A total of 75 patients were included. The main reason for calling for a specialized advice was to ask for a department transfer in 68% of cases. The time of the day when specialized advice was solicited (n (%)): in the morning 51 (68); in the afternoon 17 (23); in the evening 9 (12). The main solicited specialties were (n (%)): visceral surgery 18 (24), trauma medicine 15 (20), cardiology 10 (13), urology 5 (7), and pulmonology 5 (7). The average waiting time between calling for and getting the specialized advice was 176 ± 115 min. Seventy-five percent of the specialized advice was obtained within 1 h. The causes of the delay were (n (%)): Physician busy in the operating room 22 (39), unreachable physician 9 (12), physician in the outpatient clinics 7 (10). The impact of the waiting time was (n (%)): conflict 20 (27), worsening patient state 4 (5). The average time between calling for the specialized advice and reaching a management decision was 210 ± 127 min. Conclusion: The increasing length of stay of patients in the ED is strongly correlated to the delay in obtaining specialized advice. The implementation of a strategy to reduce the waiting time is necessary to avoid overcrowding the emergency departments and provide optimal care. Compliance with ethics regulations: Yes. Rationale: Hypnoanalgesia has been used since few years to reduce ICU-patients physical and psychological discomfort during invasive procedures. However, feasibility of overall well-being management of intubated patients with hypnosis has not been described. Patients and methods: We report here the hypnotic accompaniment of a 16-year old patient without significant medical history hospitalized in our ICU for a severe GBS during 3 months. The GBS was diagnosed by electrophysiological study and immunologic markers. Patient had nearly complete paralysis of all extremities, but no facial or bulbar muscles. He received mechanical ventilation during 87 days, including weaning time. Tracheotomy was performed at day 15. Sedative drugs were stopped 2 days after intubation. Hypnosis sessions were startedvery early after intubation by one of our trained intensivist. Eight hypnotic sessions of hypnoanalgesia or hypnotherapy were performed after approval of the patient and his parents. Time distribution is reported in Fig. 1 . First and second sessions were performed in order to induce relaxation and reduce anxiety. Following sessions were dedicated to: 1) decrease pain intensity (initially neuropathic, then induced by physiotherapy), 2) attenuate the negative perception of paralysis, 3) reduce the discomfort of tracheotomy 4) promote the belief in healing 5) facilitate swallowing exercises. Furthermore the patient was quickly trained to use self-hypnosis in order to dissociate him from pain, anxiety and ICU pollutions. Results: Feasibility of hypnosis was judged satisfactory by the operating physician, despite mechanical ventilation. After extubation, final debriefing with the patient indicates that the most efficient sessions were those focused on anxiety disorders (using the suggestion of a safe place) and suggestions of mobility (using a mangas metaphor). The patient reported very positive perception of hypnosis use. He explained that self-hypnosis was effective to reduce many discomfort. He used it frequently (generally twice a day) for a puff of anxiety or before enoxaparin injection.

Our observation suggests that hypnosis seems feasible in ICU-awake patients and may be an interesting way to improve their ICU lived experience in combination with validated measures. Further investigations are needed to evaluate its effects on post-traumaticstress disorder. Compliance with ethics regulations: Yes. Rationale: There is little medical reference for hypnosis in the intensive care field. Closed specialties such as anesthesia, emergency medicine can help and refer to hypnosis for certain technical procedures. Objective: To propose landmarks for a successful implementation of hypnosis by intensivists within the intensive care unit. Patients and methods: This monocentric prospective observational study was performed from February 2018 to June 2019 in the 15-bed medical ICU of Brest University Hospital. Collected data were: characteristics of patients and hypnosis sessions performed, demographic data, physiological parameters (heart and respiratory rates) and objective and subjective evaluation of hypnosis sessions quality. Results: 60 patients were included (mean age 55.4 ± 19 years, SAPS II 34.5 ± 14 points). 100 hypnosis sessions were performed, of which 1/3 under mechanical ventilation. Patterns of hypnosis sessions were: anxiety/comfort (53%), during a technical procedure (38%): TOE, CVC placement, thoracic drainage, upper digestive or bronchial endoscopy), initiation of noninvasive ventilation or before intubation. Most of time, the hypnotic trance was permitted by formal hypnosis techniques with travel and nature themes suggestion. Efficacy was qualitatively assessed and rated as "total effectiveness" for 60% of sessions. Qualitative evaluation by hypnotherapist, technical operator and observers was respectively 7.25 ± 1.5, 9.25 ± 0.5 and 9 ± 1/10. Heart rate decreased from 93 ± 17 to 88 ± 13 bpm and respiratory rate/min decreased from 22 ± 7 to 17.7 ± 5 rpm during sessions. Discussion: After a meeting, the healthcare team carried out a brainstorming to propose hypnosis in our unit. Several difficulties were observed to explain implementation failures such as: finding competent patient, respiratory assistance, difficult communication, noisy environment, many nursing care, unexpected emergencies, etc.…). This experience allowed writing a vademecum to perform hypnosis in intensive care. Our aims are to get more trained caregivers and to integrate hypnosis during our postresuscitation consultation, especially for post-traumatic stress. Conclusion: Hypnotic tools can facilitate technical procedures and improve patients' and caregivers' quality of life within the ICU. Compliance with ethics regulations: Yes.

Effect of a musical intervention during central venous catheterization in an intensive care unit: the MUSIC CAT prospective randomized pilot study Sophie Jacquier, Brice Sauvage, Gregoire Muller, Thierry Boulain, Mai-Anh Nay CHR, Orléans, France Correspondence: Sophie Jacquier (sophie.jacquier@chr-orleans.fr) Ann. Intensive Care 2020, 10 (Suppl 1):F-112

Rationale: Evaluate the effect of a musical intervention on patient anxiety during a central venous access or a dialysis catheter implantation in an intensive care unit. Patients and methods: The MUSIC CAT study was a prospective, single-centre, controlled, open-label, two-arm randomized trial, conducted from February 2018 to February 2019. Central venous catheterization with musical intervention was compared to standard care, i.e., the usual procedure of central venous catheterization without listening to music. Eligible patients had to be able to hear, understand explanations and consent. Randomisation was stratified according to ventilation type (mechanical ventilation or not) and catheter site (superior vena cava or femoral vein). The MUSIC CARE ® (Paris, France) application was used to make the patients listen to music through headphones. Each patient chose his/her musical topic on a digital tablet, just before the catheterization. The primary outcome was the change in anxiety Visual Analogic Scale (VAS) between the beginning and the end of the catheterization procedure (T0-TF anxiety VAS). Secondary outcomes included the patient's pain VAS at the end of the procedure (TF pain VAS). Results: 31 patients were included in the standard care group versus 36 in the musical intervention group. Main reasons for admission were the need of central catheter for chemotherapy (27, 40%), and sepsis and/or shock in both groups (26, 39%). Catheters were inserted in the internal jugular vein in most cases (56, 82%) and about one-third were tunnelled in both groups. There was no between-group difference regarding median T0-TF anxiety VAS: 0 [IQR:− 3 to 0] in the standard care group versus − 1 [− 3 to 0] in the music intervention group (P = 0.20) (Fig. 1) , with no significant interaction between the variables of stratification or the operator experience and the intervention. The median TF pain VAS was not statistically different between groups: 0 [0 to 4.1] in standard care group and 0 [0 to 2] in music intervention group (P = 0.60), with no significant interaction between the variables of stratification or the operator experience and the intervention. Conclusion: In this first randomized pilot study of musical intervention for central venous catheterization in awake patients in the intensive care unit, the musical intervention did not reduce patients' anxiety as compared to usual care. As the study may have been underpowered, larger size trials are needed. Compliance with ethics regulations: Yes. Rationale: Sleep is markedly altered in ICU-patients under mechanical ventilation and may be due to noise, light, patient-care activities, patient-ventilator asynchronies, or the result of acute brain dysfunction induced by sedative drugs. To our knowledge, sleep has never been studied at ICU admission before any sedation. Our study aimed at assessing sleep quality of non-intubated sedation-free patients admitted to ICU for acute respiratory failure. Patients and Methods: Observational study performed in a single centre of a teaching hospital. Patients admitted to ICU for acute respiratory failure (respiratory rate ≥ 25 breaths/min and PaO 2 / FiO 2 < 300 mm Hg under high-flow nasal oxygen) could be enrolled. Patients with hypercapnia, central nervous disease, intubated early after admission and those with a do-not-intubate order were excluded. Sleep was evaluated by complete polysomnography (PSG) that started in the afternoon following admission and was continuously performed until the next morning. Results: Over a 3-year period 128 patients were screened and 44 patients were included. Among them, 10 patients were excluded for the following reasons: 1 patient was intubated shortly after PSG initiation, 1 PSG was lost, and 8 EEG recordings (18%) were stopped before midnight (electrodes turned off or loss of signal). Therefore, 34 patients in whom PSG was complete during the nocturnal period were retained in the analysis (27 Rationale: Convulsive status epilepticus (CSE) is a common neurological emergency associated with high mortality and morbidity rates. There are strong experimental data suggesting a potential impact of secondary brain insults (SBI) on outcome after CSE. However, there is no clinical proof to support this hypothesis. Our objective was to evaluate the association between SBI (mean arterial blood pressure, arterial partial pressure of carbon dioxide, arterial partial pressure of oxygen, temperature, natremia, and glycemia) at day 1 and neurological outcomes 90 days after CSE. Patients and methods: This was a post hoc analysis of the HYBER-NATUS multicenter open-label clinical trial randomized 270 critically ill patients with CSE requiring mechanical ventilation to either therapeutic hypothermia (32-34 °C for 24 h) plus standard care or standard care alone. 265 patients still alive at day 2 after inclusion were enrolled from March 2011 to January 2015 in 11 French medico-surgical ICUs. The primary outcome was favourable outcome 90 days after CSE defined as a Glasgow Outcome Scale score of 5. Results: Median age was of 57 years . A previous history of epilepsy was noted in 130 (49%) patients. Most episodes (173/265, 65%) occurred out-of-hospital, and 230 (87%) were witnessed from their onset. CSE was refractory in 86 (32%) patients and total seizure duration was 67 min (35-120). A favorable 90-day outcome occurred in 126 (48%) patients. Maximal glycemia value and hyperglycemia > 9.9 mmol/L at day 1 were the only SBI variables associated with outcome in univariate analysis. By multivariate analysis, age > 65 years (OR, 0.46; 95% IC, 0.26-0.83; P = 0.01), refractory CSE (OR, 0.50; 95% IC, 0.26-0.96; P = 0.04), and primary brain insult (OR, 0.50; 95% IC, 0.25-0.99; P = 0.047) were associated with an increased risk of poor outcome, and a bystander-witnessed onset of CSE (OR, 2.49; 95% IC, 1.05-5.59; P = 0.04) was associated with a decreased risk of poor outcome. Conclusion: In our population, secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus; whereas age, bystander-witnessed onset of status epilepticus, refractory status epilepticus and primary brain insult were identified as strong predictors of 90-day functional impairment. Further studies are warranted to confirm our findings. Compliance with ethics regulations: Yes. Rationale: Acute stroke (AS) is a leading cause of morbidity and mortality worldwide. However, data on the prognosis andfunctional outcome of patients with AS requiring ICU management is limited. Our purpose was to identify factors associated with good outcome (defined by a modified Rankin score (mRS) of 0-2) 6 months after ICU admission. Patients and methods: Retrospective cohort of patients admitted to the medical ICU of a university-affiliated hospital between January 2014 and December 2018 and coded for acute stroke using the ICD-10 criteria. Patients with traumatic stroke and isolated subarachnoid hemorrhage were excluded. Results: We identified 323 patients. Median age was 67 [54.5-77] years and 173 (53.6%) were males. Main reasons for ICU admission were coma (87%), hemodynamic instability (28.2%), acute respiratory failure (26%), and cardiac arrest (5.3%). Glasgow coma score at ICU admission was 6 [4] [5] [6] [7] [8] [9] [10] and points. Types of stroke were hemorrhagic in 248 (76.8%) patients and ischemic in 75 (23.2%). Mechanical ventilation was required in 257 patients (79.6%). Seizures occurred in 11.8% of the patients and convulsive status epilepticus in 3.1%. Pneumonia was diagnosed in 60 (18.6%) patients (aspiration pneumonia n = 20, ventilator associated pneumonia n = 40). Thrombolysis or thromboaspiration were performed in 18 (24%) patients with ischemic stroke. Surgical evacuation of expanding hematoma was performed in 21 (6.5%) patients, 19 (5.9%) had craniectomy, and 61 (18.9%) had external shunt for hydrocephalus. ICU and hospital mortality were 58.8% and 61%, respectively. Six months after ICU admission, 44 (13.6%) patients had a good outcome (mRS 0-2), 42 (13.1%) had significant disability (mRS 3-5), and 200 (61.9%) were deceased (lost follow-up n = 37, 11.5%). On multivariable analysis, age (OR 0.95 per year (0.91-0.99), p = 0.01), SAPS 2 (OR 0.95 per point (0.90-0.99), p = 0.03), and hemorrhagic stroke (OR 0.27 (0.08-0.9), p = 0.03) reduced the likelihood of good outcome (mRS 0-2) 6 months after ICU admission. Conclusion: In our study, prognosis of acute stroke requiring ICU admission was poor and a good functional outcome occurred in less than 15% of the patients at 6 months. Age, severity at ICU admission, and type of stroke predicted outcome. Compliance with ethics regulations: Yes. Rationale: In intensive care units, severe spontaneous hemorrhagic brain injuries have a poor prognosis for mortality and functional outcomes. Affected patients face particular ethical issues regarding the difficulty of anticipating their eventual recovery. In this context, prognostic scores can help clinicians in patients/relatives counseling and therapeutic decisions. The previous reviews pointed out many prognostic tools for intracranial hemorrhage and subarachnoid hemorrhage but did not focus on injuries explicitly severe nor assessed the methodological limitations of the models. Our systematic review aimed to assess methodologically prognostic tools for functional outcomes in severe spontaneous haemorrhagic brain, with particular attention to their clinical utilities. Patients and methods: Following PRISMA recommendations, we queried Medline, Embase, Web of Science, and the Cochrane by February 19, 2019. We included multivariate prognostic models explicitly developed or validated on adults with severe intracranial or subarachnoid haemorrhage. We evaluated the articles following the CHARMS recommendations (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) and the TRI-POD statements (Transparent Reporting of a multivariable prediction model for Individual Prognosis. Results: Our review confirmed the multiple publications of prognostic scores, as we found 71 articles aiming to develop or validate prognostic tools. Relying on guidelines, we discarded 52 articles due to the lack of prognostic capacities, validation, or predictor selection. 8 articles developed and validated a prognostic tool and 19 externally validated existing models (Fig. 1) . No score was of good methodological quality in intracranial hemorrhage. We highlighted two prognostic scores in subarachnoid hemorrhages: the SAHIT predicting unfavorable outcome or mortality at 6 months and the FRESH predicting unfavorable outcome at 12 months. Conclusion: Although prognostic studies on haemorrhagic brain injuries abound in the literature, they generally lack of methodological robustness or show incomplete reporting. With the numerous published scores, we believe that it is time to stop developing new scores. Ongoing validation, recalibration, and impact studies would keep improving existing good tools. The use of "patient-centered" approaches could also enhance them, and be more appropriate to inform patients and families about their long-term potential recovery. These considerations should drive future research in the modern era of neurocritical care prognosis. Compliance with ethics regulations: NA. Rationale: Respiratory pattern analysis by a visual examination is an important part of clinical assessment but is dependent on caregiver expertise and is subjective. Furthermore, there is no easy medical device used in PICU to measure Tidal Volume (Vt) and Minute Ventilation (MV) in spontaneous breathing patients. The clinical research unit in critical care of CHUSJ and ETS have developed a non-invasive computerized 3D video analyzing system (RETRACT System) to detect and perform a video analysis of respiratory status in children. The aim of this study is to test the reliability of the RETRACT System to monitor respiratory distress in critically ill children.

The RETRACT System is detailed in reference 1. In summary, cameras reproduce in 3D the thorax and abdomen of a subject. The respiratory status (respiratory rate (RR), tidal volume (Vt), minute ventilation (MV)) assessed by the RETRACT System was compared on a bench test (high-fidelity mannequin) and in critically ill children, to the ventilator measurements and clinician expert evaluation (gold standard). Bland-Altman plots were used for comparison. Results: We observed a significant agreement, on mannequin, between RETRACT System and gold standard method in estimating Vt, RR and MV, i.e. 95% of the paired differences were within the limits of agreement in Bland-Altman plots, as illustrated in Fig. 1 . In critically ill children (n = 2), the correlation between the pairs of measures was also high (r > 0.95, p < 0.001) and thecoefficient of determination with a high fit (0.90 < R2 < 0.99, p < 0.0001). For good correlation, the RETRACT System needed to have a visual access to thorax and abdomen in a quiet subject.

The RETRACT System measurements of Vt, RR and MV for respiratory distress monitoring in patients seems reliable. More testing are required to validate this method in usual practice and to develop the retractions signs video analysis. Compliance with ethics regulations: Yes. Rationale: Severe bronchiolitis requires hospitalization in paediatric intensive care unit (PICU). Non-invasive ventilation (NIV) has been demonstrated to treat them since twenty years, its use is well defined but there is no consensus for the weaning. This study evaluated the application of a nurse-driven NIV weaning protocol in hospitalized infants with severe bronchiolitis and verified its safety.

This was a retrospective monocentric study in a PICU of Robert Debré hospital-Paris, France. In the epidemic period of bronchiolitis between 2015 and 2017, all patients under one year old with severe bronchiolitis and requiring NIV were included. Two groups were compared: one group using the nurse-driven NIV weaning protocol and one group without using this protocol. Occurrences of complications, duration of ventilatory support and length of stay (LOS) in PICU and total LOS were compared. Results: 191 patients were included in the study, 115 in the no-protocol group, and 72 in the protocol group. The nurse-driven protocol was using at the rate of 90% (n = 72/80 in the protocol group (p = 0.522). PICU LOS were 3.5 days [3] [4] [5] in the no-protocol group versus 4 days [3-5.5 ] in the protocol group (p = 0.383), hospital LOS was 10 days [7] [8] [9] [10] [11] [12] [13] [14] in the no-protocol group versus 10 days [7] [8] [9] [10] [11] [12] in the protocol group (p = 0.447) (Fig. 1) .

The use of this first nurse-driven NIV weaning protocol was feasible and simple with a very good application rate. Its utilization was safe. The occurrence of complications did not increase by the use of this protocol. It would allow an optimal NIV weaning without prolonging the ventilatory support duration nor PICU LOS or hospital LOS. The professional practices appeared to be coordinated and the nurses appeared to be more autonomous. Compliance with ethics regulations: Yes.

No-protocol and protocol groups comparison: CPAP duration (1), ventilatory support duration (2), PICU LOS (3), hospital LOS (4) Rationale: First-line management of severe acute bronchiolitis in infants is mainly based on Non-Invasive Ventilation (NIV) and High-Flow Nasal Cannula (HFNC) therapy. However, pediatric data regarding weaning from NIV/HFNC are lacking. This study aims to identify the weaning practices from NIV/HFNC in children with severe bronchiolitis.

The WeaNIV-survey is a cross-sectional survey. A questionnaire was sent to French-speaking physicians with key roles in pediatric intensive care units. Results: A total of 73% (24/33) of French University Hospital were represented in the study. Only 9% of pediatric centers used a protocol for weaning from NIV/HFNC and nurses were considered as key-actors of the weaning process for half of participants. Continuous Positive Airway Pressure (CPAP) was the mode of ventilation mainly used as the first-line therapy in clinical practice. The main criteriaconsidered toinitiate weaning process were: noor slight respiratory distress, a FiO 2 < 40%, a respiratory rate < 50/min and no significant apnea. Three strategies to discontinue NIV/HFNC were identified: 1/gradual decrease of ventilatory parameters (pressure or flow), 2/abrupt discontinuation and 3/gradual increase in off-ventilation time. Abrupt weaning strategy was the most commonly used, no matter the mode of ventilation. A significant level of respiratory distress, the presence of apneas, an increase in oxygen requirement, and a respiratory rate > 60/ min were identified as weaning failure criteria by most pediatric intensive care physicians. Conclusion: In most centers, the weaning process does not follow any protocol. Abrupt weaning seems to be commonly used as weaning strategy in children with severe bronchiolitis supported by NIV/HFNC. Based on the study findings, we suggest that criteria for weaning initiation and for weaning failure must be defined and weaning protocols generated. Compliance with ethics regulations: Yes. Complications secondary to prone positioning occured for 6 patients (12.2%).

Conclusion: This first study, which evaluate prone positioning efficacy in severe P-ARDS shows evidence that prone positioning improves oxygenation parameters and survival rate. These results highlight the necessity to develop a multicentric prospective randomized study to confirm these conclusions. Compliance with ethics regulations: Yes. (4 vs 2) and Vasoactive-Inotropic Score (VIS) (205 vs 50) were significantly higher in the non-survivor group. Cannulation was veno-venous (14%) or veno-arterial (67%) and 8 patients (19%) were finally not initiated on ECMO. We observed an increase of patients cannulated in our PICU over time (Fig. 1 ). There was no significant difference in mortality between patients transported on ECMO after cannulation in our PICU and those who were transported to be cannulated in a referral ECMO center. The median time between the decision and the cannulation was 3.25 h and the median time taken in charge by PICU transport team was approximately 1 h. These periods were not significantly different between cannulation on site or in an ECMO center and between survivors and not-survivors. Conclusion: In our study, multiple organ dysfunction, particularly hematologic and acuterenal failures, seems to be a risk factor of mortality. The delay between decision and management is similar whatever the cannulation site. Specific ECMO mobile team and PICU transport team seem to be essential, fast and trained to transfer these patients. It would be interesting to compare our cohort with children requiring ECMO already hospitalized in a referral ECMO center. Compliance with ethics regulations: Yes. Rationale: Life expectancy in patients with metastatic breast cancer (MBC) has substantially improved over the last decade. Life threatening complications result from advanced diseases, infection and treatment-related toxicity. Only few studies have assessed outcomes in this setting. We performed a hospital-wide study to investigate how ICU resources are needed in patients with MBC. Patients and methods: All patients with MBC managed at our hospital between 2010 and 2019 were retrospectively included. The primary outcome was overall survival (OS). Factors associated with ICU mortality were identified using a multivariable Cox proportional hazard model with sensitivity analysis. Results are expressed as median [interquartile ranges] unless stated otherwise. Results: Among the 1128 patients managed at our hospital, 68 (6%, including 1 male) were admitted to the ICU (8 [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] patients per year). Age was 55 [49-67] years. Patients were receiving their 2nd [1st-3rd] line of treatment and had 3 [2] [3] metastatic sites. SOFA score at admission was 3 [1] [2] [3] [4] [5] [6] [7] [8] . Main reason for ICU admission was sepsis (n = 23, 34%), acute respiratory failure (n = 22, 32%), coma (n = 9, 13%) and metabolic disorder (n = 7, 10%). Invasive mechanical ventilation was required for 18 patients (26%) and renal replacement therapy for 10 (15%). Sixteen (24%) patients died in ICU. Following ICU discharge, median OS was 6.4 months (95% CI [1.7-17.9 ]) and 22/52 (42.3%) patients died within 3 months. An antineoplastic treatment was resumed for 33/52 (62%) patients alive after ICU discharge. Factors independently associated with mortality were performance status ≥ 2 (HR 1.85, 95% IC [1.01-3.40] ) and SOFA score at day 1 (HR 1.19 per point, 95% IC [1.11-1.27] ). After sensitivity analysis, the number of treatment lines at ICU admission was not associated with mortality. Conclusion: ICU admission is required in the course of the MBC disease for 6% of the patients. Determinants of short term outcomes rely on performance status and disease severity but not on the characteristics of the underlying disease. Ongoing analyses will assess whether ICU survivors reach life expectancy of patients never admitted to the ICU. Compliance with ethics regulations: Yes.

Hubert Gheerbrant 1 , Jean-François Timsit 2 , Nicolas Terzi 1 , Stephane Ruckly 3 , Mathieu Laramas 1 , Matteo Giaj Levra 1 , Emmanuelle Jacquet 1 , Loic Falque 1 , Denis Moro-Sibilot 1 , Anne-Claire Toffart 1 1 CHU Grenoble Alpes, Grenoble, France; 2 APHP, Paris, France; 3 Outcom-eRea, Bobigny, France Correspondence: Hubert Gheerbrant (hgheerbrant@chu-grenoble.fr) Ann. Intensive Care 2020, 10 (Suppl 1):P-002

Rationale: The prognosis of critically ill cancer patients admitted in intensive care unit (ICU), remains an issue. Our objective was to assess the factors associated with 3-and 6-month survival of ICU cancer survivors. Patients and methods: Based on the French OutcomeRea ™ database, we included solid cancer patients discharged alive, between December 2005 and November 2013, from the medical ICU of the university hospital in Grenoble, France. Patient characteristics and outcome at 3 and 6 months following ICU discharge were extracted from available database. Results: Of the 361 cancer patients with unscheduled admissions, 253 (70%) were discharged alive from ICU. The main primary cancer sites were digestive (31%) and thoracic (26%). The 3-and 6-month mortality rates were 33% and 41%, respectively. Factors independently associated with 6-month mortality included ECOG performance status (ECOG-PS) of [3] [4] 3. 1.60-9.43). Interestingly, cancer chemotherapy prior to ICU admission was independently associated with lower 3-month mortality (OR, 0.38; 95% IC: 0.2-0.75). Among patients with an ECOG-PS 0-1 at admission, 70% (n = 66) and 61% (n = 57) displayed an ECOG-PS 0-2 at 3 and 6 months, respectively. At 3 months, 74 (55%) patients received anticancer treatment, 13 (8%) were given exclusive palliative care. Discussion: Factors associated with 6-month mortality are almost the same as those known to be associated with ICU mortality. We highlighted that most patients recovered an ECOG-PS of 0-2 at 3 and 6 months, in particular those with a good ECOG-PS at ICU admission, and could benefit from an anticancer treatment following ICU discharge. Conclusion: These results should be taken into account when deciding upon ICU admission. It is of paramount importance to have an evaluation of both patient's general condition and anticancer treatment opportunities following ICU discharge. Compliance with ethics regulations: Yes. Rationale: The decision to urgently initiate medical anti-cancer treatment in cancer patients admitted to intensive care unit for cancerrelated organ failure is an issue. We currently lack criteria to select patients who may benefit from the treatment initiation. The purpose of our exploratory study was therefore to evaluate the characteristics of patients whose medical anti-cancer treatment is initiated in ICU and to identify prognostic factors for in-hospital mortality. in these patients. Patients and methods: We analyzed retrospectively, over a period of 11 years (1/1/2007 to 31/12/2017), cancer patients over 18-year old admitted to our ICU Bordet and in whose anti-cancer medicaltreatment was initiated during in-ICU stay. To identify prognostic factors for in-hospital mortality, we carried out a multivariate analysis of the factors influencing this mortality, considered as a binary. We also analyzed the long term survival of patients alive after their hospital stay (from the day of going out of hospital). Results: Overall, 147 patients were included, 78 men (53%) and 69 women (47%), with a median age of 58 years (18-86). Of these, 79 patients (54%) had a solid tumor and 68 (46%) had a hematological tumor. In-ICU mortality is 23% (95% CI 17-31%) and in-hospital mortality 32% (95% CI 25-40%). The prognostic factors for in-hospital mortality were age (mean 61 vs 54 in those who survived), the SOFA score (median 6 vs 2), the SAPS II score (mean 41 vs 31), the Charlson score (mean 8 vs. 6.5), the number of organ failure (mean 2.5 vs 1.4) and the presence of a therapeutic limitation (NTBR stated within 24 h: 68% vs 16%). Survival at 1 year of patients who survived the hospital stay was 37% and median survival time was estimated to be 0.5 year (95% CI 0.4-0.9). In patients with a solid tumor, 1-year survival was 17% and 61% in those with a hematological tumor (p < 0.001). Conclusion: We observed, in selected cancer patients admitted to the ICU for a cancer-related complication, that the initiation of an anti-cancer medical treatment is feasible and can lead to interesting results, particularly in patients with a hematological tumor. Compliance with ethics regulations: Yes. Rationale: Considerable progress in the management of onco-hematology (OH) malignancies led to an increase in the number of patients proposed for Intensive Care Unit (ICU) admission. Several guidelines offer decision models for ICU transfer of these patients. We aimed to describe prognosis, adequacy of ICU admission and denial in oncohematology patients.

We included all OH patients proposed for ICU admission in a Tunisian medical ICU, between January 2016 and July 2019. From an admission proposal registry, were collected patient underlying condition, functional status, malignancy and predicted prognosis, acute critical illness and its reversibility, adequacy of ICU Rationale: Cancer patients frequently need intensive care support for a life-threatening condition due to the underlying neoplasm or an adverse therapy-related event. However, there are poor data on their characteristics and outcomes in the intensive care setting. The aim of the present study was to describe clinical characteristics and to identify factors associated with in-ICU mortality in critically ill cancer patients. Patients and methods: It is a retrospective study conducted in the medical ICU of Farhat Hached teaching hospital between January 2007 and December 2018. All cancer patients with complete records were included. Baseline characteristics, clinical parameters, severity of illness, primary tumor location and outcomes were collected. Univariate and multivariate regression analyses were carried out to identify factors independently associated to poor prognosis. Rationale: Prognostic impact of underlying malignancy seems limited in most studies assessing outcome of critically ill cancer patients [1] . However, only limited number of characteristics, namely disease progression status and preexisting stem cell transplantation, were usually assessed [1] . Primary objective of this study was to assess influence of hematological malignancy aggressiveness on hospital outcome. Secondary objective was to assess influence hematological malignancy aggressiveness on type of infection. Patients and methods: Post-hoc analysis of prospective multicenter cohort performed in 17 hospitals in France and Belgium and including critically ill adults with underlying hematological malignancy admitted in ICU from Jan 2010 to May 2011. A Cox model was used to adjust for confounding variables then a propensity score matching on characteristics associated with underlying malignancy aggressiveness was performed. Results: Of the 1011 included patients, 300 (29.7%) had low grade malignancy (LG), the most frequent being myeloma (n = 126), chronic lymphocytic leukemia (n = 76), and myelodysplasia (n = 46). Patients with LG malignancy were older, underwent more frequently autologous stem cell transplantation (SCT) and had less frequently altered performans status. They had more severe organ failure at ICU admission (SOFA score 6 [4] [5] [6] [7] [8] [9] vs. 5 [3] [4] [5] [6] [7] [8] , P = 0.03). Before adjustment, mortality was 36% (n = 108) and 39.9% (n = 284) respectively in patients with and without LG malignancy (P = 0.27). After adjustment for confounder using a Cox model, a higher mortality was associated with nonlow grade malignancy (OR 1.49; 95% IC 1.17-1.9). A propensity score then allowed a 1:1 matching upon variable associated with malignancy aggressiveness. After matching unadjusted mortality was 36% (n = 108) in patients with LG malignancy and 48.8% (n = 146) in patients with high grade malignancy (P = 0.002) (Figure) . In the matched cohort and after adjustment for confounder, high grade malignancies were associated with lower mortality (OR 1.42; 95% IC 1.10-1.84). Risk of fungal infection was unchanged by underlying malignancy before adjustment (6% vs. 8.6% of patients with and without LG malignancy; P = 0.26) or after adjustment (HR 1.29; 95% IC 0.71-2.41). Conclusion: Despite anti-cancer advances, aggressiveness of hematological malignancies is associated with overall ICU outcome. Lowgrade malignancies displaying a better prognosis than non-low grade. Aggressiveness of the underlying malignancy is not associated with risk of fungal infection. Compliance with ethics regulations: Yes. Rationale: Guillain-Barré syndrome is the most common cause of acute flaccid paralysis and is associated with pulmonary embolism due to the mobility limitation. The aim of this study is to describe the incidence, the severity of pulmonory embolism in patients admitted to an intensive care unit (ICU) for Guillain-Barre syndrome (GBS). Patients and methods: Twenty-eight adults patients with confirmed diagnosis of GBS were admitted to the ICU in our university hospital center over a 10-year period and they were all included. Prevalence, risk factors and course of VTE were analyzed in ICU patients with various forms and severity of GBS. Results: During the study period, 23 adult GBS patients were included. Five (17.9%) developped pulmonary embolism. The mean age was51.2 ± 16.7 years and the sex ratio was 0.86. The comparaison betewen the 2 groups with and without PE showed that factors associated with the development of this complication were: respiratory failure requiring mecanical ventilation (p = 0.03), infectious complications (p < 0.001), blood pressure lability (p = 0.029), the delay of ICU admission (p = 0.02), the delay to treatment initiation (p = 0.036), the SOFA score (p = 0.03) and the presence of quadriplegia (p = 0.031). Conclusion: Pulmonary embolism is a frequent complication in patients with GBS. Factors associated with this complication were: respiratory failure requiring mecanical ventilation, infectious complications, the delay of ICU admission, the delay to treatment initiation, a high SOFA score and the presence of quadriplegia. Preventive measures in this category of patients have to be improved. Rationale: Acute respiratory distress syndrome (ARDS) is a life-threatening pathology associated with very high morbidity and mortality (35-45%) in intensive care units (ICU) and with even higher mortality among the severly burned patients worldwide (36 à 80%). The aim of our study was to describe in Tunisia burn patients with ARDS and to identify prognosis factors. Patients and methods: We conducted a descriptive retrospective study between 01-01-2017 to 31-12-2018, in burns ICU, in Ben Arous, in Tunisia. All burns who presented an ARDS, according to the Berlin 2012 definition, during their stay in the ICU, were included. When clinical or gasometric data was uncomplete, these patients were excluded. Results: During the study period, 691 patients were admitted to our burn unit including 246 ventilated patients. Fifty patients presented an ARDS: fifteen patients were excluded for lack of information, and 35 patients were retained. The sex ratio was 2.5. Patients had a mean age of 36 ± 12 years, an average burned area of 44% ± 22%, an average unit of burn skin score (UBS score) of 94 ± 77 and an average sequential organ failure assessment score (SOFA score) of 4. None of the patients had a history of cardiovascular or pulmonary diseases. The average time of onset of ARDS was 5 ± 4 days. ARDS was mild in 1 case, moderate in 11 and severe in 23. The etiology of ARDS was pulmonary in 25 cases (71%) and extra-pulmonary in 10 (29%). The pulmonary ARDS had as cause pneumonia isolated in 15 patients, an isolated pulmonary burn in 6 patients and a combination of pneumonia and lung burns in 4 patients. Extra-pulmonary ARDS were all due to sepsis and mainly to bacteremia. Septic shock was associated with ARDS in 20 patients (57%). The treatment was a conventional treatment based on protective ventilation, curarization and prone positioning in addition to the etiological treatment. The average length of stay in ICU was 9 days and mortality was 85% in these patients. Conclusion: Mortality from ARDS in burns in Tunisia, is important especially in those with pulmonary burns as well as those with sepsis. The introduction of new treatments, such as extracorporeal membrane oxygenation, remains essential to improve the prognosis of burn patients. Compliance with ethics regulations: Yes. Rationale: Aspiration pneumonia (AP) is common in intensive care unit (ICU). The incidence of AP among adults hospitalized with pneumonia ranges between 5 and 53.2%. Usually one or more risk factors are identified to be involved in AP. The aim of this study was to determine the risk factors and predictors of mortality on patients with AP. Patients and methods: We retrospectively included patients aged more than 18 years and who were hospitalized in our ICU for AP. Patients were excluded if they had history of tuberculosis, if they have bronchiectasis or metastatic brain tumor. Results: A total of 102 patients were included. History of diabetes, hypertension, epilepsy and ischemic stroke were found respectively in 22.2%, 21.5%, 16.7%, and 7.8% of cases. The reason of ICU admission were coma (35%), acute respiratory failure (33%), poisoning (27%) and cardiac arrest (5%). The incidence of acute respiratory distress syndrome (ARDS) was 17%. The most common organism isolated was staphylococcus aureus (4 cases). Risk factors for AP were epilepsy (20%), swallowing disorders (18%), ischemic stroke (12%), COPD (9%) and degenerative neurological disease (5%). The mortality rate was 17.6%. The median duration of mechanical ventilation was 12 days [IQR 10-23]. In multivariate logistic regression analysis; SAPS II score (OR = 1.05, 95% IC [1.001-1.1], p = 0.046) and ARDS (OR = 44.04, 95% IC [3.91-495 .57], p = 0.002) were independently associated with mortality. Conclusion: Risk factors for aspiration pneumonia were epilepsy, swallowing disorders and ischemic stroke. ARDS and SAPS II score were independent predictive factors of mortality. Compliance with ethics regulations: Yes.

undetermined. The aim of this study was to evaluate the impact of hyperoxia on morbidity and mortality. Patients and methods: This was a prospective study performed in the ICU of Abderrahmen Mami Hospital during a 4-month period. All patients admitted in ICU during the study-period were included. Those who didn't need oxygen therapy or in end of life stage were excluded. Arterial blood gases were analyzed daily and each day with at least one value of oxygen arterial saturation (SaO2) > 92% was considered as a day with hyperoxia. For each patient included, the number of times and days spent in hyperoxia was recorded as well as complications during the ICU stay and the outcome. Results: During the study-period, 140 patients were included but only 112 were eligible. Mean age was 58 ± 18 years. Acute on chronic respiratory failure was the most frequent reason of admission (67%). Non-invasive ventilation was required for 18% of patients and invasive mechanical ventilation was necessary in 65% of cases. Overall mortality was 32%. Hyperoxia was observed in 96% of cases, with an average of 10 ± 10 times during the ICU stay and 6 ± 6 days. A statistically significant association was observed between a long duration of hyperoxia and the occurrence of ventilator acquired pneumonia (p < 10-3), ventilator acquired bronchitis (p = 0.001), acute respiratory distress syndrome (p < 10-3), atelectasis (p < 10-3), septic shock (p < 10-3), rythm disorders (p = 0.003), reintubation (p < 10-3) and tracheostomy (p = 0.038). On multivariate analysis, independent factors of mortality were: simplified acute physiology score II, cardiac failure, need for invasive mechanical ventilation and septic shock. Hyperoxia was not independently associated with mortality. Conclusion: Hyperoxia is frequent in ICU. It is significantly associated with ICU complications but not independently associated with mortality. Compliance with ethics regulations: Yes.

Experience of the practice of prone position in patientswith acute respiratory distress syndrome in intensive care (CHU Oran) Nabil Ghomari, Soumia Benbernou, Djebli Houria Faculté de medecine d'Oran, Oran, Algeria Correspondence: Nabil Ghomari (nabilghomari@hotmail.fr) Ann. Intensive Care 2020, 10 (Suppl 1):P-013 Rationale: Mechanical ventilation (MV) in the prone position (PP) and low tidal volume have become recommendations with a high level of scientific evidence in recent years. The PP has been practiced for 7 years in the CHU Oran emergency resuscitation service. We wanted to report the service experience in the practice of PP in patients with ARDS. Patients and methods: Retrospective study performed in patients with severe hypoxia ARDS with SPO2 < 88% under FIO2 > 80% or PAO2/FIO2 < 150 during the period March 2011 to December 2018. Results: 38 patients received ventilation in PP. ARDS was secondary to thoracic trauma in 42% of patients, septic shock in 32% and aspiration pneumonitis in 26%. Analysis of the success factors and improvement of oxygenation found that lobar ARDS, the delay < 72 h and a duration of PP ≥ 18 h were statistically significant. Conclusion: The PP must be integrated into the arsenal of care of the patients in ARDS especially in our country where we do not have all the therapeutic options. Compliance with ethics regulations: Yes.

Julien Goutay, Nicolas Cousin, Thibault Duburcq, Erika Parmentier-Decrucq CHU de Lille, Pôle de Réanimation, Hôpital Salengro, Lille, France Correspondence: Julien Goutay (julien.goutay@gmail.com) Ann. Intensive Care 2020, 10 (Suppl 1):P-014 Rationale: In Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) therapy, blood flow is the main determinant of arterial oxygenation and should be 60-80 mL/kg/min in adults. This flow rate is determined by several factors including the size of the inflow cannula. The impact on clinical outcomes of arterial cannula's size in Veno-Arterial ECMO (VA-ECMO) has already been studied, and showed no difference for survival to discharge, weaning success rate and initial flow rate between a small cannula group and a larger one. Our first objective was to describe the impact of inlet cannula size on the assistance flow rate in patients treated with VV-ECMO. Secondary objectives were to analyze its impact on ECMO weaning, mechanical ventilation characteristics and mortality. Patients and methods: We retrospectively reviewed all cases of respiratory failure treated with VV-ECMO admitted in the medical intensive care unit (ICU) of Lille's teaching hospital from January 1st, 2013 through March 31st, 2019. Inlet cannula size was collected and divided into two groups: the "small cannula" group had inlet cannula less than or equal to 23Fr, while "large cannula" were larger than 23Fr. Primary endpoint was the initial flow rate according to the inlet cannula size, and its changes during the first 48 h of assistance. Secondary endpoints were the analysis of predictive factors associated with the choice of a larger inlet cannula, and the impact of its size on clinical outcomes such as successful ECMO weaning. Results: 74 patients treated with VV-ECMO were admitted in our hospital. Eleven (15%) were cannulated with a large inlet device. Mean initial ECMO flow rate was statistically higher in the "large cannula" group than in the "small cannula" one: 5.8 L/min (± 0.7) versus 4.7 (± 0.8) respectively, p < 0.0001. The difference was also significant during the first 48 h of assistance. We found no difference between the two groups on clinical outcomes such as ECMO weaning time. In univariate analysis, weight was heavier in the "large cannula" group [94 (± 26) kg] than "small cannula" [81 (± 20)], p < 0.05. Conclusion: ECMO initial flow rate was higher in a "large inlet cannula" group (internal diameter more than 23 Fr) compared with a "small cannula" group. We found no correlation with cannula-related haemorrhagic or thrombotic complications. Inlet cannula size did not influence ECMO weaning, and duration time, but this may be a lack of statistical power. Further prospective studies should confirm this results. Compliance with ethics regulations: Yes. Rationale: Burn patients are at risk of multidrug-resistant (MDR) bacterial infections with high mortality rate. Therefore, monitoring the emergence of MDR pathogens in these vulnerable patients is important. This study aimed to assess digestive colonization with carbapenemase-producing Gram-negative bacilli (CP-GNB) in patients admitted to the burn intensive care unit. Patients and methods: Our study was prospective and conducted over a one-year period (January 2018 to December 2018). Every admitted patient was subjected to the screening. A double swab set was used to collect rectal swab specimens. One swab was used for MDR screening by disk diffusion method on selective media; the other for multiplex real-time PCR (Cepheid's GeneXpert ® ) allowing detection of the most common carbapenemase-encoding genes (CEG) (blaOXA-48, blaKPC, blaNDM, blaVIM and blaIMP). Results: Among the 125 studied patients, 71 (56.8%) were detected positive at admission for CP-GNB by the GeneXpert ® Carba-R assay. Eleven patients, initially not colonized, acquired positive faecal carriage subsequently during their hospital stay. Forty-two colonized patients (59.1%) developed CP-GNB infection during their hospitalization. The CEG blaNDM quantitatively dominated by far with 54 detections; either alone (15 cases) or associated with other CEG (39 cases). The second most frequent gene was blaOXA-48. It was detected alone eight times and in association with other CEG 38 times. Forty-three patients carried blaVIM gene, usually in association with other CEG (93%). However, only one patient carried blaKPC gene. The parallel screening by classical microbiology methods (disk diffusion on selective media) detected the presence of CP-GNB in all molecular positive samples. Conclusion: Our study describes the characterization of carbapenemase in burn patients and highlights their alarming spread. This emphasizes the importance of an active surveillance program by early detection of CP-GNB carriers and an isolation policy to limit the MDR infections expansion. Compliance with ethics regulations: Yes. Rationale: Invasive fungal infections are increasingly observed in the ICUs especially in burn units. Inthe absence of simple and accessible techniques for early microbiological diagnosis, the use of antifungal treatment is increasing. Little is known about the extent of the problem of antifungal prescription in burn ICUs. We aimed to evaluate the antifungal prescription in major burn patients. Patients and methods: During the study period (2018-2019), all prescriptions of antifungals were analysed. Analysis concerned demographics, clinical circumstances, as well as the basis of antifungal prescribing (targeted vs. empiric).

Among the 691 patients admitted in this period, 58 patients were treated with antifungals (sex ratio: 1.4; mean age: 38 ± 19 years, with low associated comorbidity). The TBSA was 34.25% [19.5-53.25 ], UBS was 57 [32. [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] . Most of the patients (87.9%) were transferred from another hospital structure within 62 ± 96 h. Antifungal treatment was started at the average of the seventh day post wound injury, more often on an empiric basis. SOFA score at the beginning of the treatment was 11 ± 3.9. Lymphopenia was present in 32% and thrombopenia was present in 41%. Index of colonisation was positif only in 4 cases. The average candida score was 2.72 ± 1.15. Microbiological results were tardily collected, within 3 weeks, in 27%. Fungal urine infections were found in 9 cases. Candidemia and catheter-related infections were considered only in 2 cases. The risk factors of fungal infection as described in literature were found in most of the patients including mechanical ventilation (84.4%), length period of stay (16 days [8.75-29.5]), central venous line (100%), severe sepsis or septic shock (100%), large-spectrum antibiotherapy for more than 3 days (100%). Conclusion: The management of antifungal infections in major burn patients is still challenging. Antifungal prescription is based on clinical presumption. The empirical prescription reflects the lack of efficient laboratory support and late microbiological results prompting physicians to rely on clinical informations. The management of fungal infections is based on the improvement of mycological investigations. Compliance with ethics regulations: NA. Rationale: Invasive candidiasis is a widespread and alarming infection in intensive care units (ICU) patients. Its diagnosis is often difficult because of the lack of specificity of clinical signs and the low sensitivity of blood cultures. While the Candida albicans species remain the most common cause of bloodstream infections, non-albicans are emerging. These infections are serious, associated with high mortality rate and requiring early diagnosis and appropriate treatment. In Tunisia, few data are available. We aimed to determine the epidemiological profile of a series of candidemia in ICU, the risk factors associated with the occurrence of candidemia and to describe the modalities of the mycological diagnosis of candidemia and their etiological profile. Patients and methods: A retrospective longitudinal descriptive study conducted in the Parasitology-Mycology laboratory with the collaboration of the medical ICU of la Rabta hospital-Tunis over a 12-year period from January 1, 2006 to December 31, 2017. All hospitalized ICU patients with at least one Candida-positive blood culture were included. Results: Forty-three patients among 2585 hospitalized patients during the study period had at least one candidemia infection. The main risk factors for development of candidemia infection include invasive procedures, a prior use of antibiotics and parenteral nutrition. C. Albicans was the most common species, detected in 41.9% of patients. Nonalbicans Candida species were prominent (58.1%), represented by C Parapsilosis, followed by C. Tropicalis and C. Krusei then C. Glabrata and finally C. Lusitaniae. All the isolates tested were sensitive to the common antifungal agents. The mortality rate of our patients was high (76.7%), and the detection of the Albicans species in blood cultures was the only prognostic factor identified (OR = 9.38 [0.83-105.23], p = 0.06).

Conclusion: Candidemia in the medical ICU patients is common and is associated with high mortality rate. Despite the progress of biological tools, the diagnosis is difficult and needs to take into account the risk factors of the patients as well as scores based on clinical and microbiological parameters. A better identification of risk patients may help to early initiate empirical antifungal treatment. Compliance with ethics regulations: Yes.

Necrotizing soft-tissue infections in the intensive care unit: a retrospective hospital-based study Kais Regaieg, Sabrine Nakaa, Arnaud Mailloux, Madjid Boukari, Johana Cohen, Dany Goldgran-Toledano Groupe hospitalier intercommunal Le Raincy-Montfermeil, Montfermeil, France Correspondence: Kais Regaieg (kais.regaieg@gmail.com) Ann. Intensive Care 2020, 10 (Suppl 1):P-018

Rationale: The objective of our study is to describe the epidemiological and clinical characteristics of Necrotizing soft-tissue infections (NSTI) and to improve therapeutic management.

We conducted a retrospective observational study that included patients admitted in the intensive care unit (ICU) of general hospital between September 2014 and Aout 2019 with a primary or secondary diagnosis of NSTI. We collected demographic and clinical data, cultured pathogens, lengths of stay, and in-ICU mortality. Results: During the study period, a total of 20 patients admitted to the ICU were diagnosed with NSTI (0.3% of the total number of patients). The mean of age was 69 years. The sex ratio (M/W) was 0.6. Ten patients (50%) were directly admitted to the ICU, others were transferred from medical or surgical wards. The mean of SAPS II was 61.6 (26.6). The main indication to admission in ICU was shock (50%). The most common comorbidity was diabetes (50%). The other co-morbidities associated with NSTI were cardiovascular diseases (33%), obesity (25%) and carelessness (25%). The sites most commonly affected were extremities in 15 patients (75%) and abdomen/ano-genital in 4 patients (20%). In ICU, a total of 17 patients (85%) were mechanically ventilated [ (median duration: 4.70 days (8.63)], 15 patients (75%) were given vasopressors, and 4 patients (20%) underwent renal-remplacement. All patients underwent one or more chirurgical intervention. 17 patients (85%) underwent radical necrosectomy. In 3 cases, an amputation was necessary. Polymicrobian infection was seen in 10 patients (50%). In 8 patients (40%), we used vacuum assited closure therapy, which in 3 patients was followed by definitive reconstruction by split skin grafts. The mortality in ICU was 50%. The mean stay in ICU was 12 days . The mean duration of hospitalization of the patients who survived was 75 days (15-180). On the basis of a univariate analysis, higher SAPS II score and lactate levels were associated with increased mortality (p < 0.01). Conclusion: NTSI is rare in ICU but it's a life-threatening and disabling disease with a high mortality requiring a multidisciplinary management. Early diagnosis and adequate treatment are necessary to improve clinical outcome and must be known by everyone. More studies are needed to estimate the interest and delay of new strategies such as negative pressure therapy. Compliance with ethics regulations: Yes. Rationale: Nosocomial infections remain a major cause of mortality and morbidity in burn patients. 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 our study was to investigate the species distribution and antibiotic susceptibility of isolated strains from a burn intensive care unit (ICU). Patients and methods: This study was performed retrospectively on all bacteriological samples taken from the burn ICU at the trauma and burn center in Tunisia during a seven year period (from January 2012 to December 2018). All isolated microorganisms 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 guidelines. Minimum inhibitory concentration of Colistin was determined using the E-Test ® method (BioMérieux), then using the EUCAST broth micro-dilution method (UMIC, Biocentric ® ) since May 2017. Results: During the study period, the most frequent identified species were Pseudomonas Aeruginosa (15.7%), Staphylococcus Aureus (15%), Klebsiella Pneumoniae (12.6%) and Acinetobacter Baumannii (12%). These strains have been mainly isolated from blood cultures (37%) and skin samples (26.6%). Pseudomonas Aeruginosa resistance to Ceftazidime increased from 9.2% in 2012 to 53.5% in 2018 and resistance to Imipenem and Ciprofloxacin was 63.3% and 42.9%, respectively. Four strains were resistant to Colistin. Rationale: Community-acquired peritonitis is a heterogeneous condition characterized by peritoneum inflammation in response to a bacteria injury. The aim of our study is to describe the epidemiological, clinical, bacteriological, etiological, therapeutic characteristics of community peritonitis, and to evaluate the prognostic factors. Patients and methods: This is a retrospective descriptive and analytical study spanning three years (Between January 2015 and December 2017) involving 114 cases of community peritonitis, hospitalized in the surgical emergency resuscitation department P33 Ibn Rochd Casablanca University Hospital. Our study included adult patients with community-acquired peritonitis who underwent medical and surgical management. The studied parameters are the demographic data, the clinical and paraclinical signs, the care taken and the evolution of the patients.

The study showed that the mean age was 54.2 ± 17.2 years, with a sex ratio of 2.17. Patients medical history included tobacco (31.60%), extra-abdominal signs [hemodynamic failure (45%), renal failure (n = 39, 50%), hematological disorders (n = 80, 70%) and respiratory disorders (n = 38, 60%)]. Therapeutic management was based on perioperative resuscitation, treatment of organ failure, probabilistic antibiotic therapy and median laparotomy surgery. The main etiologies of community peritonitis were: digestive perforation (76.3%), purulent effusion (50%), intestinal necrosis (16.7%), cholecystitis (3.5%). Intraoperative bacteriological specimens yielded the following bacteriological profile: predominance of NGB (85.9%) dominated by E. Coli (46.8%) followed by Klebsiella Pneumoniae and Enterobacter Cloacae (28.2%) The mean hospital stay was 5.4 ± 5.5 days. The mortality rate was 55.3%. Conclusion: Improvement in the prognosis of community-acquired peritonitis can only be achieved by constant assessment of very early diagnosis and initiation of appropriate resuscitation and antibiotic therapy associated with a complete surgery carefully codified according to guidelines. Compliance with ethics regulations: Yes. Rationale: Klebsiella Pneumoniae carbapenemase (KPC)-producing bacteria are a group of emerging highly drug-resistant Gram-negative bacilli causing infections associated with significant morbidity and mortality. The aim of our study is to point out the incidence of bloodstream infections (BSI) caused by KPC in ICU patients, its clinical presentation and course. Patients and methods: We conducted a retrospective descriptive study. All patients hospitalized in the ICU of our hospital who developed BSI caused by KPC from January 01, 2016 to December 31, 2017 were included. Results: During the study period, 20 patients were included. The mean age was 45.7 ± 22.5 years ranging from 8 to 91 years. Sex ratio (M/F) was 3. Trauma was the major cause of hospitalization in 12 cases (60%). The most common past medical diseases were arterial hypertension in 7 patients (35%). Length of hospital stay prior to ICU admission was 4 ± 7.2 days. At infection onset, mean SAPS II was 49 ± 13.2, mean SOFA was 10.4 ± 4.8 and mean APACHE II was 19.8 ± 6.7. During ICU hospitalization, all patients required invasive mechanical ventilation during 27.2 ± 13.2 days, had a central venous catheter (CVC) and an indwelling urinary catheter in place, 15 patients (63.9%) had tracheotomy, 12 (60%) underwent surgery, 9 (45%) presented acute kidney failure and 4 (20%) needed hemodialysis. Before the isolation of KPC, all patients presented infections. Antibiotics prescript were: Colistin in 14 patients (70%), Carbapenems in 12 patients (60%), Amoxicillin/clavulanic acid in 11 patients (55%), Cephalosporins in 9 patients (45%), Fluoroquinolones in 6 patients (30%), Tigecycline in 5 patients (25%), Aminosids in 4 patients (20%), Rifampicin in 4 patients (20%), Fosfomycin in 3 patients (15%), Glycopeptides in 2 patients (10%). The delay for KPC-BSI onset was 17.7 ± 7.5 days. The most common infection sources responsible of KPC-BSI were: CVC in 6 patients (30%) and pneumonia in 5 patients (25%). KPC infection was responsible of septic shock in 18 patients (50%). Resistance rates were: Gentamycin (65%), Amikacin (20%), Colistin (15%), Fosfomycin (10%) and Tigecycline (10%). Antibiotics used to treat KPC bloodstream infection were resumed in Table 1 . The mean length of ICU stay was 36.1 ± 16.8 days. Out of the 20 included patients, 7 patients died (The mortality rate was 35%). Death was related to KPC infection in 5 patients. Conclusion: The high prevalence of KPC-BSI in ICU patients dictates the importance of implementation of infection control measures and strict antibiotic policies. Compliance with ethics regulations: Not applicable. We identified 103 episodes of nosocomial infections in 56 patients, representing a cumulative incidence rate of 41.17 per 100 exposed patients. The incidence density was 30.43 infections per 1000 days of hospitalization. The prevalence of pneumonia was 38.83%, followed by urinary tract infections 21.35%, central venous catheterization infections 15.53%, bacteriemia16.3%, meningitis 6.7% and surgical site infections 1.9%. The incidence rate of intubation-related pneumonia was 24.47/1000 day of exposure. The incidence rate of bladder-related urinary tract infection was 9.7/1000 day of exposure. The incidence rate of positive culture of the central venous catheter was 7.05/1000 day of exposure. The incidence rate of bacteremia related to stay was 9.2/1000 day of exposure. The mortality rate was 26.5% with a significant difference between infected and uninfected patients (p = 0.041). Microorganisms were gram negative bacteria in 80% of cases. Conclusion: Epidemiological surveillance of healthcare-associated infections is needed to establish prevention plans. Compliance with ethics regulations: Not applicable.

In the prehospital setting, early identification of septic shock (SS) with high risk of mortality is essential to guide hospital orientation (emergency department (ED) or intensive care unit (ICU)) prior to early treatment initiation. In this context, the severity assessment is most of the time restricted to clinical tools. In this study, we describe the association between prehospital shock index (SI) and mortality at day 28 of patients with SS initially cared for in the prehospital setting by a mobile intensive care unit (MICU In this study, we reported an association between prehospital SI and mortality of patients with prehospital SS. A SI > 0.9 is a simple tool to assess severity and to optimize prehospital triage between ED and ICU of patients with SS initially cared for in the prehospital setting by a MICU. The association of SI with biomarkers may be helpful to improve the screening for SS and decision making of SS in the prehospital setting. Compliance with ethics regulations: Yes. 

The failure rate and complications were comparable between the 2 groups, but the ultrasound-guided internal jugular catheter appears to be faster to insert and requires fewer punctures, so it could be an alternative to the femoral one in emergency situations.

Rationale: Neuromyelitis optica (NMO) is a rare but severe disease. The prognosis of treated NMO attacks remains unclear. We evaluated our practice, the early evolution and the prognosis of NMO patients. Patients and methods: An observational study was performed on patients with NMO attacks presenting with visual or medullar symptoms admitted for plasma exchange (PE) therapy from January 2017 to August 2019. Treatment efficiency was defined as a negative shift of the visual or motor disability score (EDSS). Nonparametric Mann-Whitney and Fisher exact tests were used for statistical analysis as required. Results: Twenty-four patients had 110 PE sessions. Characteristics of the cohort are described in Table 1 . 5 (20.8%) died from complications of NMO attacks. Treatment had an effect in 15 (85.2%) patients. The shift in the ambulatory and visual EDSS was respectively − 0.4 + 2.3 and − 1.7 + 1.7. The 5 non-survivor patients had all AQP4 antibodies (p < 0.05). Residual EDSS was higher in the non-survivor group (8.7 + 1.0 vs 6.1 + 1.7, p < 0.01). Pulse steroids were administered in 1 (20%) patient in the non-survivor group vs 15 (78%) patients in the survivor group (P < 0.05). Twelve (80%) patients previously given pulse steroid therapy responded to PE. Discussion: We assessed the handling of NMO attacks and identified our flaws. We concluded that pulse steroid therapy should not be withheld or replaced by lower dosage. We also need to find a way to make attacks identified by physicians earlier to shorten the delay between its onset and patient's admission in a specialized care unit. We observed that the mean improvement is modest during the early phase of our treatment. But a modest improvement in the EDSS can have a great impact in the patient's quality of life and even survival. Conclusion: NMO attacks remain a threatening disease despite aggressive treatment. Shortening the delay of treatment and ensure adequate pulse steroid therapy coupled to PE could be a way to improve the prognosis. Compliance with ethics regulations: Yes. Rationale: Acute kidney injury in trauma patients is a problem that has been little studied in the intensive care unit (ICU). Its occurrence has been shown to be associated with high morbidity and mortality. We aim to determine the outcome of ICU trauma patients with acute kidney injury (AKI), including the incidence of death in the ICU, of nonreversible renal impairment and ICU complications. Patients and methods: This is a prospective study, conducted in the department of emergencies and ICU, including trauma patients with a minimum ICU stay of 7 days. Renal failure was defined based on the new KDIGO classification. Predictors of mortality and poor outcome were identified using univariate and then multivariate analysis. Results: One hundred and fifty patients were admitted during the study period for the management of post-traumatic injuries, among which 98 patients were included. The incidence of AKI in the studied population was 47% (46 cases) with 26 (56%) diagnosed with stage one, ten (22%) with stage two and ten (22%) with stage three. The overall mortality of patients with post-traumatic AKI was 34.8% (16 patients) with a mean ICU lengh of stay (LOS) at 22 ± 18 days and of days on ventilator at 17 ± 15. Eight patients (17.4%) needed renal replacement therapy and thirty-four had non-reversible renal impairement (74%). During ICU stay, eight patients (17%) were diagnosed with pulmonary embolism. On univariate analysis, the following variables were associated to mortality in patients with post-tramatic AKI including; age, hemodynamic instability on the day of diagnosis and bilirubin levels on the day of AKI diagnosis. Besides, according to our analysis, the use of renal replacement therapy and the non-reversibility of renal impairment during ICU stay were also associated to ICU mortality. Among these factors, the non-reversibility of renal impairment in the ICU was a predictor of mortality on multivariate analysis (p = 0.009, OR = 29, . In this cohort, the following variables were predictive of non-reversible renal impairment during ICU stay; including age (with a best cut-off of 55 years old), medical history of hypertension, higher ISS and diuretics' administration. On multivariate analysis, the age (p = 0.004, OR = 0.9, CI 0.80-0.97) and use of diuretics (p = 0.003, OR = 33, CI 3.1-359) were associated to non-reversible AKI in the ICU. Conclusion: Our study confirms that post-traumatic AKI in the ICU is associated to high morbidity and mortality. The identification of outcome predictors could be valuable to guide the management of AKI. Compliance with ethics regulations: Yes. Rationale: The occurrence of acute kidney injury (AKI) in trauma patients is a problem that has been little studied to date. Its presence has been shown to be associated with an increased risk of morbidity and mortality in affected individuals. To determine the incidence of post-traumatic AKI and identify its predictive risk factors that could be eventually prevented. Patients and methods: This is a 10-month long prospective cohortstudy, conducted in the department of emergencies and intensive care unit (ICU) of a university hospital, including trauma patients with a minimum ICU stay of 7 days. Renal failure was defined based on the new KDIGO classification. Predictors of AKI were identified using univariate and then multivariate analysis. Results: One hundred thirty patients were admitted during the study period for the management of post-traumatic injuries, among which 86 patients were included. The incidence of AKI in the studied population was 53% (46 cases) with 26 (56%) diagnosed with stage one, ten (22%) with stage two and ten (22%) with stage three. On univariate analysis, older age and medical history of diabetes or hypertension were predictors of AKI. Injury assessment found traumatic brain injury (AIS > 3), Glasgow (GCS) on admission, and the diagnosis of fat embolism to be associated to post-traumatic AKI. Moreover, hemodynamic instability on admission and during ICU stay, shock-index on admission, the amount of fluid administered the use of vasoactive drugs, sepsis, hyperbilirubinemia, P/F ratio and acute respiratory distress syndrome (ARDS) were also associated to post-traumatic AKI. Among these factors, ARDS (p = 0.001, OR = 9, CI 6-100), fat embolism (p = 0.028, OR = 2, CI 1. ) without preload-dependence, and 2 were unclassified. Multivariate analysis (using variables collected prior to hypotension) identified the following variables as risk factors for the occurrence of hypotension associated with preload-dependence: preload-dependence before hypotension (odds ratio = 4.01, p < 0.001), fluid removal rate by CRRT (OR = 0.71 per 1 increase in SD, p < 0.001), and lactate levels (OR = 1.32 per 1 increase in SD, p < 0.001).

In this single center study, preload dependence-associated hypotension was slightly more frequent than hypotension without preload dependence in ICU patients undergoing CRRT. Testing for preload dependence to adjust fluid removal could help prevent hypotension incidence during CRRT.

Rationale: Few studies report the relation between functionnal brain alterations during and after ICU stay and abnormalities of CBF displayed on TCD. Using VTI as hemodynamic parameter is unusual for evaluation of CBF. The purpose of this preliminary study was to compare the values of VTI of healthy Controls (C) versus ICU (P) with usual parameters (i.e. diastolic (Vd) and mean velocities (Vm), resistance (IR) and pulsatility index (IP)). Rationale: Accurate diagnosis of the level of consciousness is a challenge and different states such as coma, vegetative state (VS) or minimally conscious state (MCS) are often confused while they convey meaningful prognostic information. This distinction rely on the Coma Recovery Scale-revised (CRS-R) gold-standard. However, this clinical scale is imperfect since unresponsive patients can exhibit genuine signs of consciousness using advance neuroimaging techniques. Expanding the range of behaviors indexing consciousness at bedside is thus of decisive importance. Patients and methods: We designed and proposed a new clinical sign of MCS, the habituation to auditory startle reflex (ASR), based on the blink response to repeated sounds: either inhibition of the automatic ASR response (extinguishable) or nohabituation (inextinguishable response). We prospectively tested this new sing in patients suffering from disorders of consciousness after severe brain injury and first compared its diagnostic performances with the current gold-standard (CRS-R) using standard discrimination metrics (AUC, sensitivity, specificity, likelihood ratios) and their 95% confidence interval. We then investigated the correlates of this new sign on two validated neuroimaging diagnostic procedures (multivariate EEG-based classification of the state of consciousness and FDG-PET metabolic index of the best preserved hemisphere) using an ANOVA with the state of consciousness and the ASR response as independent variable. Rationale: Although continuous electroencephalography (cEEG) is commonly recommended in neurocritical care patients, implementation of this monitoring in routine is facing the need for a specific training of professionals. We evaluated the effectiveness of a training program for the basic interpretation of cEEG to critical care staffs in a prospective multicentre study. Patients and methods: After completion of a pre-test, participants (physicians and nurses) recruited in 6 French intensive care units (ICU) received a face-to-face EEG learning course, followed by additional e-learning sessions at day-1 (post-course), day-15, day-30 and day-90, based on training tests followed by illustrated and commented answers. Each test was designed in order to evaluate knowledge and skills through correct recognition of 10 predefined EEG sequences covering the most common normal and abnormal patterns. The primary objective was to achieve a success rate of more than 80% of correct answers at day-90 in at least 75% of participants. Results: Among 250 participants, 108 (43.2%) completed the full training program and 77 of these 108 (71.3%) full-training participants achieved at least 80% of correct answers at day-90. Paired comparisons between scores obtained at each evaluation demonstrated a statistically significant increase over time. At day 90, rates of correct answers were greater than 80% for all predefined usual EEG sequences, excepted for the recognition of periodic and burst-suppression patterns and reactivity, which were identified in only 42.6% (95% CI 36.4-48.8) and 60.2% (54.1-66.3) and 70.4 (64.7-76.1) tests, respectively. Discussion: This multicentric prospective study, which evaluated a training program for the basics of electroencephalography offered to critical care teams, provides interesting information about the training process and its impact on learners according to their different characteristics. We believe that participants reflect the heterogeneity of the various use of cEEG in the critical care setting. Participants came from university and non-university ICUs, and whereas some of them used to monitor patients with cEEG, others were in an implementation process when the last monitored neurocritical care patients with intermittent EEG. In accordance with previous studies, we focused to the entire medical and nursing ICU staffs. Conclusion: A 3-months training program aiming to teach the basic interpretation of continuous EEG in the intensive care units was associated with a significant attrition in participation over time. However, participants who received the full training program were capable to accurately recognize the vast majority of EEG patterns that are encountered in critically ill patients. Compliance with ethics regulations: Yes.

Mourad Goulmane Oran Hospital and University Center, Oran, Algeria Correspondence: Mourad Goulmane (goulmane.mourad@univ-oran1. dz) Ann. Intensive Care 2020, 10(Suppl 1):P-043

Rationale: Cerebral venous thrombosis (CVT) is a rare but very serious disease with various clinical and etiological aspects. Unlike ischemic arterial accidents, epidemiological studies are limited. The aim of our work was to study the clinical, etiological and evolutionary features of CVT in the Algerian population from a sample of 28 patients. Patients and methods: This is a retrospective observational study conducted in the neurology department of the CHU d'Oran between January 2016 and December 2017. In a clinical context suggestive of CVT, the diagnosis of certainty was provided by brain MRI coupled with MRA. All subjects benefited from a complete etiological assessment. The anticoagulant treatment was based on the low molecular weight heparin relayed by the anti-vitamin K. The duration of the follow-up was 12 months. Results: The mean age was 38.26 ± 13.59 years, the sex ratio was 6 (24F/4H), the onset was subacute in 55% of cases. The main early signs were headache (88.8%), visual disturbances (50%), epileptic seizures (44.4%) and motor deficit (44.4%). Thrombosis predominated in the upper sagittal sinus and lateral sinuses; Parenchymal lesions were associated in 2/3 of the cases. Gynecologic obstetric causes were by far the most frequent. The evolution was favorable in 83.3% of the cases. Discussion: CVT is characterized by its clinical polymorphism, its predominance in young women, and its most often favorable evolution. The causes are multiple and often intricate requiring the realization of a systematic etiological assessment even if the cause seems obvious. The treatment of choice remains early anticoagulation, based on heparinotherapy even in case of hemorrhagic softening.

The characteristics of CVT in the Algerian population are distinguished by a high frequency of gynecological obstetric causes. Awareness campaigns for women of childbearing age are useful. Compliance with ethics regulations: Not applicable. Rationale: The CT-DRAGON score was developed to predict longterm functional outcome after acute stroke in the anterior circulation treated by thrombolysis. Its implementation in clinical practice is hampered by the plethora of variables included. In addition, the score has not been validated in important subgroups such as stroke patients undergoing thrombectomy. Given these limitations, the current study was designed to evaluate the use of a simplified score based on machine learning, as a possible alternative.

This single-centre retrospective study included 564 patients treated for stroke, in the anterior and posterior cerebral circulation, between 01-2017 and 02-2019. At 90 days, favourable (modified Rankin Scale (mRS): 0-2) and miserable outcome (mRS: 5-6) were predicted by CT-DRAGON. Machine learning selected the aim was to describe the adherence rates to GOLD 2017 guidelines in critically ill COPD patients and to identify predictors of low adherence. Patients and methods: A prospective cohort study conducted from December 2017 to April 2019 in a 9-bed medical intensive care unit of Farhat Hached hospital. All adult patients admitted for AECOPD during the period of the study were included. Demographic and clinical data were recorded. Adherence to GOLD 2017 was evaluated. Univariate and multivariate regression analyses were carried out to identify factors independently associated to non-adherence to GOLD 2017 guidelines. Results: Seventy-seven patients were recruited. Patients' characteristics were : mean age, 65.5 ± 9 years; male 71 (92.2%); median duration of the disease, 6 [13-14] years; mMRC scale ≥ 2, 67 (88.2%); health insurance coverage rate, 57 (75%); pulmonologist follow up, 34 (59,6%); frequent exacerbator (≥3 exacerbations in the last year), 26 (34.2%); median exacerbations episodes, 2 [1] [2] [3] . Long-term oxygen use and home mechanical ventilation were respectively used in 10 (13.2%) and 5 (6.6%). Eight (10.5%), 14 (18.4%) and 54 (71.1%) belonged to COPD groups B, C and D, respectively. Pharmacological treatment included: SABA-ICS combination, 25 (32.9%), LABA-ICS, 10 (13.2%), LABA-LAMA, 10 (13.2%) and LAMA-LABA-ICS, 9 (11.8%). Overall adherence to 2017 GOLD guidelines treatment recommendations for the different stages of COPD was 22 (28.9%). Two patients (2.6%) were over treated and 52 (68.4%) were undertreated. Inappropriate treatment rate was 6 (75%) in Gold B, 12 (85.7%) in Gold C and 36 (66.7%) in Gold D. Univariate analysis identified two factors associated with non-adherence to GOLD 2017: the absence of pulmonologist follow-up (50% vs. 9.1%; p = 0.01) and the low income (35.2% vs. 9.1%; p = 0.021). In multivariate analysis only the lack of pulmonologist follow-up was identified as an independent risk factor associated with GOLD guidelines discrepancies (OR, 10; 95% CI [2.1-47.0]; p = 0.04).

There is a lack of adherence to GOLD 2017 guideline treatment recommendations in Tunisian COPD patients. This may lead to severe exacerbations. Discrepancies were due to the poor access of severe COPD patients to an appropriate pulmonologist follow-up. Compliance with ethics regulations: Yes. The operating theaters concerned were: the otolaryngology block, ophthalmology, vascular and thoracic surgery, and gynecological surgery. All patients over 18 years of age were enrolled using the clinical parameters of difficult intubation (Arne score > 11), which will benefit from orotracheal intubation. The main judgment criteria were: first-pass success rate, intubation time, which is defined as the time between inserting the slide into the patient's mouth and obtaining the capnography curve, the Cormack-Lehane score and the POGO score (percentage of opening of the glottis). Statistical analysis used SPSS software. Results: A total of 62 patients were included. No cases of failure with this device were observed, the duration of intubation was on average 21.5 s (only 3 cases required more than 1 min). The Cormack-Lehane score 1 and 2 involved 55 patients (88.7%), and the POGO score greater than 50% involved 51 patients (82.25%). One case required the features of the simplified score. Discrimination, calibration and misclassification of both models were tested. Results: 32% had proximal anterior stroke, 2% proximal posterior stroke and 50% lacunar infarcts in either circulation. In 16% no thrombus was objectivated. 13% of patients were treated with thrombectomy, 17% received thrombolysis and 9% underwent both thrombolysis and thrombectomy. 61% only received anti-platelet therapy. The area under the receiver-operating-characteristic curve (AUC-ROC) for CT-DRAGON was 0.78 (95% CI 0.74-0.81) for favourable and 0.78 (95% CI 0.72-0.83) for miserable outcome. R2 ofCT-DRAGON was 0.30 and 0.22 for favourable (lack of fit, p = 0.75) and miserable (lack of fit, p = 0.8) outcome respectively. Misclassification rate was 29% for favourable and 13% for miserable outcome with CT-DRAGON. Selection of predictors from the CT-DRAGON was done by logistic regression, bootstrap forest and decision tree analysis. NIH Stroke Scale, pre-stroke mRS and age were identified as the strongest contributors to favourable and miserable outcome, and included in the simplified score. AUC-ROC was 0.83 (95CI% 0.79-0.86) and 0.83 (95CI% 0.77-0.87) for the prediction of favourable and miserable outcome respectively. R2 was 0.42 and 0.29 for the prediction of favourable (lack of fit p = 0.34) and miserable (lack of fit p = 1.0) outcome respectively. Misclassification rate was 26% for favourable and 14% for miserable outcome with the simplified score. The simplified score had better discriminative power than CT-DRAGON for both outcomes (both p < 0.005).

The CT-DRAGON score revealed acceptable discrimination in our cohort of both anterior and posterior circulation strokes, receiving a variety of treatment modalities. The simplified score had a better discrimination, while maintaining comparable and good specificity and misclassification rate for miserable outcome. The simplified score needs further validation in a prospective, multi-centre study. Compliance with ethics regulations: Yes. Rationale: The 2017 GOLD report represents a major revision to GOLD strategy guidelines. It brings new recommendations regarding diagnosis, severity assessment, and both pharmacologic and non-pharmacologic treatment of COPD. However, adherence to evidence-based therapeutic guidelines is often poor in low-income developing countries and represents a significant barrier to optimal management. The setting up of an LMA-Fastrach (desaturation). A case of glottic edema has been noted. Discussion: This study shows a very high success rate with this technique (95.16% in the first trial and 4.83% in the second trial), in the context of a predictable difficult intubation. The video-Airtraq allows a very good visualization of laryngeal structures, a shortening of the duration of intubation, and is rarely responsible for immediate or secondary complications. All the data in the literature go in the same direction. Conclusion: At the end of this work, our perspectives are to update the difficult intubation procedure, integrating the video-Airtraq into our algorithm, as well as into our difficult intubation trolley. To take into consideration the cost of this device to eventually generalize it to all our structures. Compliance with ethics regulations: Yes. ) and 15 beds of continuous monitoring. The activity of the CP is organized in a medical visit in the morning and in conducting projects in the afternoon. The activity is presented using a 2-years balance sheet Results: The activity of pharmaceutical interventions (PI) or answers to requests from teams is shown in Table 1 . The solicitations doubled the second year. The CP is involved in the conduct of internal or polar projects (set up of cooperative sedation, nutrition…), the good use of health products (relay IV/PO, infusion, crushed tablets and compatibility with gastric probe, drug incompatibilities, proton pump inhibitors…), the efficiency of the drug circuit (link with the pharmacy, reflection on the improvement of the circuit, regular meetings with nurses), medico-economic analysis of health products spending and the formalization of actions by protocolisation. He is also very involved in clinical research: patient screening, clinical study setup: BLIPIC study (Beta-lactam's dosing In Pneumonia in ICU in patients treated by Continuous renal replacement therapy; ClinicalTrials NCT03897582) or in CANDIAREA project (Invasive infections to Candida and preemptive treatment guided by biomarkers; in progress). A satisfaction survey submitted at 6 months to nurses (12 answers/60) or to doctors/ residents (13/25) reported CP competence in the accompaniment of teams (> 80%) [in medico-economical, contribution of knowledge, vigilance reflex…], relevance of information transmitted (> 85%) [administration of drugs, dosage adjustments, …] and his relationship adapted to the units (> 90%) [communication, availability] .

The development of clinical pharmacy in ICU involves mastery of the specificities of ICU by the CP, requiring a learning period and relationships adapted to clinical situations and teams. Many health products projects specific to critical care are coordinated by the CP and made possible by medical and paramedical involvement. The CP appears as a vector of good use both in medical (reasoned prescription) and paramedical (good practices) with increasing solicitation of teams since his arrival. This reception has been facilitated by an innovative approach of clinical pharmacy deployment in our ICU on an impulse of the clinical pole Compliance with ethics regulations: Yes. Predicting models such as the NEWS has been developed in the emergency department, but it has only been fewly evaluated in the ICU. Heart rate variability (HRV) reflects the autonomic nervous system response in various pathological situations and may vary according to patients' physiological status. The ROX index, which reflects the acute respiratory failure severity, seems to be a good predictor of high-flow nasal canula failure. The aim of this study was to evaluate the potential value of NEWS, HRV and iROX (inversed ROX) as poor outcome predictors, using artificial intelligence and machine learning.

A retrospective analysis of a prospective datawarehousing project (ReaStoc clinicalTrials identifier NCT 02893462) on ICU patients who did not require invasive ventilation. Physiological parameters were collected on admission, within a 24-h delay. NEWS, HRV (in time, frequency, and non-linear domains), and iROX were computed and integrated into the prediction model. Analysis was performed using MedCalc and Matlab machine-learning work-package. Results: One hundred and twelve patients were included. Patients who died in the ICU (n = 8) had highest NEWS as compared with ICU survivors (9.0 [5.0-11.6] vs. 6.0 [5.0-7.0] respectively; p = 0.03). The iROX was higher (18. 4 [15.7-19 .8] vs. 9.0 [5.8-20.9], p = 0.008) and most HRV parameters also depicted higher values for ICU survivors. Considering a composite ICU prognostic outcome parameter (mortality and/or need for any form of respiratory assistance and/or an ICU LOS > median LOS), there was also a difference for NEWS, HRV and iROX (p < 0.0001). The best value to predict ICU mortality for NEWS was 8 (AUC = 0.73, p = 0.005), iROX > 9.5 (AUC = 0.76, p = 0.03) and HRV (Shannon entropy) > 2.9 (AUC = 0.74, p = 0.04). The best model to predict the need fo respiratory assistance combines iROX and HRV (SD1/SD2; AUC = 0.63, p = 0.0001). Adding Shannon entropy on this model predicts either the need for respiratory assistance and ICU survival (respectively AUC 0.62, p = 0.006 and AUC 0.72, p = 0.005).

In ICU spontaneously breathing patients, NEWS, iROX and HRV are different in between survivors and patients who died. The best model to predict the need for respiratory assistance combines iROX and HRV (SD1/SD2). Compliance with ethics regulations: Yes.

Rationale: Sepsis is known for its important mortality in critically ill patients. The last guidelines defined sepsis as life threatening organ dysfunction. It rejected the concept of systemic inflammatory response syndrome (SIRS) associated to suspected or confirmed infection, and considered the concept of dysregulated response to infection. Actual guidelines recommend the quick sequential organ failure assessment score (qSOFA) to identify patients with sepsis especially when outside intensive care unit. Thus, outcomes have mainly to judge the value of SIRS in the sepsis-3 era. The purpose of our study was to compare whereas qSOFA score or the SIRS criterion are superior to predict in-hospital mortality, shock and mechanical ventilation use in sepsis.

Our study includes patients in whom the sepsis-3 definition is met. Therefore, this inclusion was retrospectively performed throughout emergency department (ED) admission cases for clinically suspected infection.

We collected 93 patients admitted to ED for sepsis. Mean age was 65 years ± 14 with bornes of 24 and 92. Men were 57% of the patients. Death occurs in 29.6% of patients, sepstic shock in 25% and the use of mechanical ventilation in 5.6%. qSOFA ≥ 2 has a significant association with in-hospital mortality (p < 0.001) but not SIRS ≥ 2 (0.208). Neither qSOFA ≥ 2 nor SIRS ≥ 2 has association with the use of mechanical ventilation (p = 0.104 vs. p = 1). Whereas, both have a significant association for prediction of septic shock.

The absolute sensitivity and negative predictive value in our study can be explained by the small size of our sample. This needs confirmation with literature data about the fact that SIRS criterion are superior in term of sensitivity and NPV than qSOFA to predict septic shock. Despite the weak odds ratio (OR) of SIRS before that of qSOFA and the poor specificity and Positive predictive value (PPV), we can conclude that SIRS according to its sensitivity and NPV, seems to persist useful in the sepsis-3 era as a reliable prognostic tool in the ED. This may need more large studies for confirmation. Conclusion: Despite SIRS has no significant association with mortality in sepsis, it has largely higher sensitivity and superior NPV to predict septic shock than qSOFA in ED. Compliance with ethics regulations: Yes. Our study aimed to determine the predictive factors of mortality in our patients.

Retrospective study over 2 years in the intensive care unit of the hospital 20 August. All patients with septic shock were included. A p value < 0.05 was considered significant. Results: 81 patients were collected. The age ranged from 11 to 94 years old. The average duration of hospitalization in pre-intensive care was 5 days. The reasons for admission: (febrile respiratory distress: 31% of cases, polytrauma: 14% and 23% for sepsis), the most frequent infections: pulmonary (33%) and blood (32%). 38% received prior antibiotic therapy and 35% were immunocompromised. The overall mortality was 48%. The analytical study of the data shows that the age, the length of stay before admission in intensive care and that in intensive care, fever, hypothermia, slimming, hypotension, collapse, failures (respiratory, hematological, renal, hepatic and neurological) and the use of catecholamines are correlated with mortality, whereas sex, chest pain, tachycardia or bradycardia and mottling are not predictive of mortality. Conclusion: Despite improved techniques for the diagnosis and treatment of patients with septic shock, mortality remains high, especially in the presence of certain risk factors, hence the value of prevention in immunocompromised patients and the reduction in their length of stay in a hospital setting. Compliance with ethics regulations: Yes. Conclusion: P. mirabilis is among the leading bacteria responsible for nosocomial infections in ICU. They are emerging highly drug resistant pathogens whose incidence is rapidly increasing in ICU. So that, it early identification with in vitro testing is of paramount importance to the success of infectioncontrol efforts. Compliance with ethics regulations: Not applicable. Rationale: Influenza is a potential lethal disease causing dozens of thousands excess deaths per year both in Europe and in the United states. Besides hygiene procedures, vaccination is a cornerstone of influenza prevention and guidelines recommend for vaccination among health workers (HW), especially if they are in close contact with frail people. Despite these recommendations, the vaccination coverage is low among health workers both in Europe and in the US. The relevance of a mandatory vaccination for health workers is currently a hot topic but data are scarce regarding intensive care unit health workers' opinion. Patients and methods: Health workers from 2 medical, 6 surgical and 2 polyvalent ICUs received a link to the electronic record of the survey. Results: Among the 10 ICUs, 1637 ICU health workers (HW) (medical: 185 and paramedical: 1452) were questioned. Three hundred and forty-one ICU (21%) answered, 107 (58%) medical health workers (MHW) and 234 (16%) paramedical health workers (PHW) (p < 0.0001). Among MHW 94/107 (88%) were vaccinated vs only 119/234 (51%) PHW (p < 0.0001). Discrepancies exist between medical and paramedical ICU health workers' opinions and beliefs about vaccination for influenza and its acceptance. Medical health workers were more prone to consider influenza as a potentially lethal disease occurring not only among frail people but also in healthy people, to consider the vaccine efficient and safe. To agree with "Vaccination for influenza is mostly related with gain for pharmaceutical industry" (OR: 11 [2.3-50] ) and to disagree with "The risk of Guillain-Barré syndrome is higher after an episode of influenza than after vaccination for influenza" (OR: 4.2 [1.2-14] ) were independently associated to the disagreement with a mandatory vaccination for ICU HW.

Conclusion: Vaccination for influenza should be strongly recommended as a tool of individual protection for ICU health workers as for general population. As confidence in vaccine efficacy and concerns about vaccine side-effects impact the vaccination rate, objective information should be provided to ICU health workers about the efficacy and the side effects of vaccination for influenza. Compliance with ethics regulations: Yes. Rationale: Intra-abdominal infections are a major cause of morbidity and mortality. SFAR recommendations on this topic were published in February 2015. The purpose of this work was to evaluate whether our antibiotic therapy was adequate for these recommendations and whether they were adapted to our unit. The secondary objectives were to look for different risk factors for mortality, to evaluate the impact of inappropriate antibiotic therapy, to evaluate the relevance of carbapenem prescription.

This is a single-center retrospective observational study of secondary peritonitis in the Tourcoing intensive care unit. For each peritonitis, the epidemiological data and the co-morbidities of the patients were collected. Bacteriology and anti-infectious therapies were described to determine the rates of adaptation of our antibiotic therapy and that recommended by SFAR. The adequacy of our treatments to the recommendations was also quantifiable. The description of the stay, the occurrence of a death was specified. Results: 131 peritonitis were included. The rate of adaptation of the SFAR antibiotic therapy was 80%. The rate of adaptation of our antibiotic therapy was 73% and its adequacy rate of 24%. The main differences in prescriptions concerned over-prescription of antifungals, molecule against gram positive bacillus and a sub-prescription of aminoglycosides and beta-lactams, in particular carbapenems. The different mortality risk factors found were SOFA score > 8 (OR 5.4 95% CI 2.15-13.7), the Charlson score > 3 (OR 5.2 95% CI 1.52-17.9), the hollow organ perforation (OR 4.2 95% CI 1.63-10.59). A comparison of the appropriate or not antibiotic groups did not reveal a significant difference in mortality, number of surgical revision and length of stay. In 55% of nosocomial peritonitis, antibiotic therapy with carbapenem was recommended. After recovery of microbiological data, it was only necessary for 7.7% of cases. Conclusion: Our work showed a low rate of compliance with SFAR recommendations. These recommendations are applicable to our service by providing a particular reflection for fungal infections. Our study does not show a correlation between mortality and inadequate antibiotic therapy, surgery remaining the major treatment. Compliance with ethics regulations:Yes. Rationale: Acinetobacter baumannii is a gram-negative opportunistic bacteria that has gained several drug resistance mechanisms over the last decades. Analysis of A. baumanii's resistance profile helps to establish a prompt control and a prevention program. The aim of this study was to evaluate the epidemiology and antimicrobial resistance of A. baumannii isolates in a trauma and burn center in Tunisia. Patients and methods: Retrospectively, we studied all strains of Acinetobacter baumannii isolated over a 7-year period (from January 2012 to December 2018). Conventional methods were used for identification. Antimicrobial susceptibility testing was performed with the disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to CA-SFM guidelines. Data were analyzed using the SIR-system. Minimum inhibitory concentration (MIC) of colistin was determined using the E-test ® method (bioMérieux), then using the EUCAST broth micro-dilution method (UMIC, Biocentric ® ) since May 2017. Results: During the study period, 1248 non-repetitive strains of Acinetobacter baumannii were isolated representing 9.9% of all isolates, 14% of gram-negative bacilli (GNB) and 40.6% of non-fermenting GNB. In our center, infections due to A. baumannii were endemic with epidemic peaks. A. baumannii was mainly isolated from burn intensive care unit (67%) and anesthesiology department (22.6%). The most frequent sites of isolation were blood cultures (34.3%), catheters (20%), respiratory specimens (12.5%) and skin samples (10% Sampling duration is also reduced, improving workflow. Evaluators consider that BronchoSampler rationalizes the cumbersome sampling process and that the closed system design reduces the risk of losing sample or sample contamination. The set-up, the suction capacity, the sampling quality and quantity have all been evaluated better or far better than that usually observed with usual sampling techniques and devices. Finally, 36 (75%) of users prefer BronchoSampler to commonly used method.

Conclusion: This satisfaction survey shows that with its simple but revolutionary design, BronchoSampler brings a real effective benefit in sampling procedure enabling the clinician to perform it alone, and 39 (81%) of the survey evaluators consider that BronchoSampler should replace their current practice. Compliance with ethics regulations: Yes. Rationale: The possibility of having a sensitive, specific and prognostic biological marker for bacterial infections is a considerable challenge. A step was taken with the discovery of pracalcitonin. Patients and methods: This is a prospective observational cohort study of 120 patients in the Medical Resuscitation Department of the University Hospital of Casablanca during the 6-month period, including patients in whom the PCT was dosed. The data collected allowed us to form two groups according to the PCT value: PCT+ group with PCT > 2 ng/ml and PCT− group with PCT < 2 ng/ml. The statistical analysis of these different data was carried out using Epi Info software version 3.5.3. Results: 60% of our patients had a bacterial infection and 40% did not have one. We also distinguished community infections (42% of I+ patients) and nosocomial infections (58% of I+ patients). We found that the highest rates of PCT were in nosocomial infections and the lowest PCT rates were found in community-acquired infections. Then, in each type of organ involvement we tried to vary the PCT thresholds to 0.5-2 and 10 ng/ml in order to find the best threshold for which PCT allowed to diagnose bacterial infection, justifying our choice of departure. We concluded that the best PCT cut-off value in general was 2 ng/ml, because it gave us the best sensitivity/specificity ratio (67% and 50% respectively) with a positive predictive value of 65% and a negative predictive value of 52%. The link between PCT and bacterial infection was moderate (Yule Q-factor at 0.34). By analyzing the different therapeutic aspects, we showed that 71% of our patients had been treated with ATB before the PCT assay and that the broadest spectrum antibiotics available to our service were used in patients with PCT levels the highest. Finally, concerning the evolution, the higher the rate of PCT, the higher the death rate, especially since 100% of patients with PCT > 10 ng/ml died. Conclusion: Procalcitonin is considered to be one of the best markers of systemic bacterial infection. Indeed, its elevation is earlier than that of CRP and its specificity is better compared to IL-6 and IL-8. The rate of procalcitonin remains low in the presence of viral infection. Procalcitonin is also a prognostic marker, its elevation is correlated with the severity of the infection, and its decrease is a good indicator of the effectiveness of antibiotic therapy. Compliance with ethics regulations: Not applicable. Rationale: Due to induction immunosuppression infection is the most common cause of mortality within the first year after lung transplantation (LTx). The management of perioperative antibiotic therapy is a major issue, but little is known about worldwide practices.

We sent by email a survey to 180 LTx centers around the world dealing with 5 daily clinical vignettes concerning perioperative antibiotic therapy. We considered perioperative period as the period of the transplant surgery (per operative) and the postsurgery time before any infection occurrence (postoperative). After general questions on local practices, we asked each center for colonization definition and their diagnostic methods for microbial screening in recipients and donors. The clinical cases were related to specific issues concerning the management of antibiotic therapy in different clinical situations, including no prior colonization, prior colonization with sensitive or multi-drug resistant (MDR) microorganisms including prior colonization with MDR bacteria not sensitive to beta-lactams. The invitation and a weekly reminder were sent to lung transplant specialists for a single consensus answer per center between June and September 2018.

We received a total of 99 responses from 24 countries, mostly from Western Europe (n = 46) and the USA (n = 34), (Fig. 1) . Systematic screening for bronchial colonization before LTx was mostly performed with sputum samples (72%), regardless of the underlying lung disease. Definition of colonization was very heterogeneous and the delay between the last bacterial isolation in pre-transplant and the LTx to consider if the therapy should target these bacteria varied between 1 week and more than 1 year. In recipients without colonization, antibiotics with activity against gram-negative bacteria resistant strains (piperacillin/tazobactam, cefepime, ceftazidime, carbapenems) were reported in 72% of the centers, and antibiotics with activity against methicillin-resistant Staphylococcus aureus (mainly vancomycin) were reported in 38% of the centers. For these recipients, the duration of antibiotics reported was 7 days (33%) or less (26%) or stopped when cultures of donor and recipients were reported negatives (12%). In recipients with pre-transplant colonization, antibiotics were adapted to the susceptibility of the most resistant strain isolated in pre-transplant samples and given for at least 14 days (67%). Conclusion: Practices vary widely around the world, but resistant bacterial strains are mostly targeted even if no colonization occurs. The antibiotic duration reported was longer for colonized recipients. Compliance with ethics regulations: Not applicable. The vancomycin was therefore considered as justified or not and appropriate or not. Occurrence of nephrotoxicity and supratherapeutic exposure in this study group was compared to critically ill children control group. Results: Thirty one children receiving 43 vancomycin lines of treatment whose 13 (26%) observed a risk of acute kidney injury (AKI) (n = 8) and an AKI (n = 5) during the vancomycin treatment period were included. There was a trend to inversed relationship between plasmatic concentrations of vancomycin and estimated creatinine clearance (r2 = 0.2019). Seven patients observed a nephrotoxicity related to vancomycin, they had a higher plasmatic concentration of vancomycin (p = 0.0009). Seven patients (22%) had a supratherapeutic exposure to vancomycin. Nephrotoxicity and supratherapeutic exposure were higher in children with or combined liver-kidney transplantation than in comparative critically ill children group. We found 1 blood stream infection due to the central catheter and 7 blood stream infections probably due to the central catheter. One hundred thirtyfive bacteria were identified of which 108 (80%) were Staphylococcus coagulase negative. Nineteen (44%) lines of vancomycin were appropriate and 31 (72%) were justified. Conclusion: Vancomycin could have been avoided in one third of children with liver or combined liver-kidney transplantation during the early phase of postoperative stage. Vancomycin is associated with a risk of both nephrotoxicity and supratherapeuric exposure. Vancomycin should be used with caution, appropriate indications and dosing in this vulnerable population. Compliance with ethics regulations: Yes. Rationale: Early bacterial infection is a major and severe complication occurring within the first month after pediatric liver transplantation (LT). The rise of antimicrobial resistance, especially extended-spectrum beta lactamase producing Enterobacteriaceae (ESBL-PE), is henceforth a concern for these patients. This study aimed to assess the epidemiology of early bacterial infections, including those caused by multidrugresistant (MDR) pathogens, and to identify the risk factors for infection. Rationale: The number of cancer patients admitted to emergencies is clearly increasing and digestive oncology is the leading cause of consultation. The aim of this work is to identify the epidemiological factors, the therapeutic modalities as well as the predictive factors of mortality and to compare them with the data of the literature. Patients and methods: 81 patients admitted to visceral emergencies for an urgent syndrome revealing or complicating a primary or secondary digestive cancer, and who required immediatemedical and/or surgical intervention and who had stayed at the surgical resuscitation level in our hospital center for a duration of 2 years. Several data were entered on Excel and analyzed using the SPSS version 20 software.-Epidemiological, concerning age and sex; -Clinics including risk factors, history, general condition of the patient and clinical examination data; -Para-clinical, interesting biological assessments, and morphological examinations-Medical and surgical therapeutics; -Postoperative follow-up-Treatment results.

The three most frequent sites were rated in order of increasing frequency: colo-rectum (49%), pancreas (17%), and stomach (12%). The age group most found was age over 60 years with 48% of cases, 12% of patients had under 40 years. This series includes 46 men and 35 women with a sex ratio of 1, 31. The installation method was mostly gradual with 62% of cases. Our patients have consulted for urgent clinical presentations mainly occlusive syndrome noted in 47% of patients. Abdominal CT was the first examination performed, followed by abdominal ultrasonography in 73% and 22%, respectively. The therapeutic management was medico-surgical. The surgery done in 96% of patients, 74% for palliative indication: 40% were operated for an ostomy discharge, 24% for a digestive bypass, 24% for a palliative resection and 12% for a stoma feeding. Postoperative outcomes were 44% morbidity and 43% mortality. The main cause of death was septic shock in 80% of cases, thanks to multivariate statistical analysis three factors were deduced significantly related to mortality: The ASA score: p = 0.004; OR = 2.520; IC: [1.33; 4.74 ICU and hospital mortality rates were 60% (n = 21) and 65.7% (n = 23), respectively. Ten patients were alive 6 months after with a median Rankin score at 0 [0-1]. More than half of the patients without stupor had a favorable neurological outcome (Fig. 1) . In univariate analysis, mechanical ventilation and stupor were correlated with mortality, whereas DIC and APL were not. By multivariate analysis stupor was the only factor significantly associated with a higher mortality (HR: 8.56 [2.4-30.4] ). Conclusion: Intracranial hemorrhage is associated with a high mortality rate in AL patients, stupor at the onset of intracranial bleeding being independently associated with poor outcome. Up to one third of patients will nevertheless survive and experience a favorable neurological outcome. Compliance with ethics regulations: Yes.

Neurological outcome assessing by modified Rankin scale according to stupor or coma at intracranial hemorrhage diagnosis (blank reflect missing data) Rationale: Sinusoidal obstruction syndrome (SOS, previously known as veno-occlusive disease) is a complication of high dose chemotherapy, frequently occurring during bone marrow transplantation (BMT). Severe SOS is associated with a high mortality rate, related to multi-organ failure (MOF). Defibrotide being the only available option for prevention and treatment. Prognosis of patients with SOS requiring intensive care unit (ICU) admission remains unknown. The primary objective was to assess the outcome of these patients. Secondary objective was to assess risk factors associated with hospital mortality. Patients and methods: Retrospective study conducted between January 2007 and July 2019 in 12 French ICUs. Critically ill adult patients with SOS (according to EBMT classification) who received defibrotide were included. Results are reported as median [IQR] or number (%). Adjusted analysis was performed using Cox Model. Results: Seventy-one patients were included with a median age of 47 years . Underlying hematologic diseases were acute myeloid leukemia (41%), lymphoma (21%),myelodysplasia/myeloproliferative neoplasm (18%) or acute lymphoid leukemia (15%). SOS occurred during myeloablative allogeneic BMT (34%), reduced conditioning allogeneic BMT (41%), autologous BMT (11%) or chemotherapy (14%, including Gemtuzumab Ozogamycin in 7 patients). Median SOFA score at ICU admission was 11 ]. EBMT prognostic score was often "very severe" (69%). Main reasons for ICU admission were respiratory failure (n = 26), acute renal injury (n = 17), shock (n = 11), liver failure (n = 8), coma (n = 6) and monitoring (n = 3). Median bilirubin level at ICU admission was 51 µmol/L [IQR 36-90] and platelets count 24 G/L . Mechanical ventilation (MV), vasopressors, and renal replacement therapy (RRT) were required in 59% (n = 42), 52% (n = 37) and 49% (n = 34) of patients, respectively. Sixteen patients receiving defibrotide experienced bleeding events. ICU and hospital mortality rates were 39% and 54% respectively, mainly related to organ dysfunction. In univariate analysis, delayed defibrotide initiation, bilirubin level, organ supports, SOFA, and EBMT scores were associated with hospital mortality. Cox model identified older age (HR 1.02, 95% CI 1.00-1.04), MV (HR 1.99, 95% CI 1.00-3.99), RRT (HR 2.55, 95% CI 1.32-4.91), as associated with mortality. Prophylactic Defibrotide was correlated with a better outcome (HR 0.35, 95% CI 0.13-0.92). Similar results were observed after adjustment for center effect. Conclusion: When organ support is required, ICU management is associated with high mortality. Organ support (namely RRT and MV) and older age were associated with poor outcome. Prophylactic Defibrotide was associated with survival either due to selection process or to efficacy in this setting. Additional studies are needed to confirm these results. Compliance with ethics regulations: Yes.

Rationale: Prognosis of critically ill immunocompromised patients (CIIP) has improved over time. Neutropenia is common and is found in one third of these patients. Prognostic impact of neutropenia remains controversial and little data focus on CIIP admitted in a context of acute respiratory failure (ARF). Primary objective was to assess prognostic impact of neutropenia on outcome of these patients. Secondary objective was to assess etiology of ARF according to neutropenia. Patients and methods: Retrospective analysis of prospective multicenter multinational dataset. Adults immunocompromized patients with ARF were included. Adjusted analyses included (1) a hierarchical model with center as random effect; (2) propensity score (PS) matched cohort; and (3) adjusted analysis in the matched cohort. Results: Overall, 1481 patients were included in this study. Median age was 64 [IQR 55-72] and 613 patients (39.7%) were of female gender. Median SOFA score was 7 [4] [5] [6] [7] [8] [9] [10] and PS was 1 [0] [1] [2] [3] . Main immune defect were hematological malignancy in 533 patients (36%), solid tumor in 473 (32%), systemic disease in 155 (10.5%), and other immunosuppressive drugs in 117 (8%). Neutropenia at admission was observed in 165 patients (11%). Initial oxygenation strategy was Oxygen in 755 patients (51%), High flow nasal oxygen in 165 (11%), non-invasive ventilation in 202 (14%) and invasive mechanical ventilation in 359 (24%). Before adjustment, hospital mortality was significantly higher in neutropenic patients (54% vs. 42% in non-neutropenic patients; p = 0.006). After adjustment for confounder in a mixed model, neutropenia was no longer associated with outcome (OR 1.40, 95% CI 0.93-2.11). After PS matching, 148 neutropenic and non-neutropenic patients were compared. Hospital mortality was similar in both groups (52% vs. 46% respectively; p = 0.35). After adjustment for variables associated with mortality, neutropenia was not associated with hospital mortality (OR 1.04, 95% CI 0.63-1.72). ARF etiologies were distributed similarly in both neutropenic and non-neutropenic patients (Fig. 1) , main etiologies being bacterial pneumonia (49% vs. 46%), invasive fungal infection (11% vs. 10%), pneumocystis jiroveci pneumonia (2% vs. 0.7%), and undetermined etiology (8% vs. 10%) (p = 0.815). Conclusion: Neutropenia at ICU admission is not associated with hospital mortality in this cohort of CIIP admitted for ARF. Surprisingly, ARF etiology did not differ despite the multiplicity of observed immune defects. Compliance with ethics regulations: Yes. Rationale: Hepatic dysfunction (HD) is commonly observed in patients with hematologic malignancies and associated with an increased mortality in allogeneic hematopoietic stem cell transplantation patients. We aimed to assess incidence, risk factors and prognostic impact of HD in a large multicenter cohort study of critically ill patients with hematologic malignancies. Patients and methods: This research was a post hoc analysis of a Franco-Belgian multicenter prospective study assessing the prognosis of patients with hematologic malignancies admitted to intensive care unit (ICU) between January 2010 and May 2011. HD was defined as serum total bilirubin ≥ 33 µmol/L at ICU admission. For patients with HD, a review of medical hospital records was performed by an expert panel to assess management of HD by attending physicians. Results: Among the 1011 patients with hematologic malignancies admitted to ICU, 893 were included in the study, mainly patients with non-Hodgkin lymphoma (31.5%) or acute myeloid leukemia (27.1%). HD at ICU admission occurred in 183 patients (20.7%). Factors independently associated with HD were the use of cyclosporine (OR = 3.357, 95% CI 1.926-5.851, p < 0.0001) and antimicrobial treatment (OR = 1.578, 95% CI 1.038-2.401, p = 0.033) before ICU admission, abdominal symptoms at ICU admission (OR = 2.182, 95% CI 1.461-3.258, p < 0.0001), ascites (OR = 2.562, 95% CI 1.059-6.196, p = 0.037), hepatic Charlson comorbidity (OR = 2.228, 95% CI 1.057-4.696, p = 0.035), increased creatinine at ICU admission (OR = 1.001, 95% CI 1-1.003, p = 0.02), neutropenia (OR = 1.465, 95% CI 1.001-2.144, p = 0.049) and myeloma (OR = 0.378, 95% CI 0.188-0.761, p = 0.006). Hospital mortality was 56.3% and 36.3% in patients with HD and patients with no HD respectively (p < 0.0001). HD appeared as an independent factor of hospital mortality after adjustment with other organ failure (ORadj = 1.861, 95% CI 1.275-2.717, p = 0.001). Factors independently associated with hospital mortality among patients with HD at ICU admission are reported in Table 1 . Etiologic diagnoses for HD by physicians were undetermined for 125 patients (72.2%) including 92 (53.2%) for whom the existence of HD has not even been mentioned in the medical record. Investigations were performed in 29% and only 19% of patients received a specific treatment for HD. Conclusion: HD at ICU admission is common, underestimated, poorly investigated, and impairs outcome in critically ill patients with hematologic malignancies. HD should be considered and managed as other organ dysfunctions. It raises the importance of an early severity assessment of HD and a development of diagnosis strategies to get therapeutic options, in close collaboration between hematologists and intensivists. Compliance with ethics regulations: Yes. Rationale: Acute respiratory failure (ARF) is the main cause for admission to the ICU for patients with hematological malignancies (HM). Viral pneumonia is poorly described in this population. Respiratory viruses PCR is a rapid and sensitive diagnostic tool. Thoracic CT allows to guide the diagnosis but is also poorly described. The primary objective was to describe CT features suggesting viral pathogenicity. Secondaryobjectives were to assess risk factors associated with the use of invasive mechanical ventilation (IMV) and ICU mortality. Rationale: High-dose methotrexate (HD-MTX) is commonly used in the treatment of solid tumours and hematological malignancies. Severe toxicities are frequent, leading to organ dysfunction, multiple organ failure and death. Outcome of these patients when critical illness occurs is poorly studied. This study aims to describe MTX-induced toxicities and to assess outcome in critically ill patients.

In this retrospective study conducted in the ICU of one university hospital between January 2002 and December 2018, all the patients who were given HD-MTX (single dose greater than 500 mg/m 2 ) in the ICU were included. Results are presented as median [interquartile range] and number (percent). Results: 33 patients (24 men and 9 women) aged 48 years [34-63], were included. B-cell lymphoma had been diagnosed in 31 patients (Burkitt, n = 14; diffuse large B cell lymphoma with CNS (central nervous system) involvement, n = 9; primary CNS lymphoma, n = 5) and T-cell lymphoma in two patients. Patients were mainly admitted for coma (n = 14; 42%) or acute kidney injury (n = 8; 24%). MTX was administered at a median dose of 6.1 g [5-14] . Fourteen patients had concomitant medication interacting with MTX. Median MTX clearance was 4 days [4] [5] . Frequent MTX-related complication were mucositis (n = 21, 64%), diarrhea (n = 14, 44%) or hepatic failure (n = 15, 45%). During ICU stay, 11 patients experienced acute kidney injury (KDIGO stage 2.5 [2] [3] ). Two patients received carboxypeptidase and three underwent dialysis. Overall, 19 patients (57%) required mechanical ventilation, 10 (30%) vasopressors. Hospital mortality was 33% (n = 11). Cox model identified MTX concentration 24 h after administration higher than 4.6 µmol/L as associated with hospital mortality (HR 6.7, 95% CI 1.6-27.3) (Fig. 1) . Conclusion: To our knowledge this is the first study assessing characteristics and outcome of critically ill patients receiving HD-MTX. MTX concentration at H24 was associated with hospital mortality. Despite underlying malignancy, ICU support of these patients was associated with a meaningful survival. Compliance with ethics regulations: Yes. Rationale: High-dose methotrexate (1 g/m 2 ; hdMTX) is the cornerstone of chemotherapy in acute lymphoblastic leukemia (ALL) and several high-grade non-hodgkin lymphoma (hNHL). Despite standardized prevention, acute kidney injury (AKI) and other life-threatening complications still occur. Given the cost of glucarpidase, an enzyme that metabolizes MTX in few minutes, and the complexity of hematological patients admitted to the ICU, a better comprehensive view of the factors that predict hdMTX toxicity, as well as the role of glucarpidase as rescue therapy in patients with organ failure, is mandatory. Patients and methods: Retrospective monocenter study including all the adult patients referred for ALL or hNHL in a French university hospital, and who received hdMTX. AKI was defined according to the KDIGO classification. Univariate analysis (Fischer exact or Mann-Withney tests) followed by multivariate analysis (stepwise logistic regression) were used to identify before hdMTX the clinical and biological predictive factors of AKI. Outcomes following glucarpidase were also addressed.

Results: From Dec-2011 to Sept-2018, 468 patients received HdMTX (median dose 3 g/m 2 ; ALL n = 126, hNHL n = 342), totalizing 1264 hdMTX pulses. Sixty-nine patients (14.7%) developed AKI after a median time of 2 days (stage 1 n = 35, stage 2 n = 18, stage 3 n = 16 including one requiring dialysis in the first week). By multivariate analysis, only age, body mass index and a diagnosis of ALL were significantly and independently associated with the risk to develop AKI. MTX exposure (maximal serum concentration at H24-48) was also associated with AKI (AUC 0.85, p < 0.01). Glucarpidase was used in 42 patients (9%) that differed by a higher age and BMI, and a lower basal eGFR. Glucarpidase was followed by a rapid renal improvement but serum creatinine did not return to baseline (120 vs. 92 micromol/L). Thirty patients with AKI or delayed MTX elimination did not receive glucarpidase but none required renal replacement therapy and eGFR was only slightly but not significantly reduced at the end of follow-up. Extra-renal adverse-events (RBC and platelets transfusions, neutropenia, hepatitis, severe diarrhea, mucitis) were more frequent in patients that developed AKI. Eighteen patients were admitted to the ICU, including 9 and 6 that required mechanical ventilation or vasopressor drugs, respectively. Conclusion: Few actionable factors predict the development of AKI after HdMTX, suggesting additional genetic factors. AKI was reversed by glucarpidase but progression toward CKD was the rule. Further studies will have to identify patients that will actually beneficiate from glucarpidase. Compliance with ethics regulations: Yes.

Khaoula Ben Ismail, Sana Khedher, Ameni Khaled, Nassereddine Foudhaili, Mohamed Salem USI Digestif-service de gastroenterologie-EPS Charles Nicolles.Tunis-Tunisie., Tunisia, Tunisia Correspondence: Khaoula Ben Ismail (khaoula87@hotmail.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-085

Rationale: Infection is common and accounts for major morbidity and mortality in cirrhosis. Patients with cirrhosis are immunocompromised and have increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. We aimed to evaluate the impact of infection on hepatic encephalopathy. Patients and methods: This is a prospective study, conducted over a period of 3 years from January 2016 to December 2018. Consecutive patients with approved decompensated cirrhosis admitted to our department are included. All clinical and biological data were collected from the medical records. Univariate and multivariate analysis were used to identify the impact of infection on hepatic encephalopathy. Results: A total of 110 patients diagnosed with decompensated cirrhosis were enrolled in this study. Mean of age was 62 years (18-88). Sex ratio was 1.2. HCV (39%) was the main etiology of cirrhosis. The reasons of hospitalization were: oedema with ascitic syndrome (44% of cases), digestive bleeding (21% of cases), fever (16% of cases), and encephalopathy (36% of cases). Patients with infection seemed to have a high incidence of hepatic encephalopathy with 64% versus 36% when the patients are none infections. The results also showed that in those with hepatic encephalopathy, an effective antibiotic treatment accelerates significantly wakefulness under 48 h with a rate of 76% vs. 24% (p < 0.03) . In addition, the infection does not influence mortality or length of stay compared to other complications such as digestive bleeding. Conclusion: We found that infection caused more episodic hepatic encephalopathy than other complication and an effective antibiotherapy accelerate wakefulness. Compliance with ethics regulations: Yes. Rationale: Hepatic encephalopathy (HE) is a common cause of hospitalization in patients with cirrhosis. Pharmacologic treatment for acute (overt) HE has remained the same for decades. To compare polyethylene glycol electrolyte solution (PEG) and lactulose treatments in patients with cirrhosis admitted to the hospital for HE. We hypothesized that rapid catharsis of the gut using PEG may resolve HE more effectively than lactulose. Patients and methods: This is a prospective study, conducted over a period of 3 years. From Janury 2016 to December 2018, we have been interested in cirrhotic patients with hepatic encephalopathy. All clinical and biological data were collected from the medical records. Univariate and multivariate analysis were used to identify the difference beteween PEG and lactulose in the treatement of hepatic encephalopathy.

Results: A total of 110 patients diagnosed with decompation of cirrhosis were enrolled in this study. Mean of age was 62 years (18-88). Sex ratio was 1.2. HCV (39%) was the main etiology of cirrhosis. The hospitalization reasons were: edematous-ascitic syndrome in 44%, gastro-intestinal bleeding 21%, fever in 16%, and encephalopathy was present in 36% of cases. A total of 40 patients were randomized to each treatment arm. Baseline clinical features at admission were similar in the groups. Twelve of 20 patients in the standard therapy arm (55%) had an improvement of 1 or more in HESA score, thus meeting the primary outcome measure, compared with 17 of 20 evaluated patients receiving PEG (85%) (p < 0.01). The mean ± SD HESA score at 24 h for patients receiving standard therapy changed from 2.3 ± 0.9 to 1.6 ± 0.9 compared with a change from 2.3 ± 0.9 to 0.9 ± 1.0 for the PEG-treated groups (p = 0.002). The median time for HE resolution was 2 days for standard therapy and 1 day for PEG (p = 0.01). Adverse events were uncommon, and none wasdefinitely study related. Conclusion: We found that PEG led to more rapid HE resolution than standard therapy, suggesting that PEG may be superior to standard lactulose therapy in patients with cirrhosis hospitalized for acute HE. Compliance with ethics regulations: Yes.

Acute pancreatitis and pregnancy Janati Adnane, Lina Berrada Obstetric intensive care unit, Casablanca, Morocco Correspondence: Janati Adnane (adnanejanati@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-087

Rationale: The association of acute pancreatitis and pregnancy is rare but not negligible, it often cause a diagnostic problem given the gravidal context that can lead to serious repercussions. The objective of our study is to assess the particularities in the diagnosis, management and prognosis of acute pancreatitis during pregnancy Patients and methods: This is a retrospective study about cases of acute pancreatitis occurred during pregnancy over a 3-year period (2017-2019) at the obstetric intensive care unit of the MERIEM maternity hospital in the CHU IBN ROCHD CASABLANCA. A retrospective analysis of the medical files of these patients was carried out, considering epidemiological and etiological criteria, the treatments administered and maternal/fetal fate.

We found 10 cases during this period, with an incidence of 1/3000. The average age of onset was 28 years, 90% of cases occurred in the 3 rd trimester. Epigastric pain and vomiting were the common symptomatology. Ultrasound showed biliary lithiasis in 70% of cases with increased pancreas size in 30% of cases. Maternal mortality was zero. Uncomplicated benign forms are the most common (80%). Severe hypokalemia was found in 40% of patients. Neonatal morbidity was marked by six premature deliveries. Among them, a newborn died at day-1 of life Discussion: The association of acute pancreatitis and pregnancy is rare, more frequent during the 3 rd trimester, it mainly affects the young woman. Lithiasic biliary pathology remains by far the most frequent etiology. The diagnosis is clinical most often represented by epigastralgia with vomiting and biological via lipasemia and amylasemia dosage. Uncomplicated benign forms are the most common. Hydroelectrolytic disorders are often found. Abdominal ultrasound allows the etiological diagnosis. The treatment is above all symptomatic whose objective is the digestive rest, the correction of the hydroelectrolyte disorders but first of all relieve the pain. Conclusion: Acute pancreatitis is a rare event in pregnant women, but can have a maternal and fetal prognosis. It must be systematically evoked in front of the acute abdominal pains of the pregnant woman because the confirmation of the diagnosis is easy and the maternal results depend mainly on therapeutic management. Prematurity remains the predominant factor in neonatal morbidity. Compliance with ethics regulations: Not applicable. Rationale: ACLF is a clinical concept defined in patients with chronic liver disease who presented organ failure(s) secondary to an acute decompensated event. Liver transplantation in this indication showed good results in selected patients. The aim of this prospective study was to evaluate the outcome and the factors associated with a favorable selection to liver transplantation in this population. Patients and methods: All consecutive patients admitted to the ICU with cirrhosis and ACLF, were recruited. Patient with age < 18 years or with fulminant hepatitis were excluded. Results: Between July 2017 and February 2019, 155 cirrhotic patients were admitted to ICU. Mean age was 55.6 ± 11.3 years (71.6% Male). Cirrhosis was due to alcohol in 78.1% of the patients. ACLF grading at admission was: 44.5% ACLF3 (n = 60), 21.3% ACLF2 (n = 33), 14.8% ACLF1 (n = 23), and 19.4% ACLF0 (n = 30). Of the 155 patients, 46.5% (n = 72) were considered to be eligible for a transplant project and were assessed for liver transplantation. The main reasons were alcohol abuse (66.3%, n = 55), death within 7 days after admission (32.5%, n = 27) and rapid improvement of the liver disease. Of the eligible patients, 50% were transplanted with a mean time between admission to ICU and liver transplantation of 68.9 ± 105.1 days. Twelve patients died on the waiting list (24% of the listed patients), mainly of septic shock. Among those who were assessed for liver transplantation but not listed (n = 21), 76.2% died before the listing (n = 16) and 23.8% were not listed because of severe comorbidities (n = 5). The global mortality rate was 56.8% (n = 88). The 28 and 90 days rate mortality were respectively 42.9% and 56.2%. The overall 3-month patient survival was respectively 97% and 26% in the transplant and non-transplant group (p < 0.001) for the entire cohort. Among eligible patients, factors associated with the absence of liver transplantation, in the multivariate analyses, were mechanical ventilation (HR 8.95, 95% CI Rationale: Body composition is known to be a prognostic factor in cirrhotic patients. However, the link between this and the prognosis of patients in intensive care unit (ICU) is unknown. The computed tomography offer accurate estimations of muscle mass by analysing a cross-section usually going through the third lumbar vertebrae. This retrospective study aimed to assess the feasibility of body composition (BC) analysis in cirrhotic patients with septic shock, using Computed Tomography (CT) and evaluate the impact of BC (muscle mass, subcutaneous and visceral fat) on outcome. Patients and methods: This retrospective study included 36 cirrhotic patients with septic shock hospitalized in ICU who underwent an abdomino pelvic CT scan within 48 h of admission. We collected the surface areas of muscle mass and adipose tissue on the CT scans. We compared BC data with mortality and with the number of organ failures.

The average age was 60 years . The average Child and MELD scores were respectively 10.8 [8-14] and 28.7 . The prevalence of sarcopenia was 50%. It was not associated with a higher mortality rate at day 28 (p = 0.31) or with a higher number of organ failures at day 28 (p = 0.55). We observed a higher subcutaneous adiposity index in patients who died at day 28 (p = 0.03) and in patients with renal insufficiency at admission (p = 0.019). There was a trend (p = 0.057) towards more visceral fat in patients who died in ICU.

The assessment by CT of body composition reveal evaluation of BC using CT is feasible and reproducible and may constitute a promising tool to evaluate in cirrhosis critically ill patients. Visceral fat mass seems associated with poor outcome in cirrhotic patients with septic shock Compliance with ethics regulations: Yes.

Rachid Jabi, Mohammed Bouziane CHU Mohammed VI, Oujda, Morocco Correspondence: Rachid Jabi (jabirachid@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-090

Rationale: The infection of the necrosis constitutes a pejorative element in the management of the necrotico-haemorrhagic pancreatitis, in the absence of the drainage the mortality approaches 100%.

The morbidity and mortality of surgery can be avoided with minimally invasive treatments. Purpose: to compare the morbidity and mortality of the two groups of post-ERCP pancreatitis and the other etiologies. Patients and methods: A retrospective study over 4 years between 2016 and 2019 and a comparison between pancreatitis secondary to post-ERCP and other etiologies of pancreatitis. A P value of 0.05 is considered significant.

The surgical treatment used in 10 cases of superinfection post ERCP against seven cases of other etiologies of pancreatitis. High mortality in post-ERCP pancreatic arm 88% vs. 50% (p = 0.09). High morbidity in the operated group 66% vs. 28% (p = 0.04) represented mainly digestive haemorrhages. Duration of stay was significantly longer in the operated group 36 vs. 12 days (p = 0.04). Thrombocytopenia and beta-lactamase-producing enterobacteria have further complicated management in the post-ERCP infected pancreatitis arm. The antibiotic resistance of infected pancreatitis in post-ERCP patients is 86.65% for ciprofloxacin, 19.17% for imipenem and 65% for amikacin. Conclusion: Pancreatitis the most common adverse effect of ERCP with significant morbidity and mortality. The collaboration between the intensive care unit gastroenterologist and the surgeon improves management since the risk factors are mainly related to the patient and can not be modified. Compliance with ethics regulations: Yes.

Gautier Nitel, Aghiles Hamroun, Anne Bignon, Gilles Lebuffe CHRU Lille, Lille, France Correspondence: Gautier Nitel (gautier.nitel@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-091

Rationale: Liver transplantation (LT) has been recently experiencing an expansion of its indications, allowing patients with potentially more co-morbidities to access to transplantation. In our era of graft shortage, we should focus on the identification of the best LT candidates. The aim of our work is to study the determinants of early morbidity and mortality after LT from three angles: occurrence of a major cardiovascular event (MACE) or acute renal failure (KDIGO stage 2-3 AKI) in the first 30 days postoperative, and death in the year following LT.

Retrospective study investigating the occurrence of MACE or AKI (KDIGO 2-3) within 30 days post-operative and mortality at 1 year after LT, including patients who received a first LT between January 2014 and December 2017 in our center. Analysis of risk factors by a multivariate step-by-step analysis. Statistical significance for p < 0.05. Data presented in Odds ratio (OR) Rationale: Infectious complications are frequently reported in critically ill patients supported by Veno-Arterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) for refractory cardiogenic shock, but their diagnosis is challenging. No study has specifically studied bloodstream infection (BSI) in this population and some recommendations suggest performing systematic blood culture (BC). In our unit, systematic BC are daily sampled. We investigated the interest of systematic BC to detect BSI under VA-ECMO. Patients and methods: In a retrospective analysis (2013-2017), and after exclusion of patients dying within 24 h, all adult patients from cardio-vascular intensive care unit supported by VA-ECMO were included. Systematic daily and "on demand" BC (at the physician's discretion) performed from VA-ECMO implantation to 5 days after withdrawal were analyzed. BSI was defined as at least one BC positive to a pathogen (except for contaminants BSI which required at least two positive BC with the same bacteria in 48 h). Multivariable logistic regression was performed to identify risk factors for positivity of systematic BC. Rationale: Fungal infections are constantly increasing in hospitals. Indeed, the increase in these infections and especially candida yeast infections is almost parallel to the increase in the widespread use of a wide range of implanted medical devices such as catheters. For this reason, we have been investigating, isolating and identifying Candida yeast colonizing vascular catheters and studying the epidemiological and clinical characteristics of patients with colonized catheters. Patients and methods: It is a prospective, transversal study conducted at the intensive care and neurosurgery services of the Sétif University Hospital, evaluating the fungal colonization of vascular catheters. These are collected from hospitalized patients for a period of 5 months. A culture of the distal end of the catheter is performed directly after its ablation.

The results obtained showed that among the 30 samples taken, six are colonized by the yeasts, the incidence is 20%. Six yeast of candida spp were isolated, 50% of them were Candida albicans species, 33.33% Candida parapsilosis and 16.66% were Candida glabrata.

Conclusion: It appears that colonization of catheters occurs most frequently in patients with the following characteristics: extreme ages of life, male sex, antibiotic therapy and length of hospitalization or prolonged catheterization. Compliance with ethics regulations: Yes. Rationale: The threat of emergent extensively drug-resistant bacteria (eXDR) dissemination worldwide is real. It has become a global public health issue. In fact, Glycopeptides-resistant Enterococcus faecium (GRE) and carbapenemase-producing Enterobacteriaceae (CPE) are the lead microorganisms in the high resistant bacteria category. The aim of our study was to characterize the molecular mechanisms and to determinate the antimicrobial susceptibility profiles of GRE and CPE isolated from burn patients. Patients and methods: Prospectively, we studied all CPE and GRE strains isolated from burn patients between January and December 2018. All isolated microorganisms were identified on the basis of conventional microbiological techniques. Antibiotic susceptibility testing was carried out by the agar disc diffusion method, and susceptibility results were interpreted using clinical breakpoints according to CA-SFM guidelines. Molecular characterization was performed by multiplex real-time PCR (Cepheid, GeneXpert ® ) allowing detection of the most prevalent carbapenemase encoding genes (blaVIM, blaNDM, blaIMP, (blaOxa-48 and blaKPC) as well as the genes VanA and VanB of GRE. Results: During the study period, 53 eXDR were isolated from 42 burn patients. The most frequent sites of isolation were blood cultures (34%) and skin samples (30.2%). CPE represented 86.8% of isolated eXDR (46 strains). Among them, the most frequently identified species was Klebsiella pneumoniae (73.9%) followed by Enterobacter cloacae (13%). Twenty-four CPE (52.2%) expressed the blaNDM gene. The blaOxa-48 gene was found in 12 strains (26.1%) and ten strains (21.7%) carried both genes. Of the 46 CPE, 89.1% revealed ertapenem MIC > 1 mg/l whereas most strains were susceptible to imipinem and meropenem with 79.5% and 60.9% of susceptibility, respectively. The antibiotics showing the highest resistance rates were cefotaxime (78.3%), piperacillin-tazobactam (97.8%), ciprofloxacin (78.3%) and amikacin (42.9%). The most active agents were colistin and fosfomycin with 6.5% of resistance for each. Seven strains of GRE were isolated (13.2% of eXDR). All of them expressed the VanA gene, with vancomycin MIC > 256 mg/l. However, teicoplanin MICs ranged from 16 to 64 mg/l. All GRE strains were beta-lactam resistant and highly resistant to aminosides. Linezolid and tigecycline were the only active antibiotics.

The dissemination of these extensively drug-resistant bacteria must be contained by implementation of strict isolation methods and better hygienic procedures in order to limit their economical and health consequences. Compliance with ethics regulations: Yes. Rationale: Stenotrophomonas maltophilia has emerged as an important pathogen that induces nosocomial infections. It is a non-fermentative, gram-negative bacillus that causes severe infectious diseases, particularly bacteremia in the hospital setting. Morbidity and mortality due to Stenotrophomonas maltophilia seems to be high, particularly in critically ill patient. The aim of this study was to describe the clinical features, management and outcome of patients with Stenotrophomonas maltophilia infections. Patients and methods: This was a retrospective analysis of prospectively collected data of patients hospitalized in intensive care unit (ICU) between January 2010 and December 2018. Collected data were: age, gender, comorbidities, severity scores on admission, prior infections, use of antibiotics, use of invasive devices (urinary tract catheter, or mechanical ventilation), microbiological data, and antimicrobial therapy and outcome. Results: During the study period, 27 patients with Stenotrophomonas maltophilia infection were included, with a mean age of 51 ± 17 years. The simplified acute physiology score II and acute physiology and chronic health evaluation II on admission were respectively 35 ± 15 and 20 ± 8. Bacteremia caused by Stenotrophomonas maltophilia was observed in 25 patients (92%) and ventilator acquired pneumonia in two patients (8%). Twenty four episodes were classified as primary bacteraemia and only one as secondary bacteraemia due to urinary infection. Four patients (15%) developed septic shock. Mean SOFA on the day of Stenotrophomonas maltophilia infection was 6 ± 2. Prior antibiotic use was observed in 85% including an antipseudomonal agent in 26% of cases. Infection due to Stenotrophomonas maltophilia was considered in 26 cases. Empiric antibiotic therapy was administered to 13 patients (48%) and had included an appropriate agent in only five cases (38%). After adapting antibiotics, monotherapy was the choice for six (25%) patients while a combination of two antibiotics was indicated in the 20 others (75%). The most used antibiotic was the colistin in 11 episodes (46%). Intensive care mortality was 37%. Univariate comparison between dead and survivors showed a significant difference in prior nosocomial infection and respiratory comorbidities. No independent risk factor of mortality was found in multivariate analysis. Rationale: Thrombocytopenia is a frequent disorder in critically ill patients, and several studies have reported its correlation with poor prognosis. Considering the major role of platelets in hemostasis, a significant drop in platelet count is an alarming sign in septic patients. The aim of this study was to show the relationship between thrombocytopenia and platelet level changes and mortality in septic patients.

Patients with criteria for septic shock (based on the Third International Consensus definitions for Sepsis and Septic Shock) at admission or at any time during hospitalization were included in a prospective study conducted for a period of 8 months (January 1-August 31, 2018) in a medical surgical intensive care unit. Patients hospitalized for less than 24 h were excluded. Thrombocytopenia was defined as a platelet count less than 150.000/mm 3 , and recovery was defined as returning to levels more than 150.000/mm 3 after presenting thrombocytopenia. We assessed the platelet count during the hospitalization and its outcomes.

We included 82 patients. The mean ± SD age was 56.54 ± 18.45 years. Sex ratio was 1.92. Thrombocytopenia during sepsis (Group 1) was found in 46 patients (56%) with a mortality rate at 85%. The mortality rate among patients not showing thrombocytopenia (Group 2) was significantly lower 26% (p = 0.01). The receiver operating characteristic showed that in (Group 1), a drop in the platelet count (from admission to septic shock day) more than 45% was associated with poor outcome (sensibility = 56%, specificity = 88%, AUC = 0.82). Among the (Group1), 30% showed recovered platelet counts. The mortality was significantly higher in the patients with uncovered thrombocytopenia (90% vs. 28%, p = 0.001).

Conclusion: Thrombocytopenia was shown to be an indicatorof poor prognosis in our study. In addition, drops of > 45% and failure to recover the platelet counts were further determinants of unfavorable outcomes. Compliance with ethics regulations: Yes.

Mehdi Gaddas 1 , Sarra Dhraief 1 , Karim Mechri 1 , Imen Jami 2 , Amenallah Messaadi 2 , Lamia Thabet 1 Rationale: Pseudomonas aeruginosa is known as an opportunistic pathogen frequently causing serious infections. Multidrug resistance in this bacterium is increasing worldwide and poses a major problem in the treatment of infections due to this microorganism. Analysis of resistance profile to antibiotics of P. aeruginosa helps to establish a prompt control and prevention program. The aim of this study was to evaluate epidemiological profile and antimicrobial resistance of P. aeruginosa isolates in a trauma and burn center. Patients and methods: Retrospectively, we studied all P. aeruginosa isolates over a 7-year period (from January 2012 to December 2018). Conventional methods were used for identification. Antimicrobial susceptibility testing was performed with disk diffusion method and susceptibility results were interpreted using clinical breakpoints according to CA-SFM guidelines. Data were analyzed using the SIRsystem. Minimum inhibitory concentration of colistin was determined using the E-Test ® method (bioMérieux), then using the EUCAST broth micro-dilution method (UMIC, Biocentric ® ) since May 2017. Results: During study period, 1499 non-repetitive strains of P. aeruginosa were isolated, representing 12% of all isolates. In our center, infections due to P. aeruginosa were endemic with epidemic peaks. P. aeruginosa was mainly isolated from burn intensive care unit (73.4%) and anesthesiology department (11.1%). The most frequent sites of isolation were skin samples (35.1%), blood cultures (19.7%), catheters (12.5%) and urines (10.3%). The survey of antibiotic susceptibility showed high percentage of resistance to the different antibiotics:

33.8% of strains were resistant to ceftazidime, 65% to ticarcillin, 57.5% to pipercaillin-tazobactam, 57% to imipenem, 56.8% to ciprofloxacin and 68% to gentamicin. Resistance to colistin was rare. It concerned only four strains, isolated from burn patients. The survey of antibiotic susceptibility evolution have shown a global increase of resistance to commonly prescribed antibiotics between 2012 and 2018: from 48% to 57.2% to imipenem, from 47.5 to 61.8% to ticarcillin-clavulanate, from 7.3% to 49% to ceftazidime and from 59.2 to 65% to gentamicin. Whereas ciprofloxacin resistance rate have decreased from 60.9 to 55%. Antibiotic resistant strains were mainly isolated from burn intensive care unit, with 66% of resistance to imipenem and 40.2% to ceftazidime.

The dissemination of multidrug-resistant strains of P. aeruginosa in our center must be contained by the implementation of strict isolation methods and better hygienic procedures. Compliance with ethics regulations: Yes.

Acinetobacter baumanii: therapeutic impasse Sabah Benhamza, Mohamed Lazraq, Abdelhak Bensaid, Youssef Miloudi, Najib El Harrar Réanimation de l'hôpital du 20 Août, Casablanca, Morocco Correspondence: Sabah Benhamza (benhamzasabah5@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-098

Rationale: Acinetobacter baumanii (AB) is frequently responsible for nosocomial infection in the intensive care units, and its resistance to antibiotics continues to increase. The objective of our study is to determine the epidemiological profile and antibiotic sensitivity of isolated bacteria in the intensive care unit August 20, in order to optimize the probabilistic antibiotherapy of bacteremia in intensive care. Patients and methods: This is a retrospective study performed in the intensive care unit of the hospital August 20, 1953, spread over a period of 3 years from January 2016 to January 2019. Results: The incidence of AB infection in our department was 4.77% for all patients admitted to intensive care. The average age was 45 years ± 20, male predominance (sex ratio 2.42). The average time to onset of infection was 11 days. During the study period, 41 AB strains were isolated, 70% of which were pulmonary, 20% blood, and 8% urinary. Resistance to C3G reached 96% in 2016, 98% in 2017 and 99% in 2018. For imipenem resistance was 81% in 2016, 85% in 2017, 76% in 2018. For amikacin, resistance was 41% in 2016, 43% in 2017, and 35% in 2018. For fluoroquinolones resistance was 75% in 2016, 68% in 2017 and 74% in 2018. Cotrimoxazole resistance was around 30% in the last 3 years Conclusion: The resistance of AB to antibiotics has reached very alarming levels, especially for carbapenems. This requires resuscitators to change their antibiotic prescription behavior and to invest in the prevention of nosocomial infections. Compliance with ethics regulations: Yes.

This is a prospective observational study conducted at the ED during the period of 1 year. Data of all patients admitted with suspected infection of any cause were collected. Poor outcomes were defined as death and transfer to an ICU within 48 h. Results: During the study period, a total of 200 patients with a mean age of 68 ± 11 were included. 55% were male. Within 48 h of management in the ED, 10% of patients were transferred to the ICU and 5% died. Independent predictors of ICU-transfer and death included low systolic blood pressure, fever and tachycardia. A prediction model containing these independent predictors had a good predictive accuracy with an area under the curve of 0.89 (95% CI 0.8403-0.9296). Sensitivity was 63%, specificity 93%, positive predictive value 72% and negative predictive value 90%. Conclusion: Assessing readily available clinical variables at arrival to the ED can aid in predicting poor outcomes. [3] [4] [5] [6] [7] [8] . The most common co-morbidities were chronic respiratory failure (CRF, n = 11) and hypertension (n = 11). Respiratory distress (n = 19) and coma (n = 18) were the major indications for IV. US diaphragmatic exploration was performed at a median delay of IV at 4 days [2] [3] [4] [5] [6] [7] . 95% of patients received sedation and 27.5% received neuromuscular blockers. The ventilator mode was control volume in 35 patients via endotracheal tube (n = 33) and tracheostomy cannula (n = 7). No major incident was detected during the turning of patients. Both TID and TED decreased from the SP to the PP (Fig. 1) : TID (mm) (28 in SP vs. 24.5 in PP, p = 0.001), TED (mm) (18.7 in SP vs. 18 in PP, p = 0.037). The observed DTF was lower in the PP but without significance (37.4 vs. 42.05%, p = 0.36). No difference was showed when the comparison between SP-DTF and PP-DTF was adjusted on the ventilator mode, obesity, neuromuscular blockers and CRF.

The positioning in PP in ventilated patients reduces both tele-inspiratory and tele-expiratory diameters of the diaphragm but not altered its contractile function. Compliance with ethics regulations: Yes. Significance was considered at p < 0.05. Results: Results are presented in the table below. Discussion: Nebuliser type influences the efficiency of aerosol delivery, with the VMN delivering a significantly higher % aerosol dose than the JN at the two circuit positions (p = 0.0037 on inspiratory limb; p = 0.0004 at the dry side of humidifier). In agreement with previous reports using bias flow, for both nebulisers, the location within the circuit has a significant effect, with the nebuliser on the dry side of the humidifier delivering more aerosol than on the inspiratory limb (p = 0.0100 for VMN; p = 0.0127 for JN). Conclusion: For a mechanically ventilated adult tracheotomy patient, the type of nebuliser and the location of the nebuliser within the circuit influences aerosol delivery. Rationale: Automatic tube compensation (ATC) is a mode available in most ICU ventilators. It compensates for the resistive pressure into endotracheal tube/tracheostomy canula by continuously providing a pressure assistance based on internal diameter of a new endotracheal tube/tracheostomy tube. Its use in ICU is unclear. We designed a survey to further explore this. Patients and methods: The survey was endorsed by the acute respiratory failure section and the clinicaltrials group of the European Society of Intensive Care Medicine (ESICM). The pool was sent out via an email on June 27 2019 to the ESICM members worldwide. The following closed questions were: country, years in ICU, kind of ICU, kind of hospitals, kind of respirators, ATC use (never, always or in some patients), reasons to or not to use ATC, ventilatory mode in which ATC was used. The database was frozen on August 1 st 2019 after two reminders. We used the Gross National Income per capita (USD) provided by the world bank2016 to transform the respondent's country into a geographical-economical variable with 3 levels: High-Europe, high-nonEurope and middle (1) . ATC use was coded as yes or no. The primary end-point was ATC rate of use and the hypothesis was that less than 50% of the respondents do use it. Variables were expressed as counts. Groups were compared by Chi square test. A logistic regression analysis was performed to explore the contributing factors to ATC use.

We received 644 responses without any doublons, of which six were empty, from 72 countries. Four-hundred and nine respondents used ATC always or in some patients (64% ATC rate of use). This rate was not different between Economical-geographical regions, ICU, hospitals and years in ICU. For those respondents who did not use ATC the reasons were: ATC mode not available in ICU ventilators (41.9%), ATC not helpful mode (36.7%), ATC not known (18.8%) and ATC provides too much pressure assistance (5.7%). For those respondents who used ATC the reasons were: helpful in weaning (68.2%), set by default (30.5%) and physiological benefit (1.2%). They used ATC during spontaneous breathing trial (30.4%), with any assisted mode (27.9%) and with specific modes (11.7%). We found no risk factor for ATC use in the logistic regression model (Fig. 1) .

The ATC rate of use was unexpectedly high in this survey. This may result from respondents selection bias or from an a priori underestimation of its use. Compliance with ethics regulations: Yes. Rationale: During pressure support ventilation (PSV), adjusting the level of assistance mainly aims at maintaining the patient's respiratory effort within a normal range. However, respiratory effort measurement is impeded in clinical routine by the need of esophageal pressure recording. In this study, we evaluated the accuracy of assessing the respiratory effort from the flow and airway pressure signals using several machine learning algorithms based on the equation of motion of the respiratory system. Patients and methods: Using the ASL5000 Simulator (IngMar Medical) connected to a PB980 ventilator (Medtronic) set in PSV, we simulated a massive number of different respiratory cycles. Each simulated cycle represented a unique combination of compliance and resistance of the respiratory system, duration and intensity of the muscle pressure (Pmus), positive end-expiratory pressure (PEEP) and pressure support levels.

Using least squares regression methods, the flow waveform was fitted according to the equation of motion of the respiratory system to determine the compliance and resistance of the respiratory system, and the Pmus. The hypothesis used (alone or in combination) to constrain the system were: linearity of Pmus at the onset of the inspiratory effort, nullity of Pmus at the end of insufflation, and nullity of Pmus during expiration. Thus, nine methods were built and tested. Calculated and actual peak Pmus values were compared using the Bland-Altman method.

The nine methods of Pmus assessment were evaluated using 34 550 different simulated cycles. By limiting the analysis to selected cycles with a predefined applicability criterion (intrinsic PEEP less than 1 cmH 2 O), a limited inspiratory effort (peak Pmus less than 15 cmH 2 O) and a high quality of fitting (R 2 > 0.99), the method using the three hypothesis together to constrain the system was characterized by a bias of 0.34 cmH 2 O and limits of agreement of -0.44 and 1.12 cmH 2 O. However, when widening the analysis to all the simulated conditions, no method allowed an accurate estimation of the peak Pmus : the best one exhibited a bias of -3.38 cmH 2 O and limits of agreement of − 15.18 and 8.42 cmH 2 O. Conclusion: Among the nine machine learning methods tested, some provided an accurate estimate of the respiratory effort in selected cycles but none allowed such accuracy across all simulated conditions. This incites to assess automated methods using a more complex physiological and physical model. Compliance with ethics regulations: Not applicable. Rationale: There is a growing interest in esophageal pressure monitoring in mechanically ventilated patients. Esophageal pressure can be measured with a specific nasogastric catheter equipped with esophageal balloon and connected to a pressure transducer. It is used as a surrogate for pleural pressure and may be considered as a corner stone in advanced care of ventilated patients to better assess lung and chest wall mechanics and easily detect patient-ventilator asynchronies. However, this promising technique is still seldom used in clinical practice. Trained ICU nurses may perform oesophageal pressure measurements which may help facilitate its implementation in the usual patient care. This study aimed at assessing whether a specific educational program to train nurses to perform esophageal pressure monitoring allowed reliable measurements.

This was a prospective monocenter study performed in an academic ICU. Written informed consent was obtained from the nurses before inclusion in the study. The specific educational program consisted of a 30-min online theoretical course, a 1-h group theoretical teaching and a 30-min simulation training on a mannequin. Then each participating nurse performed three esophageal pressure measurements (using Nutrivent ® catheters and an ICU monitor connected to arterial line pressure transducers system) on three different mechanically ventilated paralysed patients under supervision. A knowledge assessment was performed with a short written MCQ test. The skill evaluation was by two trained experts. Concretely the trained nurses performed an esophageal pressure measurement without assistance. Their ability to control the esophageal balloon position by an occlusion test, to measure the inspiratory and expiratory airway and transpulmonary pressures and to calculate of respiratory system, lung and chest wall compliances was assessed at the bedside using a standardized evaluation form.

We present here the preliminary results of the first nine included nurses. The written knowledge assessment was considered as Rationale: Several modalities of ventilatory support have been proposed to gradually withdraw patients from mechanical ventilation. We conducted this study to compare T-piece and Pressure support ventilation (PSV) (8 cmH 2 0 and Peep0) in the process of weaning of mechanical ventilation in burns. Patients and methods: It was a prospective randomized trial in burn ICU in Tunisia during 9 months. Mechanically ventilated patients who met standard weaning criteria were included [1] . Patients were randomized into two groups: group1 under T-piece and group 2 under PSV. Duration of the test: 30-120 min. The tolerance of the VS test should be judged on clinical criteria. Stopping the test if occurred: agitation, tachypnea > 35 cycles/ min, tachycardia > 140 / min, SpO 2 < 90%. Successful withdrawal was defined as the ability to maintain spontaneous respiration for 48 h after extubation. Results: Thirty patients were included, randomized into two groups. The mean age was 29 ± 11 years with a ratio sex of 4. The average TBSA was 31 ± 18%. The cause of mechanical ventilation was essentially a face neck burned (79%). The following table shows the weaning outcome of both modalities. Eighty percent of succeeded extubation for both groups (N = 12/15). The cause of failure of extubation was secretion retention and clutter in majority of cases followed by neurological and cardiac distress. The duration of mechanical ventilation does not influence the outcome of the weaning test (p < 0.005), with a mean of duration of 16 ± 10 days. Conclusion: Our study did not show any difference between the two weaning modalities in the matter of outcome of extubation. The choice of weaning test of mechanical ventilation is to be judged by the clinician according of the state of his patient. Compliance with ethics regulations: Not applicable. Rationale: When expiratory tidal flow does not go up after increasing expiratory driving pressure expiratory flow limitation (EFL) occurs. It is thought that EFL heralds airway closure (AC). We investigated the role of chest wall elastance (Ecw) in both EFL and AC in acute respiratory distress syndrome (ARDS) patients. Our hypothesis was that the lower the Ecw to lung elastance (EL) ratio the higher the likelihood of EFL and AC. Patients and methods: Twenty-five moderate to severe ARDS patients were prospectively included in two centers. Mechanical ventilation was delivered in volume-controlled mode with tidal volume 6 ml/kg predicted body weight at positive end-expiratory pressure 5 cmH 2 O in semi-recumbent position. Airway (Paw) and esophageal (Pes) pressures and flow were continuously recorded during 2 min by a data logger (Biopac 150). Then, end-expiratory and end-inspiratory occlusions were performed for 5 s, then respiratory system was slowly inflated at constant flow. Finally, patient was allowed to breathe out freely to atmosphere by using a three-way stop lock by-passing expiratory valve. AC and airway opening pressure (AOP) were determined according to Chen et al. (1) . EFL was assessed by the atmospheric method (2) . Dynamic elastance of chest wall (Edyn,cw) and lung (Edyn,L) were obtained from least square linear regression method over 10 consecutive breaths. Static elastance (Est,cw and Est,L) were determined by classic formulas and also by taking into account AOP (Est,cw_aop and Est,L_aop, respectively). The performance of Ecw/EL ratio to predict EFL and AC was assessed by the area under receiver operating characteristic (AUCROC) curve. Results: EFL was observed in 9 patients (36%) and AC in 14 (56%). Median AOP was 8.2 cmH2O (95% CI 7. 6-12.8) . AUCROCs for Ecw/EL ratios to detect EFL and AC are shown in Table 1 . Edyn,cw/Edyn,L ratio was better to detect EFL than Est,cw/Est,L ratio with Edyn,cw/Edyn,L ≤ 0.16 100% sensitivity and 84% specificity. Correction for AOP made the performance of Est,cw/Est,L ratio as good as that of the Edyn ratio. AC was poorly predicted by Edyn and Est ratios but its prediction greatly improved with AOP correction. However, with the Est,cw/ Est,L_aop the critical ratio was 1.81 (sensitivity 75%, specificity 100%) and 0.60 (sensitivity and specificity 100%) for predicting EFL and AC, respectively. Conclusion: EFL and AC are frequent in ARDS at PEEP 5 cmH 2 O. Edyn,cw/Edyn,L ratio lower than 1 best predicted EFL occurrence. Once AC is taken into account Est,cw/Est,L ratio greater than 1 accurately predicts AC. EFL and AC are two distinct phenomena. Compliance with ethics regulations: Yes. Rationale: Anesthesia outside the operatingroom (AOOR) in a pediatric environment was giving increasingly increasing indications and a lot of progress because of its interest in carrying out diagnostic and/or therapeutic explorations: 20% of the acts of anesthesia are performed outside the operating room. The objective of our study is: to clarify the importance and the frequency of the practice of the AHBO, to define its particularities, as well as an evaluation of the ratio: benefit/risk in order to reduce the morbidity and mortality. Patients and methods: We report in this study the experience of the service of the resuscitation mother-child on the gestures of AOOR. This is a prospective observational study, spread over a period of 2 months: from 1/09/17 to 31/10/17, dealing with 251 acts performed for endoscopic digestive and bronchial procedures, cures in dermatology and radiotherapy, and medical imaging (CT and MRI). Results: Of the 251 procedures performed: 91 were performed for CT, 66 for MRI, 7 for arteriography and 50 for endoscopic digestive procedures, 14 for bronchoscopies, 6 for radiotherapy treatments, 17 for laser treatments in Dermatology. Anesthesia techniques use intravenous induction in 70% of cases using: hypnotics (propofol, midazolam, ketamine), morphine (remifentanyl, fentanyl), inhalation induction in 30% of cases (sevoflurane, halothane) and curare for 7 cases of bronchoscopy (rocuronium). This anesthesia was marked by the occurrence of accidents in order of frequency: cardiac in 15% of cases (tachycardia, hypotension and rhythm disorders), and then respiratory in 10% of cases. The most serious accidents were admitted in reality and are represented by 8 cases, of which 3 required an intubation (bronchoscopy), a case of cardiorespiratory arrest recovered, 2 cases of severe hypoxia associated with bradycardia and which required the ventilation with the mask (radiotherapy), and 2 cases of bronchospasm requiring the deepening of the anesthesia (absence of TCI).

A good knowledge of the patient and the intervention, and difficulties specific to each specialty is necessary, as well as a preanesthetic consultation. The AOOR must obey the same safety rules as in the operating theater and that in terms of: equipment, monitoring (Integrate the capnograph to respiratory monitoring whenever deep sedation and when the continuous control of VAS is difficult), anesthetic technique (TCBI) and post-procedure wakefulness management that must meet the same requirements as the SSPI, especially for prolonged sedation. Compliance with ethics regulations: Yes.

Umbilical vein catheterization through Wharton's jelly: a possibility for a fast and safe way to deliver treatments in the delivery room? Suzanne Borrhomée Hôpital René Dubos, France Correspondence: Suzanne Borrhomée (suzanne.borrhomee@gmail. com) Ann. Intensive Care 2020, 10(Suppl 1):P-108

Rationale: A fast and safe venous access can be a critical issue in the delivery room during neonatal cardiopulmonary resuscitation, or before endotracheal intubation. Here, we describe a new method to inject drugs using the umbilical vein, directly punctured through Wharton's jelly.

This method was performed in 10 newborns between November 2016 and May 2018. Umbilical vein was identified and punctured easily and a reflux was obtained in all patients. The first step was antisepsis, and then the umbilical vein was punctured. The puncture was made approximately 2 to 3 cm above the navel. After checking for blood reflux, the nurse injected the treatment. The cannula was left in the vein during the injection and removed as soon as the intervention was over (intubation was performed, or the heart rate had increased). Results: Here, we report ten cases of emergency injection in the delivery room using this method: -four cases of cardiopulmonary resuscitation using this method to deliver epinephrine. Cardiac massage was performed on all patients.-six cases of intubations in the delivery room using this method to administer the premedication. In all patients, the umbilical vein was identified easily. The equipment was the one usually used for venous injection in our unit and was manipulated and handled with ease. Venous access was obtained in a matter of seconds, and blood reflux was observed in all patients. The treatments were efficient in all but two patients, which was imputable to the method in one patient. Discussion: Although this method has been known in our NICU for several years, there has been no publication regarding this method in neonates. Inserting an umbilical vein catheter in the delivery room has been validated for resuscitation but this technique is lengthy and requires some sterility conditions that makes it even longer, and thus non-fitting for an emergency tracheal intubation. Our method is fast and can be performed easily with no specific training. The whole manipulation procedure, from the beginning of the puncture to the end of the flush-out takes 15 to 20 s. We only identified few specific risks related to this method, mostly infectious, and the risk of drug diffusion.

We describe a new route for administration of drugs in the delivery room that was successfully used in 9 nine neonates. Umbilical vein needle catheterization is not only safe and efficient, but is also fast and easy to perform without any special training. Compliance with ethics regulations: Yes.

Rationale: Liver transplantation (LT) is the only option for children with end stage liver disease. Recent advances in surgical procedure and immunosuppression have permitted a better patient and long term graft survival. However, acute cellular rejection remains a frequent complication occuring in 20 to 50% of the cases according to different studies. It is more likely to occur during the 4 first weeks post LT. Many predictive factors of acute rejection have been described in litterature and results differ from one study to another. Pediatric studies regarding this topic are few. The aim of this work is to study acute cellular rejection prevalence in the 30 days following LT and to determine predictive factors. Rationale: Sedation practices for pediatric magnetic resonance imaging (MRI) are highly heterogenous. The main challenge is to keep children immobile while being alone in a traumatizing environment for a long time. Clinicians have to ensure hemodynamic and respiratory stability in this isolated environment while minimizing sedation neurologic adverse effects. In this series, we report the potential usefulness, feasibility, efficacy and safety of dexmedetomidine sedation for pediatric MRI. Patients and methods: A single center retrospective review of six children sedated with dexmedetomidine for MRI in an emergency context. All children were hospitalized in the pediatric intensive care unit of a University Hospital at the time of MRI. Results: Data on six patients aged 8 months to 4 years is reported. Five patients received dexmedetomidine by intravenous route (bolus of 1-2 µg/kg over 10 min, followed by a continuous infusion of 1 µg/ kg/h). One child received dexmedetomidine by intranasal route (4 µg/ kg with atomization device). One child experienced bradycardia that did not require any intervention. Very few movements were recorded during the MRIs for which images were rated as good quality. Conclusion: Dexmedetomidine seems a promisingly useful sedation agent for pediatric MRI, thanks to its efficient sedative properties and good tolerability without respiratory compromise. Compliance with ethics regulations: Yes. Rationale: Computational models, or virtual patients, could be used to teach cardiorespiratory physiology and ventilation, determine optimal ventilation management as well as forecast the effect of various ventilatory support strategies. Currently, there is no virtual patient specifically designed for modelling children cardiorespiratory system. Thus, our research team has developed a cardiorespiratory simulator for children called "SimulResp©". According to Summers et al., the quality of a physiologic model is evaluated by three specific criteria: qualitatively, which relates to the model's ability to provide directionally appropriate predictions; quantitatively in steady states and in dynamics, which is the ability of the model to provide accurate predictions in steady state situations as well as dynamic transitions. The purpose of this study was to evaluate the quality ofSimulResp© according to these criteria.

This study consisted in a prospective evaluation of the SimulResp©'s predictions with simulated healthy subjects.

The tests were performed with patients from 8 to 18 years old (8, 10, 12, 14, 16, 18 years), with different characteristics; gender (M, F) and weight (10th, 50th and 90th percentile). Blood gas values (pH, PCO 2 , PO 2 and SpO 2 ) were simulated for several virtual healthy patients with different characteristics. This study was conducted for both spontaneously breathing and mechanically ventilated patients. SimulResp©'s quality and reliability were evaluated in terms of accuracy, robustness, repeatability and reproducibility. Results: Simulresp©'s validation procedures are ongoing. We intend Simulresp© to be accurate when simulating healthy spontaneously breathing patients. But we hypothezised that Simulresp© would not be able to simulate accurate blood gas values of mechanically ventilated patients Conclusion: Simulresp© is a promising computational model that will serve to perform calibration and validation procedures of clinical decision support systems and help clinican to determine optimal respiratory support strategies at bedside. Further calibration procedures are yet required. Compliance with ethics regulations: Yes.

the isthmic surgical tracheostomy, which was performed in the operating room by otolaryngologist under general anesthesia. The cutaneous incision was transversal in all cases.The choice of the cannula was adapted to the age, and the decanulation was carried out according to the evolution of the underlying disease. Complications associated with tracheotomy are diverse, and common complications are such as careassociated pneumonia (22.5%), tracheostomy tube obstruction (7.5%), accidental decannulation (2.5%), pneumothorax (2.5%) and cases of tracheal stenosis (2.5%). The mortality rate amounted to 27.5%, where in most cases was due to the poor prognosis of the underlying diseases. The main factors of evolution are the patient's previous condition, cranial trauma, Guillain-Barré syndrome, tracheostomy time, prolonged tracheal intubation and the presence of complications. Conclusion: Regardless of the indication, the tracheotomy is an act of survival whose usefulness and effectiveness are certain. Rationale: Aspiration pneumonia (AP) is a frequently suspected complication of drug overdose requiring mechanical ventilation (MV) and admission to intensive care unit (ICU). In the absence of reliable biomarkers for distinguishing between aspiration pneumonia and aspiration pneumonitis, antibiotic therapy is frequently prescribed. Latest studies suggest that a care protocol could better select patients requiring antibiotic therapy.

The objective was to determine the impact of a care protocol on the antibiotic prescription among patient admitted to ICU for toxic coma with MV. We conducted a prospective observational cohort study in four ICU. We included all patients admitted for toxic coma with MV. In the University-affiliated ICU, a care protocol was applied. In the three others ICU, physicians declared that they did not follow formalized conduct within the service and did as usual. Results: We included 43 patients in care protocol group and 42 in control group. The mean SAPS II was 43.3 (± 15.3) with a mean Glasgow Coma Scale score at 4.9 (± 2.1) before intubation. Within the total population, 40 patients (47%) had a pulmonary bacteriologic sample (PBS), mostly because purulent tracheobronchial aspirate and new infiltrates on the chest X-ray (respectively 36.4% and 29.4% of the population with a bacteriological sample). Among the patients with a bacteriological sample, 34 (85%) were culture positive. The incidence of probabilistic antibiotherapy did not differ between the care protocol group (n = 16) and the control group (n = 16) . There was no difference for the incidence of PBS (20 in each group). The others secondary outcomes did not differ either (Table 1) . Conclusion: Our study does not show that a care protocol allows a reduction of antibiotic prescription among patient admitted to ICU for toxic coma with MV. Our incidence of antibiotic prescription is lower than the previous studies. The absence of difference can be explain by two reasons: some of the physicians of the control group had been trained in the university-affiliated ICU in the last years and may follow a management approach similar to that of the control group; despite our precautions, the existence of the study could have modify the practices in the control group. Compliance with ethics regulations: Yes. Rationale: Pancreatic surgery is associated with high morbidity, mostly due to infectious complications, so that many centers introduce post-operative antibiotics for all patients. Such systematic prescriptions are not consensual and often rely on local practices. The aims of the study were to describe the occurrence of surgical site infection (SSI) and the antibiotic (ATB) prescription after pancreatic surgery, and to determine the risk factors of post-operative surgical site infection, in order to better define the clinical indications for the prescription of antibiotics after major pancreatic surgery. Patients and methods: All patients undergoing a scheduled major pancreatic surgery from January 2007 to November 2018 were included in the study. Patients were classified in four groups according to the occurrence of a surgical site infection and to the post-operative antibiotic prescription as follows (SSI+/ATB+; SSI-/ATB+; SSI+/ATB-, SSI-/ ATB-). In addition, risk factors (fever and pre-operative biliary prosthesis) associated with the occurrence of a surgical site infection and with the antibiotic prescription, were analyzed using a logistic regression model. Results: Data from 149 patients (115 pancreaticoduodenectomies and 34 splenopancreatectomies) were analyzed and classified as presented in the table. Thirty patients (20.1%) experienced a surgical site infection and 42 (28.2%) received post-operative antibiotics. We did not find any difference on post-operative antibiotic prescriptions (26.7% versus 28.6%, p = 0.9) between patients who developed a surgical site infection and those who did not. Amongst the 107 patients who were not prescribed antibiotics post-operatively, 85 (79.4%) did not develop a surgical site infection while 22 (20.6%) did. In-ICU mortality did not differ between infected and non-infected patients (7 versus 2%, p = 0.13). Post-operative fever was different between SSI+ and SSI-(73.3 versus 34.2%, p < 0.001), while the prevalence of pre-operative biliary prosthesis was similar (37.9 versus 26.7%, p = 0.3). Amongst patients who did not develop a surgical site infection, antibiotic prescription was not associated with fever (p = 1), but associated with a higher prevalence of preoperative biliary prosthesis (15.6 versus 52.9%, p = 0.0001). Conclusion: Non-systematic antibiotic prescription after major pancreatic surgery allowed to appropriately spare antibiotics in 85 (56%) patients at the cost of under prescription in 22 (14.8%) patients. These results suggest that systematic post-operative antibiotic prescription could be excessive.

Fever appears to be a relevant clinical sign for individual-based prescription, whereas the presence of a biliary prosthesis does not. Compliance with ethics regulations: Yes. (2, 3) . However, there is little evidence to support those recommendations (1) . We aimed to describe care paths of PM with sepsis in French hospitals and to assess outcomes depending on their hospital trajectory.

We conducted a retrospective analysis of the French medico administrative (PMSI) database of consecutive patients with PM and sepsis admitted to French hospitals, between 2010 and 2015. Only the first hospital admission was considered. Cases were identified using a combination of a diagnosis code for PM plus a diagnosis code for organ failure or a procedure code for organ support. Hospital trajectories were determined from the first admission to death or discharge, taking into account all potential transfers. Costs and endpoints were determined at the end of patients' trajectories. Five groups of patients were defined, according to care pathways: Direct ICU admission (1stICU); Secondary ICU admission, after initial admission to another unit including wards (ward2ndICU) Rationale: New-onset atrial fibrillation (AF) is a common complication in patients with sepsis and is associated with increased mortality and morbidity rates. This condition results from a complex chain of events in response to infection, involving immunologic, humoral and cellular process and sympathetic overactivity. Landiolol, the new injectable beta-blocker, with high beta1 selectivity and minimal impact on arterial blood pressure, may have beneficial effects in such a context. In this study, we aimed to investigate whether landiolol decrease the newonset of atrial fibrillation in a mice model of endotoxin-induced sepsis. Patients and methods: Thirty C57BL/6 male mice were randomly allocated to the following groups: sham (administration of 500 µL of isotonic saline intraperitoneally-IP), septic (administration of 500 µL of isotonic saline with 20 mg/kg of lipopolysaccharide-LPS-of E. coli O55:B5 IP) and septic + landiolol (administration of isotonic saline with 20 mg/kg of LPS and, two hours later 25 mg/kg of landiolol IP). Four hours later, an attempt of AF occurrence was triggered by a transesophageal electric pacing at fixed rate (as previously reported) in all mice previously anesthetized by isoflurane 2%. EKG was continuously recorded. Results: Ten mice per group (mean weight: 22 ± 2 g) have been included and analyzed. Among the sham group the mean heart rate was at 362 bpm versus 502 bpm in the septic group. Among the septic + landiolol group the mean heart rate was at 465 bpm (p < 0,001). After transesophageal stimulation, none mice in the Sham group had AF, seven mice (70%) in the septic group had an AF, and 2 mice (20%) in the septic + landiolol group had an AF. Landiolol decreased the incidence of new-onset, sepsis-induced atrial fibrillation in mice (p = 0.025). Conclusion: Landiolol seems to have a protective effect against sepsis-induced AF in mice. However, the mechanisms, including sympathetic activation and inflammasome pathways, should be investigated before drawn definitive conclusion regarding to efficiency of landiolol to prevent New-onset AF during sepsis. Compliance with ethics regulations: Yes. 20-25 mg/L at 24 or 48 h, proportion of patients with a vancomycin serum concentration < 10 mg/L, previously associated with resistance emergence and assessment of mortality and test of cure. Results: A serum vancomycin concentration between 20-25 mg/L was reported in 43 out of 179 included patients (24%). A serum vancomycin concentration < 20 ml/L and > 25 mg/L were reported in 89 patients (51%) and 44 patients (25%), respectively. Vancomycin serum concentrations during follow-up are shown in Fig. 1 . In multivariate regression analysis, a longer time between admission and initiation of vancomycin was the only parameter associated with a serum vancomycin out of this target, while acute kidney injury (AKI) was associated with a lower incidence of subtherapeutic concentration. Acute kidney injury rate was significantly higher in patients with a serum vancomycin concentration > 25 mg/L. Discussion: An adequate therapeutic target of serum vancomycin concentration was reached in 25% patients with nearly 50% < 20 mg/L, which was similar to previous studies. AKI and RRT requirement were higher in patients with serum vancomycin concentration > 25 mg/L, whereas it is hardly to know whether it is a cause or a consequence. Conclusion: These findings highlight the importance of a larger loading dose, vancomycin monitoring and measured creatinin clearance to improve vancomycin dosing protocol. Compliance with ethics regulations: Yes. Rationale: Suicide is a global phenomenon and one of the leading causes of death in the world. Tunisia ranks second in the suicide rate in the Maghreb, with 5.5 cases of suicide per 100,000 inhabitants. The aim of this study was to reconstruct the state of suicidal subjects before the act in order to identify their psychiatric profile. Patients and methods: A 3-year prospective observational singlecenter (6-bed intensive care unit) study including all patients hospitalized for suicide attempt (SA). Psychiatric evaluation of patients and contact with their families were done before intensive care unit discharge.

Results: Seventy-one patients were enrolled with female predominance (sex ratio 0.42). Mean age was 30 ± 13 years. Familial or personal history of mental illness were found in 8 (11%) and 30 cases (42%) respectively. Personal mental disorders were depression (17%), bipolar disorder (10%), schizophrenia (8%) and border line personality disorder (7%). Twenty-five per cent had prior SA. Sixty-three per cent were single, 30% married and 7% divorced. The Common methods of suicide included drug (52%), chloralose (34%) and pesticide (13%) poisoning. Mean IGS II and APACHE II scores were 30 ± 19 and 14 ± 9 respectively. On admission, 59% of all patients were in coma, 11% had shock and 48% developed aspiration pneumonia. Mechanically ventilation was done in 59% of all cases with mean duration of 3 days. The mean length of stay in intensive care unit was 4 days. Mortality rate was 7%. Psychiatric evaluation and contact with families deduced that the main precipitating factors for suicide were traumatic events. In fact: relationship problems (familial, marital or breakups), school failure and mourning were found in 66%, 6% and 1% of all cases respectively. Reactional SA accounted for 61%. Rationale: Poisoning is a worldwide problem, associated with high morbidity and moratlity. In Tunisia, the rate of fatal poisoning has been increasing in the last years, with emergence of new toxic substances. Regardless of the toxic, fatal poisining is considered as a non natural death, that requires medico-legal investigation, to assess whether it is suicidial, crimnal or accidental death. This study aimes to determine the epidemiological characteristics of the cases of fatal poisoning in South, to identify the toxics used in oder to deduce the preventive measures. Patients and methods: We conducted a retrospective study of all cases of fatal poisoning recorded in the forensic department of Habib Bourguiba University Hospital in Sfax, Tunisia, over a 12-years period (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) (2017) .

Results: During the study period, 88 cases of fatal poisoning were autopsied. The number of victims recorded per year varied between 1 and 16 cases with an average of 8 cases per year. The average age was 30 years with extrems ranging from 7 months to 85 years. Nearly half (46.5%) were younger than 40 years. A male predominance was noted with a sex-ratio of 1.04. The majority of victims were single, loweducated and from rural origin. Personal antecedent of psychiatric pathology was found in 9.1% of cases. Psychotic disorders (schizophrenia) and depression were the most common pathologies. In our study we noticed that death occured every weekday without significant difference between days. However, the frequency of fatal poisoning was slightly higher in cold seassons (53.9%). In 71.6% of cases, victims were found dead at home. Accidental fatal poisoning was the most common (56%). No criminal cases have been observed. We noted a male predominance in accidental forms and a female predominance in suicidal forms. Carbon monoxide poisoning was the most common (35 cases) followed by the organophosphorus poisoning which was noted in 15 cases. Conclusion: Decreasing the mortality rate from poison ingestion requires increasing public awareness about poisons and improving emergency service equipment and health personnel training. Compliance with ethics regulations: Yes.

Severe acute poisoning by organophosphate pesticides: report of 18 cases at the Oran hospital and university center Mourad Goulmane Hospital and university center of Oran, Oran, Algeria Correspondence: Mourad Goulmane (goulmane.mourad@univ-oran1. dz) Ann.Intensive Care 2020, 10(Suppl 1):P-126

Rationale: Organophosphate pesticides are synthetic organic pesticides widely used in agriculture mainly as an insecticide, nemacid or acaricide. These are the agricultural products, the most incriminated in poisoning in our context. The objective of this work was to determine the clinical, paraclinical, and progressive characteristics of this poisoning in a resuscitation environment. Patients and methods: Retrospective study of cases admitted to intensive care (January 2016-December 2018). Inclusion criteria were clinical, para-clinical, therapeutic and progressive. Results: 18 cases were identified: 16 women and 2 men, mean age = 26.3 ± 10 years. The suicide attempt was the main reason for the intoxication (16 cases). The Glasgow coma score averaged 11 ± 4. The central syndrome was present in 80% of our patients, followed by muscarinic syndrome 75% and nicotinic syndrome in 58% of cases. Therapeutic management consisted of mechanical ventilation in 50% of cases, the use of vasoactive drugs in 20% of cases and the administration of antidotal treatment in 100% of cases. The overall mortality was 16.66%. Conclusion: Organophosphate pesticides intoxication is a real health problem in Algeria. It is a serious condition dominated by the respiratory and neurological distress that causes most deaths. It concerns in our context especially young women who ingest the product for the purpose of autolysis. The diagnosis is based on the clinical and dosage of cholinesterase activity in the plasma. Treatment combines symptomatic measures that rely primarily on respiratory and neurological resuscitation to antidotal treatment. The clinical course in this type of intoxication is generally favorable under treatment with regression of signs in a few days. Mortality is high in our context, so it should be considered a diagnostic and therapeutic emergency. The commercial availability of these products is worrisome, justifying the use of a broad prevention program to inform the public and authorities of the danger of Organophosphate pesticides Compliance with ethics regulations: Not applicable. . The clinical examination revealed that five patients met the criteria for serious intoxication with the following signs: coma in four patients requiring the use of mechanical ventilation, seizures (n = 1), rhabdomyolysis (n = 3), shock (n = 1), toxic takotsubo (n = 1) and hepatocellular failure (n = 1) leading to patient's death. The use of mechanical ventilation was necessary in 4 patients. The analysis of the severity factors did not show a statistically significant association between severity, age (p = 0.6), sex (p = 1) and chronic consumption of psychoactive substances (p = 0.52). On the other hand, we did not find a statistically significant association between serious intoxication, the number of tablets ingested (p = 0.7), the APACHEII score (p = 0.11) and the average length of stay (p = 0.11). Conclusion: Ecstasy acute poisoning is becoming more common in our country and can potentially be very serious regardless of age, sex, medical history or number of tablets ingested. On the other hand, the concentration of NMDA could be the only factor to be taken into consideration upon admission. Compliance with ethics regulations: Yes. quarter of early trauma-related mortality, in some series. Early identification of poor outcome predictors could be valuable to guide the most appropriate care. We aim to determine factors associated to mortality in patients with severe non-penetrating chest trauma admitted to the ICU. Patients and methods: This is a prospective cohort study, including all patients with isolated severe blunt chest trauma (Abbreviated Injury Scale AIS > 3) admitted to the intensive care unit of a university hospital, over a one-year period. The primary objective was to analyse risk factors associated to death and poor outcome using univariate and multivariate analysis. Results: One hundred-thirty patients were admitted to the ICU for blunt chest trauma among them 72 were diagnosed with severe isolated chest trauma and were included. The mean age was at 33 ± 18, mean ISS at 36 ± 15 and mean TTS at 7 ± 3. Twenty-eight (39%) patients were diagnosed with acute respiratory distress syndrome, 31 (43%) with post-traumatic acute kidney injury and fourteen (19%) with post-traumatic pulmonary embolism. The mean length of ICU stay (LOS) was at 17 ± 13 days and mean number of days on ventilator was at 10 ± 9 days. Thirty-two (44%) patients underwent elective tracheostomy for prolonged intubation. Thirty-seven patients (51%) developed infections, among them thirty (42%) were diagnosed with pulmonary infection and seven (9%) with non-thoracic infections. Overall mortality had an incidence of 16.7% (12 patients Rationale: Early hyperglycaemia in traumatic brain injury (TBI) is a part of the stress response. It is an important indicator of severity and a reliable predictor of prognosis. We aimed to describe the epidemiological, clinical and paraclinical characteristics and to assess the prognostic impact of this hyperglycaemia on the TBI.

We conducted a retrospective study in the intensive care unit (ICU) of our hospital between 2009 and 2012. Were included all patients with TBI and blood glucose > 8 mmol/L at the first 24 h post-trauma. Results: During the study period, 694 patients were hospitalized in our ICU with TBI. Early hyperglycemia (> 8 mmol / l) was found in 380 patients (54.7%). In univariate analysis, glycaemia > 8.5 mmol/l (= 154 mg/dL) at admission was significantly associated with mortality (p = 0.015). We observed that glycaemia > 7.3 mmol/l at H12, > 7.2 mmol/l at H24, > 6.7 mmol/l at H36 and > 6.5 mmol/l at H48 was significantly associated with mortality (p = 0.07; p < 0.0001; p = 0.001 and p = 0.0008, respectively). The risk factors significantly associated with mortality were age > 32 years (p < 0.0001), SAPS II > 40 (p < 0.0001), initial shock (p < 0.0001), Glasgow Coma Scale (GCS) < 7/15 (p < 0.0001), coma period > 7 days (p = 0.023). The CT scan lesions statistically associated with mortality were: subdural hematoma (p < 0.0001), cerebral oedema (p < 0.0001), intra cerebral haemorrhage (p = 0.023), cortical contusion (p = 0.001), contusion of cerebral trunk (p = 0.011), contusion of the corpus callosum (p = 0.003), thalamus contusion (p = 0.004). In multivariate analysis, independent risk factors statistically associated with mortality were age > 32 years old (OR = 2.92 IC [1.52-5.78 ]; (p = 0.001)), glycaemia > 8.5 mmol/L at admission (OR = 2.25 IC [1.16-4.39 ]; (p = 0.017)),GCS < 7/15 (OR = 3.40 IC [1.8-6.24 ]; p < 0.001), intracerebral hematoma (OR = 3.2 IC [1.10-10.18 ]; p = 0.049).

We recommend a mandatory control of the blood glucose levels during a TBI with a target between 6.5 and 7.5 mmol/L in the acute phase. Compliance with ethics regulations: Not applicable.

The Fat Embolism Syndrome (FES) is a set of clinical, biological and radiological signs resulting in the obstruction of microcirculation by micro-droplets of insoluble fats.The clinical signs of the FES are not very specific, the diagnosis is difficult and the risk of misunderstanding this syndrome is very real.The FES appears after a trauma, often few days later. However, it sometimes occurs without previous trauma; and it is particularly difficult to recognize in these cases. The aim of this work is to define the epidemiological profile, the clinical and para-clinical features of this syndrome and its therapeutic management. Rationale: Sedative and analgesic treatment administered to critically ill patients with mechanical ventilation need to beregularly assessed to ovoid complications of oversedation mainly in elderly patients. Our objective is to evaluate our sedation practice in the elderlyin our unit Patients and methods: It was a prospective observational study, including elderly patients over 65 years of age without acute brain injury requiring sedation more than 48 h of hospitalization in the intensive care unit of our University Hospital between April 2018 and December 2018.

Thirty patients were included. The aged was 73.3 years, the sex ratio was 1.7. Respiratory distress was the most common reason for hospitalization 53%. The most accepted diagnoses were the decompensation of COPD in 34% of cases and septic shock in 23% of cases. The SAPS II averaged 58 ± 12 points, SOFA averaged 10 ± 2.4 points. Renal failure was found in 21 patients (70%), hepatic impairment was noted in 7 patients (23%), hypoproteinemia was marked in 17 patients (57%). Midazolam was used in 90% of patients. It was in combination with fentanyl in 63% of cases and remifentanyl in 30% of cases. The median Ramsay score 5.7 ± 0.6 on the first day of sedation and 5.3 ± 0.7 on the second day of sedation. The median RASS scale was − 4.7 ± 0.6 on the first day of sedation and − 4.4 ± 0.8 on the second day of sedation. The median BPS scale 3.6 ± 1.4 on the first day of sedation and 3.6 ± 1.2 on the second day of sedation. The mean wake up time was 6 ± 3, 38 days. Neuromyopathy of resuscitation was suspected in seven patients (20%), withdrawal syndrome was observed in two patients (7%) and acute cognitive dysfunction in two patients (7%). The median duration of sedation was 4.2 days ± 1.9 days, the median duration of mechanical ventilation was 11.1 ± 6.3 days, the median length of stay was 14.3 ± 9.8 days. Ventilator-associated pneumonia was diagnosis among 79% of patients. The mortality in intensive care was 37%. Conclusion: Sedation analgesia in the elderly person should be adapted according to age, ideal weight and renal and hepatic function by decreasing the initial doses. It should be evaluated by the recommended scores by setting a sedation objective according to the pathology. Compliance with ethics regulations: Not applicable. Rationale: More than 2500 original articles are newly indexed in Pub-Med every day. Journal Club (JC) is one way to cope with this abyssal amount of medical information. We aimed at (1) describing journals and articles analyzed during our JC sessions (2), reporting the proportion of published articles being analyzed during JC sessions and (3) assessing the clinical impact on our daily practices for each journal. Patients and methods: A retrospective analysis of prospectively collected data over a 12-year period from 2007 to 2019 in a universityaffiliated ICU. JC sessions were scheduled weekly and participants were free to choose and expose orally an article recently published in any medical journal (general, ICU or non-ICU specialized). Clinical impact of a journal was retrospectively and independently assessed by two attending intensivists (DC, HM) and was defined by the ratio of articles considered as having a direct impact on our daily practices over the number of articles of the same journal read during the same period.

Results: From August 2007 to August 2019, 313 JC sessions were held and 1712 articles-mostly original (n = 1657/1712; 97%)-from 93 journals were analyzed, accounting for 0.01% of the 11869960 articles (0.02% of the 10982188 original articles) referenced in PubMed during the same period. Median number of articles exposed per session was 6 [4] [5] [6] [7] . Median number of doctors attending each session was 7 [6] [7] [8] (attendings: 2 [2] [3] , fellows: 1 [1] [2] , residents: 3 [2] [3] ). General, ICU and non-ICU specialized journals accounted for 32%, 47% and 21% of the exposed articles, respectively. Most of the reported articles dealt with intensive care (n = 1177, 69%) especially infectious diseases (n = 286/1177; 24%), hemodynamics (n = 123/1177; 10%) or ICU-organization (n = 111/1177; 9%). Compared to general and non-ICU specialized journals, the proportion of read-over-published articles was higher for ICU-specialized journals (0.18% vs. 0.13% vs. 2.61%, respectively; p < 0.0001). Among original articles, only 93 (5.9%) [interventional (n = 61/93; 66%); observational (n = 32/93; 34%) studies] were considered as having a clinical impact on our daily practices. Compared to ICU and non-ICU specialized journals, general journals had a higher clinical impact (4.3% vs. 4.9% vs. 9 .1%, respectively; p = 0.001). Data regarding the 3 most read general, ICU and non-ICU specialized journals are detailed in Table 1 .

In a French university-affiliated ICU with regular JC sessions, the proportion of read-over-published articles and the clinical impact of medical journals appear minor. In the ocean of medical literature, general medical journals appear more worth reading by intensivists than ICU-specialized journals. Compliance with ethics regulations: Yes. Rationale: The world's population is aging and the 80 and over's age group is growing fast (+ 3.8% per year). This aging population is impacting Intensive care units with exponential rates of elderly patients (14.4% in 2011, 18% in 2017) , associated with significant mortality (from 15% to 50%). The evolution and the prognostic factors of these elderly patients in intensive care are therefore a public health issue for optimal management. Patients and methods: We included all patients aged 80 and over who were operated and admitted to surgical resuscitation in our center, with a duration of stay greater than 24 h, from April 2016 to July 2018. The data collected were: general characteristics of this population, mortality in intensive care, at day 30 and at 6 months and the prognostic factors guiding their evolution in intensive care and at 6 months. Results: Of the 102 patients included in our study, mortality was 31.4% in intensive care, 42.2% at day 30 and 60.8% at 6 months. The prognostic factors in the intensive care unit were the average dose of NORADRENALINE at Day 1 (threshold at 0.65 mg/h), the SOFA score at Day 1 (threshold at 6 points) and the IGS2 score (threshold at 66 points). The prognostic factors at 6 months were ventilatory autonomy on Day 1 (spontaneous ventilation, non-invasive ventilation, invasive ventilation), the reason for admission to intensive care (acute respiratory distress or septic shock) and the fragility score (Clinical Failure Scale with a threshold at 4). Conclusion: The mortality of patients aged 80 and over is influenced by prognostic factors easily obtained daily at patient's bed. These prognostic factors could be an aid for the resuscitation teams to evaluate the relevance of the care undertaken in elderly or even very elderly patients admitted in an acute situation. Compliance with ethics regulations: Not applicable.

Assessing patient safety culture perception in the intensive care unit in Tunisia Oussama Jaoued, Chaoueh Sabrina, Sik Ali Habiba, Wael Chemli, Gharbi Rim, Fekih Hassen Mohamed, Elatrous Souheil Hôpital Taher Sfar, Mahdia, Tunisia Correspondence: Oussama Jaoued (oussamajaoued@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-143 Rationale: In Tunisia health care system, patient safety has become a priority of quality assessment. The aim of our study was to describe the safety culture perception of the intensive care unit staff. Patients and methods: The safety attitude questionnaire (SAQ-ICU) was distributed to all intensive care unit staff by email. The questionnaire explores 6 safety culture domains: "team work", "safety climate", "job satisfaction", "stress recognition", "perception of the hospital and intensive care unit management" and "work condition". Results: Eighty participants responded to the questionnaire, 61% of them were women. Participants were doctors in 62.5%. The coordination between physicians and nurses was very good only in 21%. Thirtynine participants thought that the workload was high and 41% like their work. Medical errors are handled appropriately in 26% of cases and it was difficult to discuss errors in 19% of cases. The hospital is a good place to work in 5% of participants, 28% of participants were less effective at work when there were tired. The hospital did a good effort of training new personal in 18% of cases. The number of medical staff was lower than expected in 82% of cases. Half of participants would feel safe being treated as patients in their respective units. All domains explored by SAQ-ICU could be improved according to attendants. Conclusion: Safety culture perception among intensive care unit staff had several deficiencies, mainly the working conditions, the ignorance of medical error reporting procedures and the lack of communication. Rationale: The Simplified Acute Physiology Score II (SAPS II) is an ICU scoring system used to predict the mortality risk in patients presenting at the ICU. However the majority of critically ill patients present initially at the ED and their transfer to the ICU may be delayed for hours. Therefore, the ability to accurately assess mortality risk at ED may have a great impact. The purpose of this study was to evaluate the performance of SAPS II in predicting early and late mortality in ED patients. Patients and methods: This prospective study was conducted at the ED during a 6-month period. Data for adult ED patients were evaluated. SAPS II score was used to predict early and late mortality rates at 48-h and 30-day respectively. Discrimination was evaluated by calculating the area under the receiver operating characteristic curve (AUROC). Results: During the study period 200 patients were enrolled. The mean age was 65 ± 10 years, 52% of the patients were men. The mean SAPS II was 30. The early mortality rate was 20% and late mortality rate was 15%. SAPS II was efficient in predicting early mortality, with an AUROC of 0.84 (95% CI 0.79-0.89). However, it demonstrated no value in predicting late mortality with an AUROC of 0.44 (95% CI 0.39-0.49) Conclusion: In this study, SAPS II score was accurate in predicting early mortality, however this tool appears less suitable for predicting late mortality. Compliance with ethics regulations: Yes.

Oussama Jaoued, Chaoueh Sabrina, Sik Ali Habiba, Yosri Ben Ali, Fekih Hassen Mohamed, Elatrous Souheil Hôpital Taher Sfar, Mahdia, Tunisia Correspondence: Oussama Jaoued (oussamajaoued@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-145

Rationale: The aging of the population increased the number of hospitalizations in ICU. The aim of our study was to determine the impact of hospitalization of patients over the age of 80 on morbi-mortality and consumption of care (omega score). Patients and methods: This is a retrospective study carried out in the ICU in the hospital of Taher Sfar in Mahdia over a period of 17 years. All patients hospitalized in the ICU were included in this study. Two groups of patients were individualized: G1: patients over 80 years old, G2: patients under 80 years old. Results: During the study period, 4053 patients (3664 < 80 years old and 389 ≥ 80 years old) with a mean age 56 ± 20 years and with a mean SAPSII 32 ± 19 were included. The common reason for hospitalization was acute respiratory failure in 53% of cases. Comparing the two groups, the severity score SAPSII was higher among patients older than 80 years (43 ± 16 vs 30 ± 18, p < 0.001). The use of mechanical ventilation was more common in the first group (67% vs. 55%, p < 0.001). The incidence of nosocomial infections was similar in both groups (12% in the group G2 and 14% in group G1, p = 0.2) and the use of renal replacement therapy was also similar in tow groups (7% in the G2 group and 6% in the G2 group, p = 0.3). The duration of mechanical ventilation and length of stay were similar between the two groups. Workload evaluated by the OMEGA score was higher in the first group (57 Rationale: ICU outcome depends on quality of pre-ICU care. We aimed to assess the chain of care of Deteriorating Ward Patients (DWP), through evaluation of preadmission severity and delays before admission, and association with outcome. Patients and methods: Retrospective observational study in a single center (750 beds general hospital) for 1 year-may 15th of 2018 to 2019. All adult patients admitted in the ICU from the wards were included, except for scheduled surgery, or unexpected event in the operative theater. Preadmission severity was assessed through levels of National Early Warning Score 2 (NEWS2): Group 1 with NEWS2 inferior to 5, group 2 with NEWS2 between 5 and 7, and group 3 with NEWS2 superior to 7. These scores were established from vital signs during the 48 h before ICU admission. Patterns of patients, including SOFA and SAPS2, Knaus index, Charlson comorbidity score, cause of admission and technics used in the ICU, length of stay in the ICU and in the hospital, limitations of life-supporting care, and mortality at 30 and 90 days after ICU stay. Satistical analysis was performed through CHi 2 and Fisher tests on qualitative parameters, and with Kruskal-Wallis, Student and Mann-Whitney tests for quantitave data. Results: Sixty-eight patients were studied: 23 in group 1, 21 in group 2 and 24 in group 3. Most patients (all except 9) had not respiratory rate monitoring before ICU admission. ICU mortality was associated with rising preadmission severity (group 1: 8.7%; group 2: 38.1%; group 3: 45.8%). Base patterns (Charlson comorbidity score, Knaus index) did not differ between the 3 groups, and 61.8% of patients presented with sepsis. Main causes of admission were respiratory (45.5%), hemodynamic (25%) or neurologic (17.7%) failures. All patients admitted after cardiac arrest resuscitation (8 patients) belonged to group 3. Acute severity scores (SOFA and SAPS2) followed preadmission severity. Limitation or withdrawing of life support in the ICU was higher in group 3 (62.5%) than in groups 2 (30%) and 1 (8.7%) . Median delay between first NEWS2 equal or superior to 5 and ICU admission was 14 h, and 9 h between NEWS2 equal or superior to 7. Diffrences in delays were not associated with outcome. Discussion: Our study outlines weaknesses in the chain of care of DWP. Emphasis should be put on respiratory rate monitoring and better assessment of severity. Rationale: Access to critical care is controversial in older patients for 2 reasons: lack of available ICU-beds and speculation on induced costs. In contrast, admission of young patients aged 40 or under is infrequently questioned even though they develop catastrophic multiple-organ failure requiring full care. In addition, emotive reaction triggered in staff by these patients often represents a heavy psychological burden when ICU-stay is < 48 h. Information on the epidemiology, clinical information and induced costs regarding such patients is lacking. Patients and methods: This study retrospectively assessed the records of patients aged 40 or under, and admitted from January 2008 to August 2019. Cost-related expenses charged to care-payers were obtained from our Medical Information Department. Data (number, percentages or medians) were reported and discussed by comparison with those of nonagenarians during the same period. Results: Of 10,948 ICU-admissions, 1347 were aged 40 or under (13%), 117 of whom (8.7%) died within the ICU, with 41 (35%) dying within 48 h of admission despite full intensive care. The latter represent our study population (0.4% of the screened population). The median age was 32.8 years , male gender was prevalent (61%). Half the patients (n = 20, 48%) were referred from the emergency department, 11 (26.8%) from hematology, 3 from oncology (7.3%), 6 from medical intermediate care units (14.6%), and one from digestive surgery (2.4%). The first diagnosis at admission was septic shock (n = 17, 41.4%), followed by post-anoxic encephalopathy (n = 13, 31.7%), coma (n = 5, 12.2%), acute respiratory failure (n = 4, 9.8%) and cardiogenic shock (n = 2, 4.9%). SAPSII was 71 . All patients were ventilated and infused norepinephrine. Two patients underwent ECMO, and 2 others MARS. Mean (± SEM) retribution per stay was 13,475 ± 3565 €, and mean retribution per "day of stay" 6737 €. Discussion: Full care of these ICU-patients, with early mortality has a financial impact similar to that of nonagenarians at 13,160 ± 11,070 €; the cost per "day of stay" is therefore on average 100% higher than that of nonagerians (mean length of stay: 6.3 days), and, in our experience, 50% higher than that of average patients. Conclusion: ICU-patients aged 40 or under represent a small percentage of admissions and display half our overall mortality: one third of them die within 48 h of admission with a not insignificant financial impact for cost-payers. Septic shock is the first cause of referral, followed by unexpected cardiac arrest. Compliance with ethics regulations: Yes.

Rationale: Severity scores in patients with sepsis are useful for triaging and predicting mortality. Mortality in Emergency Department Sepsis (MEDS) score is validated in patients with sepsis in the emergency department. CURB-65 is validated in patients with communityacquired pneumonia but not in sepsis. CURB-65 is a simple bedside tool that has many common elements with new sepsis identification score-q SOFA. The study aimed to assess the accuracy of CURB-65 score in predicting ICU admittance and mortality compared to MEDS score. Patients and methods: This prospective study was conducted at the ED during a 6-month period. We enrolled all adult patients with sepsis admitted to the ED. MEDS and the CURB-65 scores were calculated at admission. Patients were studied using CURB-65 score and their ICU admission and in-hospital mortality were ascertained. Results: A total of 120 patients were enrolled. The mean age was 60 ± 10 years. 60% of the patients were men. 30% of patients had a CURB-65 score ≥ 3 points with a mean MEDS score of 13%. Among these patients, 40% were admitted to ICU and 30% died. The CURB-65 score,was efficient in predicting both ICU admittance and in-hospital mortality with an AUROC of 0.84 (95% CI 0.79-0.89) and 0.73 (95% CI 0.67-0.79), respectively. Conclusion: A higher CURB-65 score was correlated with higher rates of ICU admittance and mortality in patients with sepsis due to any cause. Compliance with ethics regulations: Yes.

Abderrahim Achouri, Hadil Mhadhbi, Khedija Zaouche, Hamida Maghraoui, Radhia Boubaker, Kamel Majed University Hospital Center Rabta of Tunis, Tunis, Tunisia Correspondence: Abderrahim Achouri (achouryabderrahim@gmail. com) Ann. Intensive Care 2020, 10(Suppl 1):P-150

Rationale: Sepsis is a major cause of mortality. In other hand, preexistent chronic diseases seem to worsen outcomes among critically ill patients. The acknowledgement of this fact may motivate studies in this type of situations in order to improve survival in sepsis. On that purpose, our study tried to check the impact of chronic pre-existent illnesses on outcomes in this type of emergency patients. Patients and methods: We have included patients in whom the sepsis-3 definition was met throughout emergency department admission cases for infection. In this study, considered outcomes were in-hospital mortality, shock occurence and the use of mechanical ventilation. Results: We collected 93 patients admitted to ED for sepsis. Mean age was 65 years ± 14 with bornes of 24 and 92. Men were 57% of the patients. Cormorbidities were: insulin dependent diabetes mellitus in 11.1% of patients, non insulin dependent diabetes mellitus in 42.6%, chronic obstructive lung disease in 20.4%, chronic renal failure in 19.4% with 12% in chronic replacement therapy from total patients, coronary artery disease in 16.7%, with stent in 8.3% and 3.7% with aortic coronary graft from total patients, arterial hypertension in 50%, chronic heart failure in 20.4%, atrial fibrillation in 10.2%,. Death occurs in 29.6% of total patients, septic shock in 25% and the use of mechanical ventilation in 5.6%. We did not find any association between comorbidity and the use of mechanical ventilation, but association with in-hospital mortality was found in pre-existent coronary artery disease (p = 0.001) and in patients with coronary artery stent (p = 0.011). Odds ratio (OR) was respectively 5.2 (95% IC = [1.8-15 .0]) and 5.6 (95% IC = [1.3-24.1] ). We found significant association between chronic heart failure and shock (p = 0.013) with OR = 3.4 (95% IC = [1. 3-9.1] ). Discussion: The small size of our sample may enlimit the contibution of other comorbidities on outcomes in sepsis such chronic renal failure, especially with renal replacement therapy and diabetes mellitus. Whereas, we can conclude that cardiac diseases have the most important impact on outcomes in sepsis.

Outcomes in sepsis can be affected by comorbidities, especially cardiac diseases. Therefore, that needs large studies to check it. Compliance with ethics regulations: Yes.

Micafungin population PK analysis in critically ill patients receiving continuous veno-venous hemofiltration or continuous veno-venous hemodiafiltration Nicolas Garbez 1 , Litaty Mbatchi 1 , Steven C. Wallis 2 , Laurent Muller 1 , Jeffrey Lipman 2 , Jason A. Roberts 2 , Jean-Yves Lefrant 1 , Claire Roger 1 1 CHU Nîmes, Nîmes, France; 2 University of Queensland, Brisbane, Australia Correspondence: Nicolas Garbez (nicolas.garbez@umontpellier.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-151 Rationale: To compare the population pharmacokinetics (PK) of micafungin in critically ill patients receiving continuous veno-venous hemofiltration (CVVH, 30 mL/kg/h) to those receiving equidoses of hemodiafiltration (CVVHDF, 15 mL/kg/h + 15 mL/kg/h).

Critically ill patients in septic shock undergoing continuous renal replacement therapy (CRRT) and receiving 100 mg micafungin once daily were eligible for inclusion. Total micafungin plasma concentrations were analyzed using Pmetrics ® . Probability of target attainment (PTA) was calculated from Monte Carlo simulations using 24-hour area under curve/minimum inhibitory concentration (AUC0-24/MIC) cut-offs 285 (C. parapsilosis), 3000 (all Candida species) and 5000 (C. non parapsilosis). Daily dosing regimens of 100, 150 and 200 mg were simulated for the first 2 days of treatment. Results: Eight patients were included in the study. Micafungin concentrations were best described by a two-compartmental PK model. No covariate, including CRRT modality (CVVH and CVVHDF), was retained in the final model, confirmed by internal validation. The mean parameter estimates (standarddeviation) were 0.96 (0.32) L/h for clearance, 14.84 (5.33) L for the volume of the central compartment, 0.36 (0.33) 1/h and 0.53 (0.24) 1/h for rate constants. The standard 100 mg daily dosing was unable to reach 90% of PTA for all Candida species except C. albicans on the second day of therapy (Fig. 1) . Conclusion: There was no difference in micafungin PK between equidoses of CVVH and CVVHDF. A dose escalation to 200 mg is suggested to achieve the PK/PD target of Candida species with MICs exceeding 0.016 mg/L in this population. These "off-label" dosing regimens should be further investigated in clinical trials knowing the favourable toxicity profile and the post-antifungal effect of micafungin in order to ensure efficacy and to prevent the emergence of resistance due to an inadequate initial antifungal dosing regimen. Compliance with ethics regulations: Yes. Rationale: Sepsis is an important cause of morbidity and mortality in hospitalized patients. Recognizing and responding to patients who experience clinical deterioration remains challenging in daily practice. Our purpose was to assess the ability of the Quick Sequential Organ Failure Assessment (qSOFA) score to identify, among patients reviewed by an intensivist, those at risk of adverse outcomes. Patients and methods: Retrospective cohort of patients with suspected infection reviewed by an intensivist in a university-affiliated hospital between January 2018 and June 2018. Outcomes of interest were hospital mortality and a combined criterion of hospital mortality or ICU stay of 3 days or more. Results: During the study period, 1163 patients were reviewed by an intensivist, of whom 459 (39.6%) had suspected infection according to the Sepsis-3 criteria. At the time of review, 192 (41.8%) patients with suspected infection were qSOFA positive (≥2) and 267 (58.2%) were qSOFA negative (0-1). Following the review, 240 (52.5%) patients were admitted to the ICU, among whom 202 (79.5%) had a prolonged stay (≥3 days). In-hospital mortality was 27.9%, and 79.9% of the patients met the combined criterion of in-hospital mortality or prolonged ICU stay. qSOFA positive patients required more frequently mechanical ventilation (52.9% vs. 36.6%, p = 0.01) and vasopressor support (50.5% vs. 28.8%, p < 0.001) than qSOFA negative patients. Moreover, qSOFA positive patients had higher hospital mortality than qSOFA negative patients (34.5% vs. 23.2%, p = 0.02). For the prediction of in-hospital mortality, a positive qSOFA had a predictive positive value (PPV) of 34%, and a negative predictive value (NPV) of 77%. For the prediction of in-hospital mortality or prolonged ICU stay, a positive qSOFA had a PPV of 83% and a NPV of 24%. Conclusion: Hospitalized patients with suspected infection for whom a review by an intensivist was requested, are at high risk of hospital mortality. Although the accuracy of qSOFA for identifying patients at risk of adverse outcomes is limited, its integration in a multimodal risk assessment approach may help distinguish the subset of patients who will benefit from an escalation of care. Compliance with ethicsregulations: Yes. Rationale: According to the Sepsis-3 consensus, sepsis is identified as an increase of at least 2 points in the Sepsis-related Organ Failure Assessment (SOFA) score in patients who presented infection. The quick SOFA or qSOFA is considered as a predictive tool of sepsis and mortality when it is equal to 2 points or more. Systemic Inflammatory Response Syndrome (SIRS) criteria are of limited utility because of their low sensitivity. Hyperlactatemia, as known is a determinant of tissue hypoperfusion. Our objective was to evaluate the prognostic value of SOFA > 2, SIRS > 2, qSOFA > 2 and lactate level > 2 mmol/l in infected patients.

Nine-month prospective cohort study. Patients aged 18 years or older who had a proven or suspected infection were included. SOFA score, SRIS criteria, SOFA q and lactate levels were determined within the first 24 h of infection. The primary endpoint was hospital mortality at 30 days. The predictive power of the studied parameters was determined using using the area under the receiver operating characteristic curve (AUROC). Results: A cohort of 71 cases was studied with mean age at 49.5 years. Bacterial pneumonia was the most common infection site (66%). In the first 24 h of onset of infection the medians [IQR 25-75] of the SOFA, SRIS, and SOFA scores and lactate levels were respectively 6 [3] [4] [5] [6] [7] [8] [9] , 3 [2] [3] , 1 [1-2] and 2.04 [0.65-3.4] . The progression to severe septic status was observed in 34 patients (48%) and norepinephrine was introduced in 32 cases. Median length of stay was 11 days [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] and mortality was 53%. Overall, the accuracy in predicting mortality of the 4 studied parameters was poor. An increase of SOFA score by at least 2 points had greater accuracy with AUROC = 0.762 [0.647-0.877], sensitivity = 74% and specificity = 79%. Conclusion: In infected patients, the SOFA score had greater prognostic accuracy than the SIRS criteria, the qSOFA score or the lactate level. These results suggest that SIRS, qSOFA, and high lactate level may be useful in screening for sepsis, but this utility is limited in predicting mortality. Compliance with ethics regulations: Yes. Rationale: Quick sequential organ failure assessement (qSOFA) has been validated for patients with presumed sepsis and others in general emergency department (ED) population. However, it has not been validated in specific subgroups of patients with a high mortality. The aim of this study is to evaluate the ability of qscore to predict prognosis in patients with decompensated liver cirrhosis. Patients and methods: This is a retrospective study, conducted over a period of 3 years from January 2016 to December 2018. Consecutive patients with decompensated cirrhosis, admitted in our department are included. Data of all patients were collected and the qSOFA score was calculated at admission. The main study endpoints were length of stay, complications and in-hospital mortality. Results: A total of 110 patients diagnosed with decompensated cirrhosis were enrolled. Mean of age was 62 years (18-88). Sex ratio was 1.2. HCV (39%) was the main etiology of cirrhosis. The reasons of hospitalization were: oedema with ascitic syndrome in 44% of cases, digestive haemorrhage (21% of cases), fevers (16% of cases), and hepatic encephalopathy was present in 36% of cases. The mean duration of stay was 10 days ± 7. In-hospital mortality rate was 20% and mean score qSOFA was 1.2.The qSOFA score was significantly correlated with length of stay (p = 0.02) and complications(p = 0.04) but not with in-hospital mortality (p = 0.99). Conclusion: The qSOFA score was not useful for predicting in hospital mortality in patients with decompensated liver cirrhosis but it was significantly correlated to the length of stay and complications. Compliance with ethics regulations: Yes.

Angioedema associated with thrombolysis for ischemic stroke: analysis of a case-control study Clara Vigneron 1 , Aldéric Lécluse 2 , Thomas Ronzière 3 , Sonia Alamowitch 4 , Olivier Fain 1 , Nicolas Javaud 5 1 Médecine Interne, Centre de Référence associé sur les angioedèmes à kinines (CRéAk), Hôpital Saint-Antoine, APHP, Paris, France; 2 Neurologie, CHU Angers, Angers, France; 3 Neurologie, CHU Pontchaillou, Rennes, France; 4 Neurologie, Hôpital Saint-Antoine, APHP, Paris, France; 5 Urgences, Centre de Référence associé sur les angioedèmes à kinines (CRéAk), Hôpital Louis Mourier, APHP, Colombes, France Correspondence: Clara Vigneron (claravigneron@hotmail.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-156 Rationale: Bradykinin-mediated angioedema is a complication associated with thrombolysis for acute ischemic stroke. Risk factors are unknow and management is discussed. The aim of this study was to clarify risk factors associated with bradykinin-mediated angioedema after thrombolysis for acute ischemic stroke. Patients and methods: In a case-control study conducted at a French reference center for bradykinin angioedema, patients with thrombolysis for acute ischemic stroke and a diagnosis of bradykinin-mediated angioedema, were compared to controls treated with thrombolysis treatment without angioedema. Two matched control subjects were analyzed for each case. Results: 53 thrombolysis-related angioedema were matched to 106 control subjects. The sites of attacks following thrombolysis for ischemic stroke mainly included tongue (34/53, 64%) and lips (26/53, 49%). The upper airways were involved in 37 (70%) cases. Three patients required mechanical ventilation. Patients with bradykinin-mediated angioedema were more frequently women (33 (62%) vs. 44 (42%); p = 0.01), had higher frequency of prior ischemic stroke (12 (23%) vs 9 (8%); p = 0.01), hypertension (46 (87%) vs. 70 (66%); p = 0.005), were more frequently treated with angiotensinconverting enzyme inhibitor (37 (70%) vs. 28 (26%); p < 0.001) and were more frequently hospitalized in intensive care unit (11 (21%) vs. 5 (5%); p = 0.004). In multivariate analysis, factors associated with thrombolysisrelated angioedema were female sex (odds ratio [OR], 3.04; 95% confident interval [CI], 1.32-7.01; p = 0.009) and treatment with angiotensin-converting enzyme inhibitors ([OR], 6.08; 95% [CI], 2.17-17.07; p < 0.001). Discussion: Because of theretrospective case-control design and the lack of the total number of thrombolysis for ischemic stroke, the incidence of this complication could not be evaluated in our study. Previous studies reported an incidence of 2.1 to 7.9% of angioedema in patients treated with a thrombolytic therapy for acute ischemic stroke. Our case-control study permits for the first time to analyse more cases to evaluate associated risk factors of this rare complication. Conclusion: This case-control study points out angiotensin-converting enzyme inhibitors and female sex as risk factors of bradykininangioedema associated with thrombolysis for ischemic stroke. Compliance with ethics regulations: Yes. Rationale: Patients with inflammatory bowel disease (IBD), frequently treated by immunosuppressive drugs, are more susceptible to be admitted to the intensive care unit (ICU). However, outcome and predictive factors of mortality are little known. Therefore, we aimed to assess the outcome and prognostic factors for critically ill IBD patients. Patients and methods: We retrospectively studied data of consecutive IBD (i.e. Crohn's disease and ulcerative colitis) patients admitted in 3 ICUs between 2007 and 2017. In-ICU and one-year mortalities were estimated and predictive factors of in-ICU mortality were identified by univariate and multivariate analysis. Results: Seventy-six patients (male: 62%, median age: 52.7 [42. 1-66.5] years, Charlson index: 2 [3.0-5.0]) entered the study. IBD type was largely represented by Crohn's disease (67.1%) and its localization was mostly extensive: L3 (58.8% of Crohn's disease) or E3 (92% of ulcerative colitis) according to the Montreal classification. Twenty-seven patients (35.5%) were treated with corticosteroids and 37 (50%) with immunosuppressive therapy (azathioprine: 26.3% and anti-TNFα: 20%). Reasons for admission were shock/sepsis (61.8%) and acute respiratory failure (19.7%). ICU diagnoses were infection (75%), IBD flare-up (48.7%) or both (32.9%), and pulmonary embolism (5.3%). At admission, SOFA score was 5 [2.0-8.0] and . Fifty-three patients (56.6%) required mechanical ventilation, 29 (38.2%) vasoactive drugs, and 8 (10.5%) renal replacement therapy. Twenty-three patients underwent emergency surgery (30.2%) and six urgent endoscopic treatment (7.9%). In-ICU and one-year mortality rate were 7.9% and 18.4%, respectively. Prognostic factors of in-ICU mortality were SOFA score (HR 1.31, 95% CI [1.17-1.47 ], p < 0.01) and azathioprine treatment before ICU admission (HR 4.13, 95% CI [1.56-10 .90], p < 0.01) (Fig. 1) . Previous immunosuppressive treatment with anti-TNF did not alter the prognosis and even the type of IBD. Conclusion: Our study showed that more than 90% of IBD critically ill patients were discharged alive from the ICU and a majority of them survived after one-year (81.6%). We also found that SOFA score and previous azathioprine immunosuppressive treatment worsened ICU outcome. Higher severity of the acute event affected short-term prognosis and should be taken into account for best ICU triage and management. Intensivists should pay particular attention to patients treated by azathioprine. Compliance with ethics regulations: Yes. Fig. 1 Outcome of IBD patients admitted to the ICU according to precious treatment with azathioprine status all APS patients with any new thrombotic manifestation(s) admitted to 24 ICUs. Results: One hundred and thirty-four patients (male/female ratio: 0.4; mean age at admission: 45.4 ± 15.0 years), who experienced 152 CAPS episodes, required ICU admission. The numbers of definite, probable or no-CAPS episodes (Fig. 1) , respectively, were: 11 (7.2%), 60 (39.5%) and 81 (53.5%). No histopathological proof of microvascular thrombosis was the most frequent reason for not being classified as definite CAPS. Overall, 35/152 (23.0%) episodes were fatal, with comparable rates for definite/probable CAPS and no CAPS (23% vs. 28.8% respectively, p = 0.4). The Kaplan-Meier curve of estimated probability of survival showed no between-group survival difference (log-rank test p = 0.5). Discussion: Our results suggest that the CAPS criteria do not sufficiently encompass all the parameters responsible for thrombotic APS patients' disease severity in the ICU. The absence of items referring to organ dysfunction/failure in the CAPS criteria probably limited their ability to predict mortality. Albeit useful for the retrospective classification and comparison of patients, the CAPS criteria may be too stringent and not yet ready-to-use for the management of ICU patients. For physicians outside expert APS centres, the absence of CAPS criteria could be misleading and lead to rejection of the diagnosis for near-CAPS patients, thereby preventing them from receiving the appropriate aggressive treatment they indeed require. We think that, when confronted with a critically-ill thrombotic APS patient, CAPS criteria should be interpreted with caution and should not be the only elements taken into account to decide the intensity of the therapeutic management. Rationale: 75% of resuscitation patients develop anemia during their stay, it can worsen the prognosis, prolong the length of stay and lead to transfusions that can be the cause of complications. The objective of our work is to specify the incidence of anemia in our unit, its etiologies and its therapeutic management. Patients and methods: We conducted a descriptive and analytical retrospective study within the surgical emergency resuscitation department of Ibn Rochd University Hospital of Casablanca, over a period of 4 years from 2015 to 2018. We included all anemic patients. Statistical analysis was performed with SPSS statistics 20. p < 0.05 was considered significant. Results: We included 361 patients with an estimated incidence of 27%, the average age was 39 years, the sex ratio H / F was 1.93. 47% of admissions were for traumatic pathology and 30% postoperative digestive surgery. 13% had hypotension at admission and the mean temperature was 38.2% .The onset of anemia and its depth were related to length of stay with 99.18% of patients who were anemic beyond the 12th day of hospitalization with a hemoglobin level that became < 8.5 g / dl beyond the 40th day. 60% of the patients had a normochromic normocytic anemia becoming microcytic with the lengthening of the duration of stay. Ferritinemia dosed in 1% of patients and was normal. 48% of our patients had exclusive parenteral nutrition while 26% had an enteral / parenteral combination. 91% were transfused in red blood cells (RBC) and 45% of patients were transfused more than once. 32% received between 3 and 4 RBC units.

In 11 patients who received 26 transfusion episodes costing 875 euros, the transfusion was inappropriate. The total cost of the transfusion was estimated at around 33,000 euros. 30% were supplemented with oral iron with an increase in hemoglobin in 6% of them. 52% of the patients came out of the intensive care unit with a hemoglobin level < 10 g/dl/L. The mortality rate of our patients was 14% with as predictive factors in multivariate analysis, hyperthermia, coagulopathy, the transfusion appears as a factor of good prognosis.

The prevention of blood spoliation and the fight against inflammation and nosocomial infection remain the pillars of the management of anemia in intensive care but in view of our results and the protective role of transfusion it would be interesting to see again the transfusion thresholds in our context. Compliance with ethics regulations: Yes. (Fig. 1 ). Discussion: We described a series of 11 patients with severe acute viral myopericarditises associated with anti-RNApol3 autoantibodies, an association that has never been reported previously. The fortuitous association of these autoantibodies with acute myopericarditis is highly unlikely. Acute myocarditis is a very rare disease with a reported incidence of 22/100,000 inhabitants. Anti-RNApol3-antibody detection is also very rare: 4.6% positive tests (including the 11 patients in this series) out of 1114 samples during a 5-year period in our Immunology Laboratory. This 63% proportion of patients with proven influenza-virus infections suggest that such severe infections could trigger anti-RNApol3 autoantibody production. However, influenza is a common disease and anti-RNApol3 autoantibodies are very rare. Furthermore, no anti-RNApol3 autoantibodies were detected in the 20 patients with severe influenza-related ARDS. Last, anti-RNApol3 autoantibodies remained detectable several months after the viral infection had been cured. Conclusion: This previously unknown association between severe acute viral myopericarditis and anti-RNApol3 autoantibodies is probably not fortuitous. Anti-RNApol3 antibody detection in acute myopericarditis patients could imply individual susceptibility to severe viral infection. Further studies are needed to investigate the pathophysiological mechanisms involved in this entity and potential specific therapeutic strategies. Fig. 1 Relative frequencies of digestive manifestations in 173 critically ill TMA patients Rationale: Arrhythmia-induced cardiomyopathy has been recognized for several decades, but most severe forms, i.e. cardiogenic shock and refractory cardiogenic shock requiring mechanical circulatory support, were rarely described in adults.

In this retrospective study, we described patients admitted in our tertiary care center for non-ischemic acute cardiac dysfunction (or worsening of previously known cardiac dysfunction) and recent onset supraventricular arrhythmia who developed cardiogenic shock requiring veno-arterial ECMO (VA-ECMO). Results: In a 10 years period, 35 patients had VA-ECMO for acute non ischemic cardiac dysfunction and recent onset supraventricular arrhythmia (Table 1 ). Fourteen (40%) patients had known nonischemic cardiomyopathy and 10 (29%) known paroxystic atrial fibrillation. Cardiogenic shock was the first manifestation of the disease in 21 patients. Atrial fibrillation was the main cause of arrythmia (77% of cases). At ECMO implantation, SOFA score was 10 [7-13], inotropic score 29 , LVEF 10% [10-15] and lactate level was 8 [4] [5] [6] [7] [8] [9] [10] [11] mmol/l. Twelve patients had sustained successful reduction after amiodarone and/or electric shock, all were weaned from ECMO and 11 survived without transplantation nor long term assist device. Among the 21 patients with failure of reduction, 7 underwent an atrio-ventricular ablation while on ECMO and 1 had atrial tachycardia ablation; all were weaned from ECMO and 7 survived. Among the remaining 13 patients without reduction and without ablation procedure, only the 6 patients who were bridged to heart transplantation or left ventricular assist device survived. In univariate analysis, factors associated with unfavorable outcome were previously known heart disease, heart rate, renal replacement therapy, NT-proBNP level, failure of rhythm reduction after amiodarone load and/or electric shock. Among the 18 patients who recovered and survived (11 with successful reduction and 7 with successful ablation), LVEF increased from 10 [10-15]% before ECMO implantation to 50 [45-55]% at long term follow-up. Discussion: This is the largest cohort of arrhythmia induced cardiomyopathies on VA-ECMO and the first description of atrio-ventricular node ablation with favorable outcome in this setting. Conclusion: Arrhythmia induced cardiomyopathy is probably underrecognized and should be considered in any patient with nonischemic acute cardiac dysfunction and recent onset supraventricular arrhythmia. Recovery is possible in the most severely ill patients on VA-ECMO, even with severe left ventricular dilation. Aggressive rate control by AV-node ablation may be warranted in case of failure of reduction, and may allow recovery and favorable outcome. Compliance with ethics regulations: Yes. Rationale: Diagnosis of sepsis is a major challenge in intensive care units and is associated with a high morbidity and mortality. Sepsis identification is even more difficult in patients with extracorporeal membrane oxygenation (ECMO) because of many confounding factors. The primary objective was to study the ability of C-reactive protein (CRP) and procalcitonin (PCT) values measured at ECMO support initiation (day 0) to predict the occurrence of early sepsis in patients undergoing venoarterial ECMO (va-ECMO) or venovenous ECMO (vv-ECMO). The secondary objectives were to study the association between these biomarkers and mortality rate during ECMO support and in-hospital mortality rate. Furthermore, we investigated the relationship between early sepsis and mortality. Patients and methods: We performed a retrospective, monocentric study in the cardiovascular Intensive Care Unit of the University Hospitals of Lille, France. Between November 1, 2014 and December 31, 2017, we included patients over 18 years old, who underwent an ECMO support for a medical or surgical indication, and for whom biomarkers (CRP and PCT) levels were available for at least the first 2 days of admission. Biomarkers and blood cultures were daily assessed for the first ECMO support days. Early sepsis was defined by sepsis diagnosis in the first 7 days after circulatory assistance initiation. In-hospital mortality rate was censored at 28 days. After univariate analysis, a Cox multivariate regression model was used to assess if the association between biomarkers levels and early sepsis or mortality rate was independent. A Kaplan-Meier survival plot was used to describe the association between early sepsis and mortality. Results: Among 100 patients included, 68 underwent va-ECMO and 32 underwent vv-ECMO. An early sepsis diagnosis was made in 17.6% of va-ECMO patients and in 100% of vv-ECMO patients. PCT and CRP levels on day 0 were significantly associated with early sepsis diagnosis (Fig. 1 Rationale: Fluids are one of the most prescribed drug in intensive care, particularly among patient with circulatory failure. Yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. Several factors may impact the haemodynamic efficacy of fluids among which the infusion rate. The aim of this study was to investigate the influence of the rate of fluid administration on the fluid pharmacodynamics, in particular by studying mean systemic pressure (Pms).

We conducted a prospective observational study in 14 patients with septic shock to compare two volume expansion strategies. A fluid bolus, 500 mL of normal saline were administered and several haemodynamic variables were recorded continuously: cardiac output (CO), arterial pressure (AP), mean systemic pressure (Pms, estimated from CI, PVC and MAP). Infusion rate was left at the discretion of the attending physician. A "slow" and a "fast" groups were determined based on the median of the infusion duration. Fluids effect was measured by the area under the curve (AUC), maximal effect (Emax) and time to maximal effect (tmax) for each haemodynamic variable.

The effects of fluid on Psm disappeared in one hour on average. Compared to patients of the "slow" group, those of the "fast" group had a shorter tmax and a higher Emax for Pms (p = 0.046 and 0.02 respectively). The AUC for Pms was identical between group, while in case of similar effect of infusion rates, it should be larger in the "slow" group. Regarding CO, tmax was also shorter in the "fast" than in the "slow" group (p = 0.048). The decreasing slope from maximal effect was comparable between groups, for Pms as for CO.

The effect of a 500 mL fluid bolus with normal saline in septic shock patients vanished within one hour. A faster infusion rate increased the maximal and total effect of the fluid bolus and shortened the delay to reach the maximal effect. Rationale: Significant hypotension following spinal anesthesia is a common issue in everyday clinical practice. Toavoid this potentially harming situation, an empirical fluid administration is usually performed before the procedure. Inferior vena cava (IVC) ultrasound has been demonstrated effective in guiding fluid therapy in critical care patients. The purpose of this study was to evaluate the IVC ultrasound guided volemic status optimization in order to decrease post-spinal hypotension rate. Patients and methods: In this prospective, controlled, randomised study, 474 consecutive patients were recruited and 429 patients were randomly assigned to a control group, consisting of pre-anesthesia empirical fluid administration (ITT), an IVC ultrasound group in which fluid management was based on an IVC ultrasound evaluation, and a passive leg raising test (PLRT) group in which volume optimization was performed following the above mentioned test. Primary outcome was the hypotension rate reduction after spinal anaesthesia following fluid optimization therapy between the groups. Secondary outcomes were the total fluid amount administered, the total vasoactive drug amount used and the time needed to realize the whole anaesthetic procedure in all three groups. Results: 11% reduction in hypotension rate (95% CI 1-24%, p = 0.086) was observed between the echocardiography group and the control group, and there was a reduction of hypotension rate by 9% (CI 95% 3-21%, p = 0.154) between the echocardiography group and the PLRT group. The total fluid amount administered was significantly greater in the ultrasound group than in the control group (593 ml; SD 369 ml, versus 453 ml; SD 458 ml, p = 0.01498). The total amine consumption was 36% in control group, 16% in IVC group and 22% in PLRT group. An increased of total study time was observed for the echocardiography group 48 min (SD 10 min) in comparison with the control group 46 min (SD 27 min) and PTLR group 40 min (SD 13 min), (p < 0.001).

The study showed a faint but positive trend toward the use of IVC-ultrasound to identify patients in spontaneous breathing needing fluid optimization before spinal anesthesia Compliance with ethics regulations: Yes. Rationale: We performed a systematic review and a meta-analysis of studies investigating the ability of the end-expiratory occlusion (EEXPO) test to predict preload responsiveness, through the changes in cardiac output (CO) or its surrogates, in adult patients.

This meta-analysis was prospectively registered on PROSPERO (CRD-42019138265). We screened PubMed, EMBASE and Cochrane Database to identify all original articles published between 1960 and 2019 evaluating the ability of the EEXPO test to predict a significant increase in CO or surrogate, compared to the one induced by a subsequent volume expansion or by passive leg raising (PLR). The meta-analysis determined the pooled area under the receiver operating characteristics curve (AUROC) of EEXPO testinduced changes in CO to detect preload responsiveness, as well as pooled sensitivity and specificity and the best diagnostic threshold. Subgroup analysis and sensitivity analysis were planned to investigate potential sources of heterogeneity. Results: Thirteen studies (530 patients) were identified and included in the analysis. Nine studies were performed in the intensive care unit and four in the operating room. Preload responsiveness was defined according to CO changes induced by fluid administration in 12 studies (fluid-induced increase in CO ≥10% or ≥15%) and according to CO changes induced by PLR in one study. The duration of the respiratory hold ranged between 12 and 30 s. For the EEXPO test-induced changes in CO, the pooled sensitivity and specificity were 87 [82-91]% and 91 [87-94]%, respectively, while the pooled AUROC curve was 0.95 ± 0.01 (Fig. 1) . The corresponding best diagnostic threshold was 5.1 ± 0.2%. When changes in CO were monitored through pulse contour analysis compared to other methods the accuracy of the test was significantly higher ( (1). Continuing (decrease to 30% of peak level) or modification (decrease < 30%) of antibiotic therapy was guided by a serum PCT assay from the third day of treatmentand every 48 h until antibiotic was stopped. This last was stopped when PCT levels had decreased of 80% from the initial value.

Results: A total of 106 patients had been diagnosed as sepsis (n = 79, 75%) and septic shoc (n = 27, 25%). Mean age was 32 years ± 14. An average UBS and ABSI score of 40% and 6. The average length of stay in ICU was 13 days. Patients were assigned into two groups: Group A (favorable evolution, n = 76); Group B (unfavorable evolution, n = 30). The therapeutic attitude according to the kinetics of the PCT are presented in the Table 1 . We found a significant difference between patients with unfavorable evolution compared to those with a favorable evolution (in whom we stopped antibiotics) (p < 0.005), in terms of hemodynamic state, PCT concentration and renal clearance. PCTguided antibiotic treatment has been proven to significantly reduce length of antibiotic therapy in our patients. The average duration of antibiotic was 5.6 ± 3 days. Conclusion: PCT measurement may help with the decision to initiate antibiotic therapy in low risk acuity of infection and allows more judicious antibiotic use by reducing antibiotic exposure. Compliance with ethics regulations: Not applicable. Rationale: Reducing the risk of severe hypoxemia during endotracheal-intubation (ETI) is a major concern in intensive care unit but little attention was paid to CO 2 variations during this period. We conducted a prospective observational study to describe transcutaneous CO 2 (PtcCO 2 ) throughout intubation in patients who received preoxygenation with standardoxygen therapy (SOT), non-invasive ventilation (NIV), or high flow nasal cannula oxygen therapy (HFNCOT). Patients and methods: Patients over 18 years undergoing ETI in ICU were continuously monitored for PtcCO 2 during intubation and the following 3 h under mechanical ventilation (MV). Haemodynamics and respiratory parameters were also recorded as well as arterial partial pressure of CO 2 (PaCO 2 ) to evaluate reliability of the transcutaneous measure. Results: Two hundred and two patients were included in the study. We found a strong correlation between PtcCO 2 recorded at preoxygenation and the last PaCO 2 available before intubation (r = 0.87, p < 0.0001). In 75% of patients PtcCO 2 values recorded at initiation of MV were out of 35-45 mmHg ranges. PtcCO 2 recorded at ETI, at initiation of MV, 30 min and 1 h of MV were significantly higher than PtcCO 2 during preoxygenation (p < 0.05 by ANOVA). Variations of PtcCO 2 were significantly different according to the preoxygenation method (p < 0.001 for interaction in ANOVA). Lastly, a decrease in PtcCO 2 higher than 5 mmHg within half an hour after the beginning of MV was independently associated with postintubation hypotension (PIH) (Odds Ratio = 2.14, 95% Confident Interval 1.03-4.44, p = 0.04). Conclusion: PtcCO 2 is a valuable tool to record PaCO 2 variation in patients requiring invasive mechanical ventilation and could be useful to prevent PIH. Compliance with ethics regulations: Yes. Rationale: Intubation in intensive care unit (ICU) is a critical procedure which leads to serious adverse event in 20 to 40% of cases. Several recent trials were conducted to help physicians to choose medications, devices and modality of intubation. Especially, videolaryngoscope (VL) led to several publications in the last few years, with increasing tools marketed and spread use (difficult airway management, routineintubation). We designed an online survey to take a picture of intubation process and devices availability in France. toolbox. It was positioned as a first line laryngoscope for every intubation in critically ill patients to reinforce the VL skill training. Present study was performed using prospectively collected data from a continuous quality improvement database about airway management in a 20-beds French teaching hospital medical ICU. All consecutive intubation procedure performed with VL from September 2018 to June 2019 were included. "First attempt success" group and "first attempt failure" group were compared by univariate and multivariate analysis in order to analyze the first attempt intubation success rate according to the level of operators' expertise, identify factors associated with first pass intubation failure and describe the intubation related complications. Results: We enrolled 202 consecutive endotracheal intubations. Overall first attempt success rate was 126 (62%). Comorbidities, junior operator, the presence of cardiac arrest and coma were associated with a lower first attempt success rate. The first attempt success rate was less than 50% in novice operators (1-5 previous experiences with VL, independently of airway expertise with direct laryngoscopies) and 87% in expert operators (greater than 15 previous experiences with VL) (Fig. 1 Rationale: Tracheostomy in intensive care unit (ICU) has many advantages. But only patient comfort and shorter ICU and hospital stay were demonstrated. The timing of this procedure is still debated. The aim of this study was to determine the impact of early tracheostomy on prognosis.

We performed a retrospective study in a medical ICU (6 beds unit) from January 2013 to November 2018. The technique of tracheostomy was exclusively surgical in the operating room made by the surgeon. The primary endpoint was mortality in ICU. The secondary outcomes were post-tracheostomy incidence of ventilator acquired pneumonia, duration of mechanical ventilation and length of stay in ICU. These criteria were assessed in relation to timing of the tracheostomy defined as early when performed before day 10 of mechanical ventilation. Results: Forty-two patients were enrolled during the study period. Mean age of patients was 55 ± 19 years. Median length of stay in ICU was of 49 days. Mortality rate was of 60%. Comparing the two groups, early vs late tracheostomy, no difference was found with respect to mortality (62% vs. 59%, p = 0.84), VAP occurrence (12% vs. 35%, p = 0.21), post-tracheostomy duration of mechanical ventilation (52 ± 81d vs. 28 ± 31d, p = 0.17), or length of stay in ICU (64 ± 78d vs. 61 ± 40d, p = 0.84). In multivariate analysis, the only factor independently related to mortality was the SOFA score patient on tracheostomy day with p = 0.041 and OR = 1.88 (CI95% [1.023-3.464] ). Conclusion: Tracheostomy in the intensive care unit remains a justified alternative despite the discordant data in the literature. In our study, the delay of the procedure didn't interfere with the evolution. However, the patient severity as attested by SOFA score at the day of tracheostomy, was the only independent prognostic factor. Those results should be confirmed by other large prospective studies. Compliance with ethics regulations: Not applicable.

Sabah Benhamza, Mohamed Lazraq, Youssef Miloudi, Abdelhak Bensaid, Najib El Harrar Réanimation de l'Hôpital du 20 Août, Casablanca, Morocco Correspondence: Sabah Benhamza (benhamzasabah5@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-187

Rationale: Many unknowns remain as to the place of tracheostomy in intensive care. Reluctance to perform a tracheotomy is numerous, especially when pre-exists chronic respiratory failure, but some data suggest benefits. We report in this work our experience in tracheotomy in the intensive care unit of the 20 August hospital, Casablanca. Patients and methods: This is a retrospective descreptive study over 2 years (January 2016 to January 2018) including all patients that have been tracheostomized in the intensive care unit of the 20 August hospital 1953. Results: During the study period, 50 patients were tracheostomized with a prevalence of 9.4% in 2 years, the predominance was male (sex ratio 2.3). The average age was 44 ± 18 years old. The indication for tracheostomy was prolonged ventilation in 76% of cases, extubation failure in 20% of cases, and intubation failure in 8% of cases. Tracheostomy was performed on average on the 12th day of intubation. All patients were tracheostomized in the operating room by ENT surgeons. The main complications attributable to tracheotomy were hemorrhage of the tracheostomy orifice in 2 patients (4%) immediately resumed, 2 cases of subcutaneous emphysema (4%), 1 case of pneumothorax (2%), 3 cases of orifice infection (6%). No patient died of a tracheostomy related cause.

The tracheotomy in intensive care is still a subject of debate especially concerning the time of its realization. However it seems to reduce the duration of mechanical ventilation, facilitates the care and also the ventilatory weaning. Compliance with ethics regulations: Yes. Rationale: HFNCO is a frequently used device providing heated and humidified high flow oxygen with several advantages: decreased work of breathing, decreased dead space, increased end expiratory lung volume (EELV), more stable FiO 2 . The increase in EELV is relying of the positive expiratory effect generated by the device. The level of generated PEP seems however to largely depend on whether the mouth is open or not. This study was aimed to assess the impact of mouth opening on EELV increase induced by HFNCO using electric impedance tomography. Patients and methods: The following HFNCO trial was proposed to healthy subjects who used HFNCO on a regular basis for patients care. Oxygen flow was set successively during 10 min periods at 0, 35 and 70 L/min (OptiflowTM; Fisher & Paykel Healthcare, Auckland, NZ). These three conditions were tested in semi recumbent and supine position chosen at random. Measurement started in supine position with no flow (baseline) and each period was separated from the following by a wash out period on 2 min during which the subject could breath normally with no supplemental oxygen. Electric Impedance Tomography (Pulmovista ® 500, Dräger Medical GmbH, Lündbeck, Germany) was performed applying a 16 electrodes belt placed between the 4th and 5th intercostal space, including a reference electrode located on the abdomen. As no spirometer was used, the data of EELV computed on the EIT device were expressed as percentage of variation of the value measured in supine or semi recumbent position with no flow. Demographic data were expressed as median and extreme values. Comparisons were performed using U Mann Whitney test. 6[19.4-29.6] accepted to participate to the study. When subjects received HFNCO with open mouth (whatever position) no modification of EELV was observed (Table 1) . Conversely, a significant increase in EELV was noted with closed mouth, whatever position. In the semi recumbent position the increase in EELV was even more important with 70L/min. Conclusion: Electrical impedance tomography illustrates the impact of mouth closure on EELV increase among healthy subjects receiving HFNCO. Compliance with ethics regulations: Yes. Rationale: In stable COPD patients, nasal high flow oxygen (NHF) use can be associated with reduction in respiratory rate (RR) and minute ventilation (MV). In thesepatients, PaCO 2 remains stable or decreases under NHF. This suggests a possible dead space reduction related to a washout effect of NHF. The aim of this study was to assess the physiological effects of NHF in hypercapnic patients with acute COPD exacerbation. Patients and methods: Crossover study in hypercapnic patients suffering from acute COPD exacerbation and treated with intermittent non-invasive ventilation (NIV). NHF 40L/min or standard oxygenotherapy (STAND O2) were randomly administered during 1 h between NIV treatments. RR, tidal volumes (VT), MV and corrected MV (corMV = MV x PaCO2/40) variations were recorded during the last 10 min of each study period using a respiratory inductive plethysmography vest. Blood gas analysis was performed at the end of each oxygen administration period. Visual analogic dyspnea score (VAS) quoted from 0 to 10 was assessed by the patient after 30 and 60 min. Results given as median [IQR] . Wilcoxon tests were used to compare data between STAND O2 and NHF. Results: Twelve patients were included and data could be recorded in 10 ( (Fig. 1 ). Dyspnea scores were not different between the 2 modalities. Conclusion: In case of acute COPD exacerbation, using NHF between NIV treatments was associated with PaCO 2 and RR decrease. MV concomitantly decreased suggesting a deadspace volume reduction related to a washout effect of NHF. Corrected MV decreased in all the patients except one. These results suggest that NHF could be used to deliver oxygen between NIV treatments to COPD patients suffering from acute exacerbation and could contribute reducing PaCO 2 . Compliance with ethics regulations: Yes. Rationale: The role of atypical micro-organisms in acute exacerbation of chronic obstructive pulmonary disease (COPD) that require mechanical ventilation is poorly none. The aim of this study was to determine the role of atypical pathogens in severe acute exacerbation of COPD. Patients and methods: In this prospective study we included all patients admitted for acute exacerbation of COPD requiring mechanical ventilation. Atypical pathogens (chlamydophila pneumoniae and mycoplasma pneumoniae) were searched by serological diagnosis and by culture of sputum samples.

In this study we included 58 patients aged 65 ± 13 years. Sixty-eight percent of sputum culture were considered significant. Six cultures were positive with 6 different microorganisms. Neither chlamydophila pneumoniae nor mycoplasma pneumoniae were found. The prevalence of chlamydophila pneumoniae was 56.9% (positive IgG serum). The demographic characteristics was similar between patients with and without positive culture. The rate of noninvasive ventilation (NIV) failure was 18% in positive serology group versus 44% in negative serology group (p = 0.032). The mortality was similar in both groups. In multivariate logistic regression analysis only positive serology (OR = 4.326; 95% IC [1.110-16.790 ], p = 0.034) was an independent factor of NIV failure. Conclusion: A positive serology of chlamydophila pneumoniae was a predictive factor of NIV failure without an impact on the morbidity and mortality of COPD patient treated with mechanical ventilation. Compliance with ethics regulations: Yes. Rationale: Emergency departments (ED) receive a growing up number of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) .Non-invasive ventilation (NIV) could be a good alternative to achieve a respiratory support, avoiding as much as possible the complications of invasive ventilation. The study aimed to assess the clinical outcomes of using NIV in acute exacerbation of COPD at ED and to identify whether clinical variables present at admission are predictive of NIV failure.

We conducted a prospective study conducted at the ED over a period of one year. Data of all patients admitted for acute exacerbation of COPD for all causes and requiring non-invasive ventilation were collected. NIV failure was defined as need for endotracheal intubation or death. Results: During the study period, a total of 70 patients with a mean age of 65 years (± 12) were included. Acute exacerbation of COPD was due to bronchitis in 46%, to pneumonia in 30% of cases. 18% of patients had no apparent etiology of acute exacerbation of COPD. Bilevel Positive Airway Pressure was performed on all patients, during a mean period of 10 h (± 6). Clinical NIV success was observed in 50 patients (71%). The predictors of NIV failure were advanced age, tachycardia, and hypercapnia. Conclusion: The efficiency of NIV in the management of acute exacerbations of COPD at ED is well documented. This is further supported by our study which showed a clinical success in 71% of patients with acute exacerbation of COPD. Compliance with ethics regulations: Yes. Rationale: Non invasive ventilation (NIV) is often performed in elderly patients with acute respiratory failure (ARF) at Emergency Department (ED). This technique may be subject to many difficulties, due to the presence of frequent co-morbidities. The aim of this study was to identify the predictive factors of NIV failure in elderly patients with ARF at ED. Patients and methods: This was a retrospective study conducted at ED on 1 year and 4 months including patients aged more than 65 years and who required the use of NIV for an ARF. All data were collected and analyzed using the SPSS 22 software. Patients were divided into two groups: NIV failure and NIV success. NIV failure was defined by inhospital mortality, requirement of intubation or hospitalization at intensive care unit. Results: During the study period, a total of 75 elderly patients that required NIV for ARF were included. Median age was 74 years (min = 65, max = 88) and sex ratio was 2.57. The median Charlson index was 5 (min = 3, max = 9). The etiological diagnoses of ARF were acute decompensation of chronic obstructive pulmonary disease (72%), acute heart failure (61%), pneumonia (37%) and pulmonary embolism (1%). The ARF was hypercapnic in 71% of cases and nonhypercapnic in 39%. NIV failure concerned 32%. Predictive factors of NIV failure were clinical signs of right heart dysfunction (p < 0.05), C reactive protein (p = 0.004), initial pH (p = 0.044) and kidney dysfunction (p < 0.05). Conclusion: In our study, NIV failure in elderly patients with ARF at ED was influenced by clinical signs of right heart dysfunction, C reactive protein, initial pH and kidney dysfunction. These clinical and biological factors could be useful to identify the most critical elderly patients and to better guide therapeutic decisions. Compliance with ethics regulations: Yes. Rationale: The interest of ECCO2R in the management of very severe acute asthma exacerbations is still unclear. Since it could help to control respiratory acidosis and /or to limit dynamic hyperinflation, its clinical benefits are uncertain, even in mechanically ventilated patients.

The REXECOR observatory is a prospective ECCO2R cohort in the great Paris area. Tencases of severe asthma treated by ECCO2R were retrospectively reviewed. Mainly, arterial blood gases (ABG), duration of ECCO2R and IMV were collected and in-ICU mortality were assessed. Data are reported as median (IQR). Results: Ten patients (7 men, age: 58 (IC: 41-61) years, BMI: 24.7 (IC: 19.3-25.9) kg/m 2 , FEV-1: 1.76 (IC: 1.27-2.57) L, (68 (IC: 60-73) %), SAPS2: 26.5 (IC: 23.5-39.7) points) were included. One patient suffered from cardiac arrest before admission and one had pneumothorax at ICU admission. Nine patients were under IMV (started on the day of admission for 8). Before ECCO2R, 10 patients received systemic corticosteroids, 8 paralyzing agents, 1 epinephrine and 10 salbutamol. Two patients suffered from pneumonia. ECCO2R was started 2 (IC: 1-3.75) days after intubation. Venous vascular access was achieved via the right internal jugular route in 8 patients and via the femoral route in 2. The Hemolung device was used in 4 patients, the iLa Activve in 5 and the Prismalung in 1. ABG before and after 1 day of ECCO2R are reported in Table 1 . Duration of ECCO2R was 8 (IC: 5.25-11) days and 3 patients were weaned from IMV under ECCO2R. For the remaining 6 patients, duration of IMV after ECCO2R was 21 (IC: 6-34.5) days. ICU stay was 28.5 (IC: 15-48.75) days. The only one NIV patient was not intubated. ECCO2R as stopped in 3 patients because of complications (one hemolysis, one internal bleeding and one membrane clotting). One patient died in ICU after limitation of life-sustaining therapy decision.

We report a preferential use of ECCO2R in IMV patients, contrasting with a marginal use in only one NIV patient to prevent intubation. The mortality rate was low, in line with previous case series of severe acute asthma with ECMO or ECCO2R support. More studies are needed (1) to better delineate the pathophysiological benefits of ECCO2R in asthma patients and (2) to confirm strong clinical benefits. Compliance with ethics regulations: Not applicable. Rationale: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are the most important events characterizing respiratory illness progression. Their management often needs noninvasive or invasive ventilation (IV). Data of literature confirm that the mortality of AECOPD requiring IV is high but are discordant about prognostic factors. The aim of our study was to describe the epidemiologic and clinical features of patients admitted for AECOPD requiring IV, the treatment and the evolution in intensive care unit in order to deduce the independent factors of mortality. Patients and methods: A 4-year retrospective analytic observational single-center study including patients hospitalized for AECOPD requiring IV. Results: Fifty-eight patients were enrolled. Mean age was 68 ± 9 years with sex-ratio of 4.8. Eighty one percent were smokers and 55% were classified GOLD stage 3. History of intensive care hospitalization and prior IV were found in 43% and 34% of all cases respectively. Mean APACHE II score was 21 ± 9. The predominant precipitating factor for AECOPD was respiratory tract infection (65% of all cases). Twenty two percent of all patients presented septic shock. IV was initiated on admission in 40% of all cases and after noninvasive ventilation failure in 60% of all cases. Forty-eight per cent of all patients developed septic shock as evolutionary complication. Mortality rate was 62%. In univariate analysis: male gender (p = 0.022), duration of respiratory disease progression (p = 0.04), annual exacerbations frequency (p < 10 −3 ), GOLD 3 stage (p = 0.008), prior IV (p < 10 −3 ), duration of symptoms before hospitalization (p = 0.03), APACHE II score (p = 0.04), pH (p = 0.004), shock on admission (p = 0.01) and septic shock as evolutionary complication (p = 0.01) were predictors of mortality in our study. Besides; shock on admission (p = 0.001) and as evolutionary complication (p = 0.017) were the two independent prognostic factors in multivariate analysis. Conclusion: Vital and functional prognosis of AECOPD requiring IV depends on the severity of the underlying respiratory illness, the severity of the exacerbation and the quality of an early management. This emphasizes the importance of controlling modifiable risk factors including smoking cessation, basic treatment improvement and early appropriate treatment of these exacerbations. Compliance with ethics regulations: Yes.

Medical background, biological parameters, death-rate and outcome of patients have been compared. Results: In total, 37 patients have been included in the "HLH" population. Death-rate in intensive care unit was 59% in the "HLH" group compared to 51% in the "Not HLH" group (p = 0.48). We used more extrarenal cleansing in the "HLH" group (67% vs. 30%, p < 0.02), the duration of assisted ventilation was longer (17.5 days vs. 7.5 days, p < 0.02), as well as the duration of extrarenal cleansing (5.1 days vs. 1.6 days, p < 0.05) and those of amines (9.9 days vs. 4.5 days, p = 0.008). The average time of hospitalization was significantly longer in the "HLH" group (17.9 days vs. 9.17 days, p < 0.01).

The secondary HLH to sepsis in intensive care unit, not well known and understudied, seems to have a different profile and a more serious outcome but no change in death-ratehas been found considering the pairing with the SOFA. Further studies are needed to plan a better therapeutic strategy within this population. Compliance with ethics regulations: Not applicable.

Serum and peritoneal exudate concentrations after high doses of ß-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study Lisa Leon, Philippe Guerci, Elise Pape, Nathalie Thilly, Amandine Luc, Adeline Germain, Anne-Lise Butin-Druoton, Marie-Reine Losser, Julien Birckener, Julien Scala Bertola, Emmanuel Novy CHRU Nancy, Vandoeuvre Les Nancy, France Correspondence: Lisa Leon (lisaleon1307@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-198

Rationale: Critically ill patients with severe intra-abdominal infections (IAIs) requiring urgent surgery may undergo several pharmacokinetic alterations that can lead to ß-lactam under dosage. The aim of this study is to measure serum and peritoneal exudate concentrations of ß-lactams after high doses and optimal administration schemes. Patients and methods: This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a ß-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The pharmacokinetic/pharmacodynamic (PK/ PD) target was to obtain ß-lactam concentrations of 100% ƒT>4x MIC (Minimum Inhibitory Concentration) based on a worst-case scenario (highest ECOFF value) before bacterial documentation (a priori) and redefined on the MIC of the isolated bacteria (a posteriori). Results: Forty-eight patients were included with a median [IQR] age of 64 [53-74] and a SAPS II score of 40 . Septic shock occurred in 23% of cases. The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered ß-lactam antibiotic (75%). Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. IAI was documented in 34 patients (70%). Enterobacteriaceae were the most isolated bacteria. Based on the MIC (n = 23) of isolated bacteria, 78% of the patients achieved the PK/PD target (100% ƒT>4xMIC). In the Fig. 1 we presented serum ß-lactams PK/PD target attainment and observed total concentrations of Piperacillin-tazobactam at each timepoint in serum and peritoneal exudate.

In critically ill patients with severe IAIs, high doses of ß-lactams ensured 100% ƒT>4xMIC in 78% of critically ill patients with severe IAIs within the first 24 h. A personalized ß-lactam therapeutic scheme with a PK/PD target based on local ecology should be warranted. Compliance with ethics regulations: Yes. Rationale: Intensive care unit acquired bloodstream infections (ICU-BSI) are frequent, and associated with high morbidity and mortality rates. The objective of our study was to describe the epidemiology and the prognosis of ICU-BSI in our ICU (Cayenne General Hospital). Secondary objectives were to search for factors associated to ICU-BSI caused by ESBL-PE, and those associated with mortality at 28 days. Patients and methods: We retrospectively studied ICU-BSI in the medical-surgical intensive care unit of the Cayenne General Hospital, during 78 months (January 2013 to June 2019). We assessed survival at 28 days from the diagnosis of ICU-BSI. Results: ICU-BSI was diagnosed in 9.5% of admissions giving a density incidence of 10.3 ICU-BSI/1000 days. The median delay to the first Rationale: Necrotizing soft tissue infections (NSTI) are a heterogenous group of severe infections. Among them, group A streptococcal (GAS) infection represent a subgroup that could benefit from specific therapies targeting the toxinic pathway, such as intravenous immunoglobulins or clindamycin. Nevertheless, previous trials evaluating these treatments suffered from a low rate of GAS infection among the study population. Early identification of patients at high risk of GAS infection would allow for assessing targeted treatment strategies. Patients and methods: We conducted a secondary analysis of a previously published cohort of 224 patients admitted to our tertiary center for surgically proven NSTI between 2006 and 2017. Admission characteristics and microbiological documentation based on surgical samples, blood cultures or subcutaneous puncture were recorded. We compared patients with a documented GAS infection to all other patients regarding admission characteristics. A generalized linear regression model was used to identify admission characteristics associated with a subsequent documentation of GAS infection. Results: Among 224 patients, 60 (27%) had a GAS infection, which was monomicrobial in 39 (17%) cases. Admission characteristics associated with GAS infections by univariate analysis were NSAID treatment before admission (19 (31.7%) for GAS infections vs 27 (16.7%) for others, p = 0.004) and leukocytosis as a continuous variable (17,200 /mm 3 [12,350-22,500] vs. 13,600 [9000-21,000], p = 0.016). Those inversely correlated with GAS infections were immunodeficiency (6 (10%) vs. 52 (31.7%), p = 0.002), and an abdominoperineal topography (1 (1.7%) vs. 37 (22.7%), p > 0.001). After multivariate analysis only immunodeficiency (OR = 0.29 [0.10-0.74], p = 0.015) and an abdominoperineal infection (OR = 0.06 [0.00-0.30], p = 0.007) remained associated with the absence of GAS infection. Using these criteria allowed for identifying subgroups of patients with increased likelihood of GAS infections: from 27% overall (n = 224) to 32% for non-abdominoperineal infections (n = 186), 33% for patients without immunodeficiency (n = 166) and 38% for both non abdominoperineal infections in patients without immunodeficiency (n = 138). A sensitivity analysis for monomicrobial GAS infections yielded similar results with the addition of younger age and non-nosocomial infections as predictors. Conclusion: Upon admission, the absence of immunodeficiency and of an abdominoperineal infection in NSTI patients were covariables associated with GAS infection. Compliance with ethics regulations: Yes. Rationale: Sickle-cell disease is the most common genetic disorder in the world. A complication of this disease is the acute chest syndrome (ACS) which is associated with a high risk of death. Respiratory tract infections are often mixed up and the introduction of betalactam antibiotics is recommended. Glomerular hyperfiltration is common and responsible of a high risk of underdosing. This study compares Cefotaxim continuous infusion to intermittent bolus in adult patients with ACS. Patients and methods: This observational retrospective monocentric study included ACS admitted in intensive care unit and treated by Cefotaxim with at least one plasmatic dosing between May 2016 and August 2019. Results: Thirty patients received bolus administration while the 30 others received continuous infusion. We observed 5 patients (16%) and 28 patients (93%) with a Cefotaxim trough level ≥ 2 mg/L in the bolus and continuous group, respectively (p < 0.001). The median residual concentration was 0 mg/L [0-0] and 10.5 mg/L [7. 4-13.3] in the bolus and continuous group, respectively (p < 0.001). There was no toxic effect induced by overdosing of Cefotaxim. Conclusion: Compared to intermittent bolus infusion, continuous Cefotaxim administration maximizes the pharmacokinetics parameters by obtaining a plasmatic concentration 5 times above the minimal inhibitory concentration of usual germs associated with ACS. Continuous infusion of time-dependant antibiotics seems to decrease the risk of underdosing in patients with sickle cell disease. Compliance with ethics regulations: Not applicable.

(n = 10, 22%), followed by esophageal varices rupture (n = 7, 15%), ulcer bleeding (n = 8, 17%) and diverticular hemorrhage (n = 7, 15%). Infectious diseases were diagnosed in three patients (7%), including one Clostridium colitis, one erosive gastritis with Helicobacter pylori and one esophageal candidiasis. Conclusion: GIB is associated with a high mortality rate in immunocompromised patients, especially in patients with hematological malignancies. Specific malignant lesions were the main etiology and may be difficult to treat. Comparison with critically ill non-immunocompromised patients with GIB will help physicians to provide specific therapeutic strategies in this population. Compliance with ethics regulations: Yes.

Risk factors for delayed defecation and impact on outcome in critically ill patients: a multicenter prospective non-interventional study Benoît Painvin 1,* , Arnaud Gacouin 2 , Antoine Roquilly 3 , Claire Dahyot-Fizelier 4 , Sigsimond Lasocki 5 , Chloe Rousseau 6 , Denis Frasca 7 , Philippe Seguin 8 1 Anesthésie-Réanimation/CHU RENNES, Rennes, France; 2 Réanimation Médicale/CHU RENNES, Rennes, France; 3 Réanimation Chirurgicale/ CHU NANTES, Nantes, France; 4 Réanimation chirurgicale/CHU POITIERS, Poitiers, France; 5 Anesthésie-Réanimation/CHU ANGERS, Angers, France; 6 Centre investigation clinique/CHU RENNES, Rennes, France; 7 Anesthésie-Réanimation/CHU POITIERS, Poitiers, France; 8 Réanimation chirurgicale/CHU RENNES, Rennes, France Correspondence: Benoît Painvin (painvinbe@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-211 Rationale: Delayed defecation is very common in Intensive Care Units (ICU) and it increases length of mechanical ventilation (MV), ICU length of stay (LOS) and possibly mortality. The objective of this prospective multicenter study was to determine risks factors for constipation in ICU and to evaluate their impact on mortality. Patients and methods: It was a prospective multicenter non-interventional trial performed in 5 university ICUs in France from January 2017 to October 2017. All patients ≥ 18 years old who had an expected LOS of 3 days and mechanically ventilated for at least 2 days were eligible. Defecation was defined as the time of the first stool passage. Results: 396 patients were included in the analysis. A stool passage was observed in 84% of the patients during their ICU stay with a mean delay of 7 ± 3 days. In multivariate analysis, risk factors for delayed passage of stool were non-invasive ventilation use and time spent under invasive ventilation whereas alcoholism, laxative treatment (before and after ICU admission) and nutrition ≤ 48 h favoured passage of stool (Table 1) . No relations between constipation and mortality were found. Conclusion: We highlighted new and important independent factors for constipation in critically ill patients leading to a better prevention of this phenomenon.. Compliance with ethics regulations: Yes. Rationale: Community peritonitis is a frequent medical-surgical emergency of the adult, acquired by the patient in a non-hospital setting. Careful multidisciplinary care is essential, involving surgeons, anesthetists, microbiologists and radiologists. The objective of our study is to determine the bacteriological aspects of intra-abdominal sepsis, to describe their sensitivity profiles and to propose treatment regimens for the management of community peritonitis.

We conducted a descriptive retrospective study spanning a period of two years from January 2017 to January 2019 involving 312 cases of community abdominal sepsis operated in the operating room of surgical emergencies of our hospital. We included in our study adult patients admitted for suspected or confirmed abdominal sepsis who had undergone bacteriological examinations on the abdominal collections. Samples taken are sent directly to the bacteriology laboratory for bacteriological analysis of the results.

The studies showed the mean age is 45.36 years old, with a sex ratio of 2.76. We found 215 positive results mainly of peritoneal origin with a percentage of 59.53% peritonitis, dominate by intestinal peritonitis 41.40% followed by the appendicular origin 33.59% then peritonitis by perforation of ulcer. The most incriminated organism in intraabdominal sepsis is E. coli with a percentage of 44.33% of the total germs found, followed by streptococcus spp 11.14%, enterococci 5.32%, non-fermenting BGN composed mainly of pseudomonas aeruginosa 5.66%, staphylococci 4.66% and Acinetobacter baumanii 3.33%. Note also the presence of Bacteroides fragilis is 1%. E. coli had a very low sensitivity profile for amoxicillin/clavulanic acid (59.4%), unlike ceftriaxone, gentamicin, amikacin and ertapenem, which had a sensitivity of 77.44%, respectively. 90.22%, 100%, 90.22%. Conclusion: Knowledge of the bacterial ecology of intraabdominal sepsis is important in the choice of probabilistic antibiotherapy, pending bacteriological findings.

No data are yet available about nutritional management and risk of malnutrition in Tunisian medical intensive care units (ICU). The purpose of this study was to describe nutritional management in medical intensive care patients and to evaluate the risk of malnutrition. Patients and methods: We conducted a prospective observational cross-sectional study in medical ICUs all around the Tunisian country on the 18th September 2018. All participant units received a questionary form about routine nutritional management and data of all patients hospitalized in ICU on the study day. Collected data were: demographic characteristics, reason for admission, severity scores and subjective evaluation of nutritional status on admission, type and volume of nutritional support on the study day and the day before, nutritional status, nutric score and biological data on the study day, reasons for nutritional interruption and other supports prescribed.

Results: Thirteen ICU all around Tunisia participated to the study. No ICU had a nutrition team and only one had a written nutrition protocol. Four ICUs evaluated systematically the nutritional status on admission. All ICUs were aware and practiced early enteral nutrition in patients unable to maintain oral intake with a systematic supplementation of oligoelements and minerals. Neither target energy nor protein intake were calculated. On the study day, 89 patients were hospitalized with an occupation rate of 58%. Mean age was 51 ± 28 years. Mean body mass index was 22 ± 9 and 69% of patients were judged well nourished. Enteral nutrition support was prescribed on admission in 66% of cases with a mean caloric intake of 1100 ± 614 kcal/day. The mean caloric target on the study day was 1721 ± 637 kcal/day with a mean caloric intake of 1677 ± 594 kcal/day and a mean caloric gap of 44 ± 43 kcal/day. The mean nutric score and body mass index on the study day were 3 ± 2 and 24 ± 6 respectively. Twenty patients were judged malnourished by the nutric score and twenty two by clinical evaluation. A good correlation was found between nutric score and clinical evaluation of nutritional status (k = 0.773). Conclusion: Tunisian ICUs don't have nutrition team or nutritional written protocol. Early enteral feeding and supplementation is common. A good correlation exists between nutric score and clinical nutrition status evaluation. Compliance with ethics regulations: Yes. Rationale: Whether more intensive glycemic control (GC) is beneficial or harmful forcritically ill patient has been debated over the last decades. GC has been shown hard to achieve safely and effectively in intensive care. The associated increased hypoglycemia and glycemic variability is associated with worsened outcomes. However, modelbased risk-based dosing approach have recently shown potential benefits, improving significantly GC safety and performances. The Stochastic TARgeted (STAR) GC framework is a model-based controller using a unique risk-based dosing approach. STAR identifies modelbased patient-specific insulin sensitivity and assesses its potential variability over the next hours. These predictions are used to assess hypoglycemic risks associated with a specific insulin and/or nutrition intervention to reach a specific target band. This study analyzes preliminary clinical trial results of STAR in a Belgian ICU compared to the local standard protocol (SP).

The mean age in our series was 54.09 years with a male predominance (sex ratio = 2.14). The main revealing symptoms were epigastralgia, weight loss and vomiting. Subtotal gastrectomy was performed in 40.9% of cases and total gastrectomy in 45.45% of cases. Curative resection could only be performed in 86.36% of cases. Operative mortality was 31.81% and morbidity was 22.71%. The main factor influencing operative mortality was age greater than 70 years. In univariate analysis the main prognostic factors; tumor size, degree of parietal invasion, presence of ganglionic invasion, presence of more than 3 ganglia invaded, presence of metastases, locally advanced tumor, tumor stage and curative nature of resection. Patient-related factors such as age associated blemishes and biological factors have a significant influence on the patient's prognosis.

The prognosis of gastrectomies, although it has improved overall, remains mediocre. The only way to improve the prognosis remains the early diagnosis with an effective surgical management and the introduction of an adapted resuscitation. Compliance with ethics regulations: Yes.

Efficacy of multiple second line agents in refractory status epilepticus in a pediatric intensive care unit Lea Savary, Claire Le Reun CHU Tours, Tours, France Correspondence: Lea Savary (lea.savary@hotmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-216

Rationale: Convulsive status epilepticus (CSE) is the most common neurological emergency in children. Refractory status epilepticus (RSE) occurs whenseizures are not controlled with first-and secondline agents. In adults, RSE requires pharmacological induced coma. In pediatric patients, association of second line treatment is often used to avoid general anesthesia although there is currently no data on the efficacy of this association.

We performed a monocentric retrospective study to assess the efficacy of multiple second line agents in pediatric RSE. All children admitted to Clocheville hospital (Tours) between January 2013 and December 2017 with a diagnosis of RSE were included. Our population was divided into two groups: need of general anesthesia (midazolam+) or not (midazolam-). Results: 55 children were included (30 in group midazolam+, 25 in group midazolam−) during the study period. Among the 48 patients with multiple second line agents, 52% did not need general anesthesia (n = 25). In group midazolam+, CSE was 20% longer in patients treated with multiple second line agents ( Rationale: Drowning is an acute respiratory failure resulting from immersion or submersion in a liquid. Patients and methods: We report 8 cases of drowning collated in the pediatric reanimation department during a period from 2010 to 2016. The aim of our retrospective study was to analyze and compare the different epidemiological, clinical, parcalinical, therapeutic and evolutionary of drowning in our study. Results: Our study contains 6 boys and 2 girls, with a sex ratio (M/F) of 3, in an age between 9 months and 8 years. For cases studied, no one was classified stage I, 37.5% classified stage II, 25% stage III, and 37.5% stage IV. All cases collected by ou service were victim of accidental drowning, 87.5% were secondary to the lack of parental supervision. Among 8 cases, 6 had respiratory complications, 4 cases of hydroelectrolytic disorders, 1 case with infectious complications, 3 cases of neurological and cases of cardiac or hypothermic complication. In our study, 5 cases recovered well and 3 cases died.

The survival of the drowned person depends on the speed and efficiency of the intervention, which in thefirst place is prehospital, thus ensuring the first actions at the scene of the accident, which will have repercussions on the hospital care. This has an equal share in the improvement of the victim's prognosis. Compliance with ethics regulations: Not applicable.

Epidemiology of severe pediatric trauma following winter sport accidents in the Northern French Alps Emilien Maisonneuve 1 , Nadia Roumeliotis 2 , Pierre Bouzat 1 , Guillaume Mortamet 1 1 CHU Grenoble, Grenoble, France; 2 CHU Sainte-Justine, Montréal, Canada Correspondence: Emilien Maisonneuve (emilienmaisonneuve@orange. fr) Ann. Intensive Care 2020, 10(Suppl 1):P-218

Rationale: This study describes the epidemiology of severe injuries related to winter sports (skiing, snowboarding and sledding) in children, and assesses potential preventive actions.

We did a single-center retrospective study in our pediatric Intensive Care Unit in the French Alps. We include all patients less than 15 years old, admitted to the Intensive Care Unit following a skiing, snowboarding or sledding accident from 2011 to 2018. Results: We included 186 patients (mean age 10.5 years and 68% were male); of which 136 (73%), 21 (11%) and 29 (16%) had skiing, snowboarding and sledding accidents, respectively. The average ISS (injury severity score) was 16. The major lesions were head (n = 94 patients, 51%) and intra-abdominal (n = 56 patients, 30%) injuries. Compared to skiing and snowboarding, sledding accidents affected younger children (7 vs. 11 years, p < 0.001); most of whom did not wear a helmet (90% vs. 8%, p < 0.001). Severity scores were similar amongst winter sports (ISS = 17 for skiing, 11 for snowboarding and 17 for sledding accident, p = 0.02). Rationale: Best strategies for the management of severe pediatric traumatic brain injury (TBI) are still not clearly established and wide variations among professional practices have been reported in the literature. Unfortunately, these variations in practice have an impact on the patient's outcome. The objectives of this work were to assess the adequacy of professional practices to the guidelines for the management of severe head injury 2019 and to assess the level of agreement of respondents in the absence of guideline. Patients and methods: A practice survey was conducted in Frenchspeaking hospitals in Canada, Belgium, Switzerland and France from April 1st to June 30th, 2019. The survey was conducted as a progressive clinical case with 70 questions based on guidelines 2012 and the literature from 2012 to 2019. The questions related to the assessment and management of TBI during the acute and intensive care phase. Results: Seventy-eight questionnaires were included. The adherence to guidelines 2019 was good, with 11 items out of 15 obtaining an adherence rate of more than 60% regardless of the annual number of TBI managed by the centre. There was strong agreement among clinicians on the intracranial pressure (PIC) (> 80%) and cerebral perfusion pressure (> 70%) thresholds used according to age. Guidelines for indication of PIC monitoring were almost perfectly followed in the case of Glasgow score < 8 and abnormal brain CT scan (n = 73, 93%). On the other hand, the natremia and glycemia thresholds and the role of transcranial doppler were not consistent. Strong adherence to recent recommendations was achieved: seizure prophylaxis with levitracetam (n = 21/33, 64%) and capnia threshold (n = 52, 67%). Assessment of O 2 pressure in brain tissue (n = 12, 16%) and autoregulation (n = 35; 45%) was not a common practice. Conclusion: Overall, practices for the management of TBI appear to be standardised. Variations persist in areas where there is a lack of literature and guidelines in paediatrics, so clinicians seem to refer to adult guidelines. Compliance with ethics regulations: Yes.

Choubeila Guetteche CHU Constantine, Constantine, Algeria Correspondence: Choubeila Guetteche (cguetteche@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-220 Rationale: Ingesting a coin cell is a common household accident in children, which can have serious consequences. The goal is to determine prognostic factors to improve management and reduce complications. Patients and methods: We conducted a retrospective study including children under 15 admitted in pediatric intensive care between January 2014 and May 2019 for ingestion of button cells, with epidemiological, clinical and paraclinical data collection. Results: Twenty-six children 17 boys (65%), and 9 girls (35%) were included, with an average age of 28 months (10-120), increased incidence in recent years. Clinical signs indicative were dysphasia with hyper-sialorrhea in 24 cases, cervical pain in one case, respiratory distress in one case, the cell was located in the upper third of the esophagus in 18 cases, third average in 6 cases, third inferior in 2 cases, the mean time before extraction was 20 h. Complications: 2 cases of mediastinitis, 2 cases of oesotracheal fistula, a case of perforation. Conclusion: The young age of the child, the diameter of the battery, and especially the time of care are risk factors for the occurrence of complications, the prevention passes through the education of the general public and creation of channel of taking into account fast charge. Compliance with ethics regulations: Not applicable.

Yacine Benhocine University Hospital Center Nedir Mohamed, Tizi-Ouzou, Algeria Correspondence: Yacine Benhocine (yacine001@yahoo.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-221 Rationale: Inhalation of foreign bodies is a common and serious accident in children, especially between 1 and 3 years old. At this age, children use their mouth to explore their environment. Asphyxia is the immediate risk and respiratory sequelae may appear secondarily. The severity of this incident has been considerably reduced due to the progress of the instrumentation and anesthesia which condition the smooth running of the therapeutic act. Aim: to evaluate the anesthetic modalities of the extraction of the foreign bodies of the airways in children, in order to optimize our care with a maximum of security.

A prospective, mono-centric, descriptive study from January 2011 to November 2013 of 128 patients treated for inhalation of foreign bodies in the airways. Study population wasdefined by: age, sex, hospitalization context, physical and radiological examination data, anestheticmanagement. Results: The average age of the patients was 39.4 months, the male predominated (81%), and the hospitalization context was polymorphic. General anesthesia was necessary in all cases, sevoflurane mainly for narcosis; the combination of an opioid in 70.8% of cases and a curare in 8.6%. Spontaneous ventilation is desirable, but 79% was manually broken down intermittently between extraction attempts. Cases of desaturation, bronchospasm, bradycardia, and pneumothorax have been reported. 86.71% had a good evolution. Discussion: The results of the epidemiological data are consistent with those of the literature. The penetration syndrome is very revealing. The chest x-ray is the key examination, the diagnosis is often based on indirect signs. In case of asphyxia by foreign body enclosed above or between the vocal cords, laryngoscopy and oxygenation is the first step to perform. In other cases, a rigid bronchoscopy is performed under general anesthesia; Inhalation induction with sevoflurane is the technique of choice for many experienced authors. Controlled ventilation is used in the majority of cases because spontaneous ventilation is not often not possible. The heterogeneity of anesthetic practices accounts for the multiplicity of clinical situations. Conclusion: The inhalation of a foreign body is a diagnostic and therapeutic emergency. Extraction of the foreign body takes place under general anesthesia, which is difficult and at risk. Compliance with ethics regulations: Yes.

Non-invasive neurally adjusted ventilatory assist (NAVA) in infants with bronchiolitis: a retrospective cohort study Alex Lepage-Farrell, Sally Al Omar, Atsushi Kawaguchi, Sandrine Essouri, Philippe Jouvet, Guillaume Emeriaud CHU Sainte Justine, Université de Montréal, Montréal, Canada Correspondence: Alex Lepage-Farrell (alex.lepage-farrell@umontreal.ca) Ann. Intensive Care 2020, 10(Suppl 1):P-222

Rationale: Bronchiolitis is one main reason for admission to pediatric intensive care unit. Most infants are successfully managed with nasal CPAP or high-flow nasal cannula, but about a third of these patients are not sufficiently supported and require an alternative support. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) improves patient-ventilator interactions and could therefore improve the effectiveness of non-invasive support. Our hypothesis is that NIV-NAVA is feasible in infants with bronchiolitis and that it reduces the respiratory effort. Patients and methods: We retrospectively studied all patients under 2 years of age with a clinical diagnosis of bronchiolitis ventilated with NIV-NAVA in our pediatric intensive care unit, between October 2016 and June 2018. Patients characteristics, respiratory and physiologic parameters, including diaphragmatic electrical activity (Edi) were extracted from an electronic medical database (data collected every 30 s). Respiratory effort was estimated using the modified Wood Clinical Score for Asthma (mWCAS) and the inspiratory peak Edi, and 2-h periods before and after NIV-NAVA initiation were compared (Wilcoxon rank test). The study was approved by the local research ethics committee. Results: During the study period, 205 patients were admitted with bronchiolitis; 64 infants (36 boys) with a median (25th-75th percentile) age of 52 (32-92) days were treated with NIV-NAVA after a failure of other non-invasive support methods, and all were included. Twentyfive subjects (39%) had at least one comorbidity. The interfaces used were predominantly face masks (92%). The maximum ventilatory settings were NAVA level of 1.0 (0.8-1.0), PEEP of 7 (7-8) cmH 2 O, FiO 2 of 60% (39-100) and maximal pressure of 20 (20-22) cmH 2 O. Total duration of non-invasive ventilation was 70 (53-133) hours, including 48 (29-76) hours in NIV-NAVA. As detailed in the Table 1 , mWCAS significantly decreased after NIV-NAVA initiation, from 3.0 (2.5-3.5) to 2.5 (2.0-3.0), p < 0.01. A decrease in inspiratory peak Edi was also observed, which was particularly clinically relevant in infants with high baseline Edi (> 20mcV). Capillary blood pH and pCO2 also significantly improved after NIV-NAVA introduction. Six patients (9%) needed escalation to endotracheal intubation. Conclusion: This study confirms the feasibility of NIV-NAVA in infants with bronchiolitis after failure of first line non-invasive support, with a low failure rate. NIV-NAVA initiation was followed by a decrease in respiratory effort and an improvement in blood gases. This observational study supports the needs for prospective interventional trial. Compliance with ethics regulations: Yes. Rationale: The use of blood transfusion is frequent in pediatric intensive care units and has increased significantly since 2002. Considered as therapeutic, it requires an assessment of the benefit / risk balance before making the transfusion decision. The aim of our study is to describe the transfusion practices in the Pediatric Resuscitation Department of the EHS Canastel, Algeria. Patients and methods: A retrospective observational study over a 6-month period from January 2018 of any blood transfusion performed in hospitalized patients, in the pediatric intensive care unit. We studied : the age, the sex, the history of blood transfusion, the indication of transfusion, the haemodynamic and respiratory parameters, the transfusional accidents, the length of stay in intensive care, the evolution after a blood transfusion. Results: These included 45 transfusion patients out of 135 hospitalizations during the 6-month period, mean age was 38 months.All patients had no transfusion history, 30% of patients had their anemia admission and 70% developed it during their stay. the reason for hospitalization was respiratory distress in 40%, convulsive condition in 30%, polytrauma in 10%, and head trauma in 20%. The indication of the transfusion was placed on a Hb inferior or equal to 7 g / dl in 50% of cases, in 30% on an Hb superior to 7 g / dl in addition to the clinical criteria of intolerance to anemia; in 20% of the cases no clinical or biological criteria found, the nature of the blood products was of the red cell in 77% of the cases and of the plasma concentrate in 13/100 of the cases and PFC in 10%. 33% received A+, 6% of A-, 15% of B+, 35% of O+ and 9% of O-. 20% of the patients had a transfusion-like reaction at 5 min after the start of the transfusion; 51% of the patients were under artificial ventilation and 29% were under hemodynamic support, 13% under diuretic.The average length of stay was 33 days; the favorable outcome was 35% of the patients after the transfusion with an increase in the Hb level beginning, 29% of the patients had complications of their pathology and the death in 33% of the cases. Conclusion: Current transfusion practices in children often do not reflect the implementation of our current knowledge of the need for transfusion. Hence the need to review the protocols and practice other transfusion alternatives to avoid complications and improve the quality of care. Compliance with ethics regulations: Not applicable. Rationale: Bacterial multi drug resistance is medical actuality nowadays, because of its morbidity and mortality especially in intensive care, it constitutes a real problem in our hospitals.

We conducted a retrospective descriptive study, to identify bacterial drug resistance profile of patients with cross infections in the department of intensive care in 20 August hospital. This study included patients hospitalized between 1st January and 31st December 2017. The data was collected from medical records of this unit as from the register of the bacteriology service of Ibn Rochd university hospital. Results: 468 patients were hospitalized in the resuscitation service, of which 98 had nosocomial infection, an incidence of 20.9%. The mean age of the patients was 51 years with male predominance (sex ratio 2.5), the average stay in intensive care was 17 days. The site of infection was pulmonary in 34% of cases, blood in 20% of cases, urinary in 18% of cases, central catheter in 13%, neuro-meningeal in 5.5% of cases. The germs isolated were: Acinetobacter baumanii in 30.5% of cases, Pseudomonas aeroginosa in 17.8% of cases, Klebsiella pneumonia in 12.9% of cases, Enterococcus feacalis in 9.4% of cases, E.coli in 8.1% of cases and Staphylococcus aureus in 7% of cases. Acinteobacter baumanii showed resistance rates of up to 90% for the impenem and 77% for amikacin. Regarding Pseudomonas, it was resistant to impenem in 57% of cases and in 46% of cases to amikacin. Compared to Klebsiella, resistance to imipenem was 52% and 2% for amikacin. The mortality rate of infected patients was 59% Conclusion: In the light of this work, we found that important emergence of multidrug resistance bacteria in intensive care unit is related to not only the immunocompomised state of patients but also to daily bad practices of health professionals such as the misuse of antibiotics. Compliance with ethics regulations: Yes.

overnight culture of Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus and Pseudomonas aeruginosa, was also sequenced. Results: Twenty-four samples and the PC were analyzed. Amplicon sequence analyses found similar results with the two primer pairs in 58% of cases. Cultured pathogen was found in 89% (8/9) for Human primer pair and in 44% (4/9) for Earth primer pair. For each ETA, NGS revealed bacteria unknown as pathogen globally identified as oropharyngeal flora in conventional microbiology (Table 1) . Alpha diversity decreased for all VAP patients overtime, average Shannon 2.5 (2; 2.8) versus 2 (1.6; 2.6), and was higher in upper respiratory tract (OS) versus lower respiratory tract (ETA): average Shannon 2.5 (1.7; 2.7) vs. 1.8 (0.7; 2.6) (NS). Conclusion: This pilot study highlights the impact of 16S rDNA amplification procedures (especially oligonucleotide sequences) used on the results in microbiome research. Concordance between NGS and bacterial culture, as well as similar evolution of the alpha diversity than previously described (1), enables us to validate our methodology using the "gut primers" pair 515F-806R. These findings allow furthers major studies on the pulmonary microbiome of ICU ventilated patients including comparison according to the occurrence of a VAP or not. Compliance with ethics regulations: Yes. Rationale: In the field of intensive care only few studies have explored bacterial microbiota whereas virome remained hardly considered. It appears essential to describe both evolution in mechanically-ventilated patients to improve the pathophysiological understanding of ventilator-associated pneumonia (VAP) development. To date no study had been simultaneously conducted on lower respiratory tract with a single nucleic acid extraction before metagenomics analysis of bacterial microbiota and virome. We conducted a preliminary study to validate our methodology based on a common automated extraction of nucleic acids. Patients and methods: Twelve mechanically ventilated patients were selected: five who developped (VAP) and seven controls (C) who did not. Endotracheal aspirate (ETA) were collected between intubation and day 12 (or DVAP for VAP patients). Conventional bacterial microbiology and multiplex respiratory viruses PCR were also performed. Total nucleic acids were extracted using NucliSENS easyMag extractor. For the bacterial microbiota, region V4 of the 16S rRNA genes was amplified. For the virome, the Nextera DNA XT kit (Illumina) and RNA Seq Trio kit (Nugen) protocols were used to prepare viral DNA and RNA libraries. Libraries underwent paired-end sequencing on the Illumina Miseq (bacteria) or NextSeq-500 (virus) platform. After bioinformatics analysis we compared the performance of metagenomics analysis with conventional bacterial culture and other common viral detection methods. Results: For culturable bacteria, concordance between conventional microbiology and sequencing was found in 89% (8/9 Table 1 .

Our preliminary results confirm the feasability of exploring both bacterial microbiota and virome on the same sample using a common extraction method. Data from metagenomics were highly concordant with conventionnal detection methods for known pathogenic viruses and bacteria in lower tract respiratory sample and enables identification of other microorganisms. This is the first step for a large cohort study that aims to compare evolution of global lung microbiome in patients at risk of VAP and assess how bacteria and virus interplay. Compliance with ethics regulations: Yes. 

References 1. Clancy

Department of Medical and Toxicological Critical Care, Lariboisière Hospital

One microorganism was isolated in 82.1% and two in 17.9% of cases. The main isolated microorganism were Enterobacteriaceae in 67.7% of patients. They were ESBL-producers in 27.6% of cases. Initial antibiotic therapy was appropriate in 65.1% of cases. Factors independently associated with ESBL-PE as the causative microorganism of ICU-BSI were ESBL-PE carriage prior to ICU-BSI

The sensitivity of ESBL-PE carriage to predict ESBL-PE as the causative microorganism of ICU-BSI was 64.9%, and specificity was 81.2%. Mortality at 28 days was 20.6% in the general population

In multivariable analysis, there was no parameter which was independently associated to mortality at day 28 from the occurrence of ICU-BSI. Conclusion: ICU-BSI complicates 9.5% of admission to ICU and was associated with 25% in-hospital mortality

Assessing and applying individualized treatment for group A streptococcal necrotizing soft-tissue infection is possible

Service de réanimation médicale

Intensive Care

Decompressive craniectomy in traumatic brain injury: about 147 cases Karama Bouchaala

Sex ratio of 8.8. The mean (SD) length of stay in ICU was 22.9 ± 21.8 days. The mean Glasgow Coma Score (GCS) (SD) was 7.2 ± 3.6 and GCS ≤ 8 in 68.1%. SOFA score > 5 was found in 71 patients (48.3%) and SAPSII score ≥ 30 in 121 patients (82.3%). The cerebral CTscan at admission showed acute subdural hematoma (ASDH) in (84.4%), cerebral oedema (65.3%) and cerebral contusions (83%)

Teaching: Fresenius Medical Care; Patent or product inventor: GML Czech Republic BANYDEEN Rishika: No conflict of interest BAPTISTE Amandine: No conflict of interest BAPTISTE Olivier: No conflict of interest BARBAR Saber Davide: No disclosure BARBIER François: No disclosure BARBIERLouise: Trainings, Teaching: Ethicon, Astellas; Invitation to national or international congresses: Sandoz, Astellas BARNERIAS Christine: No disclosure BARON Aurore: No disclosure BARON Elodie: No conflict of interest BARR ATT -DUE Andreas: No disclosure BARRAU Stephanie: No disclosure BARRAUD Damien: No disclosure BARRAUD Helene: No disclosure BARROIS Brigitte: No conflict of interest BARUCHEL André: No disclosure BASTIDE Marie Anaïs: No conflict of interest BAUDEL Jean-Luc: No conflict of interest BAUDIN Florent: Invitation to national or international congresses: Dr Baudin has received speaking fees from Maquet Critical Care (EPNV

Teaching: Drager; Invitation to national or international congresses: MSD; Hill Rom BEGANTON Frankie: No conflict of interest BEGOT Erwan: No disclosure BEINSE Guillaume: Research support/Scientific studies: Association pour la Recherche contre le Cancer

ion and Fresenius Kabi BENSAID Abdelhak: No disclosure BENSARDI Fatimazahra: No disclosure BENYAMINA Mourad: No disclosure BENZERARA Laurent: Patent or product inventor: aphp BENZERDJEB Nazim: Research support/Scientific studies: AMARAPE, iCAP; Consultancy, Expert: ALPHASIGHTS, MSD; Trainings, Teaching: MSD BEQIRI Erta: No disclosure BÉRANGER Agathe: No conflict of interest BERARD Emilie: No conflict of interest BERDAI Adnane: No disclosure BERGER Patrick: No disclosure BERNAL William: No disclosure BERNARDIN Gilles: No disclosure BERRADA Lina: No conflict of interest BERTHAUD Romain: No conflict of interest BERTHET Guillaume: No conflict of interest BERTI Enora: No conflict of interest BERTOLI Sarah: No disclosure BERTRAND Pierre-Marie No conflict of interest BESBES Lamia: No disclosure BESBES Mohamed: No conflict of interest BESCH Camille: Invitation to national or international congresses: Abbvie

No conflict of interest BOISSEAU Chloé: No disclosure BOISSEL Nicolas: No disclosure BOISSIER Florence: No conflict of interest BOIVIN Alexandra: No conflict of interest BONACORSI Stéphane: No conflict of interest BONGIOVANNI Filippo: No conflict of interest BONNARDEL Eline: No conflict of interest BONNEFOY-CUDRAZ Eric: No disclosure BONNET Sixtine: No conflict of interest BONNEVIE Tristan: Research support/Scientific studies

Invitation to national or international congresses: Fresenius Kabi and Fresenius Medi-calCare BUCUR Petru: No disclosure BUETTI Niccolo: Research support/Scientific studies: Swiss National Science foundation research grant and bangerter rhyner foundation supporting my postdoc BUI Hoang-Nam: No disclosure BURELLI Gabrielle: No conflict of interest BURGEL Pierre-Régis: No disclosure BURGHI G: No conflict of interest BUSTARRET Olivier: No conflict of interest BUTIN-DRUOTON Anne-Lise: Invitation to national or international congresses

Expert: Astra-Zeneca; Invitation to national or international congresses

Expert: Hamilton Medical; Invitation to national or international congresses: Hamilton medical CHEMLI Wael: No conflict of interest CHENOUARD Alexis: No conflict of interest CHERKAB Rachid: No conflict of interest CHEVRET Sylvie: No disclosure CHHUN Stephanie: No conflict of interest CHICHE Jean-Daniel: No disclosure CHICOISNEAU Maxence: No conflict of interest CHLILEK Abdelaziz: No disclosure CHOCRON Richard: Consultancy, Expert: ASPEN CHOMMELOUX Juliette: No conflict of interest CHOMTON Maryline: No conflict of interest CHOSIDOW Olivier: No disclosure CHOUCHANA Laurent

Expert: Biotest; Invitation to national or international congresses: Sanofi

Research support/Scientific studies: Fresenius Medical Care; Consultancy, Expert: Fresenius Medical Care; Invitation to national or international congresses: Xenios Novalung, Heilbronn, Germany DACHRAOUI Fahmi: No disclosure DAHOUMANE Redouane: No conflict of interest DAHYOT-FIZELIER Claire: No disclosure DAIX Thomas: No conflict of interest DALY Foued: No conflict of interest DAMONTI Lauro: No conflict of interest DANTAN Etienne: No conflict of interest DARMON Michaël: Research support/Scientific studies: MSD

No disclosure DAS Vincent: No disclosure DAUBIN Cedric: No conflict of interest DAUBIN Delphine: No conflict of interest DAUDON Michel: No disclosure DAUFRESNE Pierre: No conflict of interest DAUGER Stéphane: No conflict of interest DAVIET Florence: Invitation to national or international congresses: sandosz DE COURSON Hugues: No conflict of interest DE JONG Audrey: Trainings, Teaching: Baxter, Medtronic; Invitation to national or international congresses

Teaching: cardioSleep DELHAES Laurence: No disclosure DELIGNETTE Marie-charlotte: No conflict of interest DELLAMONICA Jean: Trainings, Teaching: Medtronic; Invitation to national or international congresses: MSD, General Electrics DELPIERRE Clément: No conflict of interest DELVILLE Marianne: No conflict of interest DEMAILLY Zoé: Research support/Scientific studies: SRLF DEMAREST Elsa: No disclosure DEMARET Pierre: No conflict of interest DEMISELLE Julien: No conflict of interest DEMONDION Pierre: No conflict of interest DEMOULE Alexandre: Research support/Scientific studies: Drager, Philips; Consultancy, Expert: Baxter, Respinor, LungPacer; Trainings, Teaching: Fisher & Paykel, Hamilton, Baxter; Invitation to national or international congresses: Fisher & Paykel DENIS Manon: No conflict ofinterest DEPEYRE Fanny: Invitation to national or international congresses: Pfizer DEPLANTE Yvon: No conflict of interest DEQUIN Pierre-François: Research support/Scientific studies: MedImmune Combioxin Ferring Pharmaceuticals A/S Asahi Kasei Pharma America Corporation DERAUGLAUDRE Lucie: No conflict of interest DERBEL Karim: No disclosure DERKAOUI Ali: No disclosure DERVIN Krystel: No conflict of interest DESAIVE Thomas: No conflict of interest DESGUERRE Isabelle: Research support/Scientific studies: Ptc inc, Avexis; Consultancy, Expert: Avexis, PTC inc, Biogene; Trainings, Teaching: roche, PTC inc, Avexis; Invitation to national or international congresses: sarepta, biogen, Avexis, Biomarin DESNOS Cyrielle: No conflict of interest DESROYS DU ROURE François: No conflict of interest DETOLLENAERE Charles: No conflict of interest DEVAQUET Jérôme: Invitation to national or international congresses

Expert: Lungpacer; Invitation to national or international congresses: Lungpacer DREYFUSS Didier: Research support/Scientific studies: Grant from French Ministry of Health DROUOT Xavier: No disclosure DU CHEYRON Damien: No conflict of interest DUBÉ Bruno-Pierre: Consultancy, Expert: Novartis, GSK DUBERT Marie: No conflict of interest DUBOST Baptiste: No conflict of interest DUBOST Jean-Louis: No conflict of interest DUBURCQ Thibault: No conflict of interest DUCHEMANN Boris: Consultancy, Expert: BMS, MSD, Roche; Invitation to national or international congresses

No conflict of interest FRÉROU Aurélien: No conflict of interest FRITZ Caroline: No disclosure FROMENTIN Mélanie: Research support/Scientific studies: MSD; Invitation to national or international congresses: MSD FROUIN Antoine: No conflict of interest FRUGIER Alexandre: No disclosure GABORIAU Louise: No conflict of interest GACI Rostane: Invitation to national or international congresses: BARD GACOUIN Arnaud: No disclosure GADDAS Mehdi: No conflict of interest GAILLARD Arnaud: Trainings, Teaching: Zoll Medical GAIMARD Sophie: No conflict of interest GAINNIER Marc: No conflict of interest GALBOIS Arnaud: No conflict of interest GALERNEAU Louis-Marie: Invitation to national or international congresses: Agir À Domicile GALICIER Lionel: Consultancy, Expert: NOVARTIS, EUSAPHARMA; Trainings, Teaching: Baxalta, PFIZER; Invitation to national or international congresses

No conflict of interest ICHAÏ Philippe: No conflict of interest IMEN Sioud: No conflict of interest IOOS Vincent: No disclosure ISERIN Franck: No disclosure ISSA Nahema: No conflict of interest JABER Samir: Consultancy, Expert: drager, Fisher-Paykel; Medtronic; Baxter

Xenios Fresenius; Invitation to national or international congresses: Drager

No conflict of interest JACQ Gwenaëlle: No conflict of interest JACQUET Emmanuelle: Research support/Scientific studies: Unicancer (ESME and STORM studies

Invitation to national or international congresses: Pfizer

Université Laval-Qc-CA LABBE Vincent: No disclosure LABRO Laura: No disclosure LACAILLE Florence: No conflict of interest LACAMPAGNE Alain: No disclosure LACAN Claire: No conflict of interest LACHERADE Jean-Claude: No conflict of interest LADJEMI Maha-Zohra: No conflict of interest LAFON Charles: No conflict of interest LAFON Marie-Edith: No disclosure LAFON Thomas: No conflict of interest LAGACHE Laurie: Invitation to national or international congresses

Advertising documents: Philips; Trainings, Teaching: Novartis, GSK, Astra Zeneca, Boeringher; Invitation to national or international congresses: Chiesi, Astra Zeneca, SOS oxygene, Novartis, Boeringher LAMOTH Frédéric: Consultancy, Expert: Gilead, MSD, Basilea; Invitation to national or international congresses: MSD

Expert: Norgine; Trainings, Teaching: Fujifilm, Boston Scientific LEBRETON Guillaume: No disclosure LEBRUN-VIGNES Benedicte: Research support/ Scientific studies: NOVARTIS; Consultancy, Expert: ANSM LEBUFFE Gilles: No disclosure LECLERC Maxime: No conflictof interest LÉCLUSE Aldéric: Research support/Scientific studies: PGRX AVC study; Consultancy, Expert: BMS-Pfizer, Boerhinger Ingelheim, Bayer; Invitation to national or international congresses: BMS-Pfizer, Boerhinger Ingelheim LEDOUX Didier: No disclosure LEFEBVRE Francois: No conflict of interest MACLOUGHLIN Ronan: Research support/Scientific studies: Aerogen Ltd

No conflict of interest MARI Arnaud: No conflict of interest MARIE Damien: No conflict of interest MARIJON Eloi: No disclosure MARIOTTE Eric: Consultancy, Expert: Sanofi-aventis MARJANOVIC Nicolas: No disclosure MARJANOVIC Zora: No disclosure MARONI Arielle: No conflict of interest MAROT Benoit: No conflict of interest MARQUE Sophie: No conflict of interest MARTI

Teaching: Zambon, Chiesi; Invitation to national or international congresses

No conflict of interest MATUSIK Elodie: No conflict of interest MAUCHIEN Benedicte: No conflict of interest MAURY Eric: Research support/Scientific studies: Doran International, Drager; Trainings, Teaching: Vygon MAXIME Virginie: No conflict of interest MAYAUX Julien: Invitation to national or international congresses

Stock shareholder: Tanderev; Patent or product inventor: Tanderev MERCAT Alain: Research support/Scientific studies: Fisher-Paykel, General Electric; Consultancy, Expert: Faron Pharmaceuticals

No disclosure MERHABENE Takoua: No conflict of interest MERLE Jean-claude: No disclosure MESOTTEN Dieter: No conflict of interest MESSAADI Amenallah: No conflict of interest MESSIKA Jonathan: Invitation to national or international congresses: CSLBehring; Fisher&Paykel METAXA Victoria: No disclosure METOGO MBENGONO Junette arlette: No conflict of interest MEUNIER Anne: No conflict of interest MEURICE Jean-claude: No disclosure MEYBECK Agnes: Consultancy, Expert: Janssen, Gilead; Invitation to national or international congresses

Teaching: MSD

No conflict of interest MORIMONT Philippe: No conflict of interest MORO-SIBILOT Denis: No disclosure MORTAMET Guillaume: No conflict of interest MOSBAH Nabil: No conflict of interest MOSCHIETTO Sebastien: No conflict of interest MOUCADEL Virginie: Research support/Scientific studies: bioMérieux MOULAIRE RIGOLLET Valérie: No disclosure MOULIADE Charlotte: No conflict of interest MOULIN Florence: No disclosure MOUNIR Yousfi: No conflict of interest MOURABIT Karima: No disclosure MOURVILLIER Bruno: Trainings, Teaching: MSD

Research support/Scientific studies: Aerogen; Advertising documents: Aerogen; Patent or product inventor: Aerogen MUSIARI Michele: No conflict of interest N'GUYEN Quang-thang: No conflict of interest N'GUYEN Tran: No disclosure NABIL Mosbah: No disclosure NACCACHE Lionel: No disclosure NAIMI Skander: No conflict of interest NAKAA Sabrine: No disclosure NALLET-AMATE Megan: No conflict of interest NATALIS Eloïse: No disclosure NAUDIN Jérôme: Invitation to national or international congresses: Novartis NAY Mai-Anh: No conflict of interest NEMLAGHI Safaa: No conflict of interest NEOFYTOS Dionysios: Research support/Scientific studies: MSD; Consultancy, Expert: MSD, Gilead, Pfizer; Invitation to national or international congresses: Gilead, Pfizer NESSELER Nicolas: No conflict of interest NEVIERE Remi: No disclosure NGUYEN Alexandre: No disclosure NGUYEN KHOA Thao: No conflict of interest NICOLAU-TRAVERS Marie-Laure: No disclosure NIÉRAT Marie cécile: No conflict of interest NIESZKOWSKA Ania: No disclosure NIGEON Olivier: No conflict of interest NITEL Gautier: No conflict of interest NODEA Elena Madalina: No conflict of interest NOEL Marine: No conflict of interest NOGIER Marie-béatrice: No disclosure NOORAH Zaid: No disclosure NOUIRA Wiem: No conflict of interest NOUMEIR Rita: Stock shareholder: Softmedical NOURY Norbert: No conflict of interest NOVY Emmanuel: Research support/Scientific studies: MSD; Invitation to national or international congresses: PFIZER

Expert: Air Liquide Medical System OLLIVIER Veronique: No conflict of interest ONIMUS Thierry: No conflict of interest OPPENHEIMER Anne: Invitation to national or international congresses: Gedeon Richter ORKISZ Maciej: No conflict of interest ORLIAGUET Gilles: Research support/Scientific studies

Research support/Scientific studies: OxyNov; Patent or product inventor: OxyNov PATRIER Juliette: No conflict of interest PAUGAM Catherine: No disclosure PAUL Marine: No conflict of interest PAUL-BELLON Rachel: No disclosure PAULO Nicolas: No conflict of interest PAVOT Arthur: Invitation to national or international congresses: Fresenius Medical Care France PEHLIVAN Jonathan: No conflict of interest PEIGNE Vincent: Invitation to national or international congresses: Air liquide PÉJU Edwige: No conflict of interest PENE Frédéric: Consultancy, Expert: Alexion PÉPIN-LEHALLEUR Adrien: Invitation to national or international congresses: Chiesi PERE Morgane: No conflict of interest PEREIRA Bruno: No disclosure PEREZ Didier: No disclosure PEREZ Pierre: No disclosure PEREZ Yonatan: No conflict of interest PERIER François: No disclosure PERIN Nicolas: No conflict of interest

Biomerieux ROBIN Emmanuel: No conflict of interest ROBIN Nicolas: No disclosure ROBINEAU Olivier: No disclosure ROCH Antoine: No disclosure ROCHE Anne: No conflict of interest ROGER Claire: Consultancy, Expert: PFIZER, FRE-SENIUS MEDICAL CARE; Invitation to national or international congresses: MSD,PFIZER ROLLE Amélie: No conflict of interest RONDEAU Eric: No disclosure RONZIÈRE Thomas: No disclosure ROQUILLY Antoine: No disclosure ROSSELLI Sylvène: No disclosure ROUBY Jean-Jacques: No disclosure ROUIS Sana: No conflict of interest ROULEAU Stéphane: No conflict of interest ROULET Sylvie: No disclosure ROULLAND Charlotte: No disclosure ROUMELIOTIS Nadia: No conflict of interest ROUSSE Natacha: No disclosure ROUSSEAU Anne-Françoise: Invitation to national or international congresses

No disclosure SAGNIER Anne: No disclosure SAILLARD Colombe: Trainings,Teaching: Amgen, Novartis; Invitation to national or international congresses

No conflict of interest SCHMIDT Aline: No disclosure SCHMIDT Matthieu: Consultancy

No disclosure SCHULTZ Marcus: No conflict of interest SCHWEBEL Carole: Invitation to national or international congresses: Pfizer SCICLUNA Brendon: No disclosure SCULIER Jean-Paul: No conflict of interest SEE Perrine: No conflict of interest SEGHBOYAN Jean-marie: No disclosure SEGUIN Amelie: No conflict of interest SEGUIN Philippe: Consultancy, Expert: LFB; Invitation to national or international congresses: Astellas SEJOURNE Caroline: No conflict of interest SELLAMI Walid: No conflict of interest SENDID Boualem: Research support/Scientific studies: AllFun project, FP7 European Commission; Invitation to national or international congresses: Pfizer SENHADJI Lahcen: No conflict of interest SERBOUTI Rita: Research support/Scientific studies: Fresenius Medical Care; Consultancy, Expert: Fresenius Medical Care; Trainings, Teaching: Fresenius Medical Care; Invitation to national or international congresses: Fresenius Medical Care SERFATY Lawrence: No disclosure SÉRIE Mathieu: No conflict of interest SHAW Geoffrey M.: No conflict of interest SHI Rui: No conflict of interest SHIMI Abdelkrim: No disclosure SHOJAEI Maryam: No disclosure SI-TAHAR Mustapha: Consultancy, Expert: Cynbiose Respiratory; Stock shareholder: Cynbiose respiratory SIAMI Shidasp: No conflict of interest SILVA Daniel: Research support/Scientific studies: Fresenius Medical Care France; Consultancy, Expert: Fresenius Medical Care France; Invitation to national or international congresses: Xenios Novalung, Heilbronn

No conflict of interest SIRAULT Bruno: No disclosure SIRODOT Michel: No disclosure SLAMA Michel: No disclosure SLIM Amine: No disclosure SMIELEWSKI Peter: No disclosure SOARES Marcio: Stock shareholder: Epimed Solutions

Teaching: Gilead; Invitation to national or international congresses: Pfizer SPAGNOLETTI Marco: No conflict of interest STECKELMACHER Claire: No disclosure STOCKX Luc: Research support/Scientific studies: Phenox, Medtronic; Consultancy

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 6 Farhat Hached Hospital, Sousse, Tunisia; 7 Yassminet Regional Hospital, Ben Arous, Tunisia; 8 Habib Bougatfa Regional Hospital, Bizerte, Tunisia; 9 Larabta Hospital, Tunis, Tunisia; 10 Carthagene Private Hospital, Tunis, Tunisia; 11 Regional Hospital Of Zaghouan, Zaghouan, Tunisia; 12 Regional Hospital Of Tozeur, Tozeur, Tunisia; 13 Habib Thameur Hospital, Tunis, Tunisia Correspondence: Samia Ayed (samia.ayed@yahoo.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-213

Geoffroy Hariri, Kyann Hodjat-Panah, Laurene Blum, Jean-Rémi Lavillegrand, Idriss Razach, Naike Bige, Jean-Luc Baudel, Bertrand Guidet, Eric Maury, Hafid Ait-Oufella Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Paris, France Correspondence: Geoffroy Hariri (geoffroyhariri@hotmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-158 Rationale: Hemolytic anemia (HA) is a common condition in intensive care unit but its diagnosis remains challenging. Free hemoglobin (and heme) degradation leads to CO release that can bind to hemoglobin to form carboxyhemoglobin (HbCO). We hypothesized that HbCO concentration could be used as a reliable diagnosis tool for HA. Patients and methods: We performed a monocentric retrospective study in a 18-bed intensive care unit at St Antoine Hospital, Paris, between 2012 and 2018. All patients hospitalized for HA with arterial HbCO dosage at admission were included. Arterial HbCO was measured in routine in our department with an IL system 1303 pH/ blood gas analyzer. Demographic and biological data were collected. A group control of patients with non-hemolytic anemia (Hb < 9 g/ dl) (NHA) was also included. Finally, we analyzed patients outcome according to HbCO changes during ICU stay. Results: Between 2012 and 2018, 98 patients with HA were included. 100 NHA patients were included in the control group. Patients with HA were younger than patients with NHA (47 [32; 63] vs. 69 [59; 78] years old, P = 0.001) but admission SOFA was not different between groups (6 [3; 7] , vs. 6 [4; 9] , P = NS). Among patients with HA, 55% had thrombotic microangiopathy, 25% had autoimmune hemolytic anemia and 20% had sickle cell disease. At ICU admission, HA patients had higher HbCO level than patients with NHA (3.31 [2.3; 3.9] vs. 1.34 [0.9; 1.7] %; p < 0.0001). HbCO was a reliable biomarker of hemolysis (AUC 0.92 (0.88; 0.96) p < 0.0001). An HbCO level threshold at 2.05% identify hemolysis with a sensitivity 87 (79-92) % and a specificity 88 (82-93) %. In HA group, HbCO was negatively correlated to Hb level (R = 0.41; p < 0.0001). In HA patients, changes of HbCO level during ICU management were associated with outcome, decreasing in survivors (2.7 [2; 3.4] vs. 3.1 [2.2; 4.2] ; p = 0.018) but not in non-survivors (2.8 [1.9; 3.3] vs. 2.6 [1.3; 3 .5] %; p = 0.57). Conclusion: Carboxyhemoglobin is a reliable diagnosis and prognosis biomarker for hemolytic anemia in ICU Compliance with ethics regulations: Yes. Rationale: Thrombocytopenia is the most commonly hemostatic disorder encountered in intensive care, present in 41 to 66% of patients. The mortality associated with this thrombocytopenia, the numerous pathological contexts associated with resuscitation and the lack of a recommended management strategy led to the establishment of these guidelines. The aim of our study was to determine the incidence, causes and risk factors associated with the occurrence of thrombocytopenia, as well as the impact of thrombocytopenia on the mortality and length of stay in the ICU Ibn Medical Resuscitation Unit. Rochd de Casablanca, over a period of 12 months. Patients and methods: This was a prospective study, carried out in the medical resuscitation department of Ibn Rochd University Hospital in Casablanca over a period of 12 months. There were two groups: ''sick'' group with thrombocytopenia with a platelets count < 150,000/ mm 3 , and a ''control'' group without thrombocytopenia. Patients with previous platelet disorders, hematologic malignancies, and patients undergoing chemotherapy were excluded.

Of the 317 patients included, 107 episodes of thrombocytopenia were identified, anoverall incidence of 33.75%. Sepsis was incriminated 65 times (60.7%), followed by ARDS in 12 patients (11.2%), massive filling in 10 patients (9.3%), disseminated intravascular coagulation in 9 patients (8.4%), and massive transfusion in 6 patients (5.6%). The drug origin was incriminated in 2 patients (1.8%). It was due to quinolones and imipenem. The mortality rate was 54 deaths (50.4%) which was inversely proportional to the lowest platelet count in the thrombocytopenia group, compared to 61 deaths (30%) in the control group. The mean duration of stay in the thrombocytopenia group was 11 ± 10 days with extremes ranging from 3 to 124 days. Conclusion: Thrombocytopenia was a common abnormality in the intensive care system, it occured in many pathological situations and was a factor of morbidity and excess mortality. The most common etiology in this study was sepsis. The diagnostic and therapeutic approach depended on the particular clinical context in which thrombocytopenia occurs. Its onset may constitute a hematological emergency, particularly when there is a major mucocutaneous and / or visceral hemorrhagic syndrome, which necessitates a rapid etiological diagnosis, and the establishment of an effective treatment, both symptomatic and specific. Compliance with ethics regulations: Not applicable.

Marc Pineton De Chambrun 1 , Romaric Larcher 2 , Frédéric Pene 3 , Laurent Argaud 4 , Alexandre Demoule 5 , Rémi Coudroy 6 , Elie Azoulay 7 , Yacine Tandjaoui-Lambiotte 8 , Stanislas Faguer 9 , Alain Combes 1 , Charles-Edouard Luyt 1 , Zahir Amoura 10 1 Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, Paris, Paris, France; 2 Rationale: Catastrophic antiphospholipid syndrome (CAPS), the most severe manifestation of antiphospholipid syndrome (APS), is characterised by simultaneous thromboses in multiple organs. Diagnosing CAPS can be challenging but its early recognition and management is crucial for a favourable outcome. This study was undertaken to evaluate the frequencies, distributions and ability to predict mortality of "definite/probable" or "no-CAPS" categories of thrombotic APS patients requiring admission to the intensive care unit (ICU Rationale: Septic acute kidney injury (S-AKI) is a frequent complication in critically ill patients and is associated with high morbidity and mortality. It is well known that chronic kidney disease increases the risk of pulmonary embolism (PE), but few studies have investigated the relationship between acute kidney injury (AKI) and PE occurrence in septic patients. The aim of this study is to determine whether patients with AKI are at increased risk of developing PE. Patients and methods: Were included, in a prospective study conducted over 6 months (January 01-June 30, 2018) in a medical surgical intensive care unit, all the patients older than 18 years with septic shock at admission or during hospitalization. Two groups were compared: patients with kidney injury (AKI+ group) and patients without kidney injury (AKI− group). We studied the occurrence of PE in these two groups. Results: We included 75 patients. The mean (SD) age was 56.43( ± 18) years. Sex ratio was 1.91. Thirty one (41.3%) patients developed PE. The occurrence of PE was significantly higher in (AKI + group) [27 patients (51%) vs. 4 patients (17%); p = 0.006]. The incidence of PE according to kidney injury severity was 2 patients (10%) KDIGO I, 5 patients (50%) KDIGO II, 20 patients (86%) KDIGO III. In the AKI+ group, PE was significantly associated with increased SOFA score at admission (10 points vs. 6 points; p = 0.02), lower platelets count (95,000 vs. 145,000; p = 0.032), higher lacatatemia at septic shock day [6.20 vs. 4 .9 mmol/l; p = 0.003] and higher C reactive protein level [223 mg/l vs. 150 mg/l; p = 0.005]. In a multivariate analysis the PE risk factors in (AKI+ group) were thrombopenia (Odds Ratio = 1.01; CI [1.01-1.02], p = 0.01) and C-reactive protein value (Odds Ratio = 1.016; CI[1.005-1.027], p = 0.001). Discussion: The increased risk for PE with AKI may be due to endothelial involvement, vascular injury and the related changes found in procoagulant proteins (increased levels of fibrinogen, factor VII, factor VIII, von Willebrand factor, and plasminogen activator inhibitor-1). In our study, lower platelet and higher C reactive protein level were found in patients with PE, suggesting the participation of disseminated intravascular coagulation. These factors may contribute to increase PE risk. Conclusion: The risk of PE is higher in septic patients with AKI than in those with normal kidney function. Therefore, because of paucity of evidence, larger studies are needed to understand PE pathway in septic AKI and to establish efficient prophylaxis protocols. Compliance with ethics regulations: Yes. and 33 of these patients (33.3%) required intensive care. The lasted were 16 males (48%) and a majority (72%) were younger than 65 years of age. In intensive care patients, only 6 (18.8%) had nosocomial infection, majority were community acquired infections (81.2%) with 16 (48%) pneumoniae, 4 (12.5%) profound abscess, 2 pyelonephritis (6.2%), 1 (3%) meningitidis. 27 patients(87%) required mechanical ventilation for 8 days (95% CI 4-12), length of stay in ICU was 15 days (95% CI 7-22) and mortality rate was 55%. Conclusion: HmKP infections lead young patients in intensive care unit in one third of case with a majority of pneumoniae requiring mechanical ventilation and with a high rate of mortality. Furthers studies are needed to investigate the role of this particular strain in severity. Compliance with ethics regulations: Yes. Rationale: Infections secondary to snakebite occur in a number of patients, and are potentially life-threatening. Bothrops lanceolatus bites in Martinique average thirty cases per year and may result in severe thrombotic and infectious complications. We aimed to investigate the infectious complications related to Bothrops lanceolatus bite. Patients and methods: A retrospective single-center observational study over seven years (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) was carried out, including all patients admitted to the hospital due to Bothrops lanceolatus bite. Clinical and biological data were reported using the Dx Care, x-plore et cyberlab softwares of the Emergency Medicine and analyzed.

One hundred and seventy snake-bitten patients (121 males and 49 females) were included. Thirty-nine patients (23%) presented grade 3 or 4 envenoming. Twenty patients (12%) developed wound infections. The isolated bacteria were Aeromonas hydrophila (3 cases), Morganella morganii (2 cases), group A Streptococuss, and group B Streptococcus (one case each). Patients were treated empirically with third-generation cephalosporin (or amoxicillin/clavulanate), aminoglycoside and metronidazole combinations. Outcome was favorable. The main factor significantly associated with the occurrence of infection following snakebite was the severity of envenoming (P < 0.05). Our findings clearly point towards the frequent onset of infectious complications in B. lanceolatusbitten patients presenting with grade 3 and 4 envenoming. Conclusion: Infectious bite-related complications of Bothrops lanceolatus account for approximately 10% of the cases, with a strong predominance for grade III and IV. Thus, based on the bacteria identified in the wounds; we suggest that empiric antibiotic therapy including third-generation cephalosporin should be administered to those patients on hospital admission. Compliance with ethics regulations: Yes. Rationale: Endocrine abnormalities have been reported with varying frequencies, following traumatic brain injury (TBI). Few studies have examined the clinical features and outcomes of isolated acute thyrotropic hormone deficiencies after TBI. Theaim of the study was to evaluate the early changes in thyrotropic hormone levels after traumatic brain injury (TBI) and to evaluate whether hormone changes are related to outcome Patients and methods: We conducted a 12 months long prospective cohort, including all patients admitted to a university hospital ICU with moderate to severe traumatic brain injury (TBI), defined as a Glasgow coma scale below twelve (GCS < 12). Blood samples for basal hormone values of thyroid-stimulating hormone (TSH) and free thyroxine (fT4) were obtained on days 1, 3, 7 and 10. TSH serum concentrations were considered normal at > 0.27 Mu/L; fT4 at > 12 pmol/L. A thyrotropic insufficiency was defined as low fT4 and low TSH plasma levels. All patients were screened with a brain MRI. Patients were also monitored for neurological deterioration, including cognitive decline, convulsive seizures, increase in cerebral edema and brain herniation that were simultaneous to the diagnosis. Results: During our study period's, 465 trauma patients were admitted to our ICU and 134 met the inclusion criteria. On admission, our patients had a mean age at 36.8 ± 19, a mean injury severity score (ISS) at 35 ± 11, a mean Abbreviated Injury Severity (AIS) of the Head at 4.5 ± 0.7 and a mean GCS at 7 ± 3. Of the 134 patients a thyrotropic insufficiency was diagnosed in 26 patients (20%) during the first 10 days. The median delay to thyrotropic insufficiency diagnosis was 3 days. In three of 26 (11%), the thyrotropic insufficiency was nonrecovering during the patient's ICU stay and was transient for the rest. None of the patients with acute thyrotropic insufficiency had direct hypothalamic or pituitary lesions on the brain MRI. Factors associated to the occurrence of acute thyrotropic insufficiency were: the AIS of the head (4.8 ± 0.4 vs. 4 ± 0.7, p = 0.001), cerebral contusions (95% vs. 65%, p = 0.008), subarachnoid haemorrhage (85% vs. 60%, p = 0.037) and subdural haematoma (57% vs. 30%, p = 0.012). Thyrotropic insufficiency was associated to neurological deterioration (p = 0.001) on the day of diagnosis but did not affect ICU mortality (12% vs. 11%, p = 0.6).

In this study, low pituitary-thyrotropic axis hormone levels were found in the acute phase of TBI and were associated to neurological deterioration but with no perceived effect on ICU mortality. Compliance with ethics regulations: Yes. Rationale: Acute diabetes insipidus following head injury and its effect on patients outcome have not been sufficiently evaluated in large prospective studies. The aim of this study was to determine the incidence of acute CDI, delay of onset predictive factors and its impact on TBI patients.

We conducted a prospective cohort, including all patients admitted to ICU with moderate to severe TBI, defined as a Glasgow coma scale (GCS) below twelve. For each TBI patient plasma sodium was measured daily, and if abnormally high, urine specific gravity and osmolality were measured. CDI was diagnosed using the Seckl and Dunger criteria. Acute CDI was defined as CDI diagnosed in the first week following injury. All patients were screened with a brain MRI. Results: During our study's period, 451 trauma patients were admitted to our ICU, 158 presented with moderate to severe TBI and were included. On admission, our patients had a mean age at 36.8 ± 19, a mean injury severity score (ISS) at 35 ± 11, a mean Abbreviated Injury Severity (AIS) of the Head at 4.5 ± 0.7 and a mean GCS at 7 ± 3. Twenty-three percents (37 patients) of the patients developed hypernatremia and 15% (24 patients) were diagnosed with acute CDI. In 16 of 24 (66%), the CDI was nonrecovering. The median delay to develop transient CDI was 28 h and for non-recoviring CDI was 68 h (p = 0.045). None of the patients with acute CDI had direct hypothalamic or pituitary lesions. Factors associated to the occurrence of acute CDI were: younger age (29 ± 19 vs 38 ± 19, p = 0.039), neuro-surgery (22% vs. 9%, p < 0.001), hemorrhagic shock (24% vs. 7%), p < 0.001), cerebral edema (25% vs. 10%), p < 0.019), and fractures to the base of the skull (20% vs. 8%, p = 0.022). Patients who developed CDI had a significantly higher mortality than those who did not (15 of 24 (62%) vs. 17 of 134 (12%), p < 0.001). There were no difference in terms of mortality between non-recovering and transient CDI (68% vs. 50%, p = 0.1), similarly the onset of CDI did not affect mortality (32 h vs. 35 h, p = 0.5). Patients with acute CDI had poor Glasgow Outcome Scale (2 ± 1.5 vs. 3.4 ± 1.3, p < 0.001) and longer ICU LOS (23 ± 14 vs. 12 ± 11, p = 0.001). Conclusion: Acute CDI is associated with higher mortality and poor outcome. Therefore it is essential to diagnose and treat it promptly and correctly. Compliance with ethics regulations: Yes.

Acute glucocorticoid deficiency following traumatic brain injury Mariem Dlela, Rania Ammar Zayani, Abir Bouattour, Najeh Baccouche, Mounir Bouaziz Habib bourguiba hospital, Sfax, Tunisia Correspondence: Mariem Dlela (mariem241090@gmail.com) Ann. Intensive Care 2020, 10(Suppl 1):P-203Rationale: Published data demonstrates that long-term hypopituitarism could be common after traumatic brain injury (TBI).However, few studies focused on radiological, clinical, and repetitive endocrine assessment in the acute phase. The aim of the study was to evaluate the early changes in the adrenal axis following (TBI) and to evaluate whether hormone changes affect patient's outcome.

We conducted a prospective study, including all patients admitted to a university hospital ICU with moderate to severe traumatic brain injury (TBI), defined as a Glasgow coma scale below twelve (GCS < 12). Each patient underwent sequential measurement of plasma cortisol (PC) on days 1, 3, 7 and 10 after TBI. We defined adrenal insufficiency as PC less than 100 ng/mL. Patients who received glucocorticosteroid therapy were excluded. Outcome was measured by incidence of death, and Glasgow outcome scale (GOS) on day thirty.

Souhila Sadat, Dalila Zeghdoud, Dalila Bougdal, Kamel Guenane EHS salim zemirli, Alger, Algeria Correspondence: Souhila Sadat (sadatsouhila@hotmail.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-205Rationale: The renewed interest in the pathophysiology of severe traumatic brain injury (TCG), allowed the understanding of the pathophysiological mechanisms leading to neuronal death.The non-invasive, easy, patient-based technical DTC allows evaluation of cerebral blood flow. Purpose of the study: to determine the contribution of transcranial doppler (DTP) in the prevention of post-traumatic ischemia. Patients and methods: A monocentric, observational, prospective study over a period of 2 years, including 100 TCG in the monitoring of cerebral blood flow (DSC) was provided by the DTC. We collected the following data: age, gender, lesion mechanism, lesion association, GLASGOW score at admission, time to perform the initial scan, time to perform the initial Doppler, various abnormalities found at the initial DTP, the analysis of the level of MAP according to each situation of cerebral blood flow, the proposed therapies, the time to obtain a correct DTC. (59%), the statistical analysis showed no difference between the delay in setting up a hypohemia and the presence of a correct cerebral blood flow (P = 1.000), the statistical analysis of the MAP in the DTC group hypohemia compared to the correct DTC group objectified the absence Significant difference between the two groups. The realization of DTP allowed therapeutic prioritization, the introduction of norepinephrine was in 100% of cases, osmotherapy in 100% of cases, optimization of sedation in 29.34% of cases, the introduction of penthotal in 13.54% of cases and the completion of decompressive in 8.82% of cases. Statistical analysis of mortality showed a significant difference in mortality (P = 0.07) in the hypohemic DTC group compared with the correct doppler . Conclusion: TTC is an essential monitoring tool of cerebral hemodynamics, which may in prove the neurologic outiome of TCG. Compliance with ethics regulations: Yes. Rationale: Hyponatremia is a frequent electrolyte disturbance in hospitalized patients. It is particularly common in brain-injured patients with significantly elevated morbidity and mortality. The aim was to study the prevalence of hyponatremia in the acute phase of post-traumatic cerebral aggression, its degree of severity, its predictive factors as well as its prognostic impact in the population of post-traumatic brain injury. Patients and methods: This is a retrospective study, carried out over a period of 4 years about all traumatized head patients who developed hyponatremia during the first 36 h of their stay. The descriptive part treated all patients who developed hyponatremia by detailing its different stages of severity.The analytical part treated the patients who developed a hypo-osmolar hyponatremia with a threshold of 130 mmol/L retained to define the severity.

During the study period, the incidence of hyponatremia in head trauma patients was 30.8%. The occurrence of hyponatremia was associated only with the occurrence of early seizures (p = 0.006).Severe hyponatraemia was associated with paroxysmal occurrence (p = 0.002), mass effect (p = 0.01), and hemostasis disorders. The multivariate study revealed that severe hyponatremia was associated with the Glasgow score (p < 0.001) and pupillary changes (p = 0.048). On the other hand, it is the initial variation in serum sodium that was associated with both the severity of the initial neurological examination; Glasgow (p < 0.001), SAPS2 (p = 0.001), PTS (p = 0.049) and PRISM scores (p = 0.007), haemodynamic instability (p = 0.07) and neurovegetative disorders (p = 0.04). Lesional features have also been found.Regarding the prognosis, the occurrence of initial hyponatremia had a protective effect: a more favorable GOS score p = 0.051 and a lower mortality (p = 0.045). A poor neurologic prognosis as well as a high mortality were associated with the most severe hyponatraemia and particularly with the initial variation of the sodium level (p = 0.002;). The mortality was 24.9%. It was also particularly related to the initial change in sodium levels (p < 0.001, 0.002).

We concluded that there is no association between post traumatic early hyponatremia and the severity of the initial clinical presentation. However, the depth of hyponatremia and especially the initial change in sodium levels have been associated with more severe clinical pictures and a more limited prognosis. Compliance with ethics regulations: Yes. Rationale: Post-traumatic epilepsy (PTE) is one of the complications described in the aftermath of headtrauma. Its incidence is variable in the literature because of its clinical polymorphism. Objectives of the study was to analyze the epidemiological profile (clinico-biological, radiological, therapeutic and evolutionary) of the patients having presented PTE and to determine the risk factors for this pathology by comparing them with the rest of the traumatized brain patients. Patients and methods: Our study was retrospective. It was conducted in the intensive care unit (ICU) of our University Hospital between 2009 and 2012. Were included in our study all patients admitted to the service with brain injury and a glycaemia above 8 mmol/L during the first 24 h post-trauma. Results: The incidence of PTE was 4.6%. (32 among 694) The average age was 29.5 ± 17.1 years. The sex ratio was 5.4. The average of GCS was 7.6 ± 3.6. Three (9.4%) patients had initial motor impairment. Seizures were observed in 3 (9.3%) patients during the first 24 h of hospitalization. The mean delay of occurrence of PTE was 17 ± 17.7 months. PTE was diagnosed before the end of the first post-traumatic year in 13 patients (54% of cases). The most commonly observed brain lesions were cortical brain contusions ( Rationale: Electrolytic disorders are common in neuro-resuscitation, especially dysnatremias and dyskalemias. Hyponatremias are the most frequent, including the 2 main etiologies: the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and the "cerebral salt wasting" syndrome (CSW). Diabetes insipude of central origin secondary to a lack of DHA secretion is the second most common disorder. Patients and methods: It is a prospective study, analysing all the brains injured admitted to the A1 intensive care unit of CHU HASSAN in Fez, Morocco. Study spread over a 5-month period from 01/08/2018 to 31/12/2018. The objective of the study is to detect the most frequent hydro-electrolytic disorders and to evaluate the therapeutic effectiveness of the service protocols. Results: All these brains injured have caused HE disorders over a period of time varying between D2 and D5: *18 cases of hyponatremia (30%)/12 cases of hypernatremia (19%), *19 cases of hypokaliemia (32%)/ 11 cases of hyperkaliemia (18%), *25 cases of hyperchloremia, or 41%/ 5 cases of hypochloremia (8%). *6 cases of diabetes insipidus, or 9.8%. *7 cases without HE disorder (11.4%). The treatment for these disorders was: *for hypoNa; it reached 118 mmol/L, initially corrected by a 24-hour water restriction, followed by an increase in the Basic Ration and furosemide boluses according to the ECV, even sodium loads for a single case of salt loss syndrome, while the main etiology remains the SIADH. *for HyperNa, it has reached 178 mmol/L, evaluated by the extracellular volume, corrected by enteral tap water after calculation of the hydric deficit. If HperNa is associated with polyuria greater than 2 cc/Kg/H; we speak of: *insipude diabetes, with polyuria up to 5 cc/Kg/H, compensated with potassium-containing solutions and blood ionogram monitored every 6 h. Desmopressin was used in titration, by bolus of 0.5 µg, with a diuresis objective between 1 and 1.5 ml/kg/h. *for hypokalemia, up to 2.2 g/dl, observed mainly in the acute phase of brain aggression, corrected by increase in BR for a K between 2.5 and 3 g/l, and by potassium loads if K below 2.5 g/L. The evolution: 5 deaths or 8.2% (2 cases of uncorrected diabetes insipidus), the restriction of disorders were corrected. Conclusion: A knowledge of the hydroelectrolytic disorders encountered in this context is essential, as well as the implementation of a diagnostic and therapeutic protocol, which will reduce the time required to correct these disorders. Compliance with ethics regulations: Yes. .0] U/h). However, workload was increased under STAR (12 vs. 7 measurements per day), as expected from measurement interval difference between STAR (3-hourly) and the SP (4-hourly). Conclusion: This unique patient-specific risk-based dosing approach GC framework was successful in controlling all patients safely and effectively. These preliminary results are encouraging and show GC can be achieved safely and effectively at lower target bands. In turns, these improved GC outcomes could improve patient outcomes. Compliance with ethics regulations: Yes. Rationale: Although its incidence has declined in recent years, gastric cancer remains common worldwide and is the leading cause of gastrectomy. His treatment is mainly surgical, but his prognosis remains poor. Many studies on survival and prognostic factors have been carried out in foreign series. Patients and methods: This is a retrospective study covering a period of three years from January 2014 to December 2016 interesting patients who had a gastrectomy and hospitalized in emergency resuscitation department surgical UHC Ibnou Rochd from Casablanca. The statistical analysis of the different clinical, paraclinical and therapeutic data was carried out thanks to an exploitation sheet. Rationale: Gram-negative bloodstream infections (GNBSI) require timely appropriate antimicrobial therapy in intensive care units (ICU) patients. Conventional techniques usually take 24-72 h for antimicrobial susceptibility testing (AST). Innovative approaches (Accelerate Pheno ™ system) provide pathogen identification in ~2 h and AST including Minimal Inhibitory Concentrations (MICs) in ~7 h. We report, in ICU patients with GNBSI, results of implementation of the Accelerate Pheno ™ in our laboratory.

We prospectively screened all GNBSI episodes reported in adult ICU patients between September 2018 and September 2019. To allow integration into the laboratory workflow, the Accelerate Pheno ™ was run on blood bottles positive before 10 am (Day 0), in parallel with routine procedures: MALDI-TOF identification after short incubation on solid media (Day 0), β LACTA (Bio-Rad ® ) test (Day 0) and disk diffusion method for AST (Day+1). For each episode, antimicrobial regimen was reassessed by a multidisciplinary team of bacteriologists, infectious diseases and ICU physicians by the end of Day 0. We measured: (i) Concordance of Accelerate Pheno ™ results with conventional techniques, (ii) Number of antibiotic adaptations on Day 0 and (iii) Number of patients within the therapeutic range (free fraction over 4 x MIC and below concentration at risk of adverse events), based on real-time measurement of beta-lactams concentrations. Results: Of 67 patients reported with GNBSI over the study period, 26 were included. Mean age was of 60 ± 16.5 years, 15/26 were males. Main sources of GNBSI were pulmonary (n = 8) and digestive (n = 7). Bacterial identification of the Accelerate Pheno ™ was concordant with standard techniques in 22 (85%): Enterobacteriacae (n = 18), Pseudomonas aeruginosa (n = 4). Overall categorical agreement for AST was of 96% (15 errors including 6 very major errors). By the end of Day 0, the antibiotic regimen was de-escalated in 7 (27%) patients, which was appropriate in 6 (23%). In 2 cases, de-escalation was possible, but not fulfilled by ICU physicians. Twenty patients had beta-lactams concentrations measurements: 12 were in the therapeutic range, 2 below and 6 over. Conclusion: Accelerate Pheno ™ provided rapid and accurate results for most microorganisms isolated in blood cultures of ICU patients with GNBSI. However, in a laboratory with routine MALDI-TOF early identification and β LACTA test performed on Day 0, the impact on early adaptation of the antibiotic regimen was evident in around 1 patient over 4. Compliance with ethics regulations: Not applicable.

Jean-Luc Baudel 1 , Jacques Tankovic 1 , Redouane Dahoumane 1 , Jean-Remy Lavillegrand 2 , Razach Abdallah 2 , Geoffroy Hariri 2 , Naike Bige 2 , Hafid Ait-Oufella 2 , Nicolas Veziris 1 , Eric Maury 2 , Bertrand Guidet 2 1 Service Bactériologie, Hôpital Saint-Antoine, Paris, France; 2 Service Réanimation Médicale, Hôpital Saint-Antoine, Paris, France Correspondence: Jean-Luc Baudel (jean-luc.baudel@aphp.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-226 Rationale: Evaluation of the accurateness of the Accelerate PhenoTest BC Kit for rapid analysis (1.5 h for microorganism identification and 5 additional hours for antibiotic susceptibility testing) of positive blood cultures from ICU and hematology patients. Patients and methods: From February to August 2019, we included patients from the ICU and hematology units with positive blood cultures. The following informations were collected : gender, age, duration of prior antibiotherapy, source of the infection, results obtained by conventional microbiological methods and by PhenoTest (data obtained and time to obtention of results). Informed consent was obtained from all patients. Results: 33 blood cultures were analyzed in 31 patients (m/f ratio 1.07, age 59.3±, 16 from the ICU and 15 from hematology). 57% of the patients were receiving antibiotics at the time of blood culture collection (mean duration : 7.9 days). The source of infection was unknown in 59% of cases, urinary in 21%, catheter-related in 10%, ascites in 6%, pneumonia in 4%. In 17 cases (51%), there was a perfect match between PhenoTest and conventional results (identification and antibiotic susceptibility testing). In 5 cases (15%), the bacterium responsible was not present in the PhenoTest panel. In 3 cases (9%), PhenoTest identification was correct, but some discrepancies were observed regarding antibiogram. In 4 cases (12%) PhenoTest identification was again correct but no antibiogram was available. In 2 cases (6%), where two bacteria were present, PhenoTest could not identify one of them. In 2 cases, PhenoTest did not provide bacterial identification because too few bacteria were present in the blood culture bottle. Conclusion: The PhenoTest panel covered 85% of the bacteria implicated in this study. When the bacterium responsible was present in the panel, the results given by the PhenoTest correlated in 70% of cases with those of conventional methods. Some rare discrepancies were observed regarding antibiotic susceptibility testing that have to be analyzed further. In the remaining 30% of cases, where too few bacteria or two different bacteria were present in the blood culture bottle, technical limitations did not permit to correctly identify microorganism(s) present or to obtain an antibiogram. Compliance with ethics regulations: Yes.

Mélanie Fromentin, Antoine Bridier-Nahmias, Constance Vuillard, Jean-Damien Ricard, Damien Roux INSERM UMR 1137 IAME Infection Antimicrobials Modelling Evolution, Paris, France Correspondence: Mélanie Fromentin (mel.fromentin@wanadoo.fr) Ann. Intensive Care 2020, 10(Suppl 1):P-227 Rationale: Studying human lower respiratory tract microbiota by using NGS (new generation sequencing) method is complex because of many unexpected biases due to DNA extraction and amplification procedures. Lung microbiota evolution under mechanical ventilation evolution may be highly informative to evaluate the actual risk of VAP (ventilator-associated pneumonia) development. Before starting a large study on the lung microbiome of ventilated ICU patients, a methodological study was mandatory. Patients and methods: Five control and three VAP patients were selected. Endotrachealaspirate (ETA) and oropharyngeal swab (OS) were collected at ICU admission for control patients and, 6 days before and on the day of VAP diagnosis for VAP patients. After automated extraction of total DNA, hypervariable region V4 of the 16S rDNA genes was amplified with two different pairs of primers 515F-806R: oligonucleotides from the Earth microbiome project (earth primer pair) and from the Gut microbiome project (gut primer pair), followed by sequencing on Illumina MiSeq plateform. After bioinformatics analysis with Mothur ® software, we compared the performance of NGS alongsideconventional bacterial culture. Differences in alpha diversity (microbial diversity in a sample), expressed as the Shannon index, across respiratory tract site (upper or lower) and across time (before and at VAP time) has been investigated. A positive control (PC), Rationale: Colistin is used as a last-line treatment to combat multidrug-resistant (MDR) Gram-negative bacilli (GNB). Worryingly, colistin resistance in Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii is increasingly reported worldwide. We hereby report the prevalence of colistin resistance among GNB isolated from burn patients in Tunisia.

The study was carried out on 225 strains of GNB isolated from microbiological samples of burn patients hospitalized in the intensive care unit between October 2017 and December 2018. Identification was performed by conventional methods. Antimicrobial susceptibility was tested by disk diffusion method and the results were interpreted according to CA-SFM guidelines. Minimum inhibitory concentration (MIC) of colistin was determined using the EUCAST broth micro-dilution method (UMIC, Biocentric ® ) Results: Pseudomonas aeruginosa was the most frequently isolated bacteria (111 strains), followed by Acinetobacter baumannii (99 strains) and Klebsiella pneumoniae (15 strains). The most common sites of isolation were blood cultures (45%), catheters (22%) and skin samples (21%). Most of P. aeruginosa isolates were multidrug-resistant with high levels of resistance to imipenem (71.7%), ceftazidime (63%) and ciprofloxacin (74.5%). However, all of them were susceptible to colistin. In fact, MICs of colistin against all P.aeruginosa isolates were less than or equal to 0.5 mg/L. A. baumannii strains had high resistance rates to beta-lactams : 100% to ceftazidime and 94% to imipenem. Only one strain was resistant to colistin with a MIC equal to 32 mg/L. All K. pneumoniae isolates were resistant to extended-spectrum cephalosporins. One third of these strains were resistant to imipenem and more than half (58.3%) were resistant to amikacin. Two strains were resistant to colistin with high MICs (> 64 mg/L). Both were carbapenemase-producers, carrying OXA-48 and NDM carbapenemase encoding genes. Conclusion: These data suggest that colistin-resistant or pan-drug resistant GNB clinical isolates are still relatively rare. However, they have important global public health implications because of the therapeutic problems they present, especially for vulnerable populations such as severely burned patients. Hence the need to test colistin regularly in the laboratory and to set up a monitoring program for MDR pathogens. Compliance with ethics regulations: Yes. Rationale: Descending necrotizing mediastinitis (DNM) are medicosurgical emergencies whose forecast is closely related to the precocity of the therapeutic assumption. The purpose of our work is to profile these patients as well as the therapeutic and evolutionary aspects. Patients and methods: Retrospective study over 5 years in the intensive care unit of the hospital 20 August. All patients with DNM on cervicofacial cellulitis were included.

Results: 12 cases were collected, 17% of cellulitis, incidence of 2.4 patients / year. Average age 39, sex ratio of 1.4. Smoking, chronic alcoholism and diabetes are the most common antecedents. The favoring factors were: (poor dental conditions: 100% of cases, non steroidien anti-inflammatory drugs: 33%, diabetes: 25%). In 67% of cases the front door was dental. Average time taken to take care of 10 days. C-reactive protein and procalcitonin were positive in all patients. In 33% the chest x-ray was normal. All patients received tri-antibiotic therapy. Intubation were difficult in all patients, we used nasofibroscope in 25% of cases and a rescue tracheotomy in one patient. Only one patient had a cervico-thoracic surgical approach; for all the others she was cervical alone. Streptococcus was the most isolated germ. The complications were (septic shock: 33%, ARDS: 8%). The average hospital stay was 7 days with a mortality rate of 42%. Conclusion: DNMs are poorly prognostic. The best treatment remains prevention by better management of dental abscesses and tonsillar phlegmons. Rationale: The initial, empirical antibiotic therapy of ventilator-associated pneumonia (VAP) is often based on timing of its occurrence in relation to the onset of mechanical ventilation. This is due to reported differences between causal pathogens associated with early-onset (E-VAP < 5-7 days of mechanical ventilation) compared to late-onset VAP (L-VAP ≥ 5-7 days of MV). E-VAP is most often reported to be due to antibiotic-sensitive pathogens while L-VAP is frequently attributed to antibiotic-resistant pathogens. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. The aim of our study was to compare the clinical outcomes of critically ill patients developing E-VAP and L-VAP and to compare the causative pathogens of the two groups. Patients and methods: All the patients with the diagnosis of VAP admitted between January 2014 and December 2018 were retrospectively included. VAP was suspected on the basis of clinical and chest x-ray findings. The identification of the causative organisms was performed with endotracheal aspirate (ETA) cultures. Results: Ninety patients developed VAP. E-VAP was observed in 30 patients (33,3%), whereas 60 patients (66,6%) developed L-VAP. Among patients with early-onset VAP, 53% received antibiotics prior to the development of pneumonia, compared to 88% with late-onset VAP (p = 0.001). Otherwise, no differences (sociodemographic factors, antecedents, severity score, length of stay, length of MV) between the two groups were observed. The most common pathogens associated with E-VAP were Enterobacter species (26.6%), Pseudomonas aeruginosa (23.3%) and oxacillin-resistant Staphylococcus aureus (ORSA 13,3%). Enterobacter species (36.6%), Acinetobacter baumannii (26.6%) and Pseudomonas aeruginosa (25%) were the most common pathogens associated with L-VAP. No difference was noted in the contribution of multidrug resistant bacteria MDR (50% vs. 70%). Hospital mortality was significantly greater for patients with L-VAP caused by MDR (73%) compared to patients with E-VAP (50%) (p = 0.04). Conclusion: This classification is no longer helpful for empirical antibiotic therapy, since both early-onset and late-onset VAP were caused by MDR bacteria. This justifies the need of intensive care unit-specific knowledge of causal agents associated with VAP to reduce the rate of administration of inadequate antimicrobial therapy. Compliance with ethicsregulations: Yes.