Poster Sessions – Airway management – 91-104

S28 15th Annual Congress – Barcelona, Spain – 29 September–2 October 2002

93 CLOSED ENDOTRACHEAL SUCTIONING PRODUCES INTRINSIC PEEP IN AN

ANIMAL MODEL

Almgren B.1, Wickerts C.1, Högman M.2 1Dept. of Anesthesia and Intensive Care, Danderyd hospital, Danderyd, 2Dept of Medical Cell Biology, Section of Integrative Physiology, Uppsala, Sweden INTRODUCTION. Closed Suctioning System (CSS) has been shown to prevent lung collapse during Volume Control Ventilation (VCV). One in vitro study showed that intrinsic PEEP could be induced during CSS in a lung model. A recent report showed less effective suctioning when CPAP 10 cmH2O was applied. These findings led us to investigate the tracheal pressures during insertion of CSS in healthy pigs. METHODS. Pigs (n=5) were studied during VCV and the VT was 14 ml/kg, PEEP 3 cmH2O and Inspiratory time 33%. Respiratory rate was set to 10,15, 20 or 25 in random order. The pigs were anaesthetised with Ketamin and Fentanyl in a continues-infusion. An ET-tube 6.0 mmID and CSS catheters no.12 Fr (Trach Care, Ballard Medical Products, USA) was used. Pressure was measured in the trachea with a Pressure-wire systemTM (Radi Medical System, Uppsala, Sweden). The pressure wire was position at the end, but outside, the ET-tub. RESULTS. During insertion of the CSS in the ET-tube, the pressure increased after 5 s and continued increasing after 10 s. There was a significant difference (repeated measurement ANOVA) between all different respiratory rates (p<0.001). There was a positive correlation between the respiratory rate and the intrinsic PEEP (r=0.78, p<0.001).

5 s 10 s Respiratory Rate 10

1.3 ± 0.4 2.6 ± 0.7

15 3.1 ± 0.8 6.3 ± 1.5 20 4.4 ± 1.1 8.7 ± 2.1 25 5.3 ± 0.8 10.2 ± 1.8 Delta Pressure cmH2O after 5 and 10 s with different Respiratory Rates

CONCLUSION. Pressure can be built up in the lung during insertion of the suctioning catheter with CSS and this confirms the results from previous study done in vitro. The increasing pressure is not possible to monitor in the ventilator since the suction catheter blocks the ET-tube. Whether the pressure increase is dangerous for the patient still needs to be investigated. It is also unclear what pressure levels can be produced if the PEEP level is set higher. Another question is what happens with secrete when the pressure increases. Probably secrete is pushed away from the ET tube and therefore diffICUlt to reach with the suction catheter.

94 EFFECTS ON GAS EXCHANGE AND EFFICACY OF CLOSED SYSTEM

SUCTIONING DURING CPAP MODE

Lindgren S.1, Olegård C.1, Stenqvist O.1 1Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Göteborg, Sweden INTRODUCTION. Closed system suctioning (CSS) is used to remove secretions without interrupting ventilation. Studies have shown that CSS has little side effects (1), but the efficacy during VC and PC has been questioned. This study evaluates the ventilatory and circulatory changes and efficacy during CSS with CPAP mode compared to open system suctioning. METHODS. Six pigs were anaesthetised and intubated with endotracheal tube (ETT) no 7 supplied with a tracheal pressure catheter and connected to a Servo 900C ventilator. Lung volume, gas exchange and hemodynamics were measured using side-stream spirometry, pulseoximetry and pulmonary artery catheter. Broncho-alveolar lavage with 10±3 L saline produced surfactant depletion. Effects during CSS at CPAP 0 and 10 cmH2O were studied and compared to open suctioning. Duration of suction was 10 sec, using a 12 Fr catheter at a vacuum level of -20 kPa. Measurements were registered at baseline, 1 and 5 min (Table 1). In a bench test, suctioning efficacy was evaluated by weighing the suctioning system before and after suctioning an artificial trachea of a lung model, where 15 ml of soap gel was applied (Table 2). RESULTS. See tables 1 and 2.

Open system

baseline

Open system 1

min

CSS/CPAP 0 baseline

CSS/CPAP 0 1 min

CSS/CPAP 10 baseline

CSS/CPAP 10 1 min

SvO2 % 63±6 49±9* 56±8 42±8* 63±8 58±10* SpO2 % 96±1 65±9* 96±2 64±11* 97±1 85±14* # Vt ml 323±70 225±75* 320±70 203±90* 333±57 292±54* #Ptrach cmH2O

22±2 -1±3* 22±2 0±3* 22±1 6±3* #

Table1: (n=6). Mean±SD. ANOVA * p<0,05 1 min vs. baseline, # p<0,05 CSS vs.

open system.

Open system CSS/CPAP 0 CSS/CPAP 10 Sucked gel (g) 1,9 (1,8-2,1) 1,8 (1,5-2,1) 0 (0-0,1) Table 2: Suction 10 s with 12 Fr catheter, -20kPa. Mean and range of 6 replicates.

CONCLUSION. CSS during CPAP 10 causes less ventilatory and circulatory changes when compared to open suctioning, but suctioning efficacy was minimal. If the hygienic aspects of CSS is taken into consideration, CSS at CPAP 0 cmH2O seems to be an alternative as secretion removal capacity and side effects are almost identical to those observed during open suctioning. REFERENCES. (1) Cereda et al. Intensive Care Med. 2001 27 :648-654

Poster Sessions – Airway management – 91-104 91 COMPARISON BETWEEN A STANDARD AND A NEW ACTIVE HEAT AND

MOISTURE EXCHANGER

Chiumello D1, Cadisco A1, Paganini S1, Li Bassi G1, Rocchi G1, Storelli E1, Bottino N1, Pelosi P2

1Ospedale Policlinico IRCCS, Istituo di Anestesia e Rianimazione, Milano, 2Dipartimento scienze cliniche biologiche, Università dell' Insubria, Varese, Italy INTRODUCTION. During the mechanical ventilation is fundamental to provide an adequate conditioning of the inspired gases. One of the most commonly used device is the heat and moisture exchanger (HME). However in presence of hypothermia or with high inspiratory flows the efficacy of the HME could be not optimal. A recent new device, an active HME ”Performer” (StarMed, Italy) has been developed to improve the efficacy, maintaining the simplicity of the use of an HME. We compared the temperature (T), absolute and relative humidity (AH, RH) of a standard HME (Hygroster, Mallinckrodt) versus the Performer. METHODS. The Performer is similar to a normal HME plus the possibility to an active external heating and a water adding. Two different minute ventilation (5, 10 L/min) maintaining constant the tidal volume (0.5 L) and peak inspiratory flow (0.5 L/s) were set in normothermic conditions. We also evaluated the Performer without adding heating and water. RESULTS. Results are expressed as mean±sd Hygroster 5 L/min 10 L/min T (°C) 28.6±4.3 28.9±1.0 AH (mg/L) 26.2±0.5 28.3±2.0 RH (%) 97.4±3.6 98.8±1.6 Performer Off T (°C) 29.1±0.4 30.2±0.8 AH (mg/L) 28.9±0.6 30.4±1.2 RH (%) 100±0.1 98.9±0.5 Performer On T (°C) 32.9±0.1 32.6±0.1 AH (mg/L) 34.7±1.1 34.4±0.3 UR (%) 97.9±2.8 98.6±0.9 CONCLUSION. The performer was always better to condition the inspired gases, always reached the minimal standard requirements 1). REFERENCES. 1) ANSI Z79; 9-1979.

92 CORNEAL PROTECTION IN CRITICALLY ILL PATIENTS: A RANDOMISED

CONTROLLED TRIAL OF THREE METHODS.

Bates J.1, Dwyer R.1, Kevin L.1, O'Hegarty N.1, O'Toole L.2, Logan P.2 1Anaesthesia and Intensive Care, 2Ophthalmology, Beaumont Hospital, Dublin 9, Ireland INTRODUCTION. Corneal surface disorders are very common in critically ill patients and can lead to visual loss (1). The aim of this study was to compare the efficacy of three commonly used methods of corneal protection in critically ill patients. METHODS. 28 ventilated patients were randomised to receive standard eye care in one eye and either taping or a gel membrane in the opposite eye. Patients were assessed every 24 hours for the development of superficial keratopathy. Examination was carried out by a blinded observer using fluorescein staining and blue light illumination of the cornea. RESULTS. Keratopathy was only observed in eyes where lagophthalmos was present. Keratopathy was seen in 14% of eyes treated with standard care, 7% of eyes treated with the gel membrane and no eyes treated with taping. These differences did not reach statistical significance. CONCLUSION. Superficial keratitis is very common in critically ill patients treated with ocular lubricants alone. Prophylactic lid taping appears to be effective and safe even in patients who require frequent pupillary assessment. REFERENCES. (1) Mercieca F, Suresh P, Morton A, Tullo A. 1999. Ocular surface disease in intensive care unit patients. Eye 13;231-236

15th Annual Congress – Barcelona, Spain – 29 September–2 October 2002 S29

95 THE VALUE OF ROUTINE CHEST X-RAY POST ENDOSCOPICALLY GUIDED PERCUTANEOUS DILATATIONAL TRACHEOSTOMY Gonzalez I.1, Davies A.1, Schriner S.1, Rajarajan S.1, Bonner S.1 1Intensive Care Unit, The James Cook University Hospital, Middlesbrough, United Kingdom INTRODUCTION. Percutaneous dilatational tracheostomy (PDT) is a well established technique in the Intensive Care setting. A variety of techniques are used and the fibreoptic bronchoscope is usually recommended in order to confirm anatomical positioning of the tracheostomy. In our Intensive Care Units a routine chest x-ray is performed post PDT to check for position of the tracheostomy tube and perioperative complications. This is common practice, although its value has been questioned (1,2). METHODS. A retrospective audit of the intensive care medical notes and chest radiographs of patients who underwent endoscopically guided PDT at the South Tees Acute Hospital Trust Intensive Care Units between 1996 to 2001 was undertaken to determine the complication rates detected by routine radiology. Complications identified in the medical and nursing notes during and immediately after the procedure were documented. The most recent pre-procedure chest radiograph was compared with the post-procedure chest radiograph and changes noted. RESULTS. A total of 221 cases of PDT were identified and included in the study. The overall complication rate for PDT was 8.59%. The complications detected are listed in Table 1.The routine post PDT chest radiograph detected complications in 1.8% of cases, 1 tube malposition, 2 new areas of lobe consolidation and confirmed pneumomediastinum in a patient with clinical subcutaneous emphysema noted before the radiograph had been taken. This pneumomediastinum was self-limiting and was thought to be due to several attempts at wire placement in a patient with high levels of PEEP using the blue rhino technique .

Bleeding Consolidation

Subcutaneous emphysema

Pneumo- thorax

Pneumo- mediastinum

Tube malposition

Total

All recorded complications

12 2 2 0 1 2 19 (8.59%)

Detected by CXR

- 2 - 0 1 1 4 (1.8%)

Table 1: Complications post PDT (n=221) CONCLUSION. The rate of complications post PDT documented in this study was low and compared favourably to the rates seen in other studies. Studies of non-endoscopically guided PDT have shown the incidence of pneumothorax, pneumomediastinum and paratracheal tube insertion to be much higher comparing to studies of endoscopically guided PDT (3). Most complications detected in our study, including the one case of self limiting pneumomediastinum, were identified clinically, rather than radiologically and chest radiography did not produce a significant change in the clinical management of any patients. We conclude that in adult uncomplicated endoscopically guided PDT there may be no need for routine post procedure chest x-ray. In complicated cases or in case of diffICUlty with needle placement of the trachea, a chest radiograph post PDT may still be required. We recommend that a further larger prospective randomised trial be performed. REFERENCES. 1- Tarnoff et al.Chest 1998; 113:1647-9; 2- Donaldson et al. Otolaryngology Head Neck Surg 2000; 123:236-9; 3- Berrouschot et al. Laryngoscope 1997; 107:1538-44.

96 TRACHEOSTOMY IN CRITICALLY ILL NEUROLOGICAL PATIENTS

Guerrero López F.1, Herrera Gutiérrez M.2, Fernández Mondéjar E.1, Lebrón Gallardo M.2, De la Chica Ruiz Ruano R.1, Manzano Manzano F.1 1Emergency and Critical Care Medicine, H.U. Virgen de las Nieves, Granada, 2Emergency and Critical Care Medicine, H.U. Carlos Haya, Málaga, Spain INTRODUCTION. Airway management in neurological patients with prolonged low levels of consciousness remains controversial and tracheostomy is frequently proposed. We aimed to analyse the incidence of tracheostomy in neurological patients intubated for their low level of consciousness during >48 h, and to study associated factors. METHODS. : Prospective observational study in Intensive Care Units (ICUs) of two neurological/neurosurgical reference hospitals, including neurological patients in the ICU who required endotracheal intubation and mechanical ventilation for> 48 h in a 15-month study period. Data were gathered on the incidence of tracheostomy and associated factors: age, neurological diagnosis, admission APACHE III score, and previous days on tracheal intubation and mechanical ventilation. The statistical analysis used the C2 test, Student´s t test and multivariate analysis with logistic regression. RESULTS. The study included 620 neurological patients needing mechanical ventilation; 241 of these required intubation and mechanical ventilation for >48 h. Sixty-seven patients (27.8%) underwent tracheostomy, either directly (45 cases) or after extubation failure (22 cases). The tracheostomy was performed after a median of 11 days (P25: 7, P75: 15) and the median post-tracheostomy ICU stay was 9 days (P25: 4, P75: 19). In the logistic regression, the undergoing of tracheostomy was shown to be a protective factor for both ICU and hospitality mortality (adjusted OR 0.18, CI 95% 0.07 to 0.46).

Tracheostomy (n= 67)

No tracheostomy (n= 174)

p Value

Age 46.22 ± 18.04 40.1 ± 19.1 < 0.05 APACHE III 68.31 ± 16.8 62.21 ± 24.5 < 0.05 ICU LOS (days) 23.3 ± 11.8 11.53 ± 7.6 < 0.01 Hospital LOS (days) 83.5 ± 71.4 31.6 ± 34.1 < 0.01 ICU mortality (%) 11.9% 30.5% < 0.01 Hospital mortality (%) 23.9% 33.3% 0.15 LOS: Length of stay

CONCLUSION. There is an elevated incidence of tracheostomy among patients who require mechanical ventilation for more than two days. The undergoing of tracheostomy is not an independent factor for a worse prognosis; on the contrary, it is associated with a lower mortality but longer ICU and hospital stay. Grant. FIS 00/0729

97 INTERHOSPITAL-TRANSFERS OF CRITICALLY ILL PATIENTS IN NORTHERN

GERMANY

Raymondos K.1, Homann M.2, Slupinski A.2, Przmeck M.1 1Anaesthesiology, Medical School Hannover, 2Johanniter-Unfall-Hilfe e.V., Ortsverband Wasserturm, Hannover, Germany INTRODUCTION. Approximately 60% of interhospital-transfers of critically ill patients in Northern Germany are still performed with emergency ambulances in that only limited monitoring and usually only volume-cycled emergency ventilators are available. We established an intensive care ambulance system and evaluated the characteristics of the transfers of critically ill patients performed with this system. METHODS. We prospectively recorded 403 transfers that were performed between September 2001 and April 2002 into a database. We assessed the ventilatory modes before and during the patients ́ transfer and evaluated further characteristics of the interhospital-transfers. For the ventilation during the patient`s transport the Raphael® silver ventilator (Hamilton Medical AG, Rhäzüns, Switzerland) was used with that pressure-support ventilation (PSV), airway pressure release ventilation (DuoPAP®/APRV) and the combination of both could be used. RESULTS. 38% of the 403 transferred patients received ventilatory support, 33% breathed spontaneously with and 29% without oxygen insufflation. The majority of the 152 ventilated patients received ventilatory modes supporting spontaneous breathing before (63%) and during the transfer (70%). These assisted ventilatory modes consisted in PSV (25%), APRV (20%), APRV/PSV (15%) and continuous positive airway pressure (CPAP) (3%) before the transfer. During the interhospital-transfers PSV (25%), DuoPAP® (27%), DuoPAP®/PSV (15%) and CPAP (3%) were applied. The time the intensive care ambulance team needed to prepare the transfer in ventilated patients was only several minutes longer compared to non-ventilated patients (median,min-max, 35, 5-115 min vs. 25, 5-85 min, p<0.001). The interhospital-transfers were shorter and, correspondingly, faster for ventilated compared to non-ventilated patients (38, 2-342 km vs. 65, 1-286 km, p<0.001 and 38, 5-260 min vs. 55, 5-360 min, p<0.001). The total distances and time for the intensive care ambulance team were 104 km (5-742) and 180 min (29-710) in ventilated and 196 km (5-614) and 215 min (30-810) in non-ventilated patients (p<0.001). Prior to transfer monitoring in the 403 patients included ECG (77%), pulse oximetry (69%), non-invasive blood pressure (NIBP) (63%), central intravenous (22%) and intraarterial pressure (19%), capnometry (10%) and pulmonary artery pressure (0.7%). During the interhospital-transfers patients were monitored with ECG (85%), NIBP (72%), pulse oximetry (86%), capnometry (21%), intraarterial (20%) and central intravenous pressures (2.5%. CONCLUSION. Most ventilated patients received weaning techniques before transfers and most of these modes were continued during the transport. These less-invasive ventilatory modes cannot be applied in emergency ambulances that are mostly used for interhospital-transfers in Northern Germany. Furthermore, a more extended monitoring including intraarterial pressure monitoring and capnometry was used quite frequently and, this monitoring is also not available in emergency ambulances.

98 COMPLICATIONS OF PERCUTANEOUS DILATATION TRACHEOSTOMY IN ICU Kostadima E.1, Paraforos G.2, Komnos A.2, Sfiras D.1 1Intensive Care Unit, University Hospital of Larisa, 2Intensive Care Unit, General Hospital of Larissa, Larisa, Greece INTRODUCTION. The percutaneous dilatation tracheostomy becomes a standard procedure in most of ICU’s because it is a simple and quite safe method, even performed by unexperted personnel. We present the experience of 402 self-practiced percutaneous tracheostomies in ICU’s of our hospitals and we report the observed complications. METHODS. Four hundred and two critically-ill patients (aged 15-85 yrs old) underwent percutaneous tracheostomy on 10th-16th day, in a 14-bed general intensive care units. The trachestomy set used was Portex kit. All occuring complications were recorded. RESULTS. Serious bleeding that required the discontinuing of the procedure, with no need for transfusion, occurred in 2 patients, while mild bleeding occurred in 4 patients. Fractures of the membranaceus trachea were observed in 4 patients (one of them had, unknown till then, squamous Ca of the trachea). In another patient we detected a punction of the esophagus which result in trachea-esophageal fistula, and in 2 patients we found a subcutaneous emphysema which receded spontaneously. In 3 patients we detected a pneumothorax and in 1 case a tension pneumothorax. Short time decrease of the SpO2 down to 60 mmHg occurred in 3 patients. In 1 case the procedure had to be converted to a bed-side conventional tracheostomy. CONCLUSION. We conclude that self-practiced percutaneous dilatation tracheostomy is a safe procedure in our ICU’s because of the small number of observed coplications.


101 PERCUTANEOUS TRACHEOTOMY WITH THE BLUE RHINO-TECHNIQUE: PRESENTATION OF 100 CONSECUTIVE CASES Fikkers B. G.1, Briede I. S.2, Verwiel J. M. M.2, Van den Hoogen F. J. A.3 1Intensive Care, 2Intensive Care Medicine, 3ENT, UMC Nijmegen, Nijmegen, Netherlands INTRODUCTION. Two techniques for Percutaneous Tracheostomy (PT) have been widely used until recently, both using Seldinger guidewire access to the trachea: the Ciaglia Percutaneous Tracheotomy (CPT) technique and the Guide Wire Dilating Forceps (GWDF) technique. In 1999 the Blue RhinoTM was developed. It seems to combine the advanages of both CPT and GWDF. METHODS. Between March 2000 and August 2001 100 consecutive patients underwent a PT with the Blue Rhino technique. PT was carried out as a bedside procedure in the ICU according to a standard protocol. In all procedures bronchoscopy was used to confirm correct position of the needle. Complications were recorded as described previously [1]. RESULTS. The mean procedure time was 12 min 53 s (range 2 – 60 min). The procedure was successful in all but two procedures. In 31% of the first 48 cases, the dilatation of the trachea required unusual force. From procedure 49 on a Crile’s forceps was used for blunt dissection of the cervical tissues anterior to the trachea. In the last 52 PT’s of this series the procedure was judged diffICUlt in only four cases (8%).This was statistically significant (p = 0.004). 36 peri-operative complications occurred in 30 patients. the majority were minor, but there were six major peri-operative complications: three patients had a bleeding which required exploration. Two patients had a pneumothorax. In one patient the PT failed because of diffICUlty localising the trachea. 98 patients were eventually analysed for complications while cannulated. Eightytwo patients (83.7%) had no complications. In total 16 complications while cannulated occurred with only one major complication, a bleeding two days postoperatively requiring exploration. Of the 98 patients with a PT, 30 died with the cannula in situ, one was lost to follow-up and three still had a tracheotomy in place. The remaining 64 were successfully decannulated and analysed for late complications. Only 14 late complications (21.9%) with only one major complication, a subglottic stenosis. CONCLUSION. The aim of this study was to present the early and late results with the Blue Rhino technique in 100 consecutive patients. PT with the Blue Rhino seems to be safe and easy to perform at the bedside. In comparison with other authors [2,3], our operation-time was significantly longer, although the majority of cases could be done within five minutes. In our experience, the procedure is made easier by blunt dissection before introduction of the Blue Rhino dilator. REFERENCES. (1) Fikkers BG et al. Percutaneous tracheostomy with the guide wire dilating forceps technique: presentation of 171 consecutive patients. Head and Neck, in press. (2) Bewsher MS et al. Evaluation of a new percutaneous dilatational tracheostomy set apparatus. Anaesthesia 2001;56:859-864. (3) Byhahn C et al. [Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results]. Anaesthesist 2000;49:202-206.

102 INTRAVENOUS LIDOCAINE TO ATTENUATION OF CARDIOVASCULAR RESPONSES TO TRACHEAL EXTUBATION IN PROLONGED MECHANICAL VENTILATION Isakovich B.1, Pollak N.1, Litmanovitch M.1 1General critical care department, Hillel Yaffe medical center, Hadera, Albania INTRODUCTION. Tracheal extubation and coughing during suctioning may cause severe cardiovascular responses, mainly hypertension and tachycardia, due to excessive catecholamines release. These hemodynamic changes during extubation and emergence from anesthesia and sedation may cause dangerous increase in myocardial oxygen demand in patients with Coronary arterial diseases(CAD) and in those with risk factors for CAD. During tracheal extubation , stimulation is much long timed and causes hemodynamic changes in various ways: e.g. , pain, emergence from sedation, or tracheal irritation, prolonged bed rest. The use of lidocaine in critical care may be advantageous since it may avoid prolonged recovery and cardiovascular complication, especially in prolonged sedated and prolonged mechanically ventilated patients .We have therefore prospectivly examined the use of intravenous lidocaine to prolonged mechanically ventilated critically ill patients for attenuation of cardiovascular responses to tracheal extubation METHODS. 40 mechanically ventilated patients (time of ventilatoin >48 hours). Age of patients: from 18 to 70 age. Patients were randomized into two groups of 20 patients: Patients in group one receive an intravenous continues injection of 1% (1mg/ml) lidocaine(1mg/kg/hr) 2hours prior to extubation until 30 minutes after extubation. Patients in second (control) group receive saline. Sedation (midazolame 0.1 mg/kg/h) and fentanile 1mcg/kg/h)are administered to facilitate ventilatory support, but were discontinued approximately 2 hours before anticipated tracheal extubation. The probability values will be estimated using Student's-Newman-Keuls test. Demographic differences between groups will be analyzed with the Student'st-test for continous variables and the Mann-Whitney U-test for discrete data. Statistical significance will be accepted when P, 0.05. RESULTS. There was statistical difference in the incidence of bronchospasm (6/1) and postextubation laringospasm (3/0). Significant increases in tidal volume(650+75 vs 540+54) p<0.05 and decreases in TV/f index (65+12 vs 78+22) were observed 60 min after start of lidocaine. Heart rate (84+24 vs 99+22)and Mean arterial pressure(86+28 vs 96+32) were decreased 60 min after administration of lidocaine. During sacioning decrease of heart rate, mean artery pressure in lidocaine group were statistical significant p<0.05. CONCLUSION. Intravenous lidocaine reduces the incindence of haemodynamic disturbance and myocardial ischaemia during extubation, prevented increases in heart rate and arterial pressure(p<0.05). Administration of lidocaine before extubation increased tidal volume and decreased tidal volume – rate ingex(p<0.05).We conclude that lidocaine clearly depresses the cough response in doses not associated with any central nervous system toxicity.

99 TRAINEE PERFORMANCE AT PERCUTANEOUS TRACHEOSTOMY

Vizcaychipi M.1, Pickworth A.1, Watters M.1, Juniper M.1, Beeby C.1 1Anaesthesia/ITU, Princess Margaret Hospital, Swindon, United Kingdom INTRODUCTION. Percutaneous tracheostomy is commonly performed in Intensive Care Units (ICU), with the Ciaglia method best known and most widely used (1). The advantages of the Intensive Care team being able to perform the procedure themselves, along with there being no need to transfer the patient to theatre, have increased its frequency to almost 20% of ICU patients in some units (2). In our unit, many of these procedures are done by ICU Trainees under direct supervision of senior Intensivists. We have investigated whether this is a reasonable practice. METHODS. Primary end-point: to assess outcome of percutaneous tracheostomy in an ICU where trainees perform some of the procedures. Secondary end-point: to evaluate time taken, diffICUlties encountered and complications, between trainee and senior intensivists performing percutaneous tracheostomy. Length of ventilatory support pre and post procedure and time of decannulation were also recorded. All procedures were carried out with general anaesthesia, bronchoscopic guidance and appropriate cardiorespiratory monitoring. Whether a trainee or senior intensivist carried out the procedure was at the discretion of the senior intensivist. RESULTS. 51 patients (mean APACHE II score 22) were included for study. Junior doctors performed 70.5% of tracheostomies. Chronic obstructive pulmonary disease and neurological illness were the principal admission diagnoses. Thromboprophylaxis, short neck and obesity were potential problems found. Main indications for tracheostomy were facilitation of weaning first and prolonged airway protection second. All procedures were within 14 days of first intubation, and 39 (76.4%) before day seven. No major complications were seen. No procedure took more than 23 minutes from skin incision. Most frequent complications were minor bleeding (20-50 mls) in 10 patients and oxygen desaturation (<90%) for more than a minute in 4 patients. Median time to wean from mechanical ventilation was 5 days and ITU length of stay 12 days. 31 patients (61%) were discharged to the ward after decannulation. Survival to leave intensive care was 78.4% (40/51 patients) and hospital survival 60.7%. CONCLUSION. Trainee ITU doctors are increasingly exposed to the technique of percutaneous tracheostomy. Trainee doctors under supervision can carry out the procedure with complication rates similar to more experienced operators (3). When to allow trainee doctors to perform the procedure with more distant supervision requires further assessment. REFERENCES. 1. Cooper RM. Use and safety of percutaneous tracheostomy in intensive care. Report of a postal survey of ITU practice. Anaesthesia 1998; 53: 1209-122. Simpson TP, Day CJ et al, The impact of percutaneous tracheostomy on intensive care unit practice and training. Anaesthesia 1999; 54: 186-189 3. DD Massick, DM Powell et al, Quantification of the learning curve for percutaneous dilatational tracheostomy. Laryngoscope 2000; 110: 222-228

100 EVALUATION OF THE CUFF-LEAK TEST IN A SURGICAL-MEDICAL ICU

Solsona J. F.1, Artiaga M.1, Bone C.1, Gasulla M.1, Corral M.1, Benazzouz M.1 1Intensive care medicine, Hospital del Mar, Barcelona, Spain INTRODUCTION. Objective: To determine the accuracy of the cuff-leak test in a surgical-medical ICU. METHODS. METHODS. A total of 105 patients were tested immediately before being extubated. The cuff-leak test was performed with the ventilator in the assist/control mode at a tidal volume of 7 ml/kg. The leak was taken to be the difference between pre-set inspiratory tidal volume and the average of the three lowest values for subsequent tidal volumes. A positive cuff-leak test was defined as a leak of 0 ml. RESULTS. Results. Post-extubation stridor occurred in only three patients, with leak values of 210 ml, 10 ml, and 0 ml, respectively. Twenty-two patients had a cuff-leak test of 0 ml and did not have post-extubation stridor. The test showed a specificity of 77.8%, sensitivity of 33.3%, positive predictive value of 4.8%, and negative predictive value of 97.5%. CONCLUSION. CONCLUSION. In our experience, the cuff-leak test is inaccurate and cannot be recommended for routine use in patients before extubation. We hypothesize that size tube, tracheal diameter, and position of the tube can play a role in the lack of usefulness of this test.


103 PERCUTANEOUS TRACHEOSTOMY (PT): EXPERIENCE IN 100 PATIENTS

Corso . R. M.1, Fabbri E.1, Terzitta M.1, Gudenzi P.1, Rossi R.1 1Anesthesia and Intensive Care, "G.B. Morgagni" Hospital, Forlì, Italy INTRODUCTION. Potential advantages of PT compared to full surgical tracheotomy may include speed, less immediate bleeding, smaller skin incision, less dissection and less risk of perforation of the posterior trachea. In spite of existing different techniques still there is no consensus about which is the method that presents fewer complications. Since 1997 we have adopted PT in our ICU. METHODS. Design: retrospective study Setting: Intensive Care Unit of "G.B. Morgagni" Hospital, a general hospital RESULTS. Pt was performed in 100 patients between december 2001 as a routine procedure by intensivists. Exclusion criteria were: coagulopaties, tumors and infection in the puncture site. We performed 37 PT with Ciaglia's technique and 63 with Griggs'technique. 65 patients were male and 35 female with an age average of 68+-15 years. The mean SAPSII was 53+-10 points. All procedures were performed with bronchoscopic guidance. No fatalities occured during the procedure. The intubated time before PT was 14+-8 days and the time in ICU after PT was 19+-15 days. The ICU mortality was 22%. Placement was successful in all cases. The total incidence of severe complications was 2%: a pneumothorax and one early extubation evolved to cardiorespiratory arrest and dead. The main primary indications for PT were weaning failure (29%) and neurological dysfunction (71%). It is to emphasize that the complications appeared during the period of training of the operators and both of them were PT performed with Ciaglia's technique. CONCLUSION. Pt is safe and highly effective procedure in selected patients. Experienced intensivists should perform the procedure. The continous bronchoscopic guidance may help further reduce complications rates. REFERENCES. 1) Heikkinen M. et al. Percutaneous dilatational tracheostomy or conventional surgical tracheostomy? Crit Care Med 2000;28:1399-1402 2)Kollef MH,Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714-20

104 DOES CUFF LEAK TEST DETECT BEFORE EXTUBATION HIGH RISK PATIENTS

TO DEVELOP POST-EXTUBATION STRIDOR ?

Gauthier V.1, Mahul P.1, Jospé R.1, Dumont A.1, Auboyer C.1 1reanimation Polyvalente, Hopital Nord, Saint Etienne, France INTRODUCTION. there are no objective clinical and/or paraclinical criteria predicting laryngeal dyspnea before extubation. The cuff leak test measures the leak existing between the intubation tube and the laryngeal wall; it might be an useful tool to evaluate a laryngeal oedema before extubation. In this study, we compare the different ways to perform and calculate the cuff leak test. The second goal is to determine a discriminant and predictive leak threshold of laryngeal post-extubation dyspnea. METHODS. In a single-blinded non randomised prospective study, 97 consecutive adult intensive care patients intubated more than 48 hours and with a planned extubation are enrolled. The expirated volumes are measured before and after deflation of the tube cuff. The absolute value of cuff leak test (ml) is the difference between the expirated tidal volume with the inflated cuff (Vti) and expirated tidal volume with the deflated cuff (Vtd. The relative value of cuff leak test (%) is the ratio between the absolute value and the expirated tidal volume with the inflated cuff. Measures are performed the first day of intubation with control ventilation, then the day of extubation with spontaneous ventilation (pressure support=0, PEP=0). Incidence of laryngeal dyspnea is calculated and correlated with volume leaks. the absolute and relative leak threshold are determined from ROC curves. RESULTS. Among 97 patients (59 males, 38 females), the demographic data show an age of 61°15 years, a SAPS II of 41°14 and an intubation duration of 16,6°15,9 days. 12 patients (12,4%) have developed a post-extubation laryngeal dyspnea (9 females) with 7 reintubations.the absolute and relative cuff leak volumes for patients with (LD+) or without (LD-) laryngeal dyspnea are resumed in the table. According to the ROC curves the relative leak threshold is, the day of extubation of 10%, with a sensitivity of 91,6%, a specificity of 93%, a positive predictive value of 64% and a negative predictive value of 98,7%. It corresponds to an absolute leak threshold less than 20 ml.

Vti-Vtd (ml) On Intubation

(n=82)

Vti-Vtd (ml) On extubation

(n=97)

Vti-Vtd/Vti (%)On intubation

(n=82)

Vti-Vtd/Vti (%)On extubation

(n=97) LD- 275°176 196°128 43%°25,4 38,4%°20,7 p<0,05 p<0,01 non significative p<0,01 LD+ 158°186 10°15 25,2°26,5 4,0%°5,9

CONCLUSION. In our study, the leak threshold of 10% allows to detect 11 among the 12 patients suffering of post-extubation laryngeal dyspnea. Only 2 patients with a threshold less than 10% do not develop stridor. The cuff leak test is an useful tool to determine a high risk population to develop laryngeal dyspnea after extubation.

Poster Sessions Ventilatory support – 105-118 105 THE CHANGES OF RESPIRATORY MECHANICS BY A BRONCHODILATOR

INHALATION UNDER THE VARIABLE LEVEL OF PEEP

Hong S.1, Koh Y.21Division Of Pulmonary And Critical Care Medicine, College Of Medicine Pochon CHA university, sungnam, 2Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South_Korea

INTRODUCTION. Reduced lung compliance and increased lung resistance are the primary lung mechanics abnormality in acute respiratory distress syndrome (ARDS). Although the information is scanty about the mechanisms responsible for the increases in respiratory resistance of ARDS, bronchodilators have been frequently administered in mechanically ventilated ARDS patients. To determine the effect of bronchodilator on respiratory mechanics depending on the level of applied positive end-expiratory pressure (PEEP), we measured the changes of respiratory mechanics by salbutamol inhalation under the variable PEEP level in patients with ARDS. METHODS. Fifteen mechanically ventilated paralyzed ARDS patients (14 of male, mean age 57 years) were included. Respiratory system compliance, maximum and minimum inspiratory resistance were obtained by end-inspiratory occlusion method during constant flow inflation using the CP-100 pulmonary monitor (Bicore, Irvine, CA, USA). The measurements were performed at randomly applied 8, 10 and 12 cm H2O of PEEP before and 30 mins after the administration of salbutamol by using meter-dose-inhaler (100 ug,6 puffs). RESULTS. 1) Maximum inspiratory resistance of lung was higher than the reported normal values due to increased minimal inspiratory resistance & additional resistance. 2) Maximum inspiratory resistance and peak airway pressure were significantly increased at the 12 cm H2O of PEEP compared with those at 10 cm H2O of PEEP. 3) Salbutamol induced significant decrease in the maximum and the minimum inspiratory resistance but no significant change in the additional resistance only at the 12 cm H2O of PEEP (from 15.66°1.99 to 13.54°2.41, from 10.24°2.98 to 8.04°2.34, and from 5.42°3.41 to 5.50°3.58 cm H2O/L/sec, respectively). 4) Lung compliance did not change at the applied levels of PEEP and salbutamol inhalation. CONCLUSION. Bronchodilator response would be different depending on the level of applied PEEP despite of increased respiratory resistance in patients with ARDS. REFERENCES. 1.Broseghini C, Brandolese R, Poggi R, Bernasconi M, Manzin E, Rossi A. Respiratory resistance and intrinsic positive end-expiratory pressure (PEEPi) in patients with the adult respiratory distress syndrome (ARDS). Eur Respir J 1988;1(8):726-31. 2.Pesenti A, Pelosi P, Rossi N, Aprigliano M, Brazzi L, Fumagalli R. Respiratory mechanics and bronchodilator responsiveness in patients with the adult respiratory distress syndrome. Crit Care Med 1993;21(1):78-83. 3.Morina P, Herrera M, Venegas J, Mora D, Rodriguez M, Pino E. Effects of nebulized salbutamol on respiratory mechanics in adult respiratory distress syndrome. Intensive Care Med 1997;23(1):58-64.

106 A SIMPLE METHOD TO EVALUATE THE PRACTICE OF POSITIVE PRESSURE

VENTILATION IN INTENSIVE CARE UNITS

Roche R. J.1, Mackinlay C.1, McLaughlin A.2, Panikkar K.2, Young J. D.1 1Anaesthetics & Intensive Care, Oxford Radcliffe Hospital, Oxford, 2Anaesthetics & Intensive Care, Stoke Mandeville Hospital, Aylesbury, United Kingdom

INTRODUCTION. Traditionally patients with respiratory failure are ventilated to normocarbia using tidal volumes of 10-15 ml.kg-1. However, a ‘protective’ ventilatory strategy, using more modest tidal volumes and if necessary accepting a degree of respiratory acidosis may reduce mortality (1). Patients ventilated to a non-therapeutic respiratory alkalosis with high tidal volumes or peak pressures are therefore almost certainly exposed to an unnecessary risk. The purpose of this pilot study was to devise an audit technique that could be simply and easily used in most intensive care units to identify these "at risk" patients, and to determine if feedback of the audit results altered ventilation practice. METHODS. Ventilation practice was studied on the intensive care units of a teaching (University) and a district general hospital. 30 consecutive admissions to each unit, who were ventilated for > 24 hrs, were studied. Every 12 hrs for their entire stay ventilatory pressures, volumes and associated arterial blood gas results were recorded. Any data point where, in the context of a normal arterial pH (> 7.35), the associated tidal volume (TV) was > 11ml.kg-1, or the peak inflation pressure (PIP) was > 35cmH2O, was deemed inappropriate ventilation. The proportions of ‘inappropriate ventilation’ data points were calculated for each centre, with 95% confidence intervals assuming a binomial distribution. RESULTS. The initial results are shown in table 1 in the first two data columns. In the light of these findings, a simple protocol and education programme was introduced at the district hospital to increase the involvement of nursing staff in the set-up and adjustment of mechanical ventilators. Six months after this process was completed, ventilation at the district hospital was re-evaluated (Table 1, column 3).

District hospital Teaching hospital District hospital (Re-evaluation)

TV > 11ml.kg-1 & pH > 7.35

21% (18-24%) 4% (2-6%) 5.4% (3-8%)

PIP > 35cmH2O & pH > 7.35

15% (12-18%) 2% (1-3%) 1.6% (0.2-3%)

Proportions (95% confidence intervals) of ventilation data points in ‘inappropriate ventilation’ sectors

CONCLUSION. We have devised and tested a simple and objective method to quantify inappropriate ventilation practice on intensive care units. The technique identified a clear difference in practice between two hospitals. Feedback of the results to the hospital with the more traditional ventilation strategy, and the subsequent involvement of nurses in intensive care clinical pathways, resulted in homogeneous practice between the hospitals. REFERENCES. 1. The ARDS Network (2000) N Engl J Med 342;1301-8


109 DYNAMIC END-TIDAL CO2 RESPONSE TO A CHANGE OF THE VENTILATORY

MINUTE VOLUME

Kwok H. F.1, Mills G. H.2, Mahfouf M.1, Linkens D. A.1 Automatic Control & Systems Engineering, University of Sheffield, 2Academic Anaesthesia and Critical Care, Royal Hallamshire Hospital, Sheffield, United Kingdom

INTRODUCTION. In order to calculate the changes necessary to achieve a target PaCO2 (arterial carbon dioxide tension), a dynamic model is required in the development of an advisory system for intensive care ventilators. Therefore, we attempted to derive the time-constant and gain of the CO2 response to minute volume changes. Since continuous blood gas measurement was not available, the end-tidal carbon dioxide (EtCO2) was used as an estimate of the PaCO2. METHODS. The study was approved by the local medical ethics committee. It was divided into two parts: a retrospective study on ICU patients and a prospective study on surgical patients with no history of lung diseases. For the ICU patients, we identified from the intensive care patient data management system instances when there was a change in the ventilatory minute volume resulting from a change in the inspiratory pressure or the ventilatory rate. Cases when there was significant spontaneous breathing (more than 0.5L/min) or there were changes in other ventilator settings were excluded. A first order autoregressive model with exogenous input (ARX) was fitted to each data series of minute volume and EtCO2 using the MATLAB system identification toolbox. For the surgical patients, after the induction of the anaesthesia, a 20 minutes period was allowed for the EtCO2 to settle at the initial ventilator settings. The patients were randomised to have either the tidal volume or the ventilatory rate changed. The time-series data of the minute volume and the EtCO2 was recorded. A first order ARX model was fitted to the data using the same technique as the ICU data. The time-constant and the gain of the models from the two groups were compared using the Mann-Whitney U-test. RESULTS. There were 9 ICU patients and 8 surgical patients. The median age was 53 vs 70 years (p=0.001). The continuous time equivalence of the model adopted in this study is in the form of: dEtCO2 + t(ddEtCO2/dt) = GdMV, where dEtCO2 is the EtCO2 above its baseline value, dMV is the ventilatory minute volume above its baseline, t is the time-constant and G is the gain of the system. The median gain for the ICU patients and the surgical patients was -0.49 vs -0.40 kPa/Lmin-1 (p=0.606) whereas the time constant was 11.29 vs 4.78 min (p=0.004). The time constant in the ICU patients was found to vary widely (interquartile range of 16.18min). No correlation could be found between the age and the time constant. CONCLUSION. The time constant of the EtCO2 response to a change in the ventilatory minute volume was longer in the ICU patients. Although the ICU patients were younger than the surgical patients, the difference in the time constant could not be explained by age. An adaptive approach is desirable to allow for the variation of the time constant seen in the critically ill, when designing an ICU ventilatory advisory system. Grant. EPSRC grant no. GR/M96483

110 INFLUENCE OF AMBIENT AND VENTILATOR OUTPUT TEMPERATURE ON PERFORMANCES OF HEATED HUMIDIFIERS Lellouche F.1, Taillé S.1, Maggiore S. M.1, Deye N.1, Brochard L.1 1Medical ICU, Henri Mondor University Hospital, Créteil, France INTRODUCTION. We have observed clinical situations where heated humidifier (HH) performances are impaired. The aim of this study was to assess the influence of ambient air and ventilator output temperature on performances of the HH. METHODS. Humidity of inspired gas was measured on bench by psychrometry method in different situations: 1) two ambient air temperatures : "normal" 22° to 24°C and "hot" 28° to 30°C; 2) two ventilators with different temperature of gas: Evita 4 (Dräger) (around 30°C) and TBird (around 40°C); 3) two levels of ventilation: VE=10l/min PEEP+5, and VE=21l/min PEEP+10; 4) different settings of F&P MR730 heated humidifier (proximal/distal temperature): 34°/31°C, 34°/34°, 40°/37°, 40°/40°. 32 combinations have been tested with 3 measurements for each. RESULTS. Absolute Humidity (cmH2O/l) with different settings of HH

34°C/31°C 34°C/34°C 40°C/37°C 40°C/40°C Normal ambient temperature

21.7 ± 1.6 24.1 ± 1.0 36.9 ± 0.3 40.6 ± 0.3

Hot ambient temperature

10.0 ± 0.7 14.5 ± 0.5 21.6 ± 2.0 28.2 ± 2.3

Influence of ambient air temperature on Absolute Humidity (cmH2O/l)

34°C/31°C 34°C/34°C 40°C/37°C 40°C/40°C Evita 4 13.0 ± 1.0 18.0 ± 1.5 25.2 ± 1.2 35.0 ± 0.4 TBird 11.8 ± 0.6 16.1 ± 0.8 23.9 ± 2.1 32.6 ± 1.7 Influence of ventilator output temperature on Absolute Humidity (cmH2O/l)

CONCLUSION. HH provides less humidity when the ambient temperature is high (table 1, p=0.0004) and when the ventilator delivers a gas with a high temperature (table 2, p=0.02). In these situations patients are exposed to detrimental effects of underhumidied gas. New systems compensating for these effects need to be evaluated.

107 VENTILATOR TREATMENT IN SCANDINAVIA: A REPEATED MULTICENTER

SURVEY

Karason S.1, Rossi P.2, Oldner A.2, Aneman A.3 1Anaesthesia and Intensive Care, Landspitalinn University Hospital, Reykjavik, Iceland, 2Anaesthesia and Intensive Care, Karolinska University Hospital, Stockholm, 3Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden INTRODUCTION. Mechanical ventilation may cause injury to the lungs and ventilator settings should be adjusted according to respiratory mechanics. This study investigates ventilator treatment strategies in Scandinavia with focus on parameters used to steer ventilator settings. METHODS. A one day point prevalence study was repeated at May 30th 2001 (Day 1: 27 ICUs, 108 patients) and at February 6th 2002 (Day 2: 114 ICUs, 244 patients) using the Scandinavian Critical Care Trials Group as a communication platform. A www-based survey protocol was used. Adult patients on ventilator therapy the study days were eligible. Results are shown as median (25th ,75th percentile) for all patients or as frequency (Day 1, Day 2 %) when comparing study days. A multiple stepwise linear regression model was used to study relationships. Significance was set to p<0.05. RESULTS. Patients were 65.5 (54,73) years with APACHE II 19 (13,23), in the ICU for 5 (2,13) days and ventilated for 4 (2,11) days. Demographics did not differ between study days. The most common indication for ventilator treatment was acute respiratory failure (73,76%) secondary to surgery (35,25%), sepsis (24,21%), trauma (10,7%) and pneumonia (2,20%). Only the latest indication differed between study days. Airway management was by endotracheal tube (64,59%), tracheostomy (32,29%) and facial mask (4,12%). Pressure regulated ventilator modes were used in (86, 79%) of patients and spontaneous triggering allowed in (75,60%). Tidal volume was 7 mL/kg (6, 9), peak inspiratory pressure 22 cmH2O (18,28), PEEP 7 cmH2O (5,10) and dynamic compliance 38 mL/cm H2O (30,51). FiO2 was 0.40 (0.35,0.50), SaO2 97% (95,98), PaO2 11 kPa (10,13), PaCO2 5.5 kPa (4.8,6.3), pH 7.42 (7.36,7.47) and BE 1.8 mmol/L (-0.7,5.4). The PaO2/FiO2 ratio was 201 mmHg (148,266). None of these parameters differed between the two study days. Of all investigated variables, only peak inspiratory pressure (r=0.37), mean airway pressure (r=0.36) and PEEP (r=0.33) were identified as independent variables in relation to the PaO2/FiO2 ratio. Blood gas variables had a significantly narrower frequency distribution than variables reflecting respiratory mechanics. CONCLUSION. The similarity in variables between the two study days indicates consistency in ventilator treatment in Scandinavia. Seasonal changes likely explain the difference in pneumonia frequency, probably reflecting influenza-related cases in winter. The tidal volume of 7 mL/kg confirms that a low tidal volume approach is used in Scandinavia. The lack of correlation between gas exchange and respiratory mechanics and the narrow distribution of blood gas values indicate that respiratory mechanics are not a primary guide to set the ventilator, possibly enhancing the risk of ventilator induced lung injury. These results may be useful for designing future interventional studies.

108 EFFECT OF HIGH FREQUENCY OSCILLATORY VENTILATION ON PACO2 AND MORTALITY Roberts R. G.1, Findlay G. P.1, Saayman A. G.1, Read M. S.1, Weaver C.1, Mecklenburgh J. S.2

1Critical Care Directorate, University Hospital of Wales, 2Department of Anaesthetics and Intensive Care, UHWCM, Cardiff, United Kingdom INTRODUCTION. High frequency oscillatory ventilation (HFOV) has beneficial effects on oxygenation, ventilation and is used as an effective rescue therapy for patients with severe oxygenation failure[1]. Its use is safe and effective in those critically ill patients failing conventional ventilation. PaCO2 levels in patients surviving HFOV have shown consistently lower values than non-survivors [2]. We wanted to examine the relationship between the paCO2 levels in survivors and non-survivors in our group of critically ill patients requiring high frequency oscillatory ventilation (HFOV). METHODS. We prospectively collected data in all those patients treated with HFOV (Sensormedics 3100B, Yorba Linda, CA) over 7 consecutive months. A group of 23 critically ill patients ( 10 female, 13 male, age 23 – 86 years, mean 54 years) were analysed. Arterial blood gas results were taken on conventional ventilation and then recorded within 30 minutes of commencing HFOV and then repeated at 8 hourly intervals and recorded until HFOV was ceased. The group was then split into hospital survivors (S) and non-survivors (NS). Mean paCO2 levels at 8 hourly intervals were then statistically analysed using a 2 way ANOVA test. RESULTS. Analysis of variance shows a highly significant difference in PaCO2 between the survivors (S) and non-survivors (NS) p < 0.0001. Mean PaCO2 in the non-survivors (NS) remained higher than the mean PaCO2 in survivors throughout the duration of the study. Hospital survival rate was 26.1% for our HFOV patients.

Pre oscillation

0h/8h 16h/24h 32h/40h 48h/56h 64h/72h 80h/88h

Survivors S (n=6)

7.1 6.4 / 6.7 6.4 / 6.6 6.3 / 6.3 7.1 / 6.3 6.7 / 6.5 6.5 / 7.3

Non-survivors NS (n=17)

7.3 7.2 / 7.3 7.3 / 6.7 6.7 / 6.9 7.3 / 7.9 8.2 / 8.6 9.6 / 9.1

p <0.01/<0.01

<0.05/- -/- -/< 0.01 <0.01/<0.01

<0.01/<0.01

Mean PaCO2 (kPa) levels at time (hrs post HFOV) CONCLUSION. The survivor group (S) showed a consistently lower PaCO2 level compared to non-survivors. There appears to be an association between a lower PaCO2 and survival in our group of patients. PaCO2 levels within 30 minutes of commencing HFOV may discriminate between survivors (S) and non-survivors (NS). REFERENCES. 1. Fort P, Farmer C, Westerman J,et al. High-frequency oscillatory ventilation for adult respiratory distress syndrome--a pilot study. Crit Care Med 1997 Jun;25(6):937-47 2. Mehta S, Lapinsky SE, Hallett DC, Merker D, Groll RJ, Cooper AB, MacDonald RJ, Stewart TE. Prospective trial of high-frequency oscillation in adults with acute respiratory distress syndrome. Crit Care Med 2001 Jul;29(7):1360-9


111 NEGATIVE- VERSUS POSITIVE-PRESSURE VENTILATION IN INTUBATED ARDS

PATIENTS

Raymondos K.1, Capewell M.1, Molitoris U.1, Verner L.1, Heine J.1, Piepenbrock S.1 1Dep. Anaesthesiology, Medical School Hannover, Hannover, Germany INTRODUCTION. Reducing tidal volumes for lung-protective ventilation in acute lung injury frequently results in deterioration of gas-exchange when PEEP levels are not increased sufficiently. However, high PEEP decreases preload and pulmonary blood flow especially in hypovolaemic patients. In addition, even very high PEEP may be still insufficient to maintain lung-volumes especially in ARDS patients with intrabdominal hypertension. We speculated that continuous external positive-pressure ventilation (CENPV) with a tankrespirator is applicable to intubated patients and superior to continuous positive-pressure ventilation (CPPV). METHODS. We ventilated 6 intubated ARDS patients with a tidal volume of 6 ml/kg and compared 2h of CENPV using a transparent tankrespirator covering the whole body with 2h of CPPV using a pressure controlled-mode. Before each ventilation period a lung recruitment manoeuvre was performed. Haemodynamics and blood volumes were assessed by thermal dilution with the PiCCO system (Pulsion AG, Munich, Germany). RESULTS. During CENPV tankpressures of -32.5 (-30 – -43) (median (min-max)) at inspiration and -15 (-15 – -19) cmH20 at expiration were applied. This resulted in equivalent end-expiratory lung volumes (EELV) (p>0.2) and tidal volumes (Vt) (CENPV vs. CPPV; Vt, 532 (417-578) vs. 522 (411-583) ml, p>0.2) at lower airway pressures (inspiration/expiration; -1.5 (-3 – 0)/4.5 (2-5) vs. 34.5 (30-47)/16 (16-23) cmH20, p<0.05) and lower inspiratory transpulmonary pressures (p<0.05). After 2h CENPV the median PaO2/FiO2 ratio was 35% higher as compared to CPPV (345 (183-438) vs. 256 (123-419), p<0.05). In addition, pC02 decreased and pH increased during CENPV (p<0.05). Intrabdominal pressures were considerably lower under CENPV (1 (-7- 5) vs. 20.5 (12-30) mmHg, p <0.05). Under CENPV median values of mean arterial pressure were 6 to 13 mmHg and median values of central venous pressure were 18 to 19.5 mmHg lower compared to CPPV (p<0.05). At the initiation of CENPV the cardiac index was 20% higher as compared to CPPV (p<0.05). This was associated with higher intrathoracal blood volume indeces (CENPV vs. CPPV, 1306, 1019-1801 vs. 1128, 735-1598 ml/m2, p<0.05) but no differences were found at 1 and 2h. Stroke volume variation was significantly increased after 1h CENPV compared to CPPV (12.5, 9.5-17.5 vs. 4.1,2-8.3%, p<0.05). CONCLUSION. This is the first report on the application of CENPV with a tankrespirator in ARDS patients. The tankrespirator was more effective to perform lung-protective ventilation compared to CPPV at equivalent initial lung volumes and improving haemodynamics. CENPV with a tankrespirator covering the whole body appears to be an applicable option for differential ventilatory therapy in severely ill intubated patients.

112 OPEN LUNG VENTILATION DOES NOT AFFECT RIGHT VENTRICLE EJECTION

FRACTION AFTER CARDIOTHORACIC SURGERY

Reis Miranda D.1, Gommers D.1, Meeder H.1, Struijs A.2, Schepp R.1, Kertai M.3, Bogers A.2, Klein J.1, Lachmann B.1 1Anesthesiology, 2Cardiothoracic Surgery, 3The Netherlands Institute for Health Science, Erasmus Medical Centre, Rotterdam, Netherlands INTRODUCTION. Cardiopulmonary bypass is associated with deterioration of pulmonary function as assessed by atelectasis, low pulmonary compliance, decreased diffusing capacity, intrapulmonary shunt, and pulmonary oedema suggestive for acute lung injury. It has been shown that ventilation according to the Open Lung Concept (OLC), achieved by a recruitment manoeuvre followed by application of a sufficient amount of positive end-expiratory pressure (PEEP), had a significant beneficial impact on morbidity and mortality in patients with the acute respiratory distress syndrome(1). In this regard is OLC associated with relative high intrathoracic pressure, which may impair cardiac performance. This study investigates whether OLC affects the right ventricle ejection fraction in patients who underwent cardiopulmonary bypass. METHODS. A prospective, single centre and randomised study in 18 patients scheduled for elective CABG and/or valve reconstruction with cardiopulmonary bypass. Patients were randomly assigned to receive either OLC or conventional mechanical ventilation (CMV). In the OLC group, pressure-controlled ventilation was used. Only in this group, recruitment manoeuvres (peak pressures to 50 cmH2O for 15 seconds) were applied until PaO2/FiO2>50 kPa and this was maintained by sufficient levels of PEEP. In the CMV group, volume-controlled ventilation was used at the following settings: tidal volume 8-10 ml/kg, PEEP of 5 cm H2O, frequency 10-15/min, I/E ratio=1:2, FiO2 to maintain PaO2>10 kPa. Cardiac parameters were measured with a Swan-Ganz catheter (777HF series, Edwards) and blood gases were monitored with a Paratrend catheter (Agilent). The variables were compared using two-tailed Students’ t-test. RESULTS. In the OLC group, a total (external + intrinsic) PEEP of 17 cm H2O had to be applied in order to achieve the PaO2/FiO2 > 50 kPa. Cardiac output was significantly lower in the OLC group compared to CMV group (4.9+1.2 vs 6.5+1.3 L/min, p<0.01) . Right ventricle ejection fraction (32.5+8 vs 32.6+10%, p=0.78) and pulmonary vascular resistance (160+45 vs 136+63 dynes.cm/s5, p=0.32) were comparable for both groups. End-diastolic volume of the right ventricle was significantly lower in the OLC group in comparison with CMV group (180+48 vs 225+47 ml p<0.05). CONCLUSION. The OLC does not impair the right ventricle ejection fraction. A lower cardiac output was observed in the OLC group but this can probably be attributed to decreased preload volumes. REFERENCES. (1)Amato MB, Barbas CSV, Medeiros DM, et al. Effect of a proctective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998;338:347-54

113 EFFECT OF ALVEOLAR RECRUITMENT STRATEGY ON THE PERIOPERATIVE

LUNG FUNCTION

Dostal P.1, Dostalova V.1, Navratil P.2, Brodak M.2, Parizkova R.1, Cerny V.1 1Dept. of Anesthesiology and Intensive Care, 2Dept. of Urology, Charles University, Faculty of Medicine, University Hospital Hradec Kralove, Hradec Kralove, Czech_Republic

INTRODUCTION. Impairment of respiratory mechanics and gas exchange during and after anesthesia is partly caused by atelectasis. The aim of this study was to assess the effect of modified ”alveolar recruitment strategy” (1) on peri- and postoperative lung function. METHODS. 67 ASA I-III patients scheduled for major abdominal surgery were prospectively studied. Group C (n = 34) received volume control ventilation with low level of positive end-expiratory pressure – PEEP (3 cm H2O). In the group ventilated with higher level of PEEP and recruitment maneuver – group RMP (n = 33) 15 minutes after induction of anesthesia higher level of PEEP was set (6-8 cm H2O according to body size) and modified recruitment maneuver (3 pressure limited breaths with inspiratory pressure 35 cm H2O, inspiratory time 1,5-2 s) was performed. Demographic data, type and length of operation, type of anesthesia and postoperative analgesia, co-morbidity, peroperative evolution of gas exchange (pulse oximetry, capnography), effective compliance of respiratory system, hemodynamic variables and postoperative incidence of hypoxemia (SpO2<90 % during oxygen therapy via face mask with inspiratory fraction of oxygen – FiO2<0,4), need for postoperative ventilation, incidence of other postoperative complications and length of hospital stay were recorded. Statistical analysis of data was performed, data are expressed as mean ± standard deviation, p <0.05 was considered significant (* group RMP vs group C, # vs value after induction). RESULTS. Selected results are presented. Both groups were well matched regarding demographic data, age, type of operation, type of anesthesia and postoperative analgesia and comorbidity. Both groups did not differ in the peroperative evolution of gas exchange but tidal volumes were gradually increased in group C in comparison with group RMP and the difference reached statistical significance before the end of surgery (562.5±141.7 vs 658.8±178.3 ml*). Differences in effective compliance are shown in table. There were no significant differences in the incidence of postoperative hypoxemia (3/32 vs 7/33 of postoperatively nonventilated patients in group RMP and group C respectively, p = 0,315), length of hospital stay or other postoperative complications.

After induction

After RM 1h 2h 3h End of surgery

Group RMP 43.8±13.0 58.5±22.5 # 48.3±18.5* 46.9±17.2 48.1±13.4* 52.8±20.8*Group C 42.9±9.4 - 37.5±9.4 # 43.3±10.5 35.5±9.5 # 43.0±12.4

CONCLUSION. Presented data suggest possible physiological benefit of alveolar recruitment strategy in the perioperative setting however larger cohort of patients needs to be studied to prove clinical usefulness of routine implementation of this strategy. REFERENCES. 1. Tusman G. et al. Br J Anaesth, 1999, 82, 8-13.

114 EFFECTS OF PROTECTIVE VENTILATION IN PHOSGENE INDUCED LUNG

INJURY IN AN ANAESTHETISED PIG MODEL

Harban F. M. J.1, Jugg B.2, Platt J.2, Brown R.2, Evison D.2, Hinsley D.2 1Anaesthetics, University Hospitals, Birmingham, 2Biomedical Sciences, DSTL Porton Down, Salisbury, United Kingdom INTRODUCTION. Phosgene is a common chemical widely used both in the plastics manufacturing industry and with the potential for warfare use. Previous work by the ARDS Network has shown a marked reduction in mortality with protective ventilation (PV) compared to conventional ventilation (CV) in ARDS. To date, there has been no specific research looking at (PV) in ARDS secondary to chemically induced lung injury. Using our previously described model (Brown et al), we have examined the pathophysiological changes seen with PV compared to CV, in chemically induced acute lung injury in the anaesthetised pig. METHODS. Using the model 10 large white pigs were anaesthetised, instrumented and entered into the study. Ventilation strategies consisted of CV _ tidal volume 10ml.kg-1, PEEP 3cmH20, Frequency 20 breaths.min-1, FiO2 0.3 or PV _ tidal volume 8ml.kg-1, PEEP 8 cmH20, Frequency 25 breaths.min-1, FiO2 0.4. Animals were then exposed to phosgene at a dose of 2500 CT (mg.min-

1.m-3) in groups of 5. Animals were studied for up to 24 hours depending on survival, with physiological and biochemical parameters measured throughout. RESULTS. All 5 PV animals survived to 24 hours compared to only 2 CV animals (p<0.05 ANOVA). When comparing physiological parameters the PaO2/FiO2 ratios in the PV group remained above 200mmHg for the duration of the experiment compared to the CV group whose ratios fell and remained below 200mmHg from 17 hours post exposure. The peak difference in PaO2/FiO2 ratios was 160 (341±66 vs. 181±60) mmHg (p<0.01 ANOVA) which occurred at 17 hours post exposure. The PV group also had lower mean pulmonary artery pressures and shunt fraction than the CV group throughout, with a maximum difference of 7 (24±4 vs. 31±4) mmHg at 16.5 hours and 28.5 (6.2±4.3 vs. 54.3±40.5) % (p<0.01 ANOVA) at 18 hours post exposure respectively. All data expressed as mean±s.d. CONCLUSION. Using pathophysiological criteria, we have shown that PV in lungs exposed to a chemical injury results in both improved morbidity and mortality in an animal model. By ventilating using a lung protective strategy we have been able to prevent lung deterioration to biochemical criteria for ARDS and a subsequent reduction in mortality. It would suggest that this style of ventilation is the ideal ventilation strategy in phosgene induced lung injury. REFERENCES. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342(18):1301-8 Brown RFR, Harban FMJ, Hill AA, Jugg BJA et al. Phosgene induced acute lung injury – a porcine model. Am J Resp Crit Care Med 2001;163:A450


117 HIGH TIDAL VOLUME VENTILATION INDUCES VASCULAR DYSFUNCTION IN NORMAL RATS. Valero J. A.1, De Paula M.1, Lorente J. A.2, Sánchez-Ferrer A.1, Fernández-Segoviano P.3, Esteban A.2 1research Dept., 2intensive Care Unit, 3pathology Dept., Hospital Universitario De Getafe, Getafe, Spain INTRODUCTION. We tested whether high tidal volume (VT) ventilation induces vascular dysfunction. METHODS. Sedated (diazepam, ketamine) and tracheostomized male Sprague-Dawly rats were ventilated with VT =15 ml/kg (HTVV, n=9) or VT=35 ml/kg (LTVV, n=6) (RR=60 bpm, FiO2=0.45, PEEP=0). Blood pressure (by a carotid catheter) and arterial blood gases were measured at t=0 min. and t=60 min. After 1 hour of ventilation, the aortae were extracted by thoracotomy, cut into rings of approximately 5 mm in length, and mounted in organ baths for isometric tension recording. Aortic rings from nonventilated rats (NV) were also studied(n=6). We examined the responses to (a) endothelium-dependent relaxation in norepinehrine-precontracted rings (acetylcholine, 10-8 -10-5 M); (b) relaxation induced by an NO donor (sodium nitroprusside, 10-9 -10-5 M); and contraction induced by norepinephrine (10-9 -10-5 M) (n>12 for each dose-response curve). RESULTS. The HTVV group showed markedly impaired relaxations to acetylcholine and to sodium nitroprusside, as well as decreased contractions to norepinehrine, as compared to the LTVV (p<0.0001, two-way repeated measures ANOVA). Responses of the LTVV and the NV groups did not differ. CONCLUSION. Ventilation with high VT is associated with endothelial and vascular smooth muscle dysfunction in normal rats. Grant. 00/316

118 HIGH TIDAL VOLUME VENTILATION INDUCES CYTOKINE RELEASE AND

EXPRESSION OF PRO-APOPTOTIC ENZYMES

De Paula M.1, Valero J. A.1, Blanco J.2, Fernández-Segoviano P.3, Lorente J. A.2, Esteban A.2

1Research Dept., 2Intensive Care Unit, 3Pathology Dept., Hospital Universitario De Getafe, Madrid, Spain INTRODUCTION. We tested whether ventilation of normal rats with high tidal volume (VT) induces systemic cytokine release and non-pulmonary organ dysfunction. METHODS. Anesthetized male Wistar rats were ventilated for 1 hour. We studied two groups: control group (C): VT=9 ml/kg, PEEP=5 cm H2O (n=6), and overventilated group (OV): VT=35 ml/kg, ZEEP (n=6). PaCO2 was maintained constant in both groups. Urea, creatinine, ALT (autoanalyzer), and MIP-2, IL-6 and TNFa (ELISA) serum concentrations were measured at baseline and after ventilation. The expression of several pro-inflammatory (TNFa, IL-1b, IL-6), anti-apoptotic (bcl-2, bcl-xL) and pro-apoptotic (ICE-3, bax) genes was studied by RT-PCR in the kidneys and liver. Signs of apoptosis (light microscopy and tunnel) were examined in the liver. RESULTS. OV rats had edema, necrosis of type I pneumocytes and hyaline membrane formation. No signs of apoptosis were observed by light microscopy in the liver. OV differed from C rats in several biochemical parameters and IL-6 (but not other cytokines) serum levels (Table). The expression of ICE-3, bax and bcl-2 in the liver was significantly higher in the OV than in the C group (Data: mean±SD; RU: relative units; p values for the effect of treatment, 2-way ANOVA or unpaired t test).

Control Before Control After Overventilated Before

Overventilated After

p

ALT(U/L) 49±24 49±24 54±18 85±35 0.01 Bicarbonate (mEq/L)

15.8±2.4 15.5±1.1 19.4±3.9 10.0±3.9 0.01

IL-6 (pg/mL)

36±45 58±58 36±42 250±160 0.01

PaO2/FiO2 405±39 411±33 385±69 186±71 0.002 ICE-3 (RU) 0.94±0.23 1.37±0.25 0.013 Bax (RU) 0.52±0.17 0.88±0.18 0.005 Bcl-2 (RU) 0.32±0.09 0.48±0.10 0.024

CONCLUSION. In this model, high VT ventilation induces lung injury, IL-6 release, liver dysfunction, and enhanced expression of pro-apoptotic enzymes. Grant. 00/0316

115 EVALUATION OF A NEW PROTOCOL OF SETTING THE KNOB "MINUTE

VENTILATION" IN ASV

Belliato M.1, Mediani T.1, Zanierato M.1, Santambrogio L.1, Sala Gallini G.1, Iotti G. A.1, Braschi A.2 1servizio Di Anestesia E Rianimazione I, Irccs Policlinico Sanmatteo, 2cattedra Di Anestesiologia e Rianimazione, Università degli Studi di Pavia, Pavia, Italy

INTRODUCTION. At present, during ASV ventilation mode, there are no definitive guidelines concerning the setting of minute ventilation knob (%MinVol), both in active and in passive patients. In the present study, we focused on a new protocol direct to clarify if the default start of 100% MinVol is adequate for passive and active patients, and to understand how to change this setting to achieve the patients need. METHODS. We included 14 patients, all intubated and ventilated , 6 male and 8 female with mean age 52.8±. All patients were ventilated with a ventilator Galileo (Hamilton Medical, Bonaduz CH) in ASV mode. At ICU admission, the patients were submitted to ASV, setting the correct ideal body weight (IBW) and 100% of MinVol. First step: after 30 minutes, we performed a blood gases analysis and we evaluated the adequacy of ventilation (pH and PaCO2), for passive patients, and the workload (on clinical basis) for active ones. Second step: the user, on the basis of the previous evaluation, changed the %MinVol in order to match patient needs; in passive patients free changes were allowed, while codified changes were performed in active ones. If the ASV ventilation was inadequate, the user increased the %MinVol till to reach patients’ minute ventilation; if the ASV set resulted in an over-assistance the user reduce the %MinVol to 25% for a fast ventilatory weaning or to 50% for starting a progressive weaning. Step 3: after 30 minutes we performed a second blood gases analysis and a new evaluation of the ventilation adequacy. We repeated this protocol until minute ventilation was judged adequate, or estubation or discharge from ICU were possible. RESULTS.

Adequate % Over assistance %

Insufficient %

First evaluation passive 60 40 0 First evaluation active 55.5 33.4 11.1 First Change Second evaluation passive 80 20 0 Second evaluation active 77.75 22.25 0 Second Change Third evaluation passive 100 0 0 Third evaluation active 93.3 5.12 1.55 Third Change Fourth evaluation passive 100 0 0 Fourth evaluation active 100 0 0

CONCLUSION. ASV, as start-up ventilation (with 100% of MinVol), resulted to be adequate in high percentage of both passive and active patients. The study demonstrated that ASV reaches the adequate minute ventilation in passive patients after 2 changes of %MinVol knob and after 3 changes in active ones. Moreover, we did not record any dangerous conditions of hypoventilation.

116 EFFECTS OF PEEP AND EXTERNAL ABDOMINAL WEIGHT ON RESPIRATORY

MECHANICS

Antunes T.1, Anbar J.2, Barbas C. S. V.1 1Respiratory Intensive Care Unit, 2Trauma Intensive Care Department, Hospital das Clínicas – University of São Paulo, S. Paulo, Brazil INTRODUCTION. Intra-abdominal as well as positive airway pressure can influence the respiratory system mechanics. In order to better understand this relationship we studied seventeen patients under mechanical ventilation . METHODS. We measured the inspiratory plateau pressure at the ventilator (inspiratory pause =2 seconds) and intravesical pressure after instilation of 100 ml in the vesical catheter, as described by Kron, while the patients were ventilating in Volume controlled ventilation (sedated and paralysed) , tidal volume 10 ml/kg, respiratory rate 10/m, flow 60 l/min with PEEP of 0 cmH2O and 10 cmH20. Then we repeated the measurements with an external weight on the abdomen of 5 kg with PEEP of 0 and PEEP of 10 cmH20. RESULTS. RESULTS. the patients mean age was 48.7+ 5.84 y ( 21-92); mean weight 66.85+3.11 kg ( 48-88); mean height 172.65+2.65 cm (155-194); mean Vt 667.65+128.82 ml (480-870). The mean (SD) values of Intraabdominal pressure (IAP) and Plateau pressure are in the table: IAP ( cmH2O) Plateau pressure

(cmH2O) PEEP ( cm H2O)

abdominal weight = 0 8.29 ±3.24 18.29 ±5.74 0 abdominal weight = 0 10.15 ±3.32 27.12 ±5.72 10 abdominal weight = 5 kg 13.59± 3.74 19.88 ±5.05 0 abdominal weight = 5 kg 14.32± 4.00 27.06 ±4.93 10

CONCLUSION. The weight on the abdomen and PEEP were significantly transmitted to the intra-vesical pressure (p=0.001 and p=0.005. respectively) as well as to the Plateau pressure (p=0.021 and p=0.0001. respectively), ANOVA repetitive measurements. Intravesical pressure measurements have to take in account PEEP levels.


Poster Sessions Severe sepsis: New aspects of stratification and treatment – 119-132 119 COMPARING TWO PROGNOSTIC SCORING SYSTEMS IN PREDICTING THE SEVERITY OF ACUTE PANCREATITIS IN SINGAPORE Raman S. K.1 1Dept. of Anaesthesia and Surgical Int. Care, Singapore General Hospital, Singapore, Singapore INTRODUCTION. To compare the Ranson's and Imrie's prognostic scoring systems in predicting the severity of acute pancreatitis amongst patients admitted to Singapore General Hospital. METHODS. All patients admitted for at least two days to the Singapore General Hospital over a four year period (Jan 1997 – December 2000) with discharge diagnosis of acute pancreatitis were included in this study. Demographic data, clinical and biochemical findings, sequelae and other pertinent information were collected. The sensitivity and specificity of both prognostic scoring systems were calculated. The chi-squared test was performed and significance level was set at p<0.05.

RESULTS. A total of 364 patients (187 males, 177 females) with mean age 53.73±18.00 years were included in the study. Eighteen(4.9%) patients were admitted to the ICU and 9(2.5%) patients died due to acute pancreatitis. Complications developed in 196 patients(53.8%). There were 101 severe and 263 mild cases of acute pancreatitis. In predicting the severity of acute pancreatitis, Ranson's and Imrie's prognostic scoring systems had sensitivity of 55.5% and 35.6%, respectively whereas, the specificity was 69.6% and 87.5% respectively. CONCLUSION. Ranson's scoring system was significant in predicting severity of cases when compared to Imrie's. Imrie's scoring system can be utilised to screen for acute pancreatitis in our local population as it predicts mild disease better than Ranson's.

120 DETECTION OF BRAIN INJURY IN PATIENTS WITH SEPTIC SHOCK.

Nguyen N. D.1, Su F.2, Hachimi-Idrissi S.1, Spapen H.1, De Wilde D.1, Bossuyt N.1, Hubloue I.1, Huyghens L.1 1Intensive care, AZ-VUB Hospital, 2Intensive care, Erasme Hospital, Brussels, Belgium INTRODUCTION. Neuron- Specific Enolase (NSE) is one of the more sensitive markers of neuronal injury and its elevation in peripheral blood has been reported in patients with different cerebral diseases including stroke, head injury, status epileptICUs, as well as after cardiac arrest.. In this study, NSE was measured to detect brain damage in patients with septic shock, in order to determine those in which septic encephalopathy could worsen their prognosis. METHODS. 26 patients with septic shock were included in this study, after haemodynamic stabilisation. All patients required mechanical ventilation and 24 needed inotropic support. All were sedated with Midazolam and Fentanyl except two. NSE was determined by radioimmunoassay, within the first 24 hours after their admission and once daily, for three consecutive days. It was considered elevated if the value was more than 12.5 mg/L. NSE was also measured in 20 control subjects without sepsis for comparison. Transcranial echo-colordoppler ( TCD) was performed in the first day to measure bilateral flow velocity (FV) and Pulsatility Index ( PI) of intracranial arteries. Cerebral Autoregulation (CA) was evaluated with Hyperhaemic Transient Test by compressing the Common carotid artery. RESULTS. NSE was elevated in a total of 17/ 26 patients (65%) after three days. Using Student t test and chi-square test for statistics, which showed there was no statistical difference so far as concerned Haemodynamics (HD), arterial blood gas results, inflammatory parameters, renal and hepatic function, among patients with and without elevated NSE. No difference was found either in Glycaemia, Plasma Osmolality, Lactate and Albuminaemia. The incidence of long stay in hospital, multiple organ failure and death was similar among patients with or without elevated NSE and was not influenced by the early peak elevation of the latter. In patients with elevated NSE, 6 had a normal brain CT Scan, one suffered from multiple septic emboli from mitral endocarditis, which showed during Magnetic Resonnancy and one patient had an Epileptic crisis before dying.20/ 26 patients showed the absence of CA. On the first day, there was no difference in the values of FV and PI during TCD, among patients with, or without, elevated NSE. No elevation of NSE had been detected in control subjects. CONCLUSION. Elevation of NSE in 65% of the patients showed that cerebral injury was frequent in patients with septic shock. Those injuries were not secondary to any usual HD or biological alterations and did not clearly worsen the patients’ outcome.

121 HAEMORRAGIC SHOCK INDUCES ENDOTHELIAL OXIDATIVE STRESS IN

TRAUMA PATIENTS

Laplace C.1, Huet O.2, Cheisson G.2, Martin L.2, Ract C.2, Edouard A.2, Benhamou D.2, Duranteau J.2 1Department and Laboratory of Anesthesiology, CHU de Bicetre, Université Paris Sud, 2Department and Laboratory of Anesthesiology, CHU de Bicetre, Le Kremlin Bicetre, France INTRODUCTION. Oxidative stress in haemorragic shock may contribute to endothelial dysfunction. The aim of this pilot study was to compare oxidative stress in cultured endothelial cells induced by trauma patients serum (haemorragic shock group) to isolated brain trauma patients serum (brain trauma group). METHODS. Arterial blood sample was obtained during recovery phase from haemorragic shock group or in brain trauma group. After immediate centrifugation and serum separation, samples were freezed at –80°C. Reactive oxygen species (ROS) production by perfused human umbilical vein endothelial cells (HUVEC) was studied by fluorescent microscopy [1]. ROS production was studied by using 2’7’ Dichloro-dihydrofluorescein diacetate (DCFH). Endothelial cells were exposed to patients serum perfusion during 30 minutes. Fluorescence of DCFH was compared in the two studied group by a two way ANOVA for repeated mesures. RESULTS. HUVEC’s ROS production was significantly higher in haemorragic shock group (n=7, ISS 39±16, SAPS II 40±25) than in brain trauma group (n=5). +30% vs –2%, respectively at T=30 minutes. (p < 0.05). CONCLUSION. Haemorragic shock in trauma patients increases endothelial oxidative stress. This oxidative stress could be involved in endothelial dysfunction. REFERENCES. [1] Am J Respir Cell Mol Biol 2001 ; 24 : 762-768

122 REDOX STATUS DURING AND AFTER ABDOMINAL AORTIC ANEURYSM REPAIR

Boyes S.1, Jackson J. M.2, Shearman C. P.1, Elia M.2, Brownlow H. A.3, Al-Rawi S.3, Pappachan J. V.3 1University Department of Vascular Surgery, Southampton University Hospitals Trust, 2Institute of Human Nutrition, University of Southampton, 3Department of Intensive Care Medicine, Southampton University Hospitals Trust, Southampton, United Kingdom

INTRODUCTION. Oxidative stress converts Glutathione (GSH) to glutathione disulphide (GSSG) The [GSH]/[GSSG] ratio can be used to quantify oxidant stress. Previous studies (1,2) observed significant reduction in the [GSH]/[GSSG] ratio and in GSH consentrations in whole blood ([GSH]WB) following AAA repair. This study evaluated the magnitude and time course of oxidative stress following elective AAA repair using GSH as a marker. METHODS. 12 patients were studied following ethics approval and consent. Blood was taken pre-operatively, immediately prior to release of the aortic cross clamp, 15 minutes and 6, 24, 72, 120 hours post clamp release. GSH was assayed by HPLC with fluorometric detection. SPSS was used for analysis. RESULTS. Mean (SD) uncorrected [GSH]WB fell from 1.30(0.17)mmol/L pre-operatively, to 0.80(0.17) mmol/L immediately prior to release of the aortic cross clamp (p< 0.011). This significant fall lasted 24–48 hours. When [GSH]WB was corrected for the haematocrit this sustained reduction in GSH levels was abolished. [GSH]WB did fall significantly from 3.25(0.51) mmol/LRBC to 2.76(0.53) mmol/LRBC (p< 0.012) just prior to the release of the cross-clamp but recovered to baseline 15 minutes after cross-clamp release.

Pre-op mean (SD)

Prior to unclamping mean (SD)

Post unclamping mean (SD)

6 h mean (SD)

24 h mean (SD)

72 h mean (SD)

120 h mean (SD)

Uncorrected GSH mmol/L

1.30 (0.17)

0.80 (0.17)* 0.89 (0.20)* 0.93 (0.27)*

0.91 (0.27)*

0.90 (0.18)*

0.98 (0.23)*

Packed cell volume

0.40 (0.04)

0.27 (0.04) 0.28 (0.04) 0.32 (0.38)

0.30 (0.04)

0.30 (0.05)

0.32 (0.5)

Corrected GSH mmol/L RBC

3.3 (0.51)

2.76 (0.53)* 3.12 (0.44) 2.95 (0.73)

2.96 (0.65)

3.03 (0.34)

3.05 (0.35)

GSH levels around aortic clamping *Significant difference compared to pre-op value

CONCLUSION. Our finding that an apparent fall in [GSH]WB after the aortic clamp is released is due to a reduction in red blood cell volume questions the validity of previous reports. Maximal oxidant stress occurs while the aorta is cross-clamped. GSH is an important antioxidant but we will validate these findings by measuring Total Antioxidant Capacity (TAC). Any intervention aimed at minimising the consequences of this insult should be administered prior to and during aortic cross-clamping. REFERENCES. 1) Transcription factor NFKB expression and postsurgical organ dysfunction. Foulds S et al. Ann Surg. 2001;233:70-8 2) Reduction of ischemia-reperfusion syndrome after abdominal aortic aneurysmectomy by N-acetylcysteine but not mannitol. Kretzschmar M et al. Acta Anaesthesiol Scand. 1996;40:657-64


125 MYELOPEROXIDASE AND CYTOKINES: ROLE IN RESPIRATORY AND SEPTIC

COMPLICATIONS IN ACUTE PANCREATITIS

Chooklin S. N.1, Perejaslov A. A.1 1Department of Surgery, Medical University, Lviv, Ukraine INTRODUCTION. Myeloperoxidase (MPO) and cytokines are been implicated in promoting tissue damage in various inflammatory diseases. However, MPO and cytokines blood levels in dependence of severity of AP and its time-course did not study. METHODS. Eighty-six patients with acute pancreatitis were studied. According the Atlanta criteria, the mild acute pancreatitis was defined in 48 patients (1st group) and severe – in 38 patients (2nd group). The severity was substained with a high Ranson’s (more than 3) and APACHE II (more than 9) score, presence of the organ failure and parenchymal necrosis demonstrated by computed tomography (CT). The serum levels of myeloperoxidase (MPO), interleukins (IL) 1-beta, 6 and 8, tumor necrosis alpha (TNF-alpha) in plasma were studied in all patients. The serum level of MPO was measured by MPO-EIA; cytokines – by ELISA. RESULTS. MPO blood level not exceed 10 nM/ml in most (83.3%) patients with the mild pancreatitis, while the most (84.2%) of patients with severe pancreatitis the MPO level ranged 10-20 nM/ml. MPO levels clear correlated with the levels of proinflammatory cytokines in both group of patients. The decrease of MPO blood level was noted during first three days in all patients with necrotizing pancreatitis. Development of the pancreatitis-associated lung injury accompanied with the repeated increase of MPO levels. Appearance and development of respiratory failure connected with the increased permeability of the capillaries of lung parenchyma, arterio-venous shunting, and disorders of microcirculation that mainly controlled and up-regulated by proinflammatory cytokines. The high levels of IL-8 (140.0 pg/ml) and TNF-alpha (14.0 pg/ml) on the background of relatively insignificant increase levels of IL-6 and IL-1-beta were noted in patients with respiratory failure. The primary MPO concentration in patients, which in subsequent developed an infected necrosis, was some higher than in patients with sterile necrosis, but this difference not significant. In these patients the repeated increase of MPO level was noted, when the contamination of necrotic foci was occurred. This elevation often observed after the first week of the disease onset. This finding favors the hypothesis that purulent complications may be suspected beyond 1 week in the evolution of necrotizing pancreatitis. Applying of pentoxifylline (600 mg/day) significantly reduce the MPO blood level. CONCLUSION. The present study showed the clear dependence MPO blood level on severity of AP and on cytokine blood level. Including pentoxifylline into the complex management of severe AP may improve the results of treatment.

126 TH1/TH2 CYTOKINE BALANCE IN SEVERE SEPSIS Jovanovic K.1, Surbatovic M.1, Filipovic N.1 1Intensive therapy unit, Military Medical Academy, Belgrade, Yugoslavia INTRODUCTION. The term sepsis implies a clinical response arising from infection. Many mediators of immuno-inflammatory cascade in sepsis have been described such as cytokines, interleukins (IL) (1). T-helper (Th) lymphocytes play a significant role. Pro-inflammatory (Th1) cytokines are necessary for initiating an effective inflammatory process against infection, whereas their excess production has been associated with multiple organ dysfunction syndrome (MODS) and mortality. In contrast, anti-inflammatory (Th2) cytokines seem to be prerequisite for controlling and down-regulating the inflammatory response leading to supposed depression of the immune system of patients. In this study we intended to further elucidate the patterns of the Th1 vs. Th2 cytokine release in plasma of patients with severe sepsis and to evaluate cytokine prognostic value for severity of disease and mortality. METHODS. Thirty five patients with well-documented sepsis were enrolled in this study. Sepsis severity score (Elebute and Stoner, revised by Grundman, 1988) was from 3 do 36. Twenty eight patients developed MODS and 21 died. Blood was drown on the first, third and fifth day of onset of sepsis. Concentrations of pro-inflammatory cytokines IL-8, IL-12, and anti-inflammatory cytokines IL-1 receptor antagonist (IL-1ra), IL-10 and transforming growth factor (TGF)-beta 1 were determined in plasma using ELISA assays. RESULTS. On admission, patients with severe sepsis had significantly higher levels of all measured cytokines than did controls (p<0.01). Levels of both pro- and anti-inflammatory cytokines were significantly elevated in patients with sepsis. When compared MODS group with group without MODS, we found statistically highly significant difference (p<0.01) in IL-8, IL-12, IL-1ra and IL-10 concentrations; mean values of all of those cytokines were higher in patients with MODS. When compared non-survivors with survivors, we found statistically highly significant difference (p<0.01) in IL-8, IL-1ra and IL-10 concentrations, mean values of all three cytokines were higher in non-survivors. Interestingly, TGF-beta1 was not statistically different (p>0.05) in any case (MODS vs. non-MODS; survivors vs. non-survivors) although production of this cytokine was enormous (mean value:8907,8 pg/mL, range: 2877-18637 pg/mL). CONCLUSION. Both pro-inflammatory and anti-inflammatory response is profoundly augmented in patients with severe sepsis. Best predictors of severity and mortality were IL-8, IL-1ra and IL-10. REFERENCES. 1. Dinarello CA.: Proinflammatory and Anti-inflammatory Cytokines as Mediators in the Pathogenesis of Septic Shock. Chest. 112(6):321S-329S, 1997.

123 ASSESSMENT OF CD146, A NOVEL ENDOTHELIAL CELL SURFACE ANTIGEN, IN

PATIENTS ADMITTED IN ICU

Leone M.1, Boutière-albanèse B.2, Delmas A.1, Camoin-Jau L.2, Dignat-George F.2, Martin C.1

1Intensive Care Unit and Anesthesiology, CHU Nord, 2Hematology Laboratory, CHU La Conception, Marseille, France INTRODUCTION. CD146 is an Ig-like endothelial cell adhesion molecules, at the interendothelial junction. CD146 forms a signaling complex with proteins associated with actin cytoskeleton, suggesting it plays a role in the maintenance of the monolayer integrity. We hypothesized that soluble form (sCD146) concentration could be increased in pathological conditions with endothelial injury, like sepsis or traumatic-hemorrhagic shock. METHODS. After approbation by our local ethics committee, and informed consent obtained from the patients’next of kin, plasma concentrations of sCD146 were determined using ELISA at day 1, 2, and 3. Ten patients in septic shock (ACCP/SCCM conference consensus), eight patients with severe sepsis, and ten patients with traumatic-hemorrhagic shock (ISS > 15) were prospectively included. Statistical analysis was performed using ”t” test for unpaired data. RESULTS. sCD146 plasma concentrations did not significantly vary between day 1 and 3. They increased in septic shock patients and decreased in traumatic-hemorrhagic shock patients. At day 3, the difference was statistically significant between patients with septic shock and patients with traumatic-hemorrhagic shock (Table 1). No significant difference was observed between septic shock and severe sepsis patients.

Septic shock patients

Severe sepsis patients

Traumatic shock patients

sCD146 at day 3 (ng/mL) 195 ° 112 142 ° 23 112 ° 69*

CONCLUSION. : The increase of sCD146 plasma concentrations in patients with septic shock compared to patients with traumatic-hemorrhagic shock showed that sCD146 may be a good marker of disseminated endothelial injury.

124 NITRITES-NITRATES AND NITROSOTHIOL CONCENTRATION DISCRIMINATE PATIENTS WITH SEPTIC SHOCK IN SEPSIS De Paula M.1, Abella A.2, Blanco J.2, Lorente J. A.2, Delgado M. A.3, Esteban A.2 1Research Dept., 2Intensive Care Unit, 3Surgery Dept., Hospital Universitario De Getafe, Madrid, Spain INTRODUCTION. NO is an important vasodilator in sepsis. The role of RSNOs in the regulation of vascular tone has recently been emphasized. We tested whether NOx and RSNOs serum concentrations are increased in patients with sepsis, and whether NOx, RSNOs and C-reactive protein (CRP), a marker of inflammation, discriminate patients with sepsis from those with septic shock. METHODS. We studied consecutive patients admitted to the ICU with the diagnosis of sepsis (n=9) according to the ACCP/SCCM conference, or septic shock (n=19) defined as the requirement of noradrenaline to maintain a systolic blood pressure of 100 mm Hg during at least 1 hour in the presence of normal blood volume. Within the first 24 hours of admission, we obtained samples for the measurement of (i) NOx (chemiluminescence, NO Analyzer, Sievers Instruments), (ii) RSNOs (spectrophotometric assay, Saville method), and (iii) CRP (immunoturbidimetry, Integra, ROCHE) serum concentrations. Data: mean±SD; #: number of cases with values within normal range; p value: without vs with shock, unpaired Student´s t test) RESULTS. Among the 28 patients with sepsis (with or without shock) PCR was elevated in all cases, NOx in 21 and RSNOs in 27 cases (Table). Patients with shock had higher NOx and RSNO serum concentrations than patients without shock. The area under the curve of the receiving operator curve (ROC) was 0.34, 0.78 and 0.79 for PCR, NOx and RSNOs, respectively.

Reference range

All cases (#) (n=28)

Without shock (#)

(n=9)

With shock (#) (n=19)

p

PCR (mg/L) <5 220±103 (0) 253±91 (0) 218±109 (0) 0.391 NOx (uM) <30 78±81 (7) 37±39 (4) 99±90 (3) 0.020 RSNO (uM) <1 4.7±2.5 (1) 3.2±1.5 (0) 5.6±2.6 (1) 0.017

CONCLUSION. We conclude that PCR, NOx and RSNOs serum concentrations are all increased in patients with sepsis. RSNO and NOx discriminate patients with shock than those without shock, supporting a role of these molecular species in the vascular dysfunction associated with sepsis. Grant. 00/0316


127 FAILURE OF NEUTROPHIL MIGRATION IN SEPTIC SHOCK Martins M. A.1, Antoniazzi P.1, Arraes S. M.1, Tavares-Murta B.1, Cunha F. Q.1, Basile-Filho A.1

1Intensive Care, Ribeirão Preto Medical School-University of Sao Paulo, Ribeirao Preto, Brazil INTRODUCTION. Although failure of neutrophil migration has been demonstrated in animals with sepsis, this alteration can be observed in other diseases such as cancer, diabetes and acquired immunodeficiency syndrome. However, little information is available about neutrophil migration in human sepsis. METHODS. We evaluated 9 patients with septic shock (5 men and 4 women, mean age 57.4±10.2 years, APACHE II = 26.9±6.8; % Death risk = 58.6±24.2, and Sepsis Score = 23.4±7.7) and 8 healthy controls admitted to the ICU of the University Hospital, FMRPUSP. Neutrophils were obtained from heparinized venous blood (5 mL) collected from healthy volunteers and from patients. Chemotaxis was studied in 48-well microchambers using the following chemotactic stimuli: 10-6 M N-formyl-L-methionyl-L-leucyl-L-phenylalanine (FMLP), 10-9 M leucotriene B4 (LTB4), and 10 ng.mL-1 IL-8. Eight of the nine patients studied died. RESULTS. Neutrophil migration differed significantly (p<0.05) between healthy controls and patients with septic shock, i.e., the neutrophils obtained from the healthy controls presented an expressive migration in the presence of the chemoattractants FMLP, IL-8 and LTB4 compared to patients with septic shiock when the same chemotactic stimuli and the random migration test were used. CONCLUSION. Neutrophil migration to the focal point of infection is extremely important for the local control of bacterial growth and the consequent prevention of bacterial dissemination. The present results demonstrate the failure of neutrophil migration in a population with septic shock in response to chemoattractant stimuli compared to a control healthy population. Grant. FAPESP 99/07266-7

128 DEXAMETHASONE AND INDOMETHACIN IN ADULTS WITH BACTERIAL SEPSIS AND MENINGO-ENCEPHALITIS Kepa L.1, Oczko-Grzesik B.1, Mossor K.1 1Department of Infectous Diseases, Silesian University Medical School, Bytom, Poland INTRODUCTION. The use of corticosterois (dexamethasone,DXM) as adjunctive therapy in children with purulent meningoencephalitis (PME)exerts benefical influence on the clinical course and outcome of the disease. DXM used in adults with bacterial sepsis (BS)and PME did not reveal evident positive influence on the clinical course and results of the disease treatment.Indomethacin used as adjunctive therapy in adults with BS and PME exerted beneficial influence on the clinical course and outcome of the disease in some cases. The aim of the study was the estimation of influence of DXM used together with Indomethacin on clinical course and consequences of of BS and PME in adults. METHODS. Between 1996-2000 there were 32 patients with diagnosis of PME in the course of BS hospitalised in our centre. The etiological agents were as following:Str.pneumoniae (25%), Neisseria meningitidis (19%), Staph. aureus (3%); the etiology of the disease remained unknown in 53% of cases. All subjects were divided into two groups at random way: I – 10 patients (mean age 43 yrs.) treated with antibiotics, symptomatic drugs and DXM (24-36mg/day) as well as Indomethacin (120mg/day) beginning from the 1st day of treatment, II – 18 patients (mean age 39 yrs.) treated only with antibiotics and symptomatic drugs. In all patients samples of cerebrospinal fluid (csf) were taken three times: on the 1st, the 4th and between the 10-14th day of treatment and following parameters were asessed: pleocytosis, protein, glucose, lactic acid, chloride, TNF-alpha, IL-1beta. RESULTS. Mean period of consciousness impairment and fever lasting in the group I was shorter than in group II, but mean period of hospitalisation was insignificantly longer in the group I. In patients of this group who survived faster normalisation of csf parameters was recorded (protein, lactic acid, TNF-alpha, IL-1beta concentrations) compared to group II. In fatal cases csf levels of these parameters remained elevated during the whole time of monitoring. The observed sequels of the disease were as following: partial deafness, total deafness, paresis and paralysis.

Recovery Death Complications Group I (10 subjects) 6 (60%) 3 (30%) 1 (10%) Group II (18 subjects) 11 (59%) 4 (23%) 3 (18%)

CONCLUSION. Dexamethasone in conjunction with Indomethacin used as adjunctive therapy in BS and PME in adults did not exert beneficial influence on clinical course of the disease and results of treatment in the majority of cases. However, it seems to be reasonable to perform further study in large, clinically differentiated groups of patients (as severe clinical state of patients dominated in the group I).

129 WHEN DO WE USE DROTRECOGIN ALFA (ACTIVATED) FOR THE TREATMENT

OF SEPSIS?

Marinho A. D. M. S.1, Isvarlal P.2, Pereira I.2, Faria S.2, Campos M.2, Brandao M. J.1 1Intensive Care Service, 2Haematologic Clinical Service, General Hospital Santo Antonio, Oporto, Portugal INTRODUCTION. Clinical trial efforts over the past 20+ years have failed to produce a significant successful therapy for sepsis. However recently the results of the recombinant human activated protein C (rhAPC) trial demonstrated an approximate 20% relative reduction in mortality for patients with severe sepsis (1). But in this trial, patients with an APACHE II score in the lowest quartile (score of 3-19) had a slightly higher mortality in the drotrecogin alfa group. The aim of the present study was to assess the level of protein C and antithrombin III in a group of septic patient and compare with SAPS II, SOFA, and ICU outcome. METHODS. The study was prospectively conducted. Above the data routinely collected (demographics, origin and outcome, reason of admission, length of stay – LOS), we also collected: SAPSII, SOFA at admission, and SAPSII, SOFA and the level of Protein C and antithrombin III at day 1,4,8. RESULTS. 11 patients were included (mean age 53,27±19,1; median LOS 12 days; 3 patients died; median SAPSII – 44 and median SOFA – 10 at admission). Table 1 show the different between the groups of patients who survived from those who died (all data are express as median)

Protein C (1) Antithrombi

n III (1)

SAPSII (1) SOFA (1)


n III (4)

SAPS II (4) SOFA (4)


n III (8)

SAPS II (8) SOFA (8)

Survivors 48 / 66 37 / 11 69 / 77 30 / 9 80 / 102 23 / 9 Non-Survivors 29 / 26 51 / 10 26 / 24 44 / 11 35 / 17 57 / 13

CONCLUSION. The survivors have greater values of Protein C, Antitrombin III, and lesser values of SAPS II, and SOFA, when compared with non-survivors. In the survivors the level of Protein C and Antitrombin III increased with the decrease of the scores, while in the non-survivors seems to be unchanged. These data has potential interest because it seems that the potential benefited from treatment with drotrecogin alfa are the patients with higher scores, witch is associated with lesser values of Protein C and Antitrombin III. In conclusion we think that the institutions must have guidelines for its use (according with scores levels or protein C levels) as the drug will be expensive and is associated with a potential risk of bleeding. REFERENCES. (1)Bernard GR, Vincent JL, Laterre PF, et al. Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699-709.

130 TREATMEANT WITH IGM-REACHED IMMUNOGLOBULINS AND CVV HEMOFILTRATION IN GRAM-POSITIVE SEPTIC SHOCK Marjanek Z.1, Faludi M.2, Ormenyi L.3, Szabadka H.4 1ICU, 2Nephrologic, Bajcsy-Zsilinszky Hospita, 3Nephrologic, Bajcsy Zsilinszky Hospital, 4Oto-laryngologic, Bajcsy-Zsilinszky Hospita, Budapest, Hungary INTRODUCTION. The study was conducted to estimate mortality rate of the Gram pos. septic shock treating with continous veno-venosus hemofiltration(CVVH),IgM-reached immunglobulins and empiric antibiotic treatment.Patient was treated from 1st jan, 2000 to 31st Dec,2001.The cause of septic shock was upper tract infection in 7 patients and postoperative abdominal infection in 9 patients. The pathogens were Str.pyogenes, G-type Str.and Staphylococcus aureus. METHODS. The hemodynamic paramteters-CI,SVR,DO2,VO2,ITBV,EVLW,se lactate,procalcitonin(PCT),C-reactive protein(CRP)were measured. The MOF was characterised with PO2/FiO2 < 250, urine < 0.5 ml/kg/hours, platelet < 100G/l, pH < 7.3, Se-lactate > 2.5 mmol/l,GCS < 9. The fever, the APACHE-II score were assessed. The treatment: imipenem 3x1.5 g/die + 250 mg/ kg/die IgM-reached immunglobulins + CVVH. The blood flow: 156,2±34 ml, the quantity of the UF> 32.5±14 ml/min. RESULTS. APACHE-II:24.6±5.4, GCS:9.4±3.6, fever:38.3±0.7C, CI:9.8±2.3 ml/min/m2, SVR:468±121dynsec*cm-5, DO2:587±187 ml/min/m2, VO2:171±46 ml/min/m2, ITBVI:752±246 ml/m2, EVLW: 5.4±1.7 ml/m2, Se-lactate:2.6±2.8mmol/l,PCT:10ng/ml.Two organ failures were diagnosed on 7, three organ failures were on 4, four organ failures were on 3, and five organ failures were on 2 patients. CONCLUSION. The mortality rate was 21% – two organ failures -, 28% – three organ failures -, 58% – four organ failures – and it was 100% when five organ failures were existed. The outcome was improved with early diagnosis and prompt invasive treatment when the organ failures were already existed. REFERENCES. Dennis L Streptococcal Toxic Shock Syndrome> Spectrum of Disease, pathogenesis, and New concept in treatment EID. Vol.1. No3. pp.1 Holzheimer R.G. Immunglobulins for prophylaxis and treatment of sepsis: new experience with a natural immunmodulatory compound. Sepsis. 1999.3.193-196


Poster Sessions Cardiovascular dynamics (I) – 133-146 133 MORTALITY CAUSES IN PATIENTS UNDER MECHANICAL CIRCULATORY

SUPPORT

Hernández G.1, Renes E.1, Pérez-Vela J.1, Corres M.1, Perales N.1 1Cardiac Surgery ICU, University Hospital 12 de Octubre, Madrid, Spain INTRODUCTION. To evaluate the mortality rates and death causes of the patients treated with a mechanical circulatory support device (ventrICUlar assit device: VAD), depending of the indication: elective bridge to cardiac transplantation, postcardiotomy cardiogenic shock (PCS), as a bridge to transplantation or not. METHODS. Retrospective study of all patients who required a VAD in our intensive care unit since 1989 to 2001. We analyzed the indication, type, model, location, duration, mortality and its causes RESULTS. 52 patients (0,7% of the total number of postcardiac surgery patients). Mean age 57+-13 years. Male 79%. Centrifugal pumps were used in the 81% of the patients and beating pumps in the 19%. VAD indications: PCS 85% (20% as an urgent bridge to transplantation); elective bridge to cardiac transplantation 15%. Total mortallity 73%. Mortality after discontinuing VAD 26% (70% postransplantation). Indication mortality: PCS 71% (33% if rigth VAD in postransplantation rigth ventrICUlar failure; 100% if indicated as an urgent bridge to transplantation or biventrICUlar VAD); elective bridge to transplantation 50% (25% in left VAD, 75% in biventrICUlar VAD). Centrifugal pumps mortality is 70% and beating pumps 80% (mean duration: centrifugal pumps 39+-30 hours and beating pumps 191+-79 hours; VAD indications: centrifugal pumps 83% of PCS and beating pumps 50% as an elective bridge to transplantation). Mortality causes in non discontinuing VAD patients: 76% cardiogenic shock with multiorganic failure; 12% bleeding; 12% systemic embolism (50% cerebral embolism). Mortallity causes in discontinuing VAD patients: sepsis 40%; systemic embolism 30% (66% cerebral embolism); cardiogenic shock 20%. CONCLUSION. Instead of the high mortality rates, there are some subgroups of patients that can benefit from VAD: rigth VAD in postransplantation right ventrICUlar failure and left VAD as a bridge to elective transplantation. Bridge to transplantation from PCS have a mortality of 100%. The most common cause of death in non discontinuing VAD patients is the cardiogenic shock with multiorganic failure and in discontinuing VAD patients is sepsis REFERENCES. Mechanical Cardiac Support 2000: Current Applications and Future Trial Design. Circulation. 2001; 103: 337-342.

134 IS RIGHT VENTRICULAR PERFORMANCE AFFECTED DURING ABDOMINAL COMPARTMENT SYNDROME (ACS)? Mahjoub Y.1, Plantefève G.1, Chalhoub V.1, Dupont H.1, Kermarrec N.1, Paugam-Burtz C.1, De Vaumas C.1, Mantz J.1, Desmonts J.1 1Unité Réanimation Chirurgicale, CHU Bichat-Claude Bernard, Paris, France INTRODUCTION. The ACS has been defined as multiple organ dysfunction secondary to intra-abdominal hypertension (IAH). IAH may induce acute right ventrICUlar dysfunction (ARVD) secondary to increased afterload (1). The aim of this study was to evaluate the RV performance in surgical critically ill patients suffering from ACS. METHODS. Twenty five consecutive patients with SOFA score>=3 were studied prospectively (age 62±14 years, SAPSII 47±16). Patients with known right or left ventrICUlar (LV) dysfunction were excluded. Transthoracic echocardiography was performed by the same operator and the abdominal pressure was evaluated using the bladder pressure (BD). Eleven patients with ACS (SOFA score>=3 + BD>=15mmHg) were compared to 14 control patients without ACS (SOFA score>=3 + BP<15mmHg). The ARVD was defined as a dilated RV on the long axis view (RV end diastolic area / LV end diastolic area >0.6) associated with septal dyskinesia on the M-mode on short axis view (2). Results were expressed as mean ± SD. Groups were compared with Chi2 and Mann-Whitney tests, p<.05 significant (*). RESULTS. All patients had severe sepsis except one hemorrhagic choc in ACS group and one anaphylactic choc in control group. Twenty three patients underwent mechanical ventilation. General data are exposed on the first table and echocardiographic results on the second.

ACS (n=11) No ACS (n=14) Bladder Pressure (mmHg) 22.5±6 9.5±4 * SOFA on BP measure 10±4 8±3 MAP (mmHg) 73±22 74±18 Vasopressor (n, %) 7 (63) 11 (78) Mortality (n, %) 4 (36) 3 (21) ACS (n=11) No ACS (n=14) E wave / A wave ratio 1.1±0.7 1.0±0.2 Cardiac output (l/min) 4.6±2.2 5.4±1.4 LV ejection fraction (%) 58±7 54±8 RV fractional area contraction (%) 28±1 34±1 RVEDA / LVEDA ratio 0.77±0.2 0.61±0.11 Septal dyskinesia (n, %) 10 (91) 3 (21) * RV dysfunction (n, %) 8 (73) 2 (14)*

CONCLUSION. IAH appears to be associated with ARVD. In contrast, the LV performance appeared not affected by ACS. The pathophysiology of this right ventrICUlar dysfunction remains to be clarified. However, it may contribute to hemodynamic failure observed in some patients with ACS. REFERENCES. 1. Kitano YJ et al, J Appl Physiol 1999;86:1651-6. 2. Jardin F et al, Chest 1997;111:209-17.

131 CHARACTERISATION AND VIRAL SAFETY VALIDATION OF A DOUBLE

INACTIVATED ATIII CONCENTRATE

Gensana M.1, Biescas H.1, Fernández J.1, Massot M.1, Ristol P.1, Jorquera J. I.1 1R&D Area, Instituto Grifols, S.A., Parets Del Vallès, Spain INTRODUCTION. Instituto Grifols has developed an ATIII concentrate (ATIII DAF VF) that undergoes two virus inactivation steps: pasteurisation and virus nanofiltration through Planova 15N. METHODS. Several industrial batches have been characterised "in vitro". Among other parameters, ATIII activity after reconstitution (and after 4 hours at 25 ºC) using thrombin-based chromogenic substrate assay and ATIII antigen by immunonephelometry were determined. Total protein was assessed by Kjeldahl. Crossed immunoelectrophoresis in the presence of heparin was performed. Accompanying proteins (Albumin, IgG, IgA, IgM, haptoglobin, transferrin,…) were measured by nephelometry. Purity was assessed by electrophoresis and molecular distribution by HPLC. The isoelectric point (Ip) was evaluated using a pH range of 3-9 and the molecular weight was investigated by SDS PAGE. A virus validation study of two specific virus elimination steps was performed; i.e. Pasteurisation and Nanofiltration as methods of known capacity to eliminate a wide range of viruses (enveloped and non-enveloped). RESULTS. ATIII activity was maintained (101.0±5.9%) after 4 hours incubation at 25 ºC. The specific activity was 7.8±0.4 IU ATIII/mg of protein. The ATIII antigen/ATIII activity ratio was 0.98±0.05. Crossed immunoelectrophoresis revealed a very low content of non-heparin-binding ATIII (3.7±1.5%), practically free of non-active ATIII. Most accompanying proteins assayed were undetectable. Only IgG was detected, but at trace amounts (approximately 0.1 ug/IU ATIII). Molecular distribution shows 97.7±1.4% of monomeric form. Purity obtained by electrophoresis was 97.5±0.7%. Several isoforms were detected with the Ip in the range of 4.68-4.92. The approximate molecular weight was 54kDa under non-reducing conditions. The virus validation study showed reduction factors >=9.25 log10 for HIV-1; >=10.78 log10 for the animal model virus used for human Herpes virus and Hepatitis B; >=8.89 log10 for Bovine Viral Diarrhoea Virus (BVDV) (model for human Hepatitis C and G); >=13.87 log10 for the Hepatitis A virus, and finally, 7.32 log10 for Porcine Parvovirus (model for human Parvovirus B19). No residual infectivity was detected for HIV, Hepatitis B model virus and BVDV after none of these two steps. CONCLUSION. Antithrombin III DAF VF Grifols is a high purity product that maintains ATIII´s native properties. Virus safety studies provided significant reduction values for all viruses tested, either enveloped or non-enveloped. REFERENCES. Hellstern P et al: In vitro Characterization of Antithrombin III concentrates-A single-Blind Study. Haemost 1995;25:193-201. Menache D.: Antithrombin III concentrates. Hematology/Oncology clinics of North America.Volume 6. Number 5.October 1992. Lebing WR et al: A highly purified antithrombin III concentrate prepared from human plasma fraction IV-1 by affinity chromatography. Vox Sang 1994;67(2):117-24. CPMP/BWP/268/95 "Virus validation studies". CPMP/BWP/269/95 "Medicinal products derived from human plasma".

132 TREATMENT OF SEPTIC PATIENT WITH RECOMBINANT FVIIA DURING LIFETHREATENING BLEEDING EPISODE Christoph S. M.1, Muhl E.2, Bruch H.2 1Dept of Surgery, Staedtisches Klinikum Solingen, Solingen, 2Dept of Surgery, Medizinische Universitaet Luebeck, Luebeck, Germany INTRODUCTION. There is more than proportional occurence of lifethreatening bleedings on surgical patients with sepsis. Masstransfusion is predictor for MOV. Therefor it is necessary to stop bleeding as soon as possible. FVII is promoter of extrinsic pathway. There is a severe decrease of serum level on patients with septic process. This may cause the extensive bleedings. METHODS. 12 patients were treated with recombinant FVIIa within the framework of a treatment approach. In advance there was a exclusion of surgical reasons for bleeding. Aim of th treatment was earliest possible interception of the lifethreatening bleeding episode. A Matched-pair-analysis was performed with a retrospective control group. Special focus was on thrombembolic complications. RESULTS. After administration of rFVIIa any bleeding stopped within 6 hours. The administration was fractioned. The range of the dose was between 47mg/kgBW to 135mg/kgBW. 10/12 patient survived the bleeding episode. On three patients there was an increase of MOF measured by MODS. The matched-pair-analysis showed a significance on survival rate, outcome scale, APACHE II and TISS-39 for those patients who were treated with rFVIIa. Quick was normalised much faster than during sepsis on those patients within 36 hours to almost normal level (controll group 68,5 hours). CONCLUSION. Although there is no experience on administration of rFVIIa on septiv patients, this trial showes the positive influence during lifethreatening bleeding. There was no thrombembolic complication reported. By stopping the bleeding there was a predictor of MOF diminished. The effect of rFVIIa on septic patients should be subject to further trieals.


135 ENDOVASCULAR STENT-GRAFT PLACEMENT VERSUS CONVENTIONAL OPEN SURGERY IN INFRARENAL AORTIC ANEURYSM Bölke E.1, Jehle P.2, Storck M.3, Schams S.1, Görich J.4, Steinbach G.5 1Surgery, 2Internal Medicine, University of Ulm, Ulm, 3Surgery, Leipzig, Leipzig, 4Radiology, 5Clinical Chemistry, University of Ulm, Ulm, Germany INTRODUCTION. Background: For the treatment of aortic aneurysm stent-graft implantation is an alternative method to open surgery. There is no study comparing both methods with regard to endotoxaemia, the acute phase cascade and clinical outcome. METHODS. In this prospective study, we enrolled 40 patients (34 male, 6 female, mean age 72,1 ± 7,5 [58-92] years) with infrarenal abdominal aortic aneurysm who underwent aortic surgery. Comparable groups of patients were treated with open (n = 20) or endovascular (n = 20) stent-graft implantation. To characterize the inflammatory response plasma levels of endotoxin, endotoxin neutralizing capacity (ENC), interleukin-6 (IL-6), C-reactive protein (CRP) and white blood cell count were determined. In all patients, measurements were performed on admission, skin suture, 4h and from the first to fifth postoperative day. As parameters for the clinical outcome we assessed daily temperature, lung function, pain, duration of postoperative hospital stay and morbidity. Wilcoxon rank test was used for statistical analysis. RESULTS. In both groups, a significant increase of endotoxin plasma levels and a decrease of ENC was found already after skin incision. IL-6 levels peaked 4 h postoperatively in both groups whereas CRP rose at the 1st postoperative day, reaching a maximum at day 2. Conventionally operated patients had significantly higher plasma levels of endotoxin, IL-6 and CRP and lower ENC during and after surgery than patients with stent-graft implantation. Moreover, patients with endovascular stent-grafting had significant less postoperative pain, less restriction of total vital capacity, a shorter hospital stay and a lower morbidity. CONCLUSION. Conclusions: Endovascular stent-grafting of infrarenal aortic aneurysm seems to be superior not only in terms of the imflammatory response but also in overall clinical outcome.

136 VASCULAR ENDOPROSTHESIS IN ACUTE DISSECTION OF THE AORTA

De Rojas P.1, Prieto M. A.1, García F. J.1, Chaparro M. J.1, Delgado M.1, Aragón C.1, Lebrón M.1

1ICU, Hospital Carlos Haya, Málaga, Spain INTRODUCTION. Acute dissection of the aorta is presently one of the pathologies with the greatest risk of early death and a high degree of morbidity. Treatment of a type A dissection is emergency surgical repair, whereas that of a type B dissection is initially medical therapy. An alternative to the classical treatment is the percutaneous placement of an endovascular prosthesis. This technique, however, is still relatively new, so that limited experience is available, and it is not exempt from complications. We present a series of 13 cases treated by percutaneous vascular repair. METHODS. All patients admitted to our Intensive Care Unit (ICU) in whom an aortic endoprosthesis was inserted due to acute dissection were included. This was indicated in cases of hemodynamic stability, precise diagnosis of the entry point of the dissection, and absence of intimal tear prior to the exit of the left subclavian artery. The placement of the prosthesis was verified in all cases by aortography. Among the variables studied were: type of dissection, clinical presentation, diagnostic methods, time between diagnosis and prosthesis placement, length of stay in ICU and complications. The results of the quantitative variables are expressed as the mean or median, and the qualitative variables as a percentage. RESULTS. Of the 13 patients, 11 were men and 2 women, with a median age of 70 years. Prior arterial hypertension was present in 54%. The aortic rupture was spontaneous in 77% and traumatic in 23%. The most common clinical presentation was chest pain, in 38%. Four cases presented hemothorax and another four ischemia of the lower limbs. Computerized tomography (CT) was the diagnostic method of confirmation in 92%. In 85% the dissections were type B: 62% affecting the thoracic and abdominal aorta, with the abdominal and thoracic aorta being involved exclusively in 15% and 8%, respectively. The other 15% were type A dissections. The mean time between diagnosis and placement of the endoprosthesis was three days. The median stay in the ICU was 10 days. During the operation in two patients it was necessary to place a second stent due to misplacement of the first. Three patients (23%) suffered an arterial tear during the insertion and required reparatory surgery. Another case was complicated by mesenteric ischemia and a failed attempt to resolve it with a fenestrated balloon. Another two cases suffered adult respiratory distress syndrome. The mortality rate was 15% (2 cases), both due to multiorganic failure. The remaining 11 cases are alive after 6 months follow-up. CONCLUSION. 1. The typical patient in our study was a 70-year-old man with a type B dissection, hypertensive, presenting with chest pain, diagnosed by CT and whose stay in the ICU was 10 days. 2. The percutaneous insertion of an autoexpandable prosthesis in our patients excluded the false lumen with promising results, although not lacking morbidity. The in-hospital mortality rate was 15%. The 6-month survival in the remaining 11 cases was 100%.

137 IS CARDIAC OUTPUT REDISTRIBUTED DURING HEMORRAGIC SHOCK IN EWES? Dumans-Nizard V.1, Nizard J.2, Payen D.1, Cholley B. P.1 1Anesthesiology-Intensive Care, Hôpital Lariboisière, Paris, 2Gynecology-Obstetrics, Hôpital de Poissy, Poissy, France INTRODUCTION. Esophageal Doppler measures blood velocity in the descending aorta and estimates global cardiac output (CO) assuming that a fixed fraction of blood flow (= 30%) goes to supra aortic vessels (coronaries, subclavians, and carotids). To evaluate whether this assumption is grossly erroneous or not during extreme hemodynamic situations, we measured CO and the fraction devoted to supra aortic vessels (%Qsa) during hemorragic shock in ewes. METHODS. 9 anesthetized ewes were ventilated and underwent thoracotomy to allow the placement of two ultrasonic flowmeters (Transonic) on the aortic root and the descending aorta to measure CO (L/min) and descending aortic blood flow (Qd), respectively. The fraction devoted to supra aortic vessels was calculated as: %Qsa = (CO-Qd)/CO. Instantaneous blood pressure was monitored using a pressure transducer in the aortic root (Camino). After three stable baseline measurements, iterative blood substractions (150 to 200 ml, each) were performed to achieve a 15% reduction in total blood volume. This graded hemorrhage was followed by incremental restitutions of similar volumes. At each step of the protocol, heart rate (HR), mean blood pressure (MBP, mmHg), CO and %Qsa were acquired. Data were analyzed using ANOVA for repeated measures. RESULTS. Blood substractions resulted in a decrease in MBP from 104±6 to 80±16 mmHg (p<.05) and CO from 4.4±1.1 to 2.3±0.7 L/min (p<.05) without significant change in HR and %Qsa (37±11 vs. 35±8%, NS). Blood restitution completely restored MBP (103±16 mmHg) but not CO (3.2±1.1 L/min, p<.05 vs control). In addition, %Qsa was reduced with respect to control following blood restitution (27±10 %, p<.05). CONCLUSION. In our anesthetized ewes, baseline value of %Qsa was 37% and was not altered after hemorragic shock. Blood flow was redistributed away from supra-aortic territories following blood restitution. If our ovine model is representative of human shock, these data suggest that blood flow redistribution during hemorrhage and blood transfusion is responsible for inaccuracies of less than 10% in CO values, when estimated using esophageal Doppler.

138 THE EFFECT OF ANAESTHESIA ON TISSUE PERFUSION IN A PRESSURE-CONTROLLED MODEL OF HAEMORRHAGIC SHOCK Terzi R. G. G.1, Silva W. A.1, Moraes A. C.1, Dragosavac D.1, Araújo S.1 1Surgery, State University of Campinas (UNICAMP), Campinas, Brazil INTRODUCTION. In order to evaluate the results of resuscitation maneuvers, most of the pressure-controlled models of experimental hemorrhagic shock are carried out under general anesthesia. However, it is well known that anesthesia in hemorrhagic shock is associated to altered tissue perfusion. The hemodynamic and metabolic effects of this complicating factor in experimental hemorrhagic shock have not been clearly evaluated. METHODS. Forty young pigs (Large-White), mean weight 25K, underwent invasive hemodynamic monitoring (Swan-Ganz /BESE), arterial and venous blood gases (IL-1640) and blood lactate (BL) determinations. All animals received Halothane and were kept on anesthetic surgical stage III and divided in two groups: GI (FiHalothane = 0,75±0,25%) e GII (FiHalothane = 1,4±0,25%). In each Group, 10 animals were bled to a mean arterial pressure (MAP) of 30mmHg in ten minutes. MAP was held constant thrughout the experiment by additional bloodletting. In each Group ten animals followed identical protocol except bleeding. Hemodynamic and metabolic data were recorded before hemorrhage and every ten minutes thereafter, up to two hours. No animal was transfused or given any type of fluid replacement. RESULTS. Baseline MAP before bleeding exhibited significant difference between groups (GI = 88,10±14,03mmHg versus GII = 67,00±4,19mmHg. After bleeding, despite the fact that both Groups were kept at a MAP of 30mmHg, cardiac output (CO) in GI exhibited significant reduction, as early as twenty minutes after bleeding. Similarly it was observed a significant reduction in Base Excess in the blood (BEb) and an increase in BL, as well as in the venous-arterial PCO2 difference (Delta-PCO2) and in the arterial-venous pH difference (Delta-pH). All animals in GI died up to eighty minutes after bleeding. All animals in GII survived up to 24h after bleeding.

GI GII Signif CO (L/min) 1.21±0.57 2.09±0.40 p<0.01 Lactate (mM/L) 5.80±3.37 2.58±0.93 p<0.01 BEb (mM/L) -3.20±6.41 2.99±2.94 p<0.01 Delta-PCO2 (mmHg) 22.43±8.56 13.80±3.53 p<0.01 Delta-pH (mmHg) 0.14±0.06 0.06±0.02 p<0.01 Differences in CO and metabolic makers twenty minutes after bleeding

CONCLUSION. Anesthesia is an important complicating factor in experimental pressure-controlled hemorrhagic shock. Most of the published work suggesting the type and amount of fluid replacement, but not valuing this factor, should be seriously questioned. A metabolically driven experimental model (1) should be more expressive of the systemic physiologic insult, than are pressure-controlled experimental models. REFERENCES. (1) Terzi RGG, Batista ERM,Oliveira WC, Silva WA, Moraes AC, Alvim MCF. A fatal, metabolically driven, experimental hemorrhagic shock model, in immature swine. 21st. Annual Conference on Shock. The Shock Society. San Antonio, TX, 1998. Grant. FAPESP


141 FLUID DISTRIBUTION OF A NOVEL HYDROXYETHYL STARCH FORMULATION

ASSESSED BY BIOELECTRICAL IMPEDANCE

Consales G.1, Salucci L.1, Sardu A.1, Grechi S.1, Angiolini P.1, De Gaudio A.1 1Critical Care, University of Florence, Florence, Italy

INTRODUCTION. A new formulation of hydroxyethyl starch (HES 130/0.4 Voluven®) was developed in order to improve pharmacokinetics properties preserving volume effects(1). We evaluated the distribution of fluid in body compartment after administration of HES 130/0.4 and of standard starch formulation(HES 200/0.5)using a bioelectrical impedance method,that measuring resistive forces (Rz) that tissues oppose to electricity flow,allows a non invasive assessment of total body water and extracellular water(ECW)(2). METHODS. 23 patients admitted to ICU for postoperative monitoring after major abdominal surgery were studied. Hystory of allergy and of renal insufficiency were exclusion criteria.Patients(male=12 female=11 mean age 68±5 omogeneous for SAPS II) were randomly subdivided in two groups:G1(n=12)received HES 130/0.4,G2(n=11)received HES 200/0.5 as the exclusive artificial colloid(10ml/kg in 30min)for profilaxis of hypovolemia.Cristalloids were added as needed to mantain fluid balance.For bioelectrical impedance analysis two surfacestimulating electrodes were applied distally to metacarpal and metatarsal line.Two sensor electrodes were applied on the omolateral wrist and ankle.Applaying an alternate current (50 hertz, 800 mA) the device (STA/BIA RJL Akern System Florence Italy) measures the bioimpedance that is proportional to the tissue water content.A new software arrangement allows to measure the ECW without considering the height of the patient.The measurements were conducted before the administration of colloids (T0) and then every 6 hours for 24 hours (T1=6h T2=12h T3=18h T4=24h). In all patients invasive BP, PVC and urine output were monitored.Results were compared (ANOVA) between the two groups.Untoward effects were recorded. RESULTS. Results are expressed as mean±SD.Basal Rz (G1=561±48 G2=589±33 Ohms) and ECW(G1=44±5 G2=43±3 %) do not show statistical intra nor inter group differences. In all patients Rz was increased (G1=965±34 G2=943±54 Ohms)and ECW was reduced G1= 35±3 G2=37±2 %) at T1, T2 and at T3 (p<0,01) while at T4 Rz and ECW were back to basal values. G1 patients showed values of ECW slightly lower at T1,T2 and T3 compared to G2 patients but this difference was not statistically significant.Hemodynamic stability was mantained in all patients,PVC remains stable and urine output was 1-2 ml/kg/h throughout the study period. No untoward effects were detected. CONCLUSION. The 6% HES 130/0.4 was as effective as 6% HES 200/0.5 in mantaining hemodynamic stability. Although the renal elimination of HES 130/0.4 is more rapid and complete, volume effect is similar in terms of entity and of duration,as demonstrated by bioelectrical impedance. We conclude that HES 130/0.4 is as effective as HES 200/0.5 but,due to its more favorable pharmacokinetic profile, it seems an useful alternative to standard HES formulations, althought further studies in a larger number of patients are needed to confirm our results. REFERENCES. 1Waitzinger Clin Drug Invest 1998 16 2 151 2Talluri Coll Antropol 1998 22 2 427

142 SURVIVAL PREDICTION IN CIRCULATORY SHOCK: IS BLOOD

LACTATE/PYRUVATE BETTER THAN LACTATE LEVELS?

Carvalho F. B.1, Orellana-Jimenez C. E. A.1, Rimachi R.1, De Backer D.1, Vincent J. L.1

1Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium INTRODUCTION. Blood lactate concentrations are reliable predictors of survival in circulatory shock, but the significance of hyperlactatemia in septic shock has been challenged. The objective of this study was to compare the prognostic value of blood lactate / pyruvate (L/P) ratio to lactate concentrations in the first 24 hours of shock treatment. METHODS. Blood pyruvate, lactate, base excess (BE), mixed venous oxygen saturation (SvO2), and mean arterial blood pressure (MAP) were measured every 4 hours for the first 24 hours of cardiogenic (n=11) and septic shock (n=9). A Receiver Operating Curve (ROC) was used to compare the pooled variables. All p values < 0.05 were considered significant. RESULTS. The 20 patients had an APACHE score of 21 (16-24) and a SOFA score of 10 (8-12) Nine patients survived. Areas under ROC (95% CI) were:

Lactate L/P ratio BE MAP SvO2 All patients n=20

0.846(0.772-0.920)*

0.756(0.665-0.848)*

0.786 (0.702-0.870)*

0.751(0.660-0.842)*

0.575 (0.456-0.694)

Septic shock n=9

0.938(0.877-0.998)*

0.874(0.770-0.977)*

0.871(0.761-0.980)*

0.846(0.742-0.949)*

0.813(0.614-0.941)*

Cardiogenic shock n=11

0.757(0.630-0.885)*

0.642(0.498-0.785)+

0.760 (0.636-0.884)*

0.701 (0.559-0.842)+

0.711 (0.562-0.861)+

*p < 0.0001, +p<0.05

CONCLUSION. L/P ratio is not superior to blood lactate levels as a predictor of survival in circulatory shock.

139 PREDICTION OF THE HAEMODYNAMIC EFFECTS OF VOLUME EXPANSION IN CRITICALLY ILL PATIENTS Ochagavia A.1, Baigorri F.1, Mendoza D.1, Saura P.1, Artigas A.1 1critical Care Center, Hospital De Sabadell. Corporació Parc Tauli, Sabadell, Spain INTRODUCTION. Objetives:1)To determine whether the analysis of cyclic respiratory changes in blood pressure is a better predictor of fluid responsiveness than intravascular pressures, and right ventrICUlar volumes obtained by pulmonary artery catheterization (PAC)2)To determine whether the analysis of respiratory changes of plethysmographic signal produced by pulse oximeters could be useful as a substitute of blood pressure analysis to predict fluid responsiveness. METHODS. Up to date, 18 mechanically ventilated patients without arrhythmias, and requiring invasive hemodynamic monitoring (PAC with fast-response thermistor)for clinical purposes have been included. Five hundred ml of hydroxyethylstarch were given to those patients who have clinical conditions that suggested the possibility of inadequate preload if indicated by the primary physician. Data recorded before and then 30 minutes after volume expansion: right atrial pressure, pulmonary artery occlusion pressure, cardiac output, right ventrICUlar ejection fraction and volumes, respiratory changes in systolic blood pressure, respiratory changes in pulse pressure expressed as a percentage. These parameters were compared in responders (cardiac index increase >= 15%) and non-responders (cardiac index increase < 15%) patients wiht Mann-Whitney U test. The predictive value of these parameters was also compared (ROC curves) RESULTS. Out of 18 studied patients, 6 were responders and 12 non-responders. Basal right ventrICUlar end-diastolic volume index (RVEDVI) was significantly lower in responders than non-responders patients (mean:88 ml/m2, CI 95% 55-120 vs mean:118 ml/m2, CI 95% 105-130, p=0.028). The area under the curve was 0.826 (CI 95% 0.572-1.081). We did not find statistically significant differences in any other parameter studied. CONCLUSION. In our preliminary study, reproducing common clinical practice, the analysis of cyclic respiratory changes in blood pressure in mechanically ventilated patients does not seem a better predictor of fluid responsiveness than conventional hemodynamic parameters. In addition, RVEDVI is the best predictor of hemodynamic effects of volume expansion.

140 HAEMODYNAMIC BENEFITS OF A 24-HOUR INFUSION OF LEVOSIMENDAN IN

PATIENTS WITH SEVERE HEART FAILURE

Colucci W. S.1, Slawsky M. T.2, Kivikko M.3 1Cardiovascular Section, Boston University Medical Center, 2Veterans Affairs Medical Center, Boston University, Boston, United States, 3Cardiovascular Projects, Orion Pharma, Espoo, Finland INTRODUCTION. Levosimendan is a calcium sensitiser used to treat acute decompensated heart failure. By increasing myocardial contractility and inducing vasodilation, levosimendan increases cardiac output and decreases preload while having no significant effect on oxygen consumption. The cardiovascular effects of 24- and 48-hour infusions of levosimendan in patients with NYHA class III–IV heart failure were determined. METHODS. In phase 1, patients received either levosimendan (n=98) in increasing doses up to a maximum of 0.4 microg/kg/minute, or placebo (n=48). Patients who received levosimendan in phase 1 continued to do so at half the original dose for the following 18 hours (phase 2). In phase 3, patients were again randomised to receive either levosimendan (LS+; n=42) or placebo (LS-; n=43), which were infused for a further 24 hours at the same rate given during phase 2. Haemodynamic measurements and cardiac performance were determined using a right-sided Swan–Ganz catheter and thermodilution, respectively, at 6, 24 and 48 hours. RESULTS. Significant increases in cardiac output and stroke volume, and decreases in pulmonary capillary wedge pressure, pulmonary artery pressure, right atrial pressure and systemic and pulmonary vascular resistances were observed in patients after a 6-hour infusion of levosimendan compared to placebo (p<0.001). Improved symptoms of heart failure paralleled the enhanced haemodynamics observed. At 24 h, pulmonary capillary wedge pressure (p<0.001) and systemic vascular resistance (p=0.033) had decreased further compared to measurements at 6 h (Table 1). Stroke volume and cardiac output increased but not significantly. The enhanced haemodynamic parameters and cardiac performance observed at 6 and 24 h were maintained at 48 h, regardless of treatment received during phase 2 (Table 1). The sustained benefits observed at 48 h may be associated with increased plasma concentrations of the active metabolite of LS, OR-1896, seen in both treatment groups (7.2±4.6 and 6.2±3.6 ng/ml, respectively).

Baseline 24 hours change 48 hours p-valueCO (litres/minute) 3.6°0.1 LS+ 5.2°0.2; LS-

5.2°0.2 + 0.5°0.2; +0.2°0.2 0.333

SV (ml/beat) 46.3°1.7 LS+ 62.2°3.3; LS- 62.9°3.2

+ 1.2°2.2; – 0.4°2.2 0.558

PCWP (mmHg) 26.8°0.9 LS+ 18.0°1.2; LS- 19.5°1.2

- 0.3°0.8; 0.0°0.8 0.814

PAP (mmHg) 38.4°1.1 LS+ 31.0°1.4; LS- 30.3°.4

0.0°1.0; + 0.3°1.0 0.790

SVR (dyne/s/cm5) 1753°65 LS+ 1127°64.0; LS- 1166°63.0

- 88°46; – 84°46 0.956

Table 1 CONCLUSION. Comparable haemodynamic improvements were attained after 24- and 48-hour infusions of levosimendan in patients with severe heart failure. Prolonged effects were observed at 48 hours even after discontinuation of levosimendan infusions at 24 hours. This may result from slow accumulation of the active metabolite OR-1896.


143 GOAL DIRECTED THERAPY DOES NOT HAVE TO BE "PRE"OPTIMISATION

Hamilton M. A.1, Grocott M. P. W.1, Bennett D.2, Rowan K.3 1Centre for Anaesthesia, University College London, 2Department of Intensive Care Medicine, St Georeges Hospital Medical School, 3Scientific Director, Intensive Care National Audit and Research Centre, London, United Kingdom

INTRODUCTION. Perioperative goal directed therapy, optimisation or "preoptimisation" has been demonstrated in a number of randomised controlled trials to reduce mortality following surgery 1,2. It is commonly believed that to be effective this intervention needs to be commenced prior to surgery which has significant resource implications. A recent report of early goal directed therapy in severe sepsis demonstrated reduced mortality in the protocol group for a simiar intervention, albeit in a differant context, given after the physiological insult 3. As part of a systematic review of perioperative goal-directed therapy we conducted a subgroup analysis to assess the effect of timing relative to surgery on treatment effect for this style of intervention. METHODS. Data sources: MEDLINE, EMBASE and Cochrane Controlled Trials Register, Snowballing of identified studies and reviews, industry and experts contacted. Study selection: Randomised controlled clinical trials. Study population: Adults undergoing surgery. Intervention: Perioperative administration of fluids and/or vasoactive drugs (Commenced form 24 hours before to 6 hours after surgery)targeted to increase global blood flow to explicit measured goals. Outcome: Mortality. Analysis: Published peer reviewed papers, Peto Odds Ratio for mortality – a priori subgroup analysis of preoperative (24 hours before surgery to entry into anaesthetic room), intraoperative (entry into anaesthetic room to end of surgery) and postoperative (end of surgery to 6 hours post surgery)periods. RESULTS. 12 studies including 1252 patients met the inclusion citeria. Overall mortality 6.2%. Peto Odds Ratio(95% CI): Preoperative 0.32 (0.19-0.55)n =706, Intraoperative 0.24 (0.05-1.24)n=144, Postoperative 0.34 (0.13-0.89)n=453. (Note total n>1252 due to 1 study having two intervention groups with 1 control group). CONCLUSION. Perioperative administration of fluids and/or vasoactive drugs targeted to increase global blood flow to explicit measured goals reduces mortality when commenced in the preoperative or postoperative (up to 6 hours following surgery) periods. A similar treatment effect, although not statistically significant, is observed when the intervention is commenced during the operation (entry into anaesthetic room to end of surgery) but fewer patients are contained in the studies available for inclusion. REFERENCES. 1 Shoemaker WC et al. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988 Dec;94(6):1176-86 2 Boyd O et al. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 1993 Dec 8;270(22):2699-707 3 Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001 Nov 8;345(19):1368-77 Grant. Elan Pharma, Special Trustees of University College London Hospital

144 PRACTICE SURVEY ON VASOPRESSOR AND INOTROPIC DRUG THERAPY IN

SCANDINAVIAN INTENSIVE CARE UNITS

Rossi P.1, Oldner A.1, Åneman A.2, Kàrason S.2 1Anaesthesia and Intensive care, Karolinska Hospital, Stockholm, 2Anaesthesia and Intensive care, Sahlgrenska University Hospital, Gothenburg, Sweden INTRODUCTION. Modern intensive care involves several therapeutic options of circulatory support. However, the selection of drugs, aims of treatment and strategies for monitoring may vary considerably between different ICU’s. This survey was performed to analyse the rationale for use and monitoring of vasopressor/inotropic drug therapy in Scandinavian ICU’s. An Internet based reporting system was implemented using the recently formed Scandinavian Critical Care Trials Group as a communication platform. METHODS. 223 ICU’s were identified in the Scandinavian countries and invited to participate in a one-day point prevalence study. An Internet based database was constructed and a practice survey protocol designed to identify haemodynamic monitoring, indications for vasopressor/inotropic therapy, fluids for volume loading, pre-treatment circulatory state and actual and targeted haemodynamic variables. Patients were eligible for the study if on vasopressor/inotropic therapy for more than 4 hours. The inclusion time was 8 am to 5 pm during a weekday. RESULTS. 114 ICU’s (51 university, 22 regional, 41 community hospitals), representing 925 ICU beds, reported 114 adult patients matching the inclusion criteria. 67% of the patients had received vasopressor/inotropic support for > 24 hrs and 32 % received more than one drug. Arterial hypotension (92%) and oliguria (50%) were the far most common indications for therapy in adults even when patients were subgrouped for main diagnostic category (sepsis, trauma, cardiac failure, postoperative etc). Fluid loading prior to therapy was reported in 87% of cases with Acetated Ringer (47%), saline (41%), starches (48%), dextrane (27 %), albumin (18%) and plasma (33%). Dopamine (47%) and noradrenaline (44%) were the most commonly used drugs followed by dobutamine (24%). Dopamine doses < 3 ug/kg/min were seen in less than 5%. No other drug exceeded 10 %. Non-catecholamine drugs were rarely used even in cardiac failure patients. Dopamine and noradrenaline were the most commonly (47%) combined inotropic drugs. In accordance with indications, mean arterial pressure was the most commonly used target aiming at MAP 60-69 mm Hg (37%) and 70-79 mm Hg (50%). In more than 95% of patients, invasive arterial pressure monitoring was used and central venous pressured was measured in 90% of patients. Pulmonary artery catheters were used in 19%. Other cardiac output monitoring techniques (Picco, CO2 rebreathing, aortic Doppler etc) were used in 7% of the patients. CONCLUSION. Dopamine and noradrenaline seem to be the most commonly used inotropic drugs in Scandinavia, even during combined drug therapy. Renal dosing of dopamine is largely abandoned. Traditional indications for inotropic support as hypotension and oliguria are still dominating. Invasive monitoring was used in almost all patients whereas a limited use (<20%) of pulmonary artery catheters was noted.

145 ISCHEMIC SKIN LESIONS AS A COMPLICATION OF VASOPRESSIN INFUSION:

INCIDENCE AND RISK FACTORS

Dünser M. W.1, Mayr A. J.1, Knotzer H.1, Pajk W.1, Friesenecker B.1, Hasibeder W. R.1 1General and Surgical Intensive Care Medicine, University Hospital, Innsbruck, Austria INTRODUCTION. Ischemic skin lesions (ISL) have been reported to complicate high dosage therapy with vasopressor catecholamines (1). Arginine-vasopressin (AVP) is an alternative, powerful vasopressor agent which may be used in catecholamine-resistant vasodilatory shock (2). Whereas development of ISL have been reported during AVP therapy in patients with upper gastrointestinal bleeding, no data on incidence and risk factors for the development of ISL during AVP therapy in catecholamine-resistant vasodilatory shock exist. METHODS. All patients receiving a continuous AVP infusion because of vasodilatory shock between January 1998 and June 2001 were reviewed for the development of ISL during AVP therapy. Demographic, hemodynamic, laboratory data, and skin status were evaluated 24 hours before and during AVP therapy (24 and 48 hours). Patients were grouped according to development of new ISL during AVP therapy. A mixed effects model was used to compare groups. A multiple logistic regression analysis was used to identify independent risk factors for the development of ISL. RESULTS. ISL developed in 19 of 63 patients (30.2%). Thirteen of 19 patients (68%) developed ISL in distal extremities, 2 patients (10.5%) of the trunk, 4 patients (21%) in distal extremities and trunk. Five patients (26%) had additional ischemia of the tongue. Body mass index, preexistent peripheral arterial occlusive disease, presence of septic shock, and norepinephrine requirements were significantly higher in patients developing ISL. ISL patients received significantly more units of fresh frozen plasma and thrombocyte concentrates than patients without ISL. Preexistent peripheral arterial occlusive disease and presence of septic shock were independently associated with the development of ISL during AVP therapy. CONCLUSION. Ischemic skin lesions are a common complication during continuous AVP infusion in patients with catecholamine-resistant vasodilatory shock. Presence of septic shock and a history of peripheral arterial occlusive disease are independent risk factors for the development of ISL. REFERENCES. 1. Hayes MA, Yau EHS, Hinds CJ, et al. Symmetrical peripheral gangrene: association with noradrenaline administration. Intensive Care Med 1992; 18: 433-436 2. Dünser MW, Mayer AJ, Ulmer H, et al. The effects of vasopressin on systemic hemodynamics in catecholamine-resistant septic and postcardiotomy shock: a retrospective analysis. Anesth Analg 2001; 93: 7-13

146 A NATIONAL POSTAL SURVEY ON DOPEXAMINE HYDROCHLORIDE IN

INTENSIVE CARE: VIEWS AND CLINICAL PRACTICE

Weigert A.1, Ratnam V.1, Nathwani D.1 1Department of Anaesthesia and Intensive Care, West Middlesex University Hospital, Isleworth, United Kingdom INTRODUCTION. To evaluate opinions and clinical practice among British intensive care clinicians with regard to use of dopexamine. METHODS. 272 general intensive care units were identified from the Intensive Care National Audit & Reasearch Centre (ICNARC) database and a postal questionnaire sent to the lead clinicians. Telephone follow-up was performed if the questionnaire was not returned within 4 weeks. Coded replies were analysed with a standard statistical package at a significance level of 0.05. RESULTS. 226 responses were obtained (85%). Of these, 59% used dopexamine. There was no significant difference in the use of dopexamine with regard to unit size or region. Dopexamine was widely used in unlicensed indications. These were impaired gut perfusion (81.2%, believed licensed by 42.6%), poor urine output (51.9%, believed licensed by 28.9%), sepsis (47.4%, believed licensed by 28.6%), preoptimisation (37.6%, believed licensed by 42%) and persistent metabolic acidosis (39.1%, believed licensed by 21.2%). 50% of consultants used dopexamine at a rate of less than 1mcg/kg/min, and 17% of users exceeded 2 mcg/kg/min. Monitoring during dopexamine therapy included cardiac output monitoring (55.6%) and monitoring of end-organ function (34.5%). 19.5% of users had guidelines for dopexamine administration. Three-quarters of all responders felt dopexamine had a role in improving gut perfusion. There was less consensus regarding its role in sepsis (47% thought it useful, 53% disagreed) and renal rescue therapy (39% thought it useful, 61% disagreed). 31% felt that dopexamine contributed to improved outcome in intensive care patients. Indications thought to be licensed reflected the views on the role of dopexamine in clinical practice. 34.1%thought it was licensed for improving gut perfusion, preoptimisation (28.8%), sepsis (20.8%), poor urine output (15.5%) and persistent metabolic acidosis (8.4%). 60% of responders were aware of the product license for low output states following cardiac surgery, but only 30% correctly identified exacerbation of chronic heart failure as a licensed indication. CONCLUSION. Our representative survey shows that dopexamine is widely used in British general intensive care units, mainly improving gut perfusion, renal rescue and sepsis, with less agreement about its usefulness in preoptimisation and metabolic acidosis. There is a widespread lack of awareness that dopexamine is not licensed for any of these indications(1). More formal research into clinical and outcome benefits of dopexamine is required (2). REFERENCES. 1. Elan Pharma. Dopacard. Sat Jul 21,2001. http//emc.vhn.net 2. Takala J, Meier-Hellmann A, Eddleston J, Hulstaert P, Sramek V; for the European Multicenter Study Group on Dopexamine in Major Abdominal Surgery: Effect of dopexamine on outsome after major abdominal surgery: A prospective, randomised controlled multicenter study. Crit Care Med 2000 Vol.28, No10, pp3417-3423


149 BRAIN DEATH DIAGNOSIS COMPARISON IN THE ICU OF TWO HOSPITALS

FOLLOWING SPAIN'S NEW TRANSPLANT LAW

Gracia R.1, Arraez V.2, Pont T.1, Deulofeu R.1 1Transplant Management, HGU Vall d'Hebron, Barcelona, 2Intensiv Care Departament, HGU d'Elx, Elx, Spain

INTRODUCTION. Application of the new transplant law allows for the use of the ideal medical test in each case for brain death (DB) diagnosis, including the systematic and thorough neurological examination as the only procedure when this is free of interferences. METHODS. A study of BD diagnosis, after application of the transplant law 2070/1999 in 2 university hospital I.C.U.'s (type 1 and type 2) between 2000 and 2001. There are three types of hospitals for organ donation in Spain: Type 1: with neurosurgery and transplant programs; Type 2: with neurosurgery but without transplant and Type 3: only authorized for organ extraction, without neurosurgery. We have prospectively collected all kinds of medical tests used for BD diagnosis in potential organ donors in both centres and then analysed the differences. RESULTS. Having studied 107 potential donors we can sum up the differences between the numbers of tests in the two centres: Note that complicated BD is when the clinical exam in not enough to produce diagnosis and an instrumental test is required. (See the table).In both centres the clinical examination was carried out in all patients.The type 2 hospital only has as instrumental test EEG and TCD (Transcranial Doppler). In only one case the presence of depressing drugs complicated the case and the only test carried out was TCD. Habitually, the test carried out was EEG when levels of depressing drugs were undetectable. The TCD was incomplete in 70% of cases and could not be considered.The type 1 hospital has EEG, TCD, gammagrah and evoked potentials for diagnosis of BD. Instrumental tests were also done in 96, 5% of the cases. EEG was done in 82.5% and TCD in 45, 3% of patientes. 49 cases were complicated BD. This made the instrumental test compulsory in all of them. EEG was carried out in 30 patients (although it had no legal value) plus another instrumental test. Tests had to be repeted in 9 cases. In 17 patients TCD was the only instrumental test done, while the ggraphy in 22 and evoked potentials 1.

Type 1 hospital 86 BD

Type 2 hospital 21 BD

complicated non-complicated complicated non-complicated 49 37 1 20 clin. exam 0 3 0 0 1 test 9 29 1 10 2 test 35 3 0 10 3 test 5 2 0 0

CONCLUSION. The previous law'99 demanded that 2 EEGs at 6h intervals be carried out to BD diagnosis. Although there has been a change in the Transplant Law, in both hospitals no real donor has been diagnosed of BD through repeated clinical examination. EEG is still carried out as a routine, independently of its legal value and used as a test to support diagnosis, a hang-over from the previous law. This culture of redundant test could be costly, both in terms of time (family suffering, length of stay) and money.

150 LIMITATING OF LIFE SUPORT IN CRITICALLY ILL PATIENTS

Parizkova R.1, Cerny V.1, Dostal P.1 1Anesthesiology and Intensive Care, Charles University Faculty of Medicine, Hradec Kralove, Czech_Republic INTRODUCTION. An increasing number of deaths in the intensive care setting involve withholding or withdrawing multiple life-sustaining therapies. Terminal care decisions are increasingly common, however the practice of limiting life support therapy in dying critically ill patients varies between countries. The aim of the study was to examine the frequency and practice of limiting therapy at tertiary care hospital ICU in Czech Republic. METHODS. A retrospective, descriptive study of all patients who died or in whom life support was withdrawn or withheld in period 1998-2001 was conducted. Number of admissions, number of patients with limiting therapy, Apache II score, SOFA score, length of ICU stay in days (LOS), type of admission (primary, secondary within 24 hours, secondary after 24 hours), diagnostic category, reason for limiting therapy, way of limiting therapy (withdrawing or withholding), time from admission to decision, time from decision to death and adequacy of documentation were evaluated. Statistical analysis was performed using SigmaStat Statistical Software. RESULTS. Only selected results are presented. There were 130 deaths out of 681 patients admitted in 1998-2001. Except for four, all patients were admitted at the time of admission for unrestricted and full therapy. There were 60 patients with severe brain damage and 70 patients without severe brain damage. Decision to limit life support therapy before death was made in 80 patients (61,5%). Withholding therapy was performed in 17 patients, withdrawing therapy in 63. Terminal weaning as a part of withdrawing therapy was employed in 46 patients (73% of all withdrawal therapy). CONCLUSION. End-of-life care is an important part of high-quality intensive care unit. The rate of withdrawing or withholding therapy decisions in dying patients occurred more frequently comparing to some studies (1,2). Increasing proportion of employment of ventilatory support withdrawal has been found in years 2000 and 2001. REFERENCES. 1. Smedira NG, Evans BH, Grais LS et al: Withholding and withdrawal of life support from the critically ill. NEJM, 1990, 322, 309-315. 2. Zimmermann JE, Knaus WA, Sharpe SM et al: The use and implications of do not resuscitate orders in intensive acre units. JAMA, 1986, 255, 351-356.

Poster Sessions Auditing and improving the quality of ICU practices – 147-160 147 JUSTIFYING OUR EXISTENCE – AN EPIDEMIOLOGICAL APPROACH

Ramsay S. J.1, Gomersall C. D.1, Joynt G. M.1, Tan P.1, Lam C.1, Ng K. L.1 1Dept of Anaesthesia & Intensive Care, Chinese University of Hong Kong, Shatin, Hong_Kong

INTRODUCTION. We have previously demonstrated that Intensive Care is independently associated with improved survival (1). To progress from association to true causation we must satisfy a number of criteria including demonstration of a population dose-response relationship. METHODS. We studied all adult patients referred for potential unplanned admission to our 22-bed university affiliated multidisciplinary Intensive Care Unit (ICU) over two time periods (1st December 1997 to 1st July 1998 = cohort 1; 1st December 2000 to 1st July 2001 = cohort 2). Both cohorts therefore consisted of both admitted and refused patients. Basic demographic data, time from hospital admission to ICU referral, MPM II0 score, APACHE II diagnostic category, admission status (admitted or refused) and hospital survival data were collected. Excluded patients were those referred when our ICU was closed to admissions due to lack of empty beds, burns cases and patients referred directly from another ICU. Standardized mortality ratios (SMR) for admitted and refused patients were used to assess ICU and ward performance respectively. RESULTS. Admission rates and hospital survival were significantly higher in the second time period. Basic demographics, case mix and performance were not significantly different. Even after adjusting for non-significant improvements in ward and ICU performance the improvement in survival remained significant; adjusted cohort 2 mortality = 40%, p < 0.05.

Cohort 1 (n=634) Cohort 2 (n=711) p value ICU admission rate (%) 62 74 <0.0001 Mortality (%) 46 36 <0.0005 Age (mean (SD)) 61.0 (18.0) 60.9 (17.8) NS Days to referral (median (IQR))

0 (0-3) 1 (0-3) NS

MPM II0 (mean (SD)) 0.43 (0.30) 0.39 (0.28) NS SMR – Refused (95%CI) 1.24 (1.16-1.36) 1.05 (0.95-1.17) NS SMR – Admitted (95%CI) 0.93 (0.87-1.00) 0.85 (0.80-0.90) NS APACHE II diagnostic weighting(median (inter-quartile range))

-0.14 (-0.424 to 0.393)

-0.185 (-0.584 to 0.352)

NS

CONCLUSION. There is a population dose response relationship between Intensive Care and survival; provide more Intensive Care by admitting more patients to ICU and survival increases. Previous data suggest a strong independent association between Intensive Care and improved outcome (1). It is biologically plausible that Intensive Care will increase survival and this is supported by animal data. Most but not all the criteria for proof of causation are therefore satisfied. It is highly likely that Intensive Care improves survival. REFERENCES. 1. Gomersall CD et al. Does Intensive Care improve outcome? Crit Care 1999, 3(Suppl 1):P249

148 ORGAN DONATION AND BRAIN STEM DEATH: AN AUDIT IN THE INTENSIVE

CARE UNIT

Awad I. T.1, Rohan D.1, Fanning R.1, Counihan A.2, Cunningham P.2, Dwyer R.1 1Anaesthesia and Intensive Care, 2Organ procurement and transplantation, Beaumont Hospital, Dublin, Ireland

INTRODUCTION. Great advances have been achieved with solid organ transplantation. However, shortage of organs remains a serious barrier to organ donation throughout the world (1). The solid organ donor per million of population (pmp) in the UK and Ireland have shown a steady fall from 15.6 in 1990 to 12.5 in 1999 (2). the objectives of this study is to identify the major causes of missed potential organ donors and the causes of solid wastage in the national transplantation centre in Ireland. METHODS. Following Institutional Ethical Approval, 12 months retrospective and 6 months prospective audit of all deaths in the intensive care unit of the national transplantation and neurosurgical centre of Ireland. A structured audit data sheet was completed for each patient who died during the study period using information taken from the patient's medical records, nursing staff notes, the patient clinical progress in the intensive care unit and by discussing the potential donor with the caring medical specialist. The informations were subsequently entered into a computerised excel database. RESULTS. Out of a total number of 354 patients died during the study period, 155 were identified a potential donors. The cause of death is shown in table 1. The number of patients who were suspected brain stem dead (BSD) but not tested was 78, while the number of patients who were formally tested was 77. The number of actual donors was 37. Failure of a formally tested BSD patient to become an actual donor was due to; relative refusal 25 (62%), medical contraindications to organ donation 5 (12%), organ donation not being discussed with the family 6 (15%), and others 4 (10%). Logistic reasons were the main factor contributing to organ wastage in actual donors. Of the 78 potential donors who were not tested, 50 (64%) died before testing, treatment was withdrawn in 17 (22%), and preconditions were not fulfilled prior to brain stem testing in the remaining 11 (14%) patients.

Number (%) Cerebrovascular accident 69 (44) Head injury 57 (37) Primary cerebral tumour 13 (8) cerebral hypoxia and infection 16 (10) Causes of death of potential donors. Number (%)

CONCLUSION. Early involvement of the transplant coordinators can play an important role in reducing the number of consents denied by families and also help in reducing the number of organs wasted due to logistic reasons. Aggressive haemodynamic management and promp early brain stem testing of potential donors is required. REFERENCES. 1. First MR. the donor supply. Transplant proceeding 1997; 67: 29. 2. Donor audit report 1990-1999. Uk transplant.


151 HALLUCINATION, NIGHTMARES AND DREAMS IN INTENSIVE CARE PATIENTS

Capuzzo M.1, Valpondi V.1, Cingolani E.1, De Luca S.1, Gianstefani G.1, Grassi L.2, Alvisi R.1

1Dept of Surgical, Anaesthetic and Radiological Sciences, Section of Anaesthesia and Intensive Care, 2Dept of Medical Sciences, Communication and Behaviour, Section of Psychiatry, Ferrara, Italy

INTRODUCTION. It has been reported that 38% of patients staying in Intensive Care Unit (ICU) longer than 24 h remember hallucinations and both unpleasant (nightmares) and non unpleasant dreams (HND) after ICU discharge [1]. The aim of this study was to state the incidence of those experiences in the patients with ICU-stay longer than 3 days and the relationship between presence of HND and clinical variables. METHODS. Adult (>18y) ICU survivors without history of major affective disorders, who were consecutively admitted during 1 year and stayed in ICU at least 3 days, were interviewed one week after ICU discharge. To investigate the recall of intensive care, the ICU Memory Tool [2] was administered. Past medical history and clinical variables, including the sedatives administered in ICU, were recorded. Statistical analysis was performed using ANOVA, Mann-Whitney and Chi-square tests and logistic regression. RESULTS. Out of the 100 patients enrolled in the study, 84 (median SAPS II 34) were interviewed. No difference was found between patients interviewed and non-interviewed. Five patients (5.9%) were confused and did not remember to have been in ICU, leaving 79 patients for the subsequent analysis. Thirty-seven patients (46.8%) reported at least one of HND: 12 reported only hallucinations, 6 only nightmares, 6 only dreams and 13 patients more than one of those memories. Patients reporting at least one of HND had significantly more frequently infection than those without HND (21 of 37 that is 56.8% vs 16 of 42 that is 26.2%; p=0.007) and also higher maximal body temperature (38.2±0.6 vs 37.7±0.8, respectively; p=0.004). The propofol was administered to 14 of 37 (37.8%) patients with HND and to 4 of 42 (9.5%) cases without HND (p=0.003); the physical restrain was adopted in 13 of 37 (35.1%) and in 5 of 42 (11.9%), respectively (p=0.017). The logistic regression analysis showed that only temperature of at least 38°C was significantly associated with HND memories (coefficient beta 1.656; p<0.004). The odds ratio was 2.5 (CI95% 1.6-4.1). Nearly all of HND were visual; animals and feelings involving the environment were the most frequent experiences. CONCLUSION. Nearly half of the patients staying in ICU longer than 3 days have at least one of HND. The patients with fever (temperature of at least 38°C) during the ICU stay are 2.5 times more likely to report HND memories after discharge from the ICU. REFERENCES. 1. Rundshagen I, Schnabel K, Wegner C, Schulte am Esch J. Incidence of recall, nightmares and hallucinations during analgosedation in intensive care. Intens Care Med 2002; 28: 38-43. DOI 10.1007/s00134-001-1168-3 2. Jones C, Humphris G, Griffiths RD. Preliminary validation of the ICUM tool for assessing memory of the intensive care experience. Clin Intensive Care 2000; 11: 251-253 Grant. Ministero dell’Università e della Ricerca Scientifica e Tecnologia

152 EMERGENCY PHYSICIANS PERCEPTION OF PALLIATIVE CARE IN

PREHOSPITAL MEDICINE

Lantéri-Minet M.1, Bourgeois S.1, Motamed G.2, Auger H.1, Behforouz N.1, Jourdain X.1, Lepresle E.1, Margenet A.1, Duvaldestin P.1 1SAR, Hopital Henri-Mondor, Créteil, 2Service de Gérontologie, Hopital Emile-Roux, Limeil Brévannes, France INTRODUCTION. Palliative care is an increasing part of the activity of prehospital emergency medicine however the physician’s perception of this issue has not been assessed. METHODS. In a prospective study coordinated at the SAMU (prehospital emergency medical service), all telephone calls in relation to patients necessitating palliative care were recorded. Palliative care was defined according to the French Society of Palliative Care Medicine 1996. Duration of the study was 8 consecutive months. The following parameters were recorded: the necessity or not to send a medically staffed ambulance (SMUR), the necessity or not to hospitalize, the perception of the SMUR physician (SP) on several issues including the relief of the patient after the visit, the presence of psychological pressure from the family or friends to resuscitate, the possibility to keep patients at home and the satisfaction about the final destination. RESULTS. 37 phone calls were transmitted to the physician dispatcher (PD). For 26 of them a SMUR was send. Discrepancy existed between the perception of the SP and the PD toward the necessity to send a SMUR immediately after the call 54% versus 70%, p<0.05, but this difference was not significant after the SP visit. Pressure for resuscitation from family members or friends was perceived not more than 8%.The SP estimated to have adequately relieved the patient in 62% of cases and assisted family and friends in 78%. If a hospitalization was necessary (36%), 14 out of 26 of SP were satisfied about the final destination while 80% were satisfied if a home based treatment was decided. CONCLUSION. SP express concerns about the issue of palliative care in prehospital emergency medicine. Active coordination of different care-takers including practical guidelines are mandatory.

153 INCIDENTS DURING TRACHEAL INTUBATION IN ICU: EVALUATION OF A TRAINING PROGRAMM AND WRITTEN POLICIES Auriant I.1, Annane D.2, Sharshar T.2, Clair B.2, Shadda K.2, Orlikowski D.2, Normand S.2, Raphael J.2, Gajdos P.2 1Surgical respiratory ICU, Respiratory ICU, Marie Lannelongue Surgical Center, le plessis robinson, 2Medical ICU, Raymond Poincaré Hospital, Garches, France INTRODUCTION. While tracheal intubation is generally a simple and safe procedure in the operating room, the consequences of failed intubation can be devastating. The aim of the study was the development and evaluation of a training program and written policies for tracheal intubation in ICU. METHODS. A prospective study was performed, for a 51 months period, in an 17 beds medical ICU. Four types of incidents were defined: Material incident, Hypotension, Hypoxemia, Procedure longer than 20 minutes. Tracheal intubations were prospectively studied before and after written procedure were worked out. RESULTS. 342 adult patients were included. The number of incidents was regularly decreasing during the 4 years of the study : 68.06% (first six months), 25.53% (last six months). table 1 : Variation of the number of incidents during the postintervention period

6 Months period 1998 1999 2000 2001 Number of intubation procedure

72 35 34 47

Number of incident 49 59 38 17* Number of procedure with incident

49 15 12* 12*

Hypoxemia 24 4 11 4* Time 10 8 7 1 Hypotension 7 4 3 1 Material incident 8 17 3 3 * p < 0,005 for the between year 1998 comparison

CONCLUSION. A quality insurance program with written procedures could help to improve airway management in ICU but a learning period is necessary. REFERENCE(S). 1- Schwartz D E, Matthay M A, Cohen N H : Death and other complications of emergency airway management in critically ill adults : a prospective investigation of 297 tracheal intubations. Anesthesiology 1995 ; 82 ; 367-376. 2- XVIIIth Consensus Conference in Intensive Care and Emergency Medicine : Oral or nasal tracheal intubation : which route should be used for mechanical ventilation of patients (except for newborns) in the intensive care unit. Réan Urg 1998 ; 7 : 4bis : 435-442..

154 SURVIVAL AND OUTCOME IN PATIENTS WITH A PROLONGED INTENSIVE

CARE STAY. A FIFE YEAR FOLLOW-UP

Erlacher W.1, List-Eisenburger M.1, Oczenski W.1, Schwarz S.1, Fitzgerald R.1 1Anaesthesiology and Intensive Care, Krankenhaus Lainz, Vienna, Austria

INTRODUCTION. About 10% of all patients admitted to our ICU undergo a prolonged stay (>14 days). Reasons for such a prolongation are mostly newly deveolped organ dysfunktions. Recovery of these patients can last for several weeks or even months. In the light of exploding costs for intensive care medicine outcome and survival of these patients has been questioned. The aim of the present study was to assess survival rates, outcome and quality of life of all patients with prolonged intensive care stay admitted to our ICU in the years 1996 until 2000. METHODS. A retrospective analysis of an ICU database for the years 1996, 1997, 1998, 1999 and 2000, including 2563 patients in an eigtht bed ICU (tertiary care institution) for postoperative patients. The majority were patients after cardic surgery and abdominal surgery. Adults requiring over 14 days of postoperative ICU care from Januray 1996 to December 2000 were selected from our ICU database. Organ failure was assessed by using Sequential Organ Failure Assessment (SOFA) score on the day of admission and on the seventh day. Illness severity scores of critical care admissions were recorded according to the APACHE II-scoring system. Mortality data were acquired from local government databases. Survivors to hospital discharge were evaluated for outcome and quality of life (QOL) using the Short Form-36 (SF-36) questionaire. RESULTS. The mean APACHE II score on admission was 20±9. The average mortality rate during ICU stay was 10%. The inclusion criteria (>14 days in ICU) for this study was met by 9,4% (table) of patients (=100%). Overall 77,2% of the study patients left the ICU for an intermediate or general ward. The hospital survival rate among these patients was 56%. While in 1996 almost 50% of patients transfered from the ICU died in-hospital, this number could be reduced to 12,5% in 2000. At the time of data collection (october 2001) 26% of patients from 1996, 51% from 1997, 38% from 1998, 44% from 1999 and 63% from 2000 were alive. QOL among survivors was mostly good.

1996 1997 1998 1999 2000 total Nr. of patients 472 506 554 465 566 total mortality 47 62 47 49 51 Nr. of long-term patients 39 45 45 62 49 Nr. of patients after ICU 29 35 36 47 40 patients after hospital 15 27 24 36 35 patients still living 10 23 17 27 31

CONCLUSION. The findings of our study indicate that the outcome after long-term ICU stay and the QOL is good. In-hospital mortality after ICU was markedly decreased. According to this relatively high rate of hospital-survival we postulate that full intensive care treatment was justified in our patients and that medical resources should not be withheld from these patients only on the aspect of prolonged ICU stay. REFERENCE(S). (1) Hughes M. et al.: Outcome of long-stay intensive care patients. Intensive Care Med (2001) 27:779-782


157 QUALITY OF CARE : RE-INTUBATION AS A PROXY MEASURE ON A GENERAL

INTENSIVE CARE UNIT

Macmillan R. R.1, Clark L.1 1Intensive Care Unit, Whiston Hospital, Merseyside, United Kingdom INTRODUCTION. Studies have shown that unplanned extubation may not require reintubation.(1) The causes of unplanned or failed extubation are multiple and staffing levels and knowlege are critical to minimising adverse events.(2) Quality of care is diffICUlt to measure. Adverse event detection, and comparison with other units is a useful benchmarking exercise METHODS. Details relating to the intubation, extubation and reintubations were prospectively recorded over a 6 month period. Comparison with published studies was undertaken. RESULTS. Over a 6-month period 117 patients on the ICU were intubated on at least 1 occasion. Of these 116 had an oral endotracheal tube and 1 a tracheostomy as initial management. Extubations were classified as unplanned, permissive (patient permitted to self-extubate) or planned 1 patient was reintubated because of cuff failure (1%) 2 patients had emergency reintubations following unplanned extubations. The incidence of unplanned extubation was 1.7%. This compares with reported rates of 3%-16%(3) The reintubation rate following unplanned patients was 100% compared to other studies of 15% -56 %. Of the 113 patients 29 patients required further airways of which 13 had planned tracheostomies. There were 16 patients who were orally re-intubated following extubation 10 of whom were reintubated within 24 hours. 5 of the remaining 6 patients were reintubated 24-72 hours after intubation and 1 at 6 days. Thus 10 out of 117 (8.6%) had at least one failed extubation in the first 24 hours. This compares with reported rates of 1.8% to 17% A total of 20 patients underwent tracheostomy (17% of all intubated patients) and of these 13 had a tracheostomy as a planned second procedure (13/113 : 11%). 7 had a tracheostomy following a further oral intubation(s) (7/29 : 25%). This is comparable to published figures of 2% – 25% for overall tracheostomy rates with a doubling of frequency if following a failed extubation. The study revealed 11 patients who had 3 or more intubations including 2 patients who had 3 oral intubations and 4 who had 2 oral intubations prior to tracheostomy. CONCLUSION. The unplanned extubation rate was small as was the failed extubation rate. The tracheostomy rate was within reported ranges. We conclude that our airway management is within an acceptable range though specific cases with multiple extubations should be investigated as adverse events. REFERENCES. 1 Razek T,Gracias V et al. Assessing the need for reintubation: A prospective evaluation of unplanned endotracheal extubation The Journal of Trauma 2000: 48:3: 466-469 2 Beckmann U, Gilles DM, Factors associated with reintubation in Intensive Care. Chest 2001:120: 2 538-542 3 Leitch EA, Moran JL, Grealy B Weaning and extubation in the Intensive care unit. Clinical or index driven approach. Int. Care Med 1996 22 8 752-759

158 AN AUDIT OF SEDATION AND ANALGESIC PRACTICE BY THE WEST OF

SCOTLAND TRANSFER TEAM

Manchanda L.1, Litchfield K. N.1 1Department of Anaesthesia and Intensive Care, Western Infirmary, Glasgow, United Kingdom INTRODUCTION. The Transfer Team consists of 2 anaesthestists who perform the secondary transfer of critically ill patients between hospitals either by road or air. The aim of this audit was to determine whether sedative and analgesic practice was optimal during transfer. METHODS. A retrospective audit was performed of the Clinical Shock Study Group Database for a three year period 1999-2001. Data was collected on the number of patients transferred, the number receiving sedation and the choice of agents. RESULTS. During the period audited 1386 patients were transferred. Of these patients, 1279 (92.3%) received either a sedative or analgesic agent during the transfer. The commonest technique of sedation was the use of a single agent (62.5%) and in 94% of cases the choice was propofol. The remaining patients received a combination of either two (36.5%) or three drugs. Propofol and morphine was the most common combination. An opioid analgesic agent was given to 496 of the 1279 patients (38.8%). The type of opioids used are illustrated in Table 1.

Number of patients % of total Morphine 438 88.3 Fentanyl 33 6.7 Remifentanil 15 3 Alfentanil 7 1.4 Diamorphine 3 0.6

CONCLUSION. The majority of patients transferred were receiving sedative agents. Propofol was the commonest agent used overall and is one of the agents recommended for short term sedation, in existing guidelines (1). The most frequent combination of drugs was propofol and morphine. This reflects the pattern of sedation of patients in UK intensive care units, as shown in a recent study (2). The combination of an analgesic and a sedative drug may have an additive effect and allow a reduction of dose. Adequate analgesia is important for this group of patients as pain has many adverse effects. However only 38.3% of sedated patients received an opioid drug. The commonest opioid of choice was morphine. Only 6.7% of patients received fentanyl, despite existing guidelines (1) suggesting this to be the preferred opioid for patients with cardiovascular instability. This may reflect sub optimal practice given that a significant proportion of this group of patients are cardiovascularly unstable and require inotropic support. REFERENCES. 1. Shapiro BA, Warren J, Egol AB, et al. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Society of Critical Care Medicine. Crit Care Med 1995; 23: 1596-600 2. Soliman HM, Melot C, Vincent JL. Sedation and analgesic practice in the intensive care unit: the results of a European survey. BJA 2001 87(2): 186-92

155 QUALITY OF LIFE AND PSYCHOLOGICAL OUTCOME AFTER INTENSIVE CARE -

PRELIMINARY DATA Hubble S. M. A.1, Day C. J. E.1, Purday J. P.1 1Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter, United Kingdom INTRODUCTION. Traditionally mortality has been the main indicator of ICU outcome.This view is being challenged [1]. There is increasing interest in assessing quality of life and psychological outcome after intensive care (IC)[2]. Quality of life, functional outcome and psycological state are poorly documented compared to mortality data. As clinicians look beyond mortality, quality of life in survivors will assume even greater importance. Recent studies suggest that post discharge quality of life scores are reduced compared to pre-admission values and that incidence of post traumatic stress disorder is as high as 27% [3]. METHODS. ITU follow up clinic data were collected over 14 months between 2000 and 2002, for patients with ITU stays longer than 4 days from modified SF-36 questionnaires. Pre admission quality of life, morbidity score, employment, residence, social activity and psychological state were compared with post IC scores. Data from the first clinic follow up of 61 patients are presented.(Average time to follow up 4.5 months) RESULTS. The average age of the patients followed up was 59 years with a mean ITU stay of 11.5 days. 56/58 returned home without additional support, only 19/53 patients reported a step down in quality of health with 56/58 describing health as 'good or fairly good'. 50/58 reported that IC had no or only minor effect on their lifestyle. Over 2/3 had resumed a normal social life and over half of those previously working were back in employment. Although 28/57 experienced unpleasant dreams only 3/58 had high stress scores. These patients were referred for psychological support. CONCLUSION. 1. Intensive Care follow up clinic is a useful method of assessing quality outcomes for the IC survivor. 2. The majority of our followed up survivors have no 'step down' in either place of residence, quality of life, mobility, or social life. This is more encouraging than previously published data. 3. The provision of early follow up, ITU diaries for those with memory loss, multi-disciplinary referrals and a forum to address patient anxieties may partially explain our very low survivor stress scores. 4. More research is needed into psychological outcomes. REFERENCES. 1. SA Ridley, Critical Care Outcomes. Anaesthesia 2001 56:1-3. 2. RD Griffith, C Jones. Recovery from Intensive Care. BMJ 1999; 319: 427-429 3. P Skirrow et al. Intensive Care – Easing the trauma. The Psychologist 2001; 14 No 12: 640-2

156 QUALITY OF LIFE (QOL) AND DISABILITY IN SURVIVORS OF MULTIPLE

TRAUMA ONE YEAR AFTER ICU DISCHARGE

Dimopoulou I.1, Anthi A.2, Mastora Z.1, Theodorakopoulou M.1, Konstandinidis A.2, Evangelou E.1, Mandragos K.2, Roussos C.1 1Critical Care Medicine, Evangelismos Hospital, 2Critical Care Medicine, Hellenic Red Cross Hospital, Athens, Greece INTRODUCTION. In addition to mortality and morbidity rates, QoL has been proposed as a relevant measure of the intensive care outcome in trauma victims. Thus, different QoL instruments have beeen used in variable patient populations and wide ranges in post-injury impairments and disabilities have been reported. METHODS. To further elucidate this issue 87 survivors (74 men) of severe, multiple trauma were investigated. They had a median age of 31 years and a median Injury Severity Score (ISS) of 22. The Nottingham Health Profile (NHP) and Rosser Disability Scale (RDS) were used to assess the functional consequences of trauma one year after ICU discharge. RESULTS. Sixty-four patients (74%) had a problem in at least one of the six domains described in NHP part I. The most prevalent areas affected were related to somatic subdimensions (physical mobility, energy, pain) and to emotional reactions. NHP part II, revealed that about 50% of the patients had problems in several aspects of daily life, including occupation, sex, hobbies and holidays. Fifty-nine percent of the patients experienced moderate-to-severe disability as evaluated by RDS. Logistic regression analysis showed that ISS and severity of head injury were significant and independent predictors of poor QoL and disability, whereas age, gender, and duration of ICU stay were not related to functional outcomes. CONCLUSION. One year after critical trauma many survivors have ongoing problems with aspects of their health-related QoL, including physical functioning, working ability, and emotional wellbeing. Global injury severity score and severity of head injury were found to predict poor functional capacity.


159 AN ENQUIRY ON IV DRUG ERRORS IN CRITICAL MEDICINE IN BELGIUM

Baele P. L.1, Aunac S.1, Marion E.2, Mols P.3, Waterloos H.1 1anes, 2emerg. Med., Ucl St-Luc, 3emerg. Med., Chu St-Pierre Ulb, Brussels, Belgium INTRODUCTION. Errors in drug administration are frequent and can cause morbidity or death of the patient. Factors playing a role in adverse events can be divided into human and system factors. Human failures can only partly be avoided. Error-prone systems can be corrected, if they are identified. METHODS. A task force of the Belgian Society of Anesthesia and Resuscitation (BSAR), the Belgian Society of Emergency and Disaster Medicine (BESEDIM), and the Belgian Society of Intensive Medicine and Emergency Medicine (SIZ) sent a questionnaire to all 1404 Belgian specialists in those fields concerning errors in drug injection. Members of two or more societies were asked to answer only once. RESULTS. There were 441 responders: 62% practiced anesthesia, 34% intensive care, 24% emergency medicine, some active in more than one field; pediatrics were 11% of their activity; 64% of responders drew a drug for another, while 43% injected one for another. Nearly all (97%) experienced such an error, made by themselves or somebody else, and 91% ever found ampoules in the wrong drawer or box. The most frequent mechanisms for errors were look-alike ampoules (91%), labels (72%) or iv solutions (24%), diffICUlty to read a label (56%), need to dilute (23%). The 89 involved drugs totaled 815 citations, the most frequent are listed in the table. Eighteen vasoactive drugs yielded 315 citations, 8 vials of electrolytes gave 153, 4 local anesthetics gave 125, 8 opiates gave 80, 6 curares gave 42 and 6 iv anesthetics gave only 16 citations. Drugs not intended for injection were paraffin and ethanol (for NaCl or CaCl2), surgical varnish (for dopamine), and eye irrigation (for HCO3-). Two-thirds favored regulation by a national or European authority. Only 35% of responders enjoyed a perfect vision; 64% wore glasses or lenses for various conditions; 13% combined several problems, 2% being color-blind.

n Confused with Atropine 107 Adrenaline, morphine Adrenaline 94 Atropine, ephedrine, digoxin Ephedrine 75 Adrenaline, morphine, isuprel NaCl 73 KCl, aqua pro inj., lidoc. plasco KCl 60 NaCl, NaHCO3, KCl [double] Lidocain 48 1% vs 2%, bupivacain, + adre Bupivacain 36 0,5% vs 0,25%, lidocain Sufentanil 33 Sufentanil forte

CONCLUSION. Errors with emergency drugs exceed those with anesthetics. Emergency conditions favor errors and may worsen their consequences. Responders denounced an obvious problem with legibility of emergency drugs labels. They ask to standardize names, concentrations and designs, and favor European regulations.

160 LONG TERM OUTCOME AFTER PROLONGED VENTILATORY SUPPORT Parizkova R.1, Cerny V.1, Dostal P.1, Vasatko L.2, Nalos D.2, Novak I.3, Herold I.4 1Anesthesiology and Intensive Care, Charles University Faculty of Medicine, Hradec Kralove, 2Anesthesiology and Intensive Care, Masaryk´s Hospital, Usti nad Labem, 3Internal Medicine, Charles University Faculty of Medicine, Pilsen, 4Anesthesiology and Intensive Care, Klaudian´s Hospital, Mlada Boleslav, Czech_Republic

INTRODUCTION. In-hospital mortality has been considered as a essential quality assurance tool, however quality of life (QOL) seems to be more important in assessing long-term effectiveness of delivered intensive care. The aim of the study was to assess QOL using SF-36 in critically ill patients, requiring prolonged ventilatory support (VS). METHODS. Patients admitted at four ICUs during period 1998-2000 were prospectively studied. Patients with VS > 7 days from database were extracted Group LS). Demographic data, diagnostic category, Apache II, SOFA score, length of VS, clinical outcome were recorded, data were compared to patients with VS 7 days or less (Group SS). All patients were sent the SF-36 questionnaire by mail 6 and 12 months after discharge. Data are presented as mean (SD) or median (percentiles). SigmaStat Statistical Software, *p<0.05. RESULTS. Total 1089 patients, 182 pts. of Group LS, 907 pts. of Group SS. Selected data are presented in the tables.

Group LS Group SS Age (median) 62* 56 Length of VS (median) 17 (12-28)* 1(0-3) Apache II (median) 30 (24-35)* 22 (16-19) SOFA (median) 14 (12-16)* 7 (4-10) ICU mortality 107* 144 SF 36 (6 months) SF 36 (12 months) SF 36 (Control) PF 55 60 55 RP 25* --- 80 BP 41* 51,5 75 GH 47* 48,5* 62 VT 50 52,5 52 SF 62,5 62,5 50 RE 67 67 75 MH 68* 60* 100 * vs. control

CONCLUSION. Duration of VS > 7 days was associated with higher age, higher Apache II and SOFA score and higher mortality. The QOL was impaired in several domains (BP, GH and MH), however interpretation of results must be cautious due to low rate of returned questionnaires. REFERENCES. Short TG, Buckley TA, Rowbottom MY et al: Long-term outcome and functional health status following intensive care in Hong Kong. Crit Care Med, 1999, 27, 51-57.

Poster Sessions Health services and outcome – 161-174 161 CARDIOTHORACIC INTENSIVE CARE FACILITIES IN THE UNITED KINGDOM

AND REPUBLIC OF IRELAND 2001

Moores A. H.1, Macfie A. A.2 1Anaesthetics, Western Infirmary, Glasgow, United Kingdom, 2Anaesthetics, Western Infirmary, Glasgow, INTRODUCTION. In the UK it is recommended that intensive care physicians should care for critically ill patients(1). Traditionally the care of patients following cardiothoracic surgery is provided in Cardiothoracic Intensive Care units (CICUs). We have conducted an audit of the CICUs in the United Kingdom and Republic of Ireland to determine their level of medical provision and clinical practices. METHODS. A postal questionnaire was sent to each of the Association of Cardiothoracic Anaesthetists link persons representing 41 CICUs in the UK and Republic of Ireland. This established demographic data on the type and number of cases managed by these units in the year 1st April 2000 to 31st March 2001. We looked at the provision of beds and staffing, identifying possible alternative destinations for post-operative patients (e.g. General ITU). We also identified numbers and reasons for cancellations. Data was collected on dedicated daytime and "out of hours" medical cover. Non-responders received a second questionnaire and then e-mail. RESULTS. We received 35 (85%) replies. Units varied in size from 3 to 20 beds (mean 9). 94% admitted cardiac patients to dedicated Cardiac ICU beds. 9/35 units had a step down HDU facility in the same area as their CICU. Post-operative thoracic patients requiring intensive care were admitted to CICU 23/35, to general ICU 14/35 and 4 centres admitted to either depending on bed availability. Patients with thoracic epidurals were managed on a general ward in 16/35 units, 2 units managed these patients only on ICU. 24 centres admitted to an HDU facility and 7 units admitted to all 3 clinical areas. Cancellations on the day of surgery ranged from 0 to 20%. The majority, 60% of cancellations were due to a lack of CICU beds and nurses. Anaesthetists in 12 units, surgeons in 6 units, full time intensivists in 2 units led administration in CICU. This was shared in 15 units. 12 units did not have dedicated daytime anaesthetic or surgical consultant cover. A consultant anaesthetist attached to a list, 5 of which always had a trainee with them, covered 9 of these 12 CICUs. Only 12 units had 10 or more daytime sessions covered by a dedicated consultant. Dedicated resident trainee anaesthetists provided out of hours cover in 14 units. All units had resident surgical trainee cover. CONCLUSION. : The Intensive Care Society published recommendations in 1997 "Standards for Intensive Care Units"[1] regarding the importance of adequate fixed consultant session allocation in ICUs. So far this is not being achieved in CICUs in the United Kingdom and Republic of Ireland. REFERENCES. 1. Intensive Care Society: Standards for Intensive Care Units, 1997

162 REDUCING LENGTH OF STAY BY PREOPTIMISATION INCREASES

THROUGHPUT AND INCOME FOR NHS HOSPITAL TRUSTS

Chamberlain A. N.1, Hurd R.2, Harper N.3 1Research and Development, 2Finance, 3Anaesthetics, The Whittington Hospital NHS Trust, London, United Kingdom INTRODUCTION. The aim of this study was to determine whether reduction in length of stay could be substantial enough to increase throughput of patients resulting in an increased income for the hospital Trust. Total bed days can be reduced by 41% with preoperative optimisation of high risk surgical patients by using dopexamine [1]. Preoptimisation has also been shown to be cost-effective [2,3]. Reductions in length of stay contribute towards optimising bed occupancy levels and/or providing for additional patient admissions. Health Authority income to the Trust is driven by the level of patient throughput and the efficiency of the Trust is measured by the costs of providing services adjusted for casemix and market forces factors. This study uses HRGs as a proxy for the impact on additional income or cost efficiency benefits to the Trust. METHODS. The design involved an economic model to test the hypothesis that a reduction in length of stay results in increased revenue for a London hospital trust. The sample included a cohort of high risk surgical patients who had not been preoptimised. Total bed days used by the cohort were inserted into a formula with the prediction of reducing bed days and were then approximated for a 12 month period. Number of bed days saved were divided by average length of stay to calculate possible additional admissions. Sensitivity analysis was performed on a range of predictions and extra income for the Trust was estimated. RESULTS. Analysis showed that approximately 55 additional high risk surgical patients to be hospitalised. The indicative average income to the Trust for treating these additional patients would depend on whether they developed complications and required ITU stay. However, sensitivity analysis showed that preoperative optimisation could increase throughput and subsequent income for the Hospital in many predicted circumstances. CONCLUSION. Results showed that reduction in length of stay of high risk surgical patients by preoperative optimisation can substantially increase the throughput of hospital Trusts and increase income. There is also the potential to reduce hospital waiting lists so that activity targets can be met. It is within the hospital’s interests to invest in preventative measures to provide a cost efficent service in which patients will benefit. REFERENCES. 1. Wilson J, Woods I, Fawcett J, Whall R, Morris C, McManus E (1999) Reducing the risk of major elective surgery: a randomised controlled trial of preoperative optimisation of oxygen delivery. British Medical Journal 318: 7191, 1099-1103. 2. Guest JE, Boyd O, Hart WM, Grounds RM, Bennet ED (1997) A cost analysis of a treatment policy of a deliberate perioperative increase in oxygen delivery in high risk surgical patients. Intensive Care Medicine 23: 85-90 3. Chamberlain A, Harper N, Morris S (2001) The cost effectiveness of preoptimisation in high-risk surgical patients. Critical Care, Supplement 6:1, A207.


165 A PROSPECTIVE STUDY OF THE INCIDENCE AND OUTCOME OF CRITICAL

ILLNESS IN A HAEMATO-ONCOLOGY UNIT

Gordon A. C.1, Oakervee H. E.2, Kaya B.2, Barnett M. J.3, Rohatiner A. Z.3, Lister T. A.3, Watson J. D.1, Cavenagh J. D.2, Hinds C. J.1 1Intensive Care, 2Haematology, 3Medical Oncology, St. Bartholomew's Hospital, London, United Kingdom INTRODUCTION. The poor prognosis of patients with haematological malignancies admitted to the Intensive Care Unit (ICU) is well documented. Little is known, however about the outcome when such patients become critically ill but not admitted to ICU. The aim of our study was to determine the incidence and outcome of critical illness in the total population of patients admitted to hospital with haematological malignancy. METHODS. Objective criteria for critical illness and for referral to ICU were prospectively defined. Consecutive patients admitted to hospital under the care of the Division of Haemato-oncology during 2001 were screened. Patients who became critically ill and who, at the time were receiving active management were enrolled and followed throughout their hospital admission. SAPS II and organ failure scores, calculated at the time of fulfilling study entry criteria, treatment and hospital outcome were recorded. RESULTS. There were 1437 haemato-oncology inpatient episodes, during the study period, of which 101 (97 patients 53M; 44F) were complicated by critical illness. The median age was 55 (range 19-81) and median length of hospital stay was 18 days (range 0-87). These 101 episodes resulted in 49 referrals to the intensive care team (ICT) of whom 24 patients were admitted to ICU (26 admissions). Reasons for ICU admission included continuous invasive monitoring, non-invasive or invasive positive pressure ventilation, high dose inotropes and continuous renal support. Hospital mortalities were: 47% (47/101) overall; 53% (26/49) for those referred to the ICT; 75% (18/24) for those admitted to ICU; 32% (8/25) for those referred to the ICT but managed on the ward jointly and 40% (21/52) for those critically ill patients not referred to the ICT. Treatment limitations had been implemented in all 21 patients who died without referral to the ICT. On univariate analysis those referred to ICU were younger (p<0.05), more likely to have respiratory (p<0.01) and haematological failure (p<0.05) but had similar SAPS II scores (mean 49.8 v 45.7, NS) on inclusion. There was a mean of 1.8 (range 0-5) organ failures per patient at the time of study inclusion. As has been demonstrated for patients on ICU, there was a close relationship between actual mortality and that predicted by SAPS II, for the whole population of critically ill patients, including those managed on the ward. All patients with 4 or more organ failures or SAPS II greater than 65 died. CONCLUSION. Critical illness is frequent amongst haemato-oncology patients. In our hospital the majority of critically ill patients are not admitted to ICU but are managed on the ward, usually with the assistance of the intensive care team, in part due to resource limitations. Our findings have important implications for the training and workload of ward staff and the intensive care team, as well as for the organisation of critical care services. Grant. Research Board, St. Bartholomew's Hospital, London UK

166 DISPARATE PREDICTORS OF ICU AND POST-ICU MORTALITY

Boylan J. F.1, Honan D. M.1, Crowley K. J.1 1Department of Anaesthesia and Intensive Care, St. Vincent's University Hospital, Dublin, Ireland INTRODUCTION. Multiple factors contribute to mortality in critically ill patients. Deficiencies in post-ICU care, especially unscheduled ICU discharge, may be a factor in in-hospital death. METHODS. We examined demographic, physiological and treatment factors predicting in-ICU and post-ICU mortality in 1599 admissions. Data analysis was performed using ANOVA, chi-squared testing and logistic regression. RESULTS. Acuity of illness and ICU mortality increased over the study period. Multivariate analysis indicated that predictors of ICU mortality were: APACHE II score, medical status, need for ventilation, vasopressors, CRRT or TPN, occurrence of acute renal failure. Main multivariate predictors of ward death were age, medical status, TPN, length of ICU stay and unplanned discharge.

Coefficient Std Error Z P > z APACHE .079 .011 7.384 0.000 Vent 1.063 .233 4.555 0.000 ARF .794 .237 3.356 0.001 CRRT 1.109 .273 4.068 0.000 TPN .844 .281 3.000 0.003 ICU Mortality

Discharge Planned -.740 .336 -2.204 0.028 MedSurg .804 .230 3.494 0.000 TPN 1.003 .300 3.336 0.001 LOSICU .048 .013 3.632 0.000 Post-ICU Mortality

CONCLUSION. Deaths following ICU discharge are not related as much to in-ICU respiratory or renal dysfunction but (after adjusting for initial severity of illness) are related to patient age, prolonged stay and need for TPN, and to the occurrence of unplanned discharge. The latter finding has resource implications at both ICU and ward level.

163 EFFECTS OF OUTREACH ON CARDIO-RESPIRATORY ARRESTS

Khoo C.1, Rechner I. J.1, Kapila A.1, Odell M.1, Fielden J. M.1 1Department of Intensive Care, Royal Berkshire NHS Trust, Reading, United Kingdom INTRODUCTION. Sub optimal care leads to cardio-respiratory arrest (CRA)1. The review of critical care services in the UK2 recommended the introduction of outreach, to detect and treat critically ill patients. In our hospital, outreach is run by senior intensive care unit nurses. Outreach involvement is initiated by ward staff, who can use a modified early warning system (MEWS) in addition to clinical judgement, to assess the patient. Our aim was to study the impact of outreach on CRA. METHODS. Ethical approval was sought but not deemed necessary. Outreach services were introduced in May 2001. As most outreach activity occurred in general surgical wards, this was our study group. General medical patients, having minimal outreach intervention, served as the control group. We studied changes in CRA rates before (August – December 2000) and after (August – December 2001) the introduction of outreach. Arrest data was obtained from returned event forms, which were verified against crash call logs kept by the hospital telephone switchboard. Ward activity levels were obtained from bed occupancy data and expressed in patient-days. Patient-days were calculated as the sum of daily patient headcount. Outreach team workload was assessed from the outreach database, which includes the ward attended. RESULTS. Between the two study periods, the number of CRA events fell 54.5% in the surgical wards and 37.5% in the medical wards. Controlling for patient activity levels between study periods, CRA rates (per patient-day) fell 55.8% in the surgical wards and 31.3% in the medical wards. From August to December 2001, the outreach team attended surgical wards 179 times (92.3%) and medical wards 15 times (7.7%).

Surgical ward CRA

Surgical patient-days

Medical ward CRA

Medical patient-days

Aug-Dec 00 11 9455 40 16817 Aug-Dec 01 5 9732 25 15310 Number of cardio-respiratory arrests (CRA) and patient activity

CONCLUSION. The data shows a downward trend in CRA rates in both surgical and medical wards. This has been described before3 and may be part of a national trend. This reduction could be due to better training, more appropriate do not attempt resuscitation orders, or possibly changing patient mix. However, there is a greater fall in the study group where outreach and MEWS play a larger role. We believe that outreach has contributed to this. Nevertheless, given the continuing decline in overall CRA numbers, demonstrating statistical significance may be diffICUlt. REFERENCES. 1. Smith AF, Wood J. Resuscitation 1998; 37:133-7 2. Department of Health 2000. Comprehensive critical care. Department of Health. London 3. Buist MD, Moore GE et al. BMJ 2002; 324:387-90

164 INOTROPIC DRUG SUPPORT DURING THE TRANSPORT OF CRITICALLY ILL

PATIENTS BY A SPECIALIST TRANSFER TEAM

Litchfield K. N.1, Manchanda L.1 1Anaesthetics, Western Infirmary, Glasgow, United Kingdom INTRODUCTION. Transfer of critically ill patients is potentially hazardous [1,2] and could have a beter outcome if undertaken by a dedicated team [2,3]. Often the Transfer Team need to escalate treatment in order to stabilise the patient for transfer [4]. This might include initiating or changing inotropic drugs. With increasing interventions the potential of an adverse event also increases. We reviewed the current practice if inotropic drug usage during transport of critically ill patients by the Transfer Team, a team of 2 anaesthetists who perform secondary transfer of these patients between hospitals in the West of Scotland. METHODS. A retrospective analysis of the Clinical Shock Group Database was performed for a 3 year period 1999 to 2001. This database holds information on patients transferred by the Transfer Team within the West of Scotland. We reviewed data including number of transfers, mode of transfer, type and combination of inotropic drugs used during transfer and patient outcome. RESULTS. During this 3 year period 1409 patients were assessed for transfer, with 1386 actually transferred by air or road. 512 (36.9%) patients received inotropes. The most commonly used inotopic drug overall was Epinephrine in 391 (76.4%) cases. Other drugs used were Norepinephrine 76 (14.8%), Dopamine 22 (4.3%) and Dobutamine 23 (4.5%). 425 (83.0%) patients received a single inotropic agent. 86 (16.8%) patients required 2 drugs and only 1 (0.2%) received 3 inotropic drugs. When a single inotrope infusion was used it was Epinephrine in 329 (77.4%)and Norepinephrine in 61 (14.4%) patients. When 2 inotropes were infused the most common combination was Epinephrine/Norepinephrine in 55 (64.0%) cases. CONCLUSION. Patients being transferred often require continued support with inotropic drugs or initiation of these drugs to stabilise them for the transfer. During this 3 year period 36.9% of the patients transferred were receiving inotropes. There were no deaths during transfer. Most patients required a single agent and in 77.4% of the time this was Epinephrine. This would indicate that most patients, even though critically ill, can be transferred on a single inotropic drug. Decreasing the amount of drug infusions simplifies the transfer process and decreases the potential for complications. When more than 1 inotrope was required Epinephrine/Norepinephrine combination was used 64.0% of the time. There is no consensus on which is the inotrope of choice for this varied group of patients but perhaps the drugs used reflect current practice in intensive care units. We have reviewed the current use of inotropic drugs for transfer of critically ill patients by our Transfer Team and found it to be safe and rational. REFERENCES. 1. Smith I, Flemming S, Cernaiana A, Crit Care Med, 1990; 18: 278-81 2. Bellingan G, Olivier T, Batson S, Webb A, Crit Care Med, 2000; 26: 740-4 3. Koppenberg J, Taeger K, Current Opinion in Anaes, 2002; 15: 211-15 4. Runcie CJ, Reeve WR, Wallace PG, Anaesthesia, 1992; 47: 327-31


167 HAEMOGLOBIN LEVEL AT ICU DISCHARGE Rooney K. D.1, Sandbach J. A.2, Garrioch M. A.2 1Anaesthesia & Intensive Care Medicine, Glasgow Royal Infirmary, 2Anaesthesia & Intensive Care Medicine, Southern General Hospital, Glasgow, United Kingdom INTRODUCTION. Red-cell transfusion may be detrimental1. A restrictive transfusion strategy is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients2. Our aim was to audit our practice to assess our compliance with a restrictive transfusion strategy and to assess whether patients were being liberally transfused on return to the general wards. METHODS. We retrospectively recorded the haemoglobin (Hb) at ICU discharge. The setting was a university teaching hospital. All patients over a 12-month consecutive period (1st August 2000 to 31st July 2001) were audited. Each patient was followed up for four weeks post-ICU discharge to see if and when they were being transfused. We also recorded the post-ICU discharge transfusion trigger and the post transfusion Hb.Mann-Whitney U-Test was used to calculate significance for non-parametric data. RESULTS. 206 patients were discharged over the 12-month period. Of these, 146 survived giving an ICU mortality of 29.1%. 12 or 17.5% of survivors (3 medical and 9 surgical) were transfused on return to the wards. Only 1 patient was transfused within 24 hours of discharge. This patient’s Hb on discharge was 5.5 g/dL, and they were discharged from ITU prior to transfusion, because of an urgent need for an ITU bed. In table 1 the discharge Hb is higher in medical than surgical survivors (p value = 0.0013). We propose that medical patients are less likely to have any blood loss; therefore we are less likely to transfuse them and manipulate their Hb.

Median Haemoglobin Range All Patients 10 g/dL 4 – 16.7 Deaths 9.75 g/dL 4 – 15.5 Survivors 10.15 g/dL 4 – 16.7 Medical Survivors 10.9 g/dL * 6.4 – 16.7 Surgical Survivors 9.8 g/dL * 4 – 14.7 Table 1

Range Haemoglobin at discharge 8.55 g/dL 5.5 – 9.3 Transfusion trigger 8.25 g/dL 5.5 – 10.3 Post transfusion 9.65 g/dL 8.6 – 13.5 Table 2 – Patients that were transfused post-discharge

CONCLUSION. Our discharge haemoglobin is higher than the maintenance values recommended by Hébert et al2. Perhaps by adhering more rigidly to a restrictive transfusion policy, we could reduce our ICU mortality. REFERENCES. 1.Bordin JO, Heddle NM, Blajchman MA. Blood 1994; 84:1703-21 2.Hébert PC, Wells G, Blajchman MA et al. N Engl J Med 1999; 340:409-17.

168 THE VALUE OF ROUTINE CHEST X-RAY AFTER INSERTION OF A CENTRAL

VENOUS CATHETER

Ramnarain D.1, Bouman . E. A. C.1, Steveninck van . A. L.1, Barnas . M. G. W.1, Braams . R.1

1Intensive care, UMC Utrecht, Utrecht, Netherlands INTRODUCTION. In the ICU a routine chest X-ray (RCXr) is often made after insertion of a central venous catheter (CVC) in the superior vena cava (SVC) to rule out pneumothorax and to assess the line position. On the basis of predominantly retrospective studies the benefit of this routine procedure is controversial. We prospectively evaluated the results of RCXr’s performed after insertion of a CVC in the SVC. METHODS. In our ICU a RCXr is performed after insertion of a CVC in the SVC. After insertion of a CVC in the SVC a questionnaire was completed by the performing physician. Beside demographic data the following items were scored;1. Procedure: easy (1 or 2 attempts), diffICUlt (3 or more attempts), complicated, not successful. 2. Chest X-ray: abnormal findings related to insertion CVC?. 3. Classification chest X-ray: 3A. No abnormal findings related to insertion CVC, no therapeutic intervention. 3B. Abnormal findings related to insertion CVC, no therapeutic intervention. 3C. Abnormal findings related to insertion of CVC, therapeutic intervention. 4. Did complications related to the CVC procedure arise after the RCXr was performed?. 5. Also, the following question had to be answered directly after the procedure before the RCXr was made: if no RCXr would have been performed, would the physician have ordered a post-procedural chest X-ray to rule out complications or to check the position of the line? No/Yes, specify. RESULTS. A total of 232 CVC procedures performed by residents, fellows and staff were evaluated, 198 concerning the subclavian vein and 34 the internal jugular vein. Of the 232 procedures 155 were scored as easy, 40 diffICUlt, 29 complicated and 16 not successful. Complications consisted of pneumothorax 4, arterial punction 11, haematoma 5, arrhythmia 7, failure to advance guide wire 2. Abnormal findings on the 232 RCXr related to the insertion procedure were encountered 27 times consisting of 22 catheter malpositions, 1 pleural fluid collection and 4 pneumothorax. The RCXr’s were classified as follows; A: 205, B: 1, C: 26. In 2 cases complications (pneumothorax) were diagnosed after RCXr. Subsequent to 40 procedures the performing physician stated that he/she would have specifically ordered a post procedural chest X-ray. Of the RCXr following these procedures 5 were classified as 3C. Of the RCXr’s following the other 192 procedures 19 were classified as 3C. Of the 4 cases of pneumothorax 1 was suspected by the performing physician after a complicated procedure, 1 was seen on the RXCr after an easy procedure and 2 were not visible on the RCXr after an easy procedure and were diagnosed later. CONCLUSION. Abnormal findings with therapeutic consequences were seen in 27/232 RCXr's. The assessment of the procedure by the performing physician was not helpful in predicting post procedural complications. Two of 4 pneumothorax were not visible on the post-procedural RCXr. Our data justify a (prospective) investigation of omitting RCXr after a CVC in the SVC.

169 THE VALUE OF IONIZED CALCIUM IN PREDICTING MORTALITY OF

CRITICALLY ILL PATIENTS

Hästbacka J.1, Pettilä V.1 1Department of Anaesthesiology and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland INTRODUCTION. Ionized hypocalcemia is extremely common among critically ill patients. Its prevalence in different adult patient materials ranges from 15 to 88% [1, 2]. Hypocalcemia has been reported to be associated with increased mortality by several authors [2-11]. While some of these authors have suggested prognostic implications, the predictive and discriminative power of ionized calcium has not been investigated in large ICU populations. The purpose of this study was to assess the performance of ionized calcium as an independent predictor of hospital and ICU mortality. METHODS. All patients treated in the Helsinki University Central Hospital 9-bed medico-surgical ICU between January 1999 and December 2000 were initially included. Patients having received calcium supplementation were excluded.Data was obtained retrospectively from our Intensive Care database (HPCareVue, HewlettPackard Co, Andover,MA,USA. Primary outcome was D-28 mortality. Discriminative power of ionized calcium was assessed by ROC analysis (graphROC 2.0 for Windows) and multivariate logistic regression analysis with SPSS 10.0 for Windows was used to determine the performance of Ionized calcium as an independent predictor of mortality. RESULTS. Initially 992 patients were included, 51 of them were excluded, having received calcium supplementation. D-28 mortality and ICU mortality were 23.8% and 15.3%, respectively. Prevalence of ionized hypocalcemia was 56.2% on admission and 84.3% at some time during ICU stay. AUCs for admission and lowest P-Ca-Ion in ROC analysis for d-28 mortality were 0.619(SE 0.023) and 0.663(SE 0.022), respectively, and the corresponding values for ICU mortality weremortality were 0.650(SE 0.028) and 0.715 (SE 0.025). Ionized calcium was not an independent predictor of mortality as judged by stepwise multivariate regression analysis. CONCLUSION. This study shows that ionized calcium is not an independent predictor of hospital or ICU mortality. Its discriminative power in predicting hospital or ICU mortality as judged by AUC is relatively poor. REFERENCES. 1)Zaloga GP et al, AnnSurg 1985 Nov;202(5):587-94 2)Zivin JR et al, Am J Kidney Dis 2001 Apr;37(4):689-98 3)Broner CW et al, CCM 1990 Sep; 18(9):921-8 4)Chernow B et al, CCM 1982 Dec; 10(12):848-51 5)Burchard KW et al, Ann Surg 1990 Oct; 212(4):543-9 6)Cardenas-Rivero N et al, J Pediatr1989 Jun;114(6):946-51 7)Gauthier B et al, CCM 1990 Nov; 18(11): 1215-9 8)Zaloga GP1987 et al, Ann Intrn Med 1987 Jul; 107(1):36-41 9)Henderson SA et al, Clin Orthop 1992 Feb; (275):306-11 10)Desai TK et al, Am J Med 1988 Feb;84(2):209-14 11)Wilson RF et al ,Am J Surg 1979 Aug; 45(8):485-90

170 FEMALE REPRODUCTION RATE AFTER INTENSIVE CARE

Flaatten H.1, Trovik J.2, Flaatten K.3 1Anaesthesia and intensive care, 2Gynaecology and Obstetrics, 3Medical Student, Haukeland University Hospital, Bergen, Norway INTRODUCTION. Outcome after intensive care can be evaluated in several ways, the most usual being survival and quality of life (QOL). However, other endpoints may also be of interest. We wanted to investigate another measure of outcome in the female ICU population using reproduction rate (child birth) as an indicator. METHODS. Female ICU patients in their reproductive age (16 to 42) admitted to the general ICU at Haukeland University Hospital of Bergen between 1994 and 1999 were investigated. Patients were followed after hospital discharge, and for those surviving more than 18 months all childbirth before and after the ICU stay was registered. For this purpose data from the Norwegian Birth Registry was used. Then an age matched sample with regard to normal birth frequency was created from the Norwegian female population using available data about birth rates in Norway published by Statistics Norway (1). The expected birth rate could then be compared with our female ICU population before and after the ICU stay. RESULTS. During these six years 144 patients met the inclusion criteria. Mean age was 29.2 years, with a mean ICU stay of 3.9 days (SD 5.4 days). Mean SAPS II was 33.8 and mean ventilator days (n=89 patients) was 4.2 days (SD 5.6 days). 110 patients survived more than 18 months (74%). Four patients (all non-Norwegians) were lost to follow up. The total observation time in the remaining 106 patients was 1772 years, 1336 before and 436 years after ICU stay. In the normal Norwegian female control group the number of births was expected to be 107.2 before ICU stay and 29.9 after (birth rate of 80/104 and 69/104). The observed numbers of births was 128 and 10 respectively (birth rate 96/104 and 23/104). The difference and the 95% CI (ICU females vs normal population females) was 16% before (-6 to 37%)and -46% after (-18 to -73%) the ICU stay. CONCLUSION. We have found a significant reduction in female reproduction in long-term survivors after intensive care. The reason or reasons for this observation remains unknown at present but could be related to medical condition after ICU, a voluntary constraint or both. REFERENCES. 1. Statistics Norway. Table 5: Age dependent birth rates 1961-2000 http://www.ssb.no/emner/02/02/10/fodte/tab-2001-05-29-05.html


173 EVALUATION OF VARIABLE COSTS AND NURSING WORKLOAD SPENT ON

OCTOGENARIANS ADMITTED TO THE ICU

Spronk P. E.1, De Munck P.2, Van der Klaauw B.2, Rommes J. H.1 1Intensive Care Medicine, 2Organisation & Informatics, Gelre ziekenhuizen (Lukas), Apeldoorn, Netherlands INTRODUCTION. Critical care involves more and more the elderly population. Recent WHO calculations underline the expected rise in the consumption of ICU resources by people of respectable age. We evaluated the variable ICU costs and nursing workload in relation to outcome in octogenarians admitted to the ICU. METHODS. Over a 3-year period (1999-2001) APACHE-II scores, daily TISS-28 scores, and daily variable costs (top-down method) were determined for all patients admitted to our mixed 10 bed ICU. All patients in this group with an age at admission above 79 years were included in this study. RESULTS. In the studyperiod, 230 octogenarians (127 female, 103 male) were admitted to the ICU. The mean age was 86 years, the mean APACHE-II score was 16.7 and the mean ICU treatment duration (LOS-ICU) was 3.8 days. Those patients assembled 6563 TISS-28 points with an accumulated variable cost of EUR 75.691,=. In survivors (N=169), the mean LOS-ICU was shorter (2.6 days) than in non-survivors (N=61; 7.4 days; P<0.001). As expected, the mean APACHE-II at admission and the mean TISS-28 scores during ICU-treatment were higher in non-survivors (21.9 and 33) than in survivors (14.9 (P<0.001) and 27.7 (P<0.001)). The mean daily variable costs were higher in non-survivors (EUR 431,=) than in survivors (EUR 284,= ; P<0.001). CONCLUSION. Mortality in octogenarians admitted to the ICU is high. In this elderly group, the treatment duration, daily variable costs, and nursing workload spent on non-survivors are considerably higher than in survivors.

174 AMSTERDAM TEST EXAMINATION FOR THE EUROPEAN DIPLOMA IN

INTENSIVE CARE MEDICINE 2001 IN GENEVA

Fennema N.1, Wester . J. P. J.1, Bosman . R. J.1, Oudemans-van Straaten . H. M.1, Van der Spoel . J. I.1, van Luin . G. E. A.2, Zandstra . D. F.1 1Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, 2Master in Learning & Development, , Amstelveen, Netherlands INTRODUCTION. In the Netherlands, the national training programme of Intensive Care Medicine is organized by the Gemeenschappelijke Intensivisten Commissie (GIC). Participation in the written examination to obtain the European Diploma in Intensive Care Medicine (EDIC) organized by the European Society of Intensive Care Medicine (ESICM)[1,2] is compulsory according to the regulations of the GIC. The theoretical preparation takes place in two ways. The GIC currICUlum committee is responsible for the national theoretical training programme. The hospitals themselves have organized, each in their own way, local courses of theoretical fellow education. We describe our experience with the initiative of the organization of the first Amsterdam test examination for the preparation of the EDIC 2001 in Geneva. METHODS. For the fellows of the three training Intensive Care Units in Amsterdam, a test examination was organized on September 11, 2001. This informal test examination reflected the EDIC examination and consisted of 100 questions with 5 true/false alternatives in the English language to be answered in 2 hours. We analysed the results of the test examination in comparison with the results of the EDIC examination and performed a questionnaire. RESULTS. Seven fellows participated in both the test examination and the EDIC examination. The mean score of the group of 7 fellows increased from 67.2°10.1% (range 53.1-84.6%) for the test examination to 76.0°3.9% (range 69.8-79.4%) for the EDIC exam. Based on the assumption that the level of diffIculty of both exams was comparable, the increase of the score with 8.8°7.8% (95% confidence interval for difference 1.6-16.1%) would achieve statistical significance (paired Wilcoxon-test: p=0,043). The questionnaire suggested indeed a learning curve to be responsible for the better results. Furthermore, the questionnaire revealed that the fellows unanimously considered the test examination stimulating in preparing the EDIC examination. CONCLUSION. The performance of a test examination seems to be useful in the preparation for the European Diploma in Intensive Care Medicine (EDIC). REFERENCES. 1. European Society of Intensive Care Medicine & European Society of Paediatric Intensive Care. Guidelines for a training programme in intensive care medicine. Intensive Care Med 1996;22:166-72. 2. Bion JF, Ramsay G, Roussos C, Burchardi H, on behalf of the Task Force on Educational issues of the European Society of Intensive Care Medicine. Intensive Care training and specialty status in Europe: international comparisons. Intensive Care Med 1998;24:372-7.

171 OUTCOME AND HEALTH CARE COSTS ASSOCIATED WITH SEVERE SEPSIS IN

SWEDEN

Nordling S.1, Persson U.2, Wennberg E.3 1IHE, The Swedish Institute for Health Economics, 2IHE, The Swedish Instituet for Health Economics, Lund, 3Department of Anesthesiology and Critical Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden INTRODUCTION. Information of the outcome of severe sepsis and the associated economic burden for the health care system in Sweden is very limited. The purpose of this study was to estimate the outcome and health care costs associated with severe sepsis in Sweden. We defined severe sepsis as documented infection and acute organ failure using criteria based on the International Statistical Classification of Diseases and Related Health Problems – Tenth Revision (ICD-10) [1]. METHODS. We estimated the outcome and burden of health care costs in hospital care with information obtained from three databases containing short-term-care; the National register of in-patient care from the National Board of Health and Welfare, Cost per patient data base from the Federation of County councils and the Sahlgrenska Hospitals’ accounting system. To identify cases with severe sepsis, we selected all acute care hospitalisation with ICD-10-CM codes for both a bacterial or fungal infectious process and a diagnosis of an acute organ failure [2]. RESULTS. The number of cases with severe sepsis increased with age, such that 75% of the patients were older than 50 years and 33% older than 75 years. The overall hospital mortality rate was 20% and among patients with underlying comorbidity like diseases of the circulatory system, respiratory system and neoplasm the mortality were between 27-40%. Mortality rose with age from 6% in those 0-24 years to 29% in those 75-99 years. The average cost per case was estimated to €20,900 (assuming €1= SEK9.05), median cost was (€7,500) and the mean number of bed-days was 19.5. Non-survivors had a similar number of bed-days (23 days) but considerably higher costs per case (€31,500). But the highest cost and longest stay were identified with ICU-patients. The total average costs per case for these patients were €68,300, where ICU costs for these patients were on average €31,000. The average total cost for an ICU treated survivor was €79,600 and for an ICU treated non-survivor €51,400. The ICU-survivors’ longer stays explained their greater costs. CONCLUSION. This study has for the first time quantified the economic burden of severe sepsis in Sweden. We have also provided new information about underlying comorbidity and mortality associated with severe sepsis. The results clearly show the significant burden associated with severe sepsis in Sweden. REFERENCES. 1. Klassifikationer av sjukdomar och hälsoproblem 1997. (Swedish version of ICD-10). Stockholm: The National Board of Health and Welfare, 1996. 2. Angus AC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J & Pinsky MR. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29(7): 1303-1309. Grant. Eli Lilly, Sweden

172 EVALUATION OF VARIABLE COSTS AND NURSING WORKLOAD IN RELATION

TO ICU ADMISSION DIAGNOSIS

Spronk P. E.1, De Munck P.2, Van der Klaauw B.2, Rommes H.1 1Intensive Care Medicine, 2Medical Informatics, Gelre Ziekenhuizen (Lukas Hospital), Apeldoorn, Netherlands INTRODUCTION. The evaluation of resource use and costs related to intensive care medicine is important in every modern ICU. We tried to elucidate the relation between diagnosis at admission on the one hand and variable costs and nursing workload on the other. METHODS. Over a 3-year period (1999-2001) APACHE-II scores, daily TISS-28 scores, and daily variable costs (top-down method) were determined for all patients admitted to our mixed 10 bed ICU. RESULTS. During the study period 1339 consecutive patients (799 male, 540 female) were evaluated. The mean age was 64.8 years with a mean ICU treatment duration of 4.7 days. The mean APACHE score at admission was 15.7, the mean TISS-28 score was 28.9 points. These patients assembled 235362 TISS-28 points with an accumulated cost of EUR 641.053,=. Daily variable costs were EUR 386,= over all diagnosis categories. Most expensive diagnoses included neurotrauma (average costs EUR 1067,=) and vascular surgery (EUR 920,=). The least expensive diagnoses included carotis desobstruction (EUR 201) and hypertensive crisis (EUR 88,=). Gastrointestinal bleeding was the most expensive diagnosis when corrected for nursing workload (36 EUR per TISS-28 point). The cost of TISS points ranged EUR 4-36 over all diagnosis categories. CONCLUSION. Analyzing variable ICU costs in relation to TISS-28 points and disgnosis categories inproves the insight into ICU resource use. The cost per TISS-28 point varies considerably between diagnosis categories in ICU patients.


176 A TRIAL ON NON-INVASIVE VS CONVENTIONAL MECHANICAL VENTILATION

IN SEVERE ACUTE RESPIRATORY FAILURE

Honrubia T.1, García F. J.2, Daguerre M.3, Alía I.4, Algora A.5, Franco N.1, Mas M. on behalf of EMVIRA Study .1 1Intensive Care, Hospital de Móstoles, Móstoles, 2Epidemiology, Puerta de Hierro, Madrid, 3Intensive Care, Hospital Príncipe de Asturias, Alcalá de Henares, 4Intensive Care, Hospital de Getafe, Getafe, 5Intensive Care, Fundación Hospital de Alcorcón, Alcorcón, Spain

INTRODUCTION. The potential role of non-invasive mechanical ventilation (NIMV) as an alternative to conventional mechanical ventilation (CMV) in hypoxemic acute respiratory failure is controversial. Our aim was to compare the efficacy and resource consumption of NIMV versus CMV in patients with severe acute respiratory failure. METHODS. A multicentre randomised controlled trial in 7 medical ntensive care units (ICU) on patients with acute respiratory failure who needed mechanical ventilation according to criteria previously set. The intervention group was treated with NIVM with facial mask in pressure support ventilation plus positive end expiratory pressure. The control group received CMV with intubation. Resource use was assessed by length of stay in the ICU and hospital and the Therapeutic Intervention Scoring System (TISS-28). RESULTS. We enrolled 31 patients in the NIMV group and 33 in the CMV group. The two groups were similar in all baseline measurements. The causes for respiratory failure were pneumonia (18), acute exacerbations of chronic obstructive pulmonary disease (17), acute pulmonary edema (16), bronchospasm (4), and others (9). Mean PaO2:FiO2 ratio was 120 (standard deviation -SD- 62) and mean APACHE II score was 24.8 (SD 8.3). In the NIMV group 18 patients received endotracheal intubation (58%) against 33 from the CMV group (100%) -relative risk reduction 43% (95% confidence interval: 27%, 55%, P=0.00003). Mortality in the ICU was 23% (NIMV) and 39% (CMV) (relative risk reduction 47%, 95% confidence interval: -10%, 74%, P=0.09). Mortality in hospital was 32% (NIMV) and 42% (CMV) (relative risk reduction 27%, 95% confidence interval: -34%, 61%, P=0.30). Complications during stay in ICU occurred in 52% (NIMV) and 70% (CMV) (P=0.07) of patients. Functional outcome at ICU discharge measured by the Barthel index was similar in the two groups. Geometric means of ICU lengths of stay were 8.9 -SD 2.6- days (NIMV) and 9.7- SD 3.0- days (CMV), (P=0.69) and geometric means of hospital length of stay were 20.3 -SD 2.2- days (NIMV) and 16.8 -SD 2.8- days (CMV), (P=0.42). TISS-28 showed differences in the first day -medians (range), 27 (22 a 60) (NIMV) and 32 (28 a 46) (CMV) (P=0.007)-, and in the first three days, 27.7 (15.3 a 56.3) (NIMV) and 31 (23.3 a 46.7) (CMV) (P=0.03). CONCLUSION. Non-invasive mechanical ventilation decreases the need for intubation in severe acute respiratory failure and could improve survival in ICU and hospital and reduce complications during stay in ICU. When compared with conventional mechanical ventilation non-invasive mechanical ventilation decreases the amount of therapeutic interventions in the first treatment days but does not decrease the length of stay. Grant. Fondo de Investigación Sanitaria (FIS 99/0043)

Poster Sessions Non-invasive ventilation and weaning (II) – 175-188 175 PERFORMANCE OF A NEW ”HELMET” VERSUS A STANDARD FACE MASK DURING NON-INVASIVE MECHANICAL VENTILATION Chiumello D.1, Carlesso . E.1, Cadisco . A.1, Paganini . S.1, Libassi . G.1, Storelli . E.1, Rocchi . G.1

1Institute of Anesthesia and Critical Care, Policlinico Hospital IRCCS, Milano, Italy INTRODUCTION. Non invasive mechanical ventilation (NIMV) may provide effective ventilatory support in selected patients with acute or exacerbation’s of chronic respiratory failure, avoiding the risk of endotracheal intubation (1). A large numbers of failures, that prematurely stops the NIMV, are due to patient’s intolerance to the face mask. A new device the ”helmet” has been developed to deliver NIMV. The helmet, by avoiding a direct contact with the face, may increase the patient’s tolerance and increase the length of NIMV. In this study, we evaluated the performance of the new helmet versus a standard face mask. METHODS. In six healthy subjects, two helmets (large and small size, L and S respectively)(Castar, StarMed, Italy) and a face mask (Medivalv, Vital Signs, USA) were evaluated during: 1) a continuous flow CPAP (Down’s flow generator, Vital Signs, USA); 2) a CPAP delivered by a mechanical ventilator (Servo 300, Siemens, Sweden); 3) a pressure support ventilation (PSV) using the same ventilator as above. The level of PEEP and pressure support were set at 5 cmH2O. RESULTS. Results are expressed as mean±SD RR VT VE PTP (bpm) (ml) (l) (cmH2o*s/min) Continuous flow CPAP

Helmet L 14.4±4.1 420±50 5.9±1.3 81±16 Helmet S 14.8±4.3 440±140 6.1±1.3 71±14 Face Mask 14.9±4.1 500±70 7.3±1.2 84±17 Ventilator CPAP

Helmet L 14.8±3.6 560±160 7.9±1.6 105±52 Helmet S 13.5±2.7 630±120 8.4±1.3 85±145 Face Mask 14.8±4.3 550±100 7.8±1.8 81±49 PSV Helmet L 12.5±3.3 680±150 8.2±1.4 28±24 Helmet S 13.1±3.7 680±180 8.7±2.4 30±21 Face Mask 15.6±3.6 620±150 9.5±3.0 2±1° ° P<0.05 vs Helmet L and Helmet S CONCLUSION. During both CPAP the helmets are comparable to the face mask while during PSV the face mask is better. REFERENCE(S). International consensus conference on NIMV. Am J Respir Crit Care Med 2001; 163:283-291.

177 PHYSIOLOGICAL RESPONSE OF HYPOXEMIC PATIENTS TO DIFFERENT MODES

OF NON INVASIVE VENTILATION

L'Her E., L'Her E.1, Taillé S.1, Deye N.1, Lellouche F.1, Fraticelli A.1, Demoule A.1, Brochard L.1

1Medical Intensive Care Unit, Hôpital Henri Mondor, Créteil Cedex, France

INTRODUCTION. Noninvasive ventilation (NIV)decreases mortality and morbidity in patients with acute hypoxemic respiratory failure (AHRF). However, optimal ventilatory modes and settings are controversial. The aim of our study was to investigate the physiologic effects of different modes of NIV during AHRF. METHODS. Six patients (4 ALI/2 CPE; 69 years; SAPSII=30) were included. Data were recorded during 4 randomized periods: spontaneous breathing (baseline); Continuous Positive Airway Pressure (CPAP=10 cmH2O); and two Pressure Support Ventilation settings (PS=10/PEEP=10 – PS=15/PEEP=5 cmH2O). Changes in esophageal (Pes), gastric (Pga), and transdiaphragmatic (Pdi) pressures were measured using the balloon-catheter technique. The pressure-time product for inspiratory muscles (PTP: index of muscle energy expenditure), arterial blood gases, comfort, clinical and ventilatory parameters were monitored at each period. Results are presented as median (5th-95th centile). Differences were evaluated with a Wilcoxon matched-pairs test. A p value 0.05 was considered significant. RESULTS. Both ventilatory settings decreased Pdi swings and PTP. The most important decrease in inspiratory muscle load was observed during PS15/PEEP5. Highest PaO2/FIO2 variation was observed for PS10/PEP10. No difference was observed for RR and PaCO2 between periods. Comfort was improved during NIV, but seemed to be highest for PSV settings.

Baseline CPAP 10 cm H20 PS 10 cm H20-PEEP 10 cm H20

PS 15 cm H20– PEEP 5 cm H20

Vte (ml) 0.48 [0.42-0.81] 0.30 [0.15-0.68] *

0.46 [0.19-0.87] §

0.54 [0.16-0.87] *§

Leaks (%) 28.0 [16.7-46.2] 32.8 [27.7-70.5] 39.2 [23.2-80.0] 33.3 [24.0-79.4]RR (b/min) 22.0 [21-27.3] 24.0 [21.0-28.5] 23 [19.5-26.8] 23.5 [18.8-25.8]Pdi (cm H2O) 11.2 [4.9-18] 7.6 [3.5-13.5] 4.1 [1.6-9.7] *§ 5.2 [0.5-9] *§ PTP (cm H2O/s) 8.2 [3.0-12.5] 6.2 [2.7-8.1] * 4.3 [1.8-8.5] 4.4 [1.7-6.0] * PaO2/FIO2 (mm Hg) 79.0 [62.2-

218.5] 154.5 [78.6-282] 164.3 [84.0-

434.8] * 127 [90.2-172.1]

§ PaCO2 (mm Hg) 37.8 [30.1-58.2] 35.3 [28.0-69.5] 35.2 [26.6-68.0] 35.1 [28.7-63.1]

* : p<0.05, compared to baseline; § : p<0.05, compared to previous setting CONCLUSION. The results of the present study give new insights into the physiological rationale of NIV use during AHRF. Simplified CPAP systems can be used in the emergency care, where it may be diffICUlt to use NIV systems, but the efficiency of the diaphragm in generating tidal volume are better using PSV. PSV and PEEP have additive effects on the PaO2/FIO2 ratio. We conclude that in AHRF patients, (1) PSV improves ventilation and reduces inspiratory muscle effort; (2) the combination of PSV and PEEP better unload the inspiratory muscles.

178 DO NON-INVASIVE MECHANICAL VENTILATION AND PCA HAVE A ROLE IN THERAPY OF PATIENTS WITH FLAIL CHEST? Gunduz M.1, Unlugenc H.1, Ozalevli M.1, Inanoglu K.1, Akman H.1 1Anaesthesiology and Reanimation, Cukurova University School of Medicine, Adana, Turkey INTRODUCTION. In this study we aimed to compare the effects of continued controlled mechanical ventilation and noninvasive CPAP procedure via a face mask on blood oxygenation, duration of staying in intensive care unit, complications and mortality in cases with isolated chest trauma and developed flail chest. METHODS. 20 of 26 adult patients, observed in the years 2000-2001, aged between 23 to 49 and diagnosed as flail chest were included in the study. Contusions in lung and brain parenchyma were determined as establishing factors. Thoracic travma severity score was used for lung contusion evaluation. Patients with no lung contusion or only a mild contusion were included in the study. Patients were randomly divided into two groups. Controlled mechanical ventilation was applied to patients in group I, whereas noninvasive CPAP procedure was applied to group II. Patients in group I received fentanyl infusion for analgesia (0.002 mcgkg-1 min-1) whereas patient controlled analgesia (PCA) with morphine sulphate was provided to patients in group II (infusion;0,2 mcg.kg-1.min-1, lockout time;30 min,PCA dose;12mcg.kg-1). RESULTS. Although the duration of staying in intensive care unit in group II was less when compared to group I, the difference was not statistically significant. (p>0.05) Pneumonia was diagnosed in 60% of patients in group I, whereas no patient in group I had pneumonia (p<0.01) Mortality was found as 40% in group I, whereas 0% in group II (p<0.01).Because the failure of oxygenation in patients treated with noninvasive CPAP procedure was thought to be related to severe pain, morphine was infused intravenously via a patient controlled analgesia device in our study (1) CONCLUSION. Noninvasive CPAP and PCA procedures can be useful in improving the morbidity and mortality of patients with flail chest, however evaluation of more patients and results from different centers are still needed and would be beneficial. REFERENCES. 1-Tanaka H, Tajimi K, Endoh Y, Kobayashi K: Pneumatic stabilization for flail chest injury: an 11-year study. Surg Today 2001;31(1):12-7.


181 COMPARISON OF DIFFERENT INTERFACES DURING NIV Fraticelli A.1 1Medical ICU, Henri Mondor University Hospital, Créteil, France INTRODUCTION. The rate of NIV failure remains relatively large (about 40%) and is influenced by leaks, patients' tolerance and ability to correct ABG. Instrumental dead space imposed by interface and its tolerance may play an important role. The effect of different masks during NIV has rarely been evaluated. The aim of this study was to estimate the influence of four interfaces on respiratory parameters, index of patient's effort and gas exchange, and to evaluate their tolerance by patients. METHODS. Prospective, randomised and cross-over study concerning consecutive patients admitted in ICU for acute respiratory failure requiring NIV. Both hypercapnic (PaO2=45 mmHg) and hypoxemic (SatO2=90 in air) patients, with a RR=25 breath/min, were included. An arterial catheter for blood samples, and a nasogastric tube, with esophageal and gastric balloons, to evaluate inspiratory muscles pressures, were inserted. Four interfaces were compared: facial mask Airvie (Peters), facial Full face mask (Koo), integral mask Inspir'aid (Bacou), and mouth piece Oracle (Fisher&Paykel Healthcare), during 4 periods of NIV (20 minutes each, PS 10±2 and PEEP 5±2) in a randomised order. Between every NIV period, breathing with oxygen for 15 minutes were allowed. For every period we evaluated respiratory parameters, indexes of patient's effort (Pressure time product -PTP- and swings of diafragmatic pressure-DPdi-), leaks, arterial blood gases (ABG) and comfort (VAS from 0 to 10). RESULTS. Seven patients were included, 4 hypercapnic and 3 hypoxemic (2 females and 5 males, age 68±12 years, SAPS2:43±14). With each mask ABG were improved, without significant differences on correcting respiratory acidosis or improving oxygenation. All masks reduced indexes of patient's effort , but no significant difference were found in PtPes and DPdi among them. Frequent asynchronies were observed with leaks. Comfort was comparable on average, with large interindividual variations.

Baseline Airvie Koo Full Face

Inspir'aid Oracle P

Dpdi (cmH2O) 8.1 3.1 4.0 4.0 4.1 0.021 PTPes*RR (cmH2O*s/min)

181 106 96 123 133 0.015

VAS - 5.4 3.9 6.4 4.0 0.24 Leaks (%) 12 32 39 25 54 0.024

CONCLUSION. All type or interfaces were efficient to reduce effort and to improve gas exchange. Large interindividual variations in leaks and comfort suggest that having different interfaces may help in optimising NIV in individual patient.

182 ACCURACY OF AUTOMATIC TUBE COMPENSATION (ATC) IN NEW-

GENERATION MECHANICAL VENTILATORS

Haberthür C.1, Elsasser S.2, Mols G.3, Stocker R.4, Guttmann J.3 1Surgical Intensive Care Medicine, Central Hospital, Lucerne 16, 2Internal Medicine, Hospital, Langenthal, Switzerland, 3Anesthesia and Intensive Care Medicine, University Hospital, Freiburg i.Br., Germany, 4Surgical Intensive Care Medicine, University Hospital, Zurich, Switzerland INTRODUCTION. We performed this prospective randomized benchmark study to compare accuracy of flow-adapted inspiratory and expiratory compensation of endotracheal tube resistance (known as automatic tube compensation, ATC) between the original ATC system [1] and three commercially available ATC solutions (Evita 2 prototype, Evita 4 (both from Dräger, Germany) and Puritan-Bennett 840 from Mallinckrodt, St. Louis, USA). METHODS. The four ventilators under test were alternatively connected via the ventilator tubings, the endotracheal tube (ETT) under test, the artificial trachea to the active lung model. Test conditions consisted of two ventilatory modes (ATC vs. the continuous positive airway pressure (CPAP) mode; three different sized ETTs (7.0 vs. 8.0 vs. 9.0 mm of inner diameter); two patterns of breathing (respiratory frequency 15/min vs. 30/min otherwise identical); and four levels of positive end-expiratory pressure (PEEP of 0, 5, 10, and 15 cmH2O). Accuracy of tube compensation was established – amongst others – on the amount of the tube-related (i.e., additional) work of breathing (WOBadd) calculated on the basis of tracheal pressure. RESULTS. Compared to CPAP breathing ATC significantly (p<0.0001) reduced inspiratory WOBadd by 58%, 70%, 50%, and 97% with the Evita 4, the Evita 2 prototype, the Puritan-Bennett 840, and the original ATC system, respectively. Depending on the inner diameter of the ETT and the breathing pattern, inspiratory WOBadd was 0.12-5.18 J/L with the original ATC system, 1.50-28.94 J/L with the Puritan-Bennett 840, 10.35-21.01 J/L with the Evita 2 prototype, and 10.08-36.08 J/L with the Evita 4 (difference between the ventilators: p<0.0001). Expiratory WOBadd was reduced by 5%, 18%, 1%, and 70% with the Evita 4, the Evita 2 prototype, the Puritan-Bennett 840, and the original ATC system, respectively (for Evita 2 prototype and the original ATC system: p<0.0001). The expiratory WOBadd brought on by an ETT of 7.0 mm inner diameter was 5.48-42.17 J/L at 15 breaths/min and 19.57-82.28 J/L at 30 breaths/min whereby it was always lowest with the original ATC system and highest with the Evita 4 ventilator (p<0.025). CONCLUSION. Flow-adapted compensation of the resistance of an endotracheal or tracheostomy tube significantly reduces the tube-related work of breathing not only during inspiration but also during expiration. This holds true for the original ATC system whereas the commercial ATC ventilators do still suffice for inspiratory but hardly for expiratory tube compensation. REFERENCE(S). [1] Fabry B, Guttmann J, Eberhard L, Wolff G. Automatic compensation of endotracheal tube resistance in spontaneously breathing patients. Technology and Health Care 1994; 1: 281-291

179 NON-INVASIVE MECHANICAL VENTILATION (NIMV) IN CARDIOGENIC PULMONARY EDEMA. ANALYSIS OF 176 CASES Carrillo A.1, Pardo J.1, Rodriguez M.1, Esquinas A.1, Gonzalez G.1, Parraga M.1 1ICU, H.Morales Meseguer, Murcia, Spain INTRODUCTION. The CPAP utilisation through mask has shown a reduction in the need of endotracheal intubation and a tendency to decrease the mortality in patients with acute cardiogenic pulmonary edema (APEc). Likewise, the use of BIPAP has similar effects. In spite of that, there are not sufficient data about its efficacy and the risk factors for the technique failure. METHODS. We enrolled consecutive adult patients with APEc admitted to ICU. The criteria for eligibility were a respiratory rate > 30 breaths/min, a PaCO2/FiO2 ratio < 200 while the patient was breathing oxygen through a Ventury mask; and active contraction of the accessory respiratory muscle. All patients were ventilated with NIMV via a facial mask. Strict intubation criteria were adopted for failures. The success of the technique was defined as avoiding endotracheal intubation and patients survive at least 24 hours outside ICU. RESULTS. Over a period of 61 months, 176 patients with pre-selected criteria were enrolled. Of the hole 129 (73.3%) were cardiomyopathies, 31 (17.6%) valvular diseases, 4 (2.3%) both pathologies, 9 (5.1%) hypertensive emergencies, 2 (1.15) arrhythmia, and 1 case (0.6%) congenital heart disease. Seventy-seven (43.8%) were men. Mean age was 73± 9 years and the initial SAPS II 45±14. There was a history of ischemic heart disease in 53.4% and acute myocardial infarction (AMI) in 36.4%. The NIMV was successful in 130 patients (73.9%), mortality was 21.6% in ICU and 31.8% during hospitalization . By multivariate analysis, the variables related to NIMV failure and in-hospital mortality were: SHOCK at admission: Odds Ratio (OR)= 3.289, CI-95%=1.063, 10.204 (p: 0.001); PaCO2 at admission: OR= 0.952, CI-95%= 0.922, 0.984 (p: 0.003); PaO2/FiO2 after 1 hour:OR= 0.958, CI-95%= 0.937, 0.980 (p< 0.0001); AMI: OR=6.849, CI-95%= 2.192, 21.276 (p: 0.001); SOFA maximum: OR=1.549, CI-95%=1.263, 1.901 (p< 0.0001); EPAP maximum: OR=1.410 , CI-95%=1.014, 1.960 (p: 0.041). In-hospital death, Order of Not intubation: OR=7.574, CI-95%= 2.573, 22.297 (p< 0.0001); NIMV success: OR= 79.471, CI-95%= 24.378, 259.074 (p< 0.0001) CONCLUSION. The use of NIMV has a great rate of success in acute cardiogenic pulmonary edema. The factors associated with technique’ failure are hemodinamic instability, AMI as aetiology, great necessity of EPAP, PaCO2 at admission, and evolution of PaO2/FiO2 ratio one hour after NIMV and the severity of organic dysfunction.

180 PHYSIOLOGICAL EVALUATION OF FIVE INTERFACES DURING NON-INVASIVE VENTILATION IN HEALTHY SUBJECTS Lellouche F.1, Fraticelli A.1, Taillé S.1, Deye N.1, L'Her E.1, Demoule A.1, Alvarez A.1, Abadie Y.1, Brochard L.1, Mancebo J.2 1Medical ICU, Henri Mondor Hospital, Créteil, France, 2Medical ICU, Sant Pau University Hospital, Barcelona, Spain INTRODUCTION. The interface during NIV is an important determinant of patient’s comfort. New interfaces have very different designs. The aim of the study was to evaluate the physiologic effects of different interfaces. METHODS. 8 healthy subjects were non invasively ventilated in pressure support, with 5 different interfaces in a randomised order: a bucconasal mask with low dead space (Airvie, Peters), a bucconasal mask with large dead space (Koo full face mask, Koo), a mouthpiece (Oracle, Fisher&Paykel), an integral full face mask (Inspir'aid, Bacou) and the Castar helmet (Resmed). At the end of each period, comfort (VAS), EtCO2, ventilatory parameters and pressure-time product (PTP) were measured. RESULTS. Indexes of patients effort were significantly increased with the helmet compared to the other interfaces. This was associated with a significant increase in end inspiratory CO2, suggesting CO2 rebreathing. This interface was also associated with the smallest level of leaks (1%). The other interfaces with high dead space (Inspir'aid, Bacou), did not lead to substantial increase in patient’s effort.

Ve l/min Leaks % Dpdi cmH2O PTP*RR cmH2O*s/min

VAS

SB 9.5±4.2 7±16 10.3±4.7 115±38 8.0±2.0 Inspir'aid 12.6±4.1 30±8 6.3±4.1 96±22 7.1±1.2 Airvie 13.0±7.6 26±15 4.2±5.4 90±71 7.8±1.6 Koo 11.4±5.2 35±10 4.6±3.8 81±53 6.6±2.3 Oracle 15.1±6.1 17±14 4.5±3.6 80±56 4.8±3.0 Castar 15.1±3.5 1±4 9.6±4.4 196±60 6.3±0.6 ANOVA 0.1 0.003 0.01 0.006 0.005

CONCLUSION. In this study the most significant result was a large increase in patient’s effort with the helmet. Nevertheless, experimental study conditions and ventilatory settings may have influenced the results.


183 EXTUBATION AFTER VENTILATORY SUPPORT. AN OBJECTIVE

MATHEMATICAL METHOD DECISION

Bisbal E.1, Belenguer . A.1, Sánchez . F.1, Mut . T.1, Abizanda . R.1, Periró . S.1 1intensive Care Department, Hospital General De Castellón, Castellón De La Plana, Spain INTRODUCTION. Remove ventilatory support and perform the extubation of patients under ventilatory support are decisions usually based on clinical experience and on subjective evaluation of patient´s capability to undertake spontaneuous breathing. This attitude is frequently associated with reintubation and reinitiation of ventilatory support. Our paper tries to develop an objective mathematical method for indicating the opportunity of extubation maneuvers. METHODS We present a prospective experimentally designed study performed on a non randomized cohort of patients from May 2000 to July 2001. During this time, 470 patients out of 1033 consecutive admissions (45 %) were mechanically ventilated in our medical-surgical ICU in a teaching reference hospital. Median and mode ventilatory time were 2 and 0.5 days respectively. Two hundred and nine (209) patients were under ventilatory support less than 48 hours. We tried in 95 mechanically ventilated patients, a weaning _ extubation protocol. This protocol consists of a period of 15 minutes on T piece oxygen supply. During this time haemodynamic and ventilatory data were collected. If there was no contraindication, patients were definitely disconnected and tracheal tube was removed. Failure was considered if reintubation has to be performed in less than 48 hours. Success ocurred in 89 out of 95 (93,68 %). RESULTS. With available data a logistic regression equation has been formulated by means of step by step enter method, and best results were obtained if age was 45 _ 65 years (OR 20.8, 95 %IC 0.9 _ 462.3), if the diagnosis that caused the ventilatory support was acute respiratory failure (OR 14.3, 95 %IC 0.6 _ 631.7), if time of ventilatory support was 2 _ 10 days (OR 0.04, 95 %IC 0.01 _ 10.1) and if RR/Tidal volume quotient was greater than 75 (OR 7.4; 95 %IC 0.1 _ 418.6). Discrimination capability was defined by the area under the ROC curve (0.9521) and calibration according Hosmer-Lemeshow C test was defined by Chi2 6.01 for 8 freedom degrees, pNS. Under these conditions, this mathematical method predicted a succesfull extubation with a sensibility of 87.5 %, and a specificity of 96,7 %. CONCLUSION. Our method is an excelent objective predictive indicator of success in extubating critically ill patients under ventilatory support.

184 A REVIEW OF WEANING AND LONG TERM VENTILATION SERVICES IN ENGLAND Pepperman M. L.1 1Critical Care Programme, NHS Modernisation Agency, Leicester, United Kingdom INTRODUCTION. Comprehensive Critical Care, the Report of an Expert Group to the Department of Health, was published in 2000. It outlined a far-reaching modernisation programme for the development of critical care services around a new approach based upon the severity of illness. The Expert Group identified several issues impacting directly upon the level of critical care support within NHS Trusts which would require additional, detailed evaluation. One such area related to the needs of patients with acute and chronic respiratory insufficiency, including specialist weaning, long term ventilation and the use of non-invasive ventilatory support. METHODS. The working group of experts began by defining terms such as ventilatory dependence (acute and chronic) and weaning (delayed or failed). Secondly, the group evaluated the existing literature regarding 'best practice' to address the issues, where possible, in an evidence-based fashion. Thirdly, an assessment of the nature and size of the diagnostic groups was made, which ranged from the relatively common (eg COPD) to the clinical disorders requiring highly specialised evaluation and management (eg muscular dystrophies, spinal injuries). Fourthly, the way in which such services (where present currently) have evolved was considered in order to assess their place in the context of a comprehensive critical care service. Optimal staffing and their training needs, and the best way of auditing any services were debated. Finally, where epidemiological data were unavailable for England, specifically relating to the evidence of delayed or failed weaning, a survey was undertaken which provided invaluable information RESULTS. The report of the working group recommends that: 1. Every acute hospital should develop a non-invasive ventilatory service for the management of patients with acute respiratory failure. 2. One hospital within a geographical area should develop a specialist non-invasive ventilatory service to which patients suffering from delayed weaning can be referred. 3. A national service for the provision of long term invasive and non-invasive support for patients with failed weaning should be established in a few strategically located centres. All services should be adequately resourced. CONCLUSION. The report identifies a cost-effective approach to improving access, experience and outcomes for patients suffering from respiratory insufficiency within the context of a modernisation programme for the development of critical care services. REFERENCES. Comprehensive Critical Care – a review of adult Critical Care Services; www.doh.gov.uk/nhsexec/compcritcare.htm

185 MATHEMATICAL MODELING AND CLINICAL VALIDATION OF CYCLING DURING PRESSURE SUPPORT VENTILATION (PS) Tassaux D.1, Gainnier M.2, Michotte J.2, Jolliet P.2 1Division of Anesthesiology, University Hospital, 2Medical ICU, Hopital Cantonal Universitaire, Geneva, Switzerland INTRODUCTION. INTRODUCTION. During PS, transition from inspiration to expiration ("cycling") occurs when inspiratory flow (V'insp) decreases to a predetermined fraction of peak inspiratory flow (V'peak), the V'insp/V'peak ratio being termed "expiratory trigger". In a theoretical mathematical model, it has been shown that V'insp/V'peak depends primarily on the ratio between the time constant of the respiratory system (RC) and the duration of inspiratory effort (ti), V'insp/V'peak increasing as RC/ti rises (1). The goals of this study were: 1) to determine whether V'insp/V'peak values obtained by mathematical modeling were correlated with those obtained on a mechanical test lung and in both normal volunteers rendered "obstructive" with an external resistance on noninvasive ventilation and mechanically ventilated ICU patients; 2) To study the relationship between V'insp/V'peak and Rc/ti. METHODS. METHODS. a) mechanical lung model with adjustable mechanical characteristics; b) normal volunteers breathing through an external resistance, undergoing face mask pressure support (PS 10 and 25 cmH2O); c) intubated ICU patients ventilated with pressure support. Measurements: duration of inspiratory effort by external diaphragmatic electromyography, respiratory system time constant (RC), V'insp/V'peak, the latter also computed by the mathematical model (1). RESULTS. RESULTS. obtained in: a) 25 conditions in mechanical lung model; b) analysis of 10 pressure support cycles in 10 volunteers with external resistance; c) analysis of 4 cycles in 15 ICU patients.

r p a) Mechanical model 0.94 < 0.0001 b) Volunteers with external resistance

0.83 < 0.0001

c) Intubated ICU patients 0.79 < 0.0001 Table 1: Correlation between measured and computed values (mathematical model) of V'insp/V'peak a) Mechanical model 0.95 < 0.0001 b) Volunteers with external resistance

0.77 < 0.0001

c) Intubated ICU patients 0.65 < 0.001 Table 2: Correlation between V'insp/V'peak and RC/ti

CONCLUSION. CONCLUSION. As predicted by the mathematical model, synchronization between the end of patient inspiratory effort and pressure support cycling depends mostly on the duration of inspiratory effort and respiratory system mechanics, expressed as RC/ti. Setting the cycling value of the expiratory trigger should take the RC/ti ratio into account. REFERENCES. (1) Yamada, J Appl Physiol 2000; 88: 2143-2150

186 OPTIMAL EXPIRATORY TRIGGER SETTING DURING PRESSURE SUPPORT

VENTILATION

Tassaux D.1, Michotte J.2, Gainnier M.2, Jolliet P.2 1Division of Anesthesiology, 2Medical ICU, University hospital, Geneva, Switzerland INTRODUCTION. INTRODUCTION. During PS, transition from inspiration to expiration ("cycling") occurs when inspiratory flow (V'insp) decreases to a predetermined fraction of peak inspiratory flow (V'peak), the V'insp/V'peak ratio being termed "expiratory trigger" (ETS). ETS, which is a fixed value (usually 0.25) in most mechanical ventilators, is now adjustable on some machines, within a range of 0.05 to 0.5. Theoretically, ETS depends mainly on respiratory system mechanics and the duration of inspiratory effort (ti)(1). The goal of this study was to determine the ideal value of ETS in various conditions of respiratory system mechanics obtained in both normal volunteers rendered "obstructive" with an external resistance on noninvasive ventilation and mechanically ventilated ICU patients. METHODS. METHODS. a) normal volunteers breathing through an external resistance, undergoing face mask pressure support (PS 10 and 25 cmH2O); b) intubated ICU patients ventilated with pressure support. Measurements: duration of inspiratory effort by external diaphragmatic electromyography, respiratory system time constant (RC), V'insp/V'peak at the end of ti. RESULTS. Results (median and 25 – 75%): Table 1p<0.0001 ICU patients vs. volunteers with external resistance

median 25% – 75% a) Volunteers with external resistance 0.650 0.525 – 0.730 b) Intubated ICU patients 0.840 0.765 – 0.940 Table 1: V'insp/V'peak

CONCLUSION. CONCLUSION. The ideal value of ETS during pressure support, in the conditions of this study, were higher than those available in current mechanical ventilators. Further evaluation of ideal ETS cutoff values in larger series of patients, as well as in other conditions of respiratory mechanics and inspiratory effort, are warranted to help determine the optimal range of ETS setting possibilities. REFERENCES. (1) Yamada, J Appl Physiol 2000; 88: 2143-2150


Poster Sessions Technological developments (I) – 189-202 189 COMPUTER ASSISTANCE IN INFECTION CONTROL: HISA EXPERIENCE Maviglia R.1, Marchese M.1, Auricchio D.1, Fragasso T.1, Petrucci S.1, Pratesi P.1, Nicoletti R.1, Antonelli M.1 1Intensive care and anesthesiology, Università Cattolica del Sacro Cuore, Rome, Italy INTRODUCTION. Computer decision support systems and Computer antimicrobial resistances analysis can effectively aid clinicians in their decision-making processes(1). We present our experience using a computer assistance in infection control in our ICU (HISA – Hospital Infections Surveillance Assistant, UMS – Firenze – Italy). METHODS. Using parameters desumed by literature(2,3), Hisa software was developed and used as well for database management and basic statistical analysis. Since 01/09/00 to 31/05/01 all patients admitted to our 21 bed ICU have been monitored both in standard cartaceous surveillance system and using digital protocol: only patients with more than 24h ICU LOS entered in the study, while all admissions were still monitored according to our former surveillance system. Whole admission data, diagnosis as well as clinical scores for each patient were archived and extracted from the digital clinical record. A single daily form for each patient was collected. The per-patient and overall collection times were recorded for both optimisation and economical evaluation purposes. Validation of software was performed by statistical analysis of each patient diagnosis, from 50 random patients, as made by clinicians (validated) vs derived by mathematical algorithms (computer estimated) and both matched to control pool and compared to literature evidence. RESULTS. During the study 974 patients were admitted to our ICU: 552 were the over 24 h, 504 (91,3%) in HISA group. The daily form amount in HISA database is of 2662 records (47,1% of the predictable). The total amount of diagnosis in the control group was 289: 172 were nosocomial infectious diseases (17,6% of the total admitted population and 59,5% of all diagnosis). Cartaceous surveillance system reached 252 single day data for 21 pts collected in an overall time of 21 min. Whit HISA protocol 1071 data for 21 pts/day (425% of cartaceous) were collected in 8±2 minutes per patient. No differences were observed between percentage of human diagnosis in the HISA and in the control pool, while important considerations about the human vs computer aided diagnosis number difference must be made. In order to make proper infectious disease/syndrome diagnosis evaluations, the software needed to use additional temporal criteria for parameters coexistence during admission days. No statistically significant differences between HISA database population data and literature data were observed. CONCLUSION. The daily data collection surplus can be justified if considering the more interesting (actually in advanced elaboration) ability of the software to interface different expert software tools: antibiotic prescription, bacterial resistance analysis as well to advanced evidence based analysis networks. REFERENCES. 1) Payne TH: Chest Volume 118 Number 2 August 2000;2) Garner JS et al: Am J Infect Control 16(3): 128-140, 1988;3) Bone RC et al: Chest, 101(6): 1644-55, 1992

190 TRACHEAL PRESSURE CAN BE RELIABLY CALCULATED BREATH-BY-BREATH

UNDER DIFFERENT VENTILATORY CONDITIONS

Kawati R.1, Lattuada M.1, Sjöstrand U.1, Guttmann J.1, Hedenstierna G.1, Lichtwarck-Aschoff M.1

1Departments of Surgical and Medical Sciences, University Hospital Uppsala, Uppsala, Sweden

INTRODUCTION. For unloading a spontaneously breathing patient of the endotracheal tube (ETT) related flow dependent resistive pressure drop (tube compensation), the tracheal pressure must be known. Direct determination 1 is cumbersome, not without risks and hardly possible on a breath-by-breath basis. Since tube compensation can be used together with different patterns of assisted/supported spontaneous breathing (SB) we compared direct measurements of tracheal pressure (Ptrach) with calculated Ptrach (according to 2, 3) during different ventilator settings. METHODS. 15 piglets before and after bronchoalveolar lavage at PEEP levels of 0 and 12 cm H2O and with tidal volumes (VT) from 150 to 600 mL were studied during volume controlled ventilation (VC). Another 14 healthy piglets were studied during spontaneous ventilation supported either by pressure support (PS; PEEP 5, pressure over PEEP 5 cm H2O) or during BiPAP (lower pressure level 4, upper level 10 cm H2O) and with VTs from 100 to 250 ml. Ptrach was measured with a tip transducer (Ptrach,meas) and compared with Ptrach,calc 2, 3. The agreement between the measured and the calculated Ptrach curve was evaluated in terms of root mean square error (RMS), indicating how much these curves differ on average. RESULTS. Three successive breaths were analyzed and averaged, resulting in 250 averaged breaths during VC; 72 during PS; and 50 during BiPAP. For all ventilatory patterns together the RMS was 0.68 cm H2O (0.66 to 0.70 95% confidence interval)(VC: 0.60 (0.57-0.62); PS: 0.81 (0.80-0.83); BiPAP: 0.93 (0.91-0.95)). This means that even in the worst case the calculated pressure would not differ from the measured pressure by more than 0.95 cm H2O. CONCLUSION. Virtually all methods of measuring tracheal pressure directly suffer from drawbacks such as non-homogeneous pressure profile over the cross section at the transit from the ETT to the trachea, clotting of the eye(s) of the catheter with secretions or not well defined position of the catheter with respect to the ETT and the tracheal wall. By contrast, calculating Ptrach from the flow data is reliable and makes it possible to re-adjust the non-linear pressure support for tube compensation breath by breath. REFERENCES. 1.Karason S, Sondergaard S, Lundin S, Wiklund J, Stenqvist O. Evaluation of pressure/volume loops based on intratracheal pressure measurements during dynamic conditions. Acta Anaesthesiol Scand 2000; 44:571-7. 2.Guttmann J, Kessler V, Mols G, Hentschel R, Haberthur C, Geiger K. Continuous calculation of intratracheal pressure in the presence of pediatric endotracheal tubes. Crit Care Med 2000; 28:1018-26. 3.Guttmann J, Eberhard L, Fabry B, Bertschmann W, Wolff G. Continuous calculation of intratracheal pressure in tracheally intubated patients. Anes-thesiology 1993; 79:503-13. Grant. Laerdal Foundation

187 THE USE OF END POSITIVE AIRWAY PRESSURE IN WEANING PATIENTS IN RELATION TO WORK OF BREATHING Vieira S. R. R.1, Rieder M. M.1, Costa A. D.1 1Intensive Care Unit, Hospital de Clínicas de Porto Alegre and Santa Casa, Porto Alegre, Brazil INTRODUCTION. The use of spontaneous EPAP in weaning from mechanical ventilation has been little explored. In theory EPAP can prevent airway collapse during expiration. The purpose of our complementary study is to compare EPAP with pressure support ventilation (PSV) and T-piece in patients undergoing weaning in relation to work of beathing oxigenation and auto-peep. METHODS. Thirty one patients who needed mechanical ventilation for more than 48 hours in two general intensive care unit were prospectively evaluated in a randomized cross-over study. All patients were submitted to the three methods (EPAP, PSV and T-piece) during 30 minutes. Each method was followed by a rest time (at least 30 minutes). They were monitored by VentTrack (Novametrix, USA). Variables measured at 15 and 30 minutes were: work of breathing (WOB), auto-peep (PEEPi) minute ventilation (MV), arterial oxygenation (SatO2) and respiratory rate (RR) Comparisons were done by the one way analysis of variance and t test. The level of significance was p<0.05. RESULTS. EPAP PSV T-PIECE p-value 15 min WOB 1.05 0.68 0.23 0.001 * MV 8.05 10.8 8.19 0.00012** 30 min WOB 1.16 0.23 0.64 0.03*** MV 8.35 11.89 8.63 0.008**** The variables SatO2, Peepi and RR did not show alteration. CONCLUSION. Those results showed that EPAP offered greater WOB than PSV or T-piece, smaller MV than PSV but similar to T-piece and similar SatO2 to PSV and T-piece. Auto-peep does not change with the use of EPAP. In general, EPAP offered no advantage in oxigenation over the other methods. REFERENCES. 1. Esteban, A..; Alía I. And The Spanish Lung Failure Collaborative Group Modes Of Mechanical Ventilation And Weaning. Chest 106: 1188-1193, 1994. 2. Knaus, W.A.. Prognosis With Mechanical Ventilation: Influence Of Disease, Severity Of Disease Age, And Chronic Health Status On Survival Froman Acute Illness. Am. Rev. Respir. Dis, 140: S8-S13, 1989 3. Langhi, Franco.; Tobin, Martin J. Weaning From Mechanical Ventilation. Review Article. Current Opinion In Critical Care, 1:71-76, 1995. 4. Tobin, Martin J. Principles And Practice Of Mechanical Ventilation. New York; Macgraw-Hill. 1994. 5. Accp Consensus Conference: Mechanical Ventilation. Chest 104: 1833-1859, 1993. 6. Lessard, M.R., Brochard L.J. Weaning From Ventilatory Support. Clinics Chest Med 17: 475-489, 1996. 7. Jubran A., Tobin M.J.. Pathophysiologic Basis Of Acute Respiratory Distress In Patients Who Fail A Trial Of Weaning From Mechanical Ventilation. Am J Respir Crit Care Med; Mar 155 (3): 906-15, 1997.

188 DOUBLE LUMEN TUBE ABOLISHES THE ADDITIONAL LOADS ON VENTILATION

POSED BY CONVENTIONAL AIRWAYADJUNCTS

Pluemers C.1, Marien T.1, Reissmann H.1, Pothmann W.1, Schulte am Esch J.1 1Klinik- und Poliklinik f. Anaesthesiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany

INTRODUCTION. In many ICUs heat and moisture exchangers (HMEs) and pieces of extra tubing (XT) are routinely inserted between a single lumen endotracheal tube (SL-ETT) and y-piece of the ventilator. We studied the reaction of healthy volunteers to the additional loads posed by both deadspace (DS) and resistance (R) of these devices. The subjects were artificially restricted by elastic strapping of the trunk and were offered pressure support (PS). In comparison, they also breathed an ETT with two lumina, designed to separately extend both limbs of the ventilator tubing into the trachea (DL-ETT), thus eliminating DS and inspiratory resistance associated with conventional SL-ETTs. METHODS. With ethics committee approval and informed consent 20 subjects were included. They breathed spontaneously via mouthpiece, HME and pneumotachygraph (PT) with pressure tab(CO2SMO+, Novametrix) on an EVITA2 ventilator (Draeger) without CPAP. Abdomen and lower thorax were strapped by elastic bandages approximately doubling chest wall elastance. 5 different ways of connecting to the ventilator were applied for approx. 10min each in random order: 1) tubing, y-piece, mainstream capnometre (CO2SMO+), SL-ETT (Mallinckrodt 10 contour, 8,5 I.D.); 2)+ HME between SL-ETT and capnometre; 3)+XT; 4) +HME +XT; 5) DL-ETT instead of SL-ETT and y-piece (capnometre of PT). The first and last settings were in addition studied without strapping. In all settings data were acquired both without and with PS at the level of subjects ́ choice. The subjects were blinded with respect to the devices. CO2, flow and pressure were continuously recorded. At the end of each phase short airway occlusions were performed for measuring P0.1, and the subjects gauged their effort on a visual analogue scale (VAS). RESULTS. Additional deadspace is combined with an increasing PS and also increasing level of VAS. All subjects demand the highest PS being connected with HME+XT. Increments of DS by HME and HME+XT and decrements by connection via DL-ETT effected individually different changes in ventilation and CO2 levels.

Deadspace (DS) [ml]

Ventilation [l/min] *

EtCO2 [mmHg] *

VAS [% indiv. max] *t

Pressure support [mbar]

SL-ETT 242.93+27.34 8.23+2.34 39.58+7.04 73+19.64 4.95+1.50 SL-ETT+HME

323.48+34.09 8.79+2.41 41.59+6.71 81+19.02 5.75+1.78

SL-ETT+XT

272.50+40.51 7.78+2.39 41.82+6.22 71+23.39 5.25+1.41

SL-ETT+HME+XT

349.39+33.55 7.91+1.62 42.67+5.22 84+18.95 6.70+2.08

DL-ETT 217.99+24.20 8.19+1.87 38.44+7.01 44+26.45 3.25+1.34 Mean + SD * without pressure support

CONCLUSION. In restricted patients the addional loads by HME and XT have similar effects as in unrestricted breathing. The subjects desired a level of PS compensating the imposed work. Potentionally disadvantageous high tidal volumes and workloads can be reduced significantly by the DL-ETT.


191 EFFECTS OF VOLUME LOADING AND DOBUTAMINE ON TRANSPULMONARY

THERMODILUTION GLOBAL ENDDIASTOLIC VOLUME

Michard F.1, Alaya S.1, Zarka V.1, Anguel N.1, Richard C.1, Teboul J. L.1 1Medical ICU, Bicetre hospital, University Paris XI, Le Kremlin Bicetre, France

INTRODUCTION. The single transpulmonary thermodilution allows the assessment of the largest volume of blood contained in the 4 heart chambers, called the global end-diastolic volume (GEDV). In order to assess the value of GEDV as an indicator of cardiac preload, we have investigated the effects of volume loading and dobutamine infusion on GEDV index (GEDVI) in patients with severe sepsis.

METHODS. Hemodynamic parameters were evaluated in triplicate by the PiCCO monitor (Pulsion Medical Systems, Munich, Germany) 1) before and after 66 fluid challenges (500 mL 6% HES over a 30 minutes period) in 27 patients and 2) before and after 40 changes in dobutamine infusion rate in 9 patients.

RESULTS. Volume loading induced a significant (p < 0.001) increase in GEDVI (711 ± 164 vs 769 ± 144 mL/m2), in stroke volume index (SVI) and in cardiac index (CI). Changes in GEDVI were correlated (r = 0.72, p < 0.001) with changes in SVI. The pre-infusion GEDVI was negatively correlated with the percent increase in GEDVI (r = – 0.65, p < 0.001) and in SVI (r = – 0.50, p < 0.001). Therefore, the lower the pre-infusion GEDVI, the more marked were the hemodynamic effects of volume loading. The decrease in dobutamine (n = 22) induced a significant decrease in CI but no significant change in GEDVI (842 ± 221 vs 826 ± 230 mL/m2). Similarly, the increase in dobutamine (n = 18) induced a significant increase in CI but no significant change in GEDVI (756 ± 171 vs 789 ± 159 mL/m2).

CONCLUSION. We conclude that 1) the GEDV behaves as an indicator of cardiac preload, 2) a mathematical coupling between GEDVI and CI is unlikely, 3) GEDV measurement may help in decisions concerning the appropriateness of fluid loading in patients with severe sepsis. Grant. Pulsion Medical Systems

192 AUTOMATIZED BEDSIDE ESTIMATION OF SHUNT AND VENTILATION-PERFUSION MISMATCH Kjaergaard S.1, Rees S.2 , Andreassen S. 1Department of Anaesthesiology, Aalborg Hospital, 2Centre for Model Based Medical Decision Support, Aalborg University, Aalborg, Denmark INTRODUCTION. Abnormalities in pulmonary gas exchange leading to oxygenation problems are common in the ICU. In order to treat these abnormalities a bedside method describing pulmonary gas exchange may be of benefit. A non-invasive method has previously been presented[1]. This method can be automatized and built into a standard ventilator[2]. METHODS. A system has been built for Automatic Lung Parameter Estimation (ALPE). This system combines a ventilator (Siemens, Servo 300), a gas analyzer with pulse oximeter (Bruel and Kjaer, BK104), and a PC. The PC collects data from the ventilator and gas analyser used to estimate shunt and ventilation-perfusion (V/Q) mismatch. The experimental procedure has been described previously[3]. Three pigs were used for the present study. Lung damage was induced by infusion of oleic acid, and hereafter the level of PEEP was titrated from 5 – 18 cmH2O to improve oxygenation. On each PEEP level shunt and V/Q mismatch was estimated. RESULTS. The system provided continuous data collection, which enabled estimation of shunt and V/Q mismatch in all cases. The mean time used for an experiment was 14.5 minutes. The results shown in the table illustrates the effects of PEEP on oxygenation, i.e. a marked reduction in shunt-fraction and DPO2 (a measure of the effects of V/Q mismatch). In addition, the system gives a graphical representation of the changes in shunt and DPO2, which may be clinically useful for the interpretation of changes in oxygenation.

PEEP = 5 cmH2O PEEP = 10 cmH2O PEEP = 18 cmH2O Pig 1 shunt(%)/DPO2 48 / 25.2 31.5 / 17.5 11.5 / 7.2 Pig 2 shunt(%)/DPO2 26 / 15.8 29 / 11.6 15.6 / 6.9 Pig 3 shunt(%)/DPO2 30.4 / 15.5 22.5 / 11.5 10.2 / 6.3 Changes in shunt and DPO2 when changing PEEP.

CONCLUSION. Using this system it is possible to obtain a more precise description of pulmonary gas exchange than the usual clinical standard, i.e. calculation of effective shunt. The experimental procedure is simple and has short duration, and as such this system may have application in several clinical settings, including the ICU, guiding clinical decisions. REFERENCES. 1. Kjaergaard S, Rees SE et al. A method for monitoring of postoperative hypoxaemia. Eur J Anaesthesiol 18[S21], A102. 2001. 2. Rees SE, Kjaergaard S et al. The Automatic Lung Parameter Estimator (ALPE) system: Non-invasive estimation of pulmonary gas exchange parameters in 10-15 minutes. J Clin Monit Comput 2001. In press. 3. Kjaergaard S, Rees SE et al. Modelling of hypoxaemia after gynecological laparotomy. Acta Anaesthesiol Scand 2001; 45: 349-56.

193 DIAGNOSTIC CAPABILITY AND THERAPEUTIC IMPACT OF HAND-HELD

ECHOCARDIOGRAPHY IN CRITICALLY ILL PATIENT

Vignon P.1, Chastagner C.1, François B.1, Gastinne H.1 1Intensive Care Unit, Dupuytren teaching hospital, Limoges, France

INTRODUCTION. Echocardiography has become a powerful noninvasive imaging modality for the assessment of critically ill patients. Limitations are related to the need of a specific training and equipment cost. Hand-held echocardiography is an emergent technique which is attractive when considering its relatively low cost and portability. We sought to evaluate the diagnostic capability and therapeutic impact of transthoracic hand-held echocardiography (HHE) in critically ill patients in a general ICU. METHODS. Over a 4-month period, all patients requiring a transthoracic echocardiography (TTE) were studied. Attending physicians adressed well-defined clinical questions. All HHE studies were performed by the same investigator, experienced in echocardiography (Optigo, Philips Ultrasound: 9 x 23 x 33 cm; 3.5 kgs). This device provides two-dimensional imaging and allows color-Doppler mapping, but has no ECG, M-mode, and spectral Doppler. Subsequently, a conventional TTE study (Sonos 5500®, Philips Ultrasound) was independently performed by a second investigator trained in echocardiography who was unaware of HHE results. TTE was used as the gold standard imaging modality. The number of acoustic windows and duration of the procedure were noted. Diagnostic capability was defined by the percentage of responses to clinical problems and therapeutic impact corresponded to changes in acute care which resulted directly from the procedure. RESULTS. 125 consecutive patients, including 92 under ventilator (74%), were studied (age: 60±18 years; IGSII: 45±13). Among them, 85 (68%) were admitted in the ICU for a medical condition, 25 (20%) for complicated surgery, and the remaining 15 (12%) for multisystem trauma. The number of adequate acoustic windows were similar using both imaging techniques (table). No image was obtained using HHE and TTE in 10 patients (8%). HHE was consistently more rapidly performed than TTE (table). Diagnostic capacity of both HHE and TTE was similar (243/275 clinical questions solved vs. 249/275: p = 0.5). HHE missed 5 major diagnoses (grade III mitral regurgitation [n=1], pulmonary hypertension [n=1], systolic left ventrICUlar obstruction [n=3]) and 4 minor diagnoses. HHE and TTE had a similar therapeutic impact in 71 and 73 patients, respectively (table). Both imaging modalities prompted surgery in 14 patients (11%) and selected 6 cardiac donors in brain dead patients (5%). An additional transesophageal echocardiography was performed in 52 patients (42%).

Acoustic windows (n) Duration (mn) Diagnostic capability (%)

Therapeutic impact(%)

HHE 292 6±3 88.5 56.8 TTE 296 9±4* 90.3 58.4 *: p<0.05

CONCLUSION. In this study, HHE was easy to perform and provided adequate imaging quality in the majority of ventilated severely ill patients. In experienced hands, HHP appears to provide a similar diagnostic capability and therapeutic impact when compared to conventional TTE, while being more rapid to perform. Its main limitation is related to the absence of spectral Doppler. Grant. Philips Ultrasound, France.

194 A NEW ALGORITHM FOR BIOIMPEDANCE CARDIOGRAPHY, INDEPENDENT OF HEMATOCRIT OR BLOOD RESISTIVITY Heethaar R. M.1, Goovaerts H. G.1, De Waal E. E. C.2 1Clinical Physics and Informatics, Institute of Cardiovascular Research, Amsterdam, 2Dept. of Anesthesiology, UMC Utrecht, Utrecht, Netherlands INTRODUCTION. Monitoring cardiac pump function non-invasively, continuously and reliably has been a challenge in medicine. Several bio-impedance cardiac output systems are available on the market and used in a wide variety of clinical and laboratory situations. However these systems show a wide dispersion on results (1). Some of them require the measurement of the hematocrit or blood resistivity (Kubicek algorithm based devices), in others the blood resistivity is replaced by a function of thoracic dimensions (Sramek algorithm based devices). The purpose of this study was to find evidence that our new algorithm, that needs no information about hematocryt or thoracic dimensions was applicable in patients in which the hematocrit and thus the resistivity of blood changed over a wide range. METHODS. After Hospital Ethics Committee approval and written informed consent, fourteen patients with preserved LV-function at cineangiography or echocardiography scheduled for coronary artery bypass grafting were included. For the bioimpedance (BIC) system two current injecting electrodes were placed on the forehead and the left thigh respectively and two voltage sensing electrodes were used: one above the left clavicle at the base of the neck and the other at the level of the xyphoid in the left midaxillary line. Stroke volume was calculated and compared to stroke volume calculations with the PiCCO-system (Pulsion, Munich, Germany). Hemodynamic measurements from each technique were recorded at three moments in time: before the operation, after weaning from CPB before sternal closure and just after sternal closure. Hematocrit was measured from a standard blood sample and blood resistivity calculated with the formula of Geddes and Sadler (2). Linear regression and Bland-Altman analysis was performed. Results with p<0.05 were considered statistically significant. RESULTS. Over the three moments in time hematocrit varied between 0.19 and 0.43 with corresponding blood resistivities ranging from 80 till 137 Ohm cm. An overall correlation coefficient was found of 0.8 between stroke volumes of the both methods. The bioimpedance method underestimated on the average with 16 ml. (bias 16 ml, precision 11 ml). No significant correlation was found between the difference in stroke volume between the both methods and the hematocrit or blood resistivity. CONCLUSION. The new algorithm, for which the hematocrit or blood resistivity is not a required parameter performed well for hematocrits ranging from 0.19 till 0.43. The new bioimpedance cardiographic system using this new algorithm and a simplified electrode configuration showed good agreement with the reference technique and was easy to use. In selected patients this non-invasive system might replace invasive CO measurements during the perioperative period. REFERENCES. Crit Care Med 1999; 27/6: 1203-1213, J Appl Physiol 1972, 33, 278-281


197 PATIENT REQUIRING PROLONGED MECHANICAL VENTILATION: CLINICAL

CHARACTERISTICS AND OUTCOME

Calero Blazquez C.1, Allepuz A.2, Bosque M.1, Palomar M.1, Campos A.1, Marquina S.1 1Intensive Medicine, 2Preventive Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain INTRODUCTION. Mechanical ventilation is one of the most usual procedures performed in the ICU, but it is not exempted from complications. The aim of our study was to describe the clinical characteristics and outcome for patients requiring prolonged mechanical ventilation (MV) and to assess the incidence of complications related to. METHODS. Prospective observational study involving all patients (n=58, 15.72% of all patients) admitted in a surgical-medical ICU requiring MV for more than 7 days from October 2001 to February 2002. The mean age was 56 (26-77). Twenty- seven patients were female and thirty-one were male. Sixteen patients (27.58%) had neurological disease, twenty-three patients (39.65%) had respiratory disease and nineteen patients (32.76%) formed an heterogeneous group. In 45 patients (77%) tracheostomy was performed and it was decided by physician in charge. Patients were divided into 3 groups. Group 1: patients with no tracheostomy. Group 2: patients whith tracheostomy performed before the 10th day. Group 3: patients whith tracheostomy after the 10th day. Complications related to endotracheal intubation (CREI), APACHE III, duration of mechanical ventilation, length of stay, need of sedation and antibiotics, infectious complications and mortality were studied. RESULTS. The results were as follows:

GROUP 1 n=11 GROUP 2 n=14 GROUP 3 n=33 APACHE III 78.25 66.36 77.61 LOS ICU (days) 21.18 38.28 45 MV (days) 14.91 29 40.21 Sedation (days) 9.36 12.07 21.82 Antibiotics (days) 22.8 21.7 38.5 Pneumonies n (%) 2 (18.18) 2 (14.28) 9 (27.27) CREI * n (%) 0 (0) 2 (14.28) 3 (9) Mortality n (%) 2 (18.18) 2 (14.28) 11 (36.36) *Five patients developed eight CREI: none in Group 1, 4 in Group 2 (2 stridors, 1 granuloma, 1 paralysis)and 4 in Group 3 (1 fistula tracheo-esophagical,1 palatine ulcer, 1 paralysis and 1 stridor)

CONCLUSION. Patients who underwent tracheostomy presented a longer period of MV, LOS in ICU and more CREI. In those which tracheostomy was delayed, mortality, LOS in ICU, the period of MV, antibiotics and sedation and the cases of pneumonies were the highest and the CREI were more serious.

198 STROKE VOLUME VARIATIONS IN CARDIAC SURGERY PATIENTS WITH

REDUCED LEFT VENTRICULAR FUNCTION

Reuter D. A.1, Kirchner A.2, Kilger E.2, Lamm P.3, Goetz A. E.2 1Department of Anesthesiology, University of Munich, Munich, Germany, 2Department of Anesthesiology, 3Department of Cardiac Surgery, University of Munich, Munich INTRODUCTION. Mechanical ventilation is known to cause cyclic changes in cardiac stroke volume, which is in partICUlar so during hypovolemia. (1) The assessment of left ventrICUlar stroke volume variations (SVV) by arterial pulse contour analysis enables to predict volume responsiveness in ventilated patients with normal cardiac function. (2,3) Aim of this study was to investigate the ability of SVV to predict volume responsiveness and to assess changes in preload in cardiac surgery patients with reduced left ventrICUlar function. METHODS. Mechanically ventilated patients with a left ventrICUlar ejection fraction (LVEF)<0.35 (study group; n=12) were compared to a control group (LVEF>0.50; n=14) immediately after coronary artery bypass grafting. After baseline measurements of SVV, central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP) and left ventrICUlar end diastolic area index (LVEDAI), an initial volume loading step was performed using 10 ml x body mass index of hetastarch 6%. If stroke volume index (SVI) increased (DSVI>5%), successive volume loading was performed until no further increase in SVI was reached (DSVI<5%). RESULTS. In the study group, SVV at baseline correlated significantly with DSVI ((R=0.64; p<0.05) as did baseline LVEDAI (R=-0.73, p<0.05) and PAOP (R=-0.68; p<0.05). For CVP, no significant correlation to DSVI could be shown. In the control group, baseline SVV correlated significantly to DSVI (R=0.74; p<0.005) whereas baseline LVEDAI, CVP and PAOP did not. In the study group, changes in SVV (DSVV) correlated significantly to DSVI (R=-0.80; p<0.01) as did changes in LVEDAI (DLVEDAI) (R=0.88; p<0.001). For DPAOP and DCVP, no significant correlation was found. In the control group, DSVV correlated significantly to DSVI (R=-0.87; p<0.001) as did DLVEDAI (R=0.69; p<0.05). No significant correlation could be found between DPAOP or DCVP and DSVI. Using receiver operating characteristic (ROC) analysis, in the study group, areas under the curve for SVV, PAOP, CVP and LVEDAI did not differ significantly. In the control group, the area under the curve for SVV was statistically larger than for PAOP, CVP and LVEDAI. CONCLUSION. Continuous and real-time measurement of SVV by pulse contour analysis can predict volume responsiveness and allows real-time monitoring of the hemodynamic effect of volume expansion in cardiac surgery patients with reduced left ventrICUlar function. REFERENCES. 1. Jardin F, Farcot JC, Gueret P et al. Circulation 1983; 83: 266-74 2. Berkenstadt C, Margalit N, Hadani M et al. Anesth Analg 2001; 92: 984-9 3. Reuter DA, Felbinger TW, Schmidt C et al. Intensive Care Med 2002; 28: 392-8

195 COMA THRESHOLD IN CRITICALLY ILL PATIENTS USING AUDITORY EVOKED

POTENTIALS: THE ROLE OF SEDATIVES

Kyprianou T. C.1, Nanas S. N.1, Roussos C.1 1Dept Intensive Care, Medical school, University of Athens, Athens, Greece INTRODUCTION. Coma threshold determination in critically ill sedated patients is an obviously useful though extremely diffICUlt task. Clinical assessment is often misleading whereas data from using objective indices of awareness (i.e. EEG) in the setting of intensive care unit (ICU) are very limited.The aim of the study was to determine a ”coma threshold” using indices from the auditory evoked potrentials in a group of ICU patients receiving combinations of sedatives. METHODS. Level of consciousness and middle latency auditory evoked potential (MLAEP’s) indices (latencies and amplitudes) were recorded repeatedly from 14 ICU patients (M/F: 10/4, Age 45-84, APACHE-score 7-27) in various infusion rates and/or after dicontinuation of sedatives (i.v. midazolam ± fentanyl or propofol ± fentanyl, rate in accordance with attending’s assessment of patients’needs). MLAEP’s wave-forms (window 0-100 ms) were recorded from the classic positions (CZ, mastoids, FpZ), smoothed and analysed off-line, with a Neuropack 332 Nihon Cohden recorder. NA-latency, PA- latency, NB-latency, NA-PA latency, PA-NB latency, NA-PA amplitude êáé PA-NB amplitude (latencies in ms, amplitudes in mV) were calculated. Level of sedation was assessed using a clinical scale (Sedation Assessment Scale of Athens). Unpaired students t-test, were used to compare value-distributions between comatose and non-comatose patients. Pearson’s correlation coefficient (r2) was used to assess correlations. RESULTS. We obtained 82 sets of data (total SASA score and dimensional scores for consciousness-S1, calmness-S2, muscle tone-S3 and respiration-S4, as well as latencies and amplitudes of NA, PA, NB). NB-latency and PA-latency were best correlated with total SASA-score (r2=0.31, 0.30, p< 0.05) but also with all S1, S2, S3, S4. Coma threshold (~75% sensitivity / specificity) can be set to Pa-latency value of < 40 ms only if we exclude patients receiving fentanyl. Nb-latency and Pa-latency values were significantly different between comatose and non comatose patients (66±12 vs 54±8ms, p<0.001 and 0.41±0.2 vs 0.58±0.3ms, p<0.01) Changes in patient’s sedation level and changes in MLAEP’s were correlated: ÄSASA-ÄNb-latency (r2=0.41, p=0.001). Co-administration of fentanyl seemed to weaken these correlations. CONCLUSION. Conclusions: MLAEP’s indices can identify the transition from ”coma” to ”non-coma” conscious state however, this is influenced by the co-administration of opioids which seem to impose diffICUlties in interpretation of MLAEP’s values.

196 BASIC DESIGN OF A COMPUTER PROGRAM TO BE USED IN INTENSIVE CARE

MEDICINE

Jacquet L. M.1, Bachy J.1, Spiette M.2, Rutsaert R.3 1Intensive Care, Saint-Luc Hospital, 2Intensive Care, Hôpital Longchamps, Brussels, 3Intensive Care, OLV, Antwerpen, Belgium INTRODUCTION. Back in 1987,a group of Belgian doctors and nurses involved in intensive care gathered to write the basic requirements for a computer program to be used at the bedside in ICU,the aim being to improve direct patient care(i.e.by avoiding unnecessary rewriting,performing automatic tasks...) and improve research whether retro- or prospective. METHODS. The group made an in-depth analysis for a program designed to acquire in real time all the data concerning patient care and unit management. The way data have to be entered and accessed through the program is described aswell as the necessary links to be created (with the bedside monitors,the laboratories,the pharmacy...)Every data has a unique code when entered in the data base allowing easy multicentic studies. RESULTS. Based on this analysis ,a medical software company wrote a computer program that has progressively been implemented in several hospitals of the group and refined based on the users' comments and suggestions.At this time,the program has enough capabilities to allow working paperless in one hospital unit. CONCLUSION. The aim of the group to have a tool to create a complete database of all ICU patients is almost reached.The group is still working on improving the program,especially by maintaining the program up-to-date following ICU evolution and by developping tools for data management.


199 UTILITY OF INFERIOR VENA CAVA PRESSURE MEASUREMENT IN SEVERE

LIVER DISEASE

Sutcliffe R.1, Meares H.2, Auzinger G.2, Wendon J.2 1Institute of Liver Studies, King\'s College Hospital, 2Institute of Liver Studies, King's College Hospital, London, United Kingdom

INTRODUCTION. Measurement of inferior vena cava pressure (IVCP) has been recommended as a reliable alternative to superior vena cava pressure (SVCP) in critically ill patients [1, 2]. However, although femoral vein catheters are commonly employed in critically ill patients with severe liver disease and coagulation abnormalities, the utility of IVCP in such patients is unknown.

METHODS. SVCP, IVCP, intra-abdominal pressure (IAP) and positive end-expiratory pressure (PEEP) were documented prospectively in randomly selected, critically ill, mechanically ventilated patients with severe liver disease at 4 time points over a two hour period. SVCP and IVCP were compared using Wilcoxon signed ranks and one way Anova.

RESULTS. Data was collected from 17 patients (acute or decompensated liver disease 10; post-liver transplantation 4; blunt hepatic trauma 3). There was a statistically significant difference between SVCP and IVCP at all time points in the presence of normal and raised IAP (Means: SVCP 17°6 mmHg; IVCP 20°6 mmHg: Wilcoxon rank, p = 0.0001). In addition, intra-abdominal hypertension, which was present in 53% of patients (n = 9; IAP > 15 mmHg), caused significant elevation of IVCP but not SVCP (IVCP: p = 0.0001; SVCP: p = 0.026).

CONCLUSION. Central venous pressure measurement via the femoral route does not accurately reflect superior vena cava pressure in patients with severe liver disease and its utility as an indicator of cardiac preload is limited in such patients. Since intra-abdominal hypertension is a common finding in patients with liver disease, intra-abdominal pressure measurement should be routinely performed in this group.

REFERENCES. 1. Walsh JT, Hildick-Smith DJ, Newell SA, Lowe MD, Satchithananda DK, Shapiro LM. Comparison of central venous and inferior vena caval pressures. Am J Cardiol 2000; 85(4): 518-20 2. Joynt GM, Gomersall CD, Buckley TA, Oh TE, Young RJ, Freebairn RC. Comparison of intrathoracic and intra-abdominal measurements of central venous pressure. Lancet 1996; 347(9009): 1155-7

200 SKELETAL MUSCLE AND SUBCUTANEOUS MULTIPARAMETER MONITORING CORRELATE IN A MODEL OF HEMORRHAGIC SHOCK Puyana J. C.1, Sims . C.2, Menconi . M.3, Shim . I.3, Ochoa . C.3, Van Bastelaar . J.1, Clavijo . J. A.1 1Trauma & CCM, UPMC Presbyterian, Pittsburgh, 2Surgery, MGH, 3Surgery, BWH, Boston, United States INTRODUCTION. Mucosal PCO2 measured by gastric tonometry has been correlated with splanchnic hypoperfusion in shock. This technique is cumbersome and not practical to apply in the acute trauma setting (1). In an effort to identify other more accessible tissue beds for tissue perfusion monitoring, our laboratory had demonstrated that skeletal muscle (SM) tissue acidosis correlated significantly with the severity of blood loss during shock using multiparameter tissue monitoring (2). In this study we hypothesized that Subcutaneous tissue (SQ) changes (pH, PCO2 and PO2) are comparable to changes seen in bowel tonometry and SM tissue during shock and resuscitation; therefore providing valuable surrogate information in the assessment of the mesenteric circulation during hemorrhagic shock and resuscitation. METHODS. Thirteen male mini swine (25-35 kg) (n=4 control, n=9 shock) underwent laparotomy and jejunal tonometry. Multi-parameter sensors (Diametrics Medical, MN) were placed in the chest SQ and the adductor muscle of the leg. PaCO2 was maintain between 40 and 45 mm Hg. Hemorrhaged Animals were kept at MAP of 40mm Hg by infusing or withdrawing blood as needed. Animals were bled until decompensation (Decomp) (Reinfusion of more than 10% of the maximum shed blood was required to maintain the MAP at 40 mm Hg). Animals were resuscitated with shed blood + 2X shed volume in LR (20 min) and observed for 3 hrs. Data were analyzed using repeated measures ANOVA (Tuckey's), paired t tests and Fisher Z value. RESULTS. Average blood loss was 47.2 ± 8.7%. Jejunal hipercarbia occurred during shock and returned to baseline (BL) within 30 min from resuscitation (Resus). (BL: 53±12; Decomp: 79±16, p<0.01; 30 min Resus: 63±15 mm Hg) SM and SQ pCO2 showed similar changes but returned promptly to BL values during Resuscitation. SM and SQ pH, PCO2 and PO2 continuous monitoring presented high correlations during all the phases of the experiment (BL-decomp; Resus-End of the experiment)(see table).

pH BL-Decomp PCO2

PO2 PH Resus-End PCO2

PO2

R2 0.951 0.931 0.748 0.697 0.490 0.384 Simple regressions between SQ & SM parameters in the hemorrhaged group animals.

CONCLUSION. Subcutaneous multiparameter monitoring provide similar information to the bowel tonometry and SM multiparameter monitoring during hemorrhagic shock and resuscitation, and could potentially be considered as an accessible surrogate site for the monitoring of the splanchnic circulation. REFERENCES. 1. Gutierrez G, Brown SD. Gastrointestinal tonometry: a monitor of regional dysoxia. New Horiz 1996;4(4):413-9. 2. Sims C, Seigne P, Menconi M, Monarca J, Barlow C, Pettit J, et al. Skeletal muscle acidosis correlates with the severity of blood volume loss during shock and resuscitation. J Trauma 2001;51(6):1137-45; discussion 1145-6. Grant. Harvard Center for Minimally

201 EXTREMELY LOW OXYGEN TENSION IN THE RECTAL LUMEN IN NORMAL

HUMAN SUBJECTS

Jørgensen V.1, Bonde J.1, Kann T.1, Perner A.2 1Dept of Anaesthesia and Intensive Care, Herlev Hospital, Herlev, 2Dept of Anaesthesia and Intensive Care, Rigshospitalet, Copenhagen, Denmark INTRODUCTION. It is likely that mucosal hypoxia contributes to gut barrier dysfunction and morbidity in critical ill patients, but values of PO2 in gut mucosa is currently unknown. In an attempt to estimate mucosal PO2 non-invasively, we performed luminal equilibrium dialysis in the rectum in healthy subjects. METHODS. Twelve healthy subjects were subjected to rectal equilibrium dialysis. Dialysis tubing (OD 1 cm; cut-off 12 kDa; Sigma, St. Louis, MO, USA) was cut in 12 cm pieces, which were tied off at the ends with silk suture. The distal end was fitted with 5 cm of Tygon tube (Cole-Parmer Instruments, Vernon Hills, IL, USA) and a three-way stopcock for airtight sampling and the bags were filled with 4 ml of 10% Dextran 40 in isotonic saline (Pharmacia, Uppsala, Sweden). Prior to dialysis, digital examination was performed to ensure that the rectum was free of pathology and solid faeces. Bags were placed in the rectal lumen for 4 hours, which was the time required for 100%'s equilibrium of O2 in saline baths kept at 37oC and a constant PO2 of 2 kPa. Dialysates were sampled in N2-flushed syringes and PO2 values were measured by auto-analyser (ABL 625, Radiometer, Copenhagen, Denmark). In 3 subjects, rectal dialysis was followed by O2 measurement with a Clark-type O2-electrode (Licox system, MGS, Kiel-Mielkendorf, Germany), which was inserted into the rectal lumen via a plastic tube (Ch 08) and placed with the tip 10 cm above the anus. RESULTS. The mean value of PO2 in the rectal dialysates from healthy subjects was 1.5 [SEM, 0.4] kPa and in 4 subjects dialysate PO2 was 0.0 kPa. When dialysates after sampling were equilibrated against room air for 10 minutes, a normal PO2 (20.5 [0.2] kPa, n=5) was obtained. Using the O2-electrode, stable values were observed 10 minutes after the insertion into the rectal lumen and the values of PO2 equalled those obtained by dialysis (mean difference 0.4 [0.4] kPa). CONCLUSION. Luminal PO2 is extremely low in the normal human rectum indicating that luminal bacteria metabolise O2. Therefore, it appears unlikely that luminal PO2 may be applied for clinical monitoring of mucosal PO2 in the large bowel in critical ill patients.

202 THE IMPACT OF INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY ON AN UNSELECTED CARDIAC SURGICAL POPULATION Fletcher N.1, Forrest P.2, Hu J.2, Lovelock N.3 1Cardiac Anaesthesia and Intensive Care, St George's Hospital, London, United Kingdom, 2Anaesthesia, Royal Prince Alfred Hospital, 3Anaesthesia, Liverpool Hospital, Sydney, Australia INTRODUCTION. Although intraoperative transoesphageal echocardiography (TOE) has an established role in the management of some cardiac surgical procedures, there is little data on its impact in an unselected adult cardiac surgical population that includes low-risk coronary artery bypass graft (CABG) cases. This is a retrospective review of the surgical impact of intraoperative TEE on 2,343 consecutive unselected cardiac cases METHODS. All TOE report forms over a period of four years were sourced. The surgical impact of each examination had been scored at the time. The surgical impact of TOE findings were rated E (essential) – resulted in changes to the proposed surgical procedure or V (valuable) – the surgical technique for the planned surgery was altered. The surgical impact that routine TOE had on low, medium and high-risk CABG cases was also examined. RESULTS. The surgical impact of TOE for the total study population (E+V) was 4.7%. The impact was greatest in combined CABG + mitral valve procedures (18%). The impact in CABG cases was 3.5% overall, with an estimated impact in low-risk patients of 2.8% (95%CI. 2.7-3.0%) versus 6.7% (95% CI. 5.9-7.7%) in high-risk cases. The commonest E-impact in CABG patients was unscheduled valve surgery (2.6% of high-risk patients). The complication rate attributable to TOE was 0.09% CONCLUSION. These findings suggest that the routine use of TOE in high risk patients having CABG surgery maximises surgical benefit to the patient. Routine TOE may also be justified in the low risk CABG surgery population REFERENCES. 1. Mishra M, Chauhan R, Sharma K et al. Real -time intraoperative echocardiography-how useful? Experience of 5,016 cases. J Cardiothorac Vasc Anesth 1998;112(6):625-632 2. Click R, Abel M, Schaff H. Intraoperative transesophageal echocardiography: 5-year prespective review of impact on surgical management. Mayo Clin Proc. 2000;75:241-247


205 SEVERE COMMUNITY-ACQUIRED PNEUMONIA: EXPERIENCE OF THREE YEARS Pereira J.1, Paiva J.1, Aguiar L.1, Barbosa S.1, Gomes J.1, Honrado T.1, Maia I.1, Massada S.1, Rios M.1, Sousa Dias C.1, Mota A.1 1ucip Urgência. Serviço De Cuidados Intensivos, Hospital S. João, Porto, Portugal INTRODUCTION. Severe community-acquired pneumonia (SCAP) is a frequent cause of admission in Intensive Care and is associated with high morbidity and mortality. The goal of our study was to study the impact of severe community-acquired pneumonia in terms of incidence, co-morbidities, markers of severity, therapy and mortality. METHODS. We retrospectively studied all patients with SCAP admitted to a 12-bedded Intensive Care Unit (ICU) of a central university hospital from the 1st January 1999 to 31st December 2001. Chi-square and Mann-Whitney U tests were used. RESULTS. 85 patients with SCAP were admitted (8,5% of all admissions), with a median age of 59 years. Most frequent symptoms were dyspnea (82%) and cough (68%). COPD (34,5%) and congestive heart failure(23%) were the most frequent co-morbidities and only 16% of the patients had no co-morbidity. Mean SAPS II was 44 and the need of mechanical ventilation and a PaO2/FiO2 below 250 (96%) were the main severity criteria on admission to ICU. Microbiological etiology was only found in 33% of the cases, Streptococcus pneumoniae, Legionella pneumophila and Haemophylus influenza being the first, second and third most prevalent agents. 60% of the patients were treated with the association of a macrolide and ceftriaxone or cefotaxime and only 5% of the patients were put on monotherapy. An anti-pseudomonal regimen was used in 28% of the patients. The initial empiric regimen was modified in 25% of the cases and the median duration of antibiotherapy was 10 days, while median time to defervescence was 3 days. Median duration of mechanical ventilation and of ICU stay were respectively 9 and 11 days. 41% of the patients died in the ICU and in 59% of these death was attributed to the pneumonia. CONCLUSION. SCAP is a frequent cause of admission to our ICU and is frequently associated with clinically relevant co-morbidities. In spite of good compliance with antibiotic guidelines, mortality was high, resulting from the CAP, the co-morbidities or complications.

206 ETIOLOGY AND OUTCOME OF SEVERE COMMUNITY-ACQUIRED PNEUMONIA:

OVERVIEW OF ICU CASES IN 1998

Tomic V.1, Drinovec I.2, Sifrer F.2, Trinkaus D.2 1Laboratory for respiratory bacteriology, 2Intensive Care Unit, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia INTRODUCTION. The aim of our retrospective study was to determine the causative agent of severe community-acquired pneumonia (CAP), review the antimicrobial therapy and establish the mortality rate for patients treated for severe CAP in our ICU in 1998. METHODS. We searched medical records of 55 patients who were treated for severe CAP in our ICU during 1998. All patients had different specimens taken for microbiological examination (sputum, tracheal aspirate, mini bronchoalveolar lavage, pleural effusion, blood culture). In selected cases serologic testing for atypical pathogens was performed. RESULTS. During 1998 there were 55 patients admitted to our ICU: 34 males and 21 female. The average age was 64,6 years (range 20-89 years). Majority of patients (91%) had at least one comorbid illness, most common being chronic obstructive pulmonary disease (22%), chronic heart disease (22%), diabetes mellitus (13%), alcoholism (9%). The most frequent causative agent was Streptococcus pneumoniae (10/55 patients). Other causative agents were Staphylococcus aureus (5 strains – 3 MRSA and 2 MSSA), Klebsiella pneumoniae (3), Pseudomonas aeruginosa (2), Acinetobacter baumanii (1), Escherichia coli (1), Haemophilus influenzae (1), Legionella

pneumophila (1), Chlamydia pneumoniae (1), Mycoplasma pneumoniae (1). Etiologic agent was established in 47% of patients. Due to severe respiratory insufficiency 23 patients (42%) had to be mechanically ventilated and 10 of those patients (43,5%) died. Overall mortality rate was 23,6% (13/55 patients). In addition to 10 mechanically ventilated patients 3 non-intubated patients died. For empirical therapy penicillin (alone and in combination with macrolid), amoxicillin with clavulanic acid, ceftriaxon, cefpiramid, ciprofloxacin (alone or in combination with beta-lactam antibiotic)were used. In 27 patients empirical therapy has been changed after acquisition of microbiology reports or because of no improvement/worsening of clinical signs and symptoms. CONCLUSION. 1- Majority of patients with severe CAP had at least one comorbidity. 2- Patients with severe CAP who were mechanically ventilated because of respiratory failure had high mortality rate. Overall mortality rate was one of the lowest reported in the literature. 3- Despite investigative efforts (several specimen per patient) we were able to determine etiology of severe CAP in less than half of the patients. 4- Empirical antibiotic therapy had to be changed in too many cases. 5- Adequate medical supportive measures (mechanical ventilation, hydration, nutrition, etc.) are as important as adequate antibiotic therapy.

Poster Sessions Severe pneumonia – 203-215 203 MYCOBACTERIUM TUBERCULOSIS AND SEVERE COMMUNITY-ACQUIRED

PNEUMONIA – FIVE YEARS IN A PORTUGUESE ICU

Mapril J.1, Mapril J.1, Mapril J.1, Andrade Gomes J.1, Gaspar I.1, Simões I.1, Carmo E.1, Neves J. L.1, Monteiro E.1, Abecasis P.1 1Unidade de Cuidados Intensivos Gerais, Hospital Egas Moniz, Lisbon, Portugal

INTRODUCTION. Community-Acquired Pneumonia (CAP) remains a major cause of mortality and morbidity despite the availability of new antimicrobials. Patients admitted to the ICU have the greatest mortality rate, distinct epidemiology and different distribution of etiologic agents. Although generally considered an infrequent cause of CAP, Mycobacterium tuberculosis remains an important pathogen in Portugal. METHODS. We retrospectively studied all cases of CAP occurring in nonimmunosuppressed individuals, admitted to our ICU from January 1996 till December 2000. Evaluated variables included: demographic data, etiologic agent, need for mechanical ventilation, associated shock or renal failure requiring RRT, severity scores and mortality. RESULTS. Over a period of 5 consecutive years a total of 119 nonimmunosuppressed patients (78 men and 41 women aged 60,7 ± 17,6 years) were admitted to our ICU with a diagnosis of CAP. The causal agent was determined in 43 cases (36,1%) and Mycobacterium tuberculosis was the most frequently isolated microorganism, accounting for 8 cases (6,7%), followed by Haemophilus influenzae (5,9%), Streptoccocus pneumoniae, Pseudomonas aeruginosa and Klebsiella spp (4,2% each). Candida spp, MSSA, Legionella pneumophila and Moraxella

catarrhalis were responsible for the remaining 10 cases of severe CAP. In 6 cases (5,0%) multiple agents were identified. Etiology was determined exclusively by microbiology of tracheal aspirate in 24 patients and the remaining cases by blood cultures, BAL and serologic methods. Median ICU length of stay was 8,5 days. A total of 112 patients (94,1%) required mechanical ventilation for a median period of 6,2 days. 46 patients (38,7%) developed sepsis or septic shock and 17 (14,3%) required RRT for renal failure. The SAPS II and APACHE II were respectively 45,6 and 22,4. The ICU and hospital mortality rates were 30,3% and 42,0%. CONCLUSION. In our study an etiologic agent for severe CAP was identified in only 36,1% of cases. Mycobacterium tuberculosis was the most frequently isolated microorganism accounting for 6,7% of cases. In a country with a high prevalence of tuberculosis, this etiology must be considered in the differential diagnosis of severe CAP, even in nonimmunosuppressed patients. REFERENCES. 1. Moine P., Vercken J.B., Chevret S., Chastang C., Gajdos P. Severe Community-Acquired Pneumonia. Etiology, Epidemiology and Prognosis factors. Chest 1994;105:1487-1495 2. Ruiz M., Ewig S., Torres A., Arancibia F., Marco F., Mensa J., Sanchez M., Martinez J.A. Severe Community-acquired Pneumonia: risk factors and follow-up epidemiology. Am J Respir Crit Care Med 1999;160:923-929

204 SEVERE COMMUNITY-ACQUIRED PNEUMONIA: ANALYSIS OF MORTALITY RISK FACTORS Pereira J.1, Paiva J.1, Aguiar L.1, Barbosa S.1, Gomes J.1, Honrado T.1, Maia I.1, Massada S.1, Rios M.1, Sousa Dias C.1, Mota A.1 1ucip Urgência. Serviço De Cuidados Intensivos, Hospital S. João, Porto, Portugal INTRODUCTION. Severe community acquired pneumonia (SCAP) is a frequent cause of mortality. Risk stratification and the precocity and adequacy of antibiotherapy are key issues for the success. METHODS. We retrospectively studied a group of variables as risk factors for mortality in a population patients with SCAP admitted to a 12-bedded Intensive Care Unit (ICU) of a central university hospital from the 1st January 1999 to 31sr December 2001. Goal variables were: mortality attributed to SCAP, global hospital and ICU mortality. Chi-square test was used. RESULTS. 85 patients with SCAP were admitted with a median age of 59 y. Mean SAPS II was 44. Microbiological etiology was only found in 33% of the cases. Median duration of mechanical ventilation and of ICU stay were respectively 9 and 11 days. Global hospital mortality, ICU mortality and mortality attributed to SCAP were respectively 46%, 41% and 23%. The following variables were studied: several co-morbidities, severity criteria on admission, SCAP microbiologically documented, ”unusual pathogens”, association of a 3rd gen Cephalosporin with Clarythromycin and change in antibiotherapy. The only ones significantly associated with at least one of the goal variables were as showned in table 1. All patients with SCAP caused by ”unusual pathogens” had multiple co-morbidities (Table 2).

Incidence N = (%)

ICU-Mortality (%) N= 34

P = * Mortality Attributed To

Scap (%) N= 18

P = *

Global Hospital Mortality (%) N=

39

P = *

Cancer 8 (10) 21 0.007 21 ns 18 0.02 Immunossupression

12 (14) 27 0.012 21 ns 26 0.005

CRF 6 (7) 15 0.038 16 ns 13 ns Unusual pathogens

6 (7) 42 ns 40 ns 100 0.005

CRF- Chronic Renal Failure; ”Unusual pathogens”: MRSA, Pseudomonas aeruginosa and Acinetobacter spp.. CHF DM CPD Immunossupression RCF MRSA X MRSA X X MRSA X Acinetobacter spp. X X Acinetobacter spp. + Ps. aeruginosa X Ps. aeruginosa X CPD: chronic pulmonary disease, CHF: congestive heart failure, DM: diabetes mellitus, CHD: chronic hepatic disease

CONCLUSION. Cancer, immunossupression, chronic renal failure and ”unusual pathogens” as cause of SCAP are the only variables associated with mortality and ”unusual pathogens” are clearly associated with significant co-morbidities and with inadequacy of the first-line empiric therapy.Therefore an epidemiological approach to the decisions of risk stratification and therapy of SCAP must be emphasized.


207 DOES VAP PROLONG MECHANICAL VENTILATION IN PATIENTS WITH

PERCUTANEOUS TRACHEOSTOMY?

Lorente C.1, Vazquez . J. R.1, Diaz . E.1, Gilavert . C.1, Bodi . M.1 1Critical Care, Joan XXIII University Hospital, Tarragona, Spain INTRODUCTION. Ventilator-associated pneumonia (VAP) prolongs mechanical ventilation (MV) in orotracheal intubated patients. The objective of the study was to assess if VAP episodes modified MV time in tracheostomized critically ill patients. METHODS. Prospective observational study of consecutive ventilated patients requering tracheostomy for weaning from mechanical ventilation. Patients transfered to other hospital or deaths while MV were excluded. Patients were stratified based on whether they developed or not VAP after tracheostomy was performed. Parameters evaluated were age, gender, case-mix (medical, surgical and traumatic patients), APACHE II at admission and at tracheostomy day, total time under MV (in days), time before and after tracheostomy. Statistical analysis: CIA package (significant p<0.05). RESULTS. During a 24 month period we studied 84 patients. A total of 34 patients were exclude due death (30) or transfering to other hospital (4) before weaning from MV. Finally, 50 patients were elegible for the study, 37 whom were male (74%). Mean age was 62.9+-17.5 years. In the study period 8 patients (16%) presented VAP, after a mean of 15.6+-8.1 days of MV and 6.1+-4.2 after the tracheostomy procedure.

VAP No VAP p value APACHE at admission 11.6+-6.0 15.5+-6.1 ns APACHE II at trach.day 12.0 10.6+-5.4 ns Medical 50% 66.7% ns Surgical 12.5% 14.3% ns Trauma 37.5% 19% ns Pretracheostomy MV days 9.5+-6.1 11.2+-5.6 ns Postracheostomy MV days 27.6+-22.5 8.7+-9.6 <0.05 Total MV days 37.1+-26.9 20.6+-10.7 <0.05

CONCLUSION. Ventilator-associated pneumonia prolongs time of mechanical ventilation in patients with tracheostomy. Grant. CIRIT SGR 2001/441

208 COMPARISION OF PATIENTS WITH EARLY-ONSET VS LATE-ONSET

NOSOCOMIAL PNEUMONIA IN THE ICU

Kivistik U.1, Hommik K.1 1ICU, Mustamäe Hospital, Tallinn, Estonia INTRODUCTION. Pneumonia is the most commonly reported nosocomial infection among ICU patients, occurring predominately in individuals requiring mechanical ventilation. Inadequate empiric antibiotic (AB) treatment substantially increases the mortality rate (1). We undertook a prospective audit to assess the efficacy of our routine practice. The objective of the analysis was to compare the adequacy of empirical treatment of early- and late onset pneumonia and to elaborate a policy of modification of empiric antibiotic treatment (2). METHODS. The present study included all the 611 patients admitted to the 12–bed medical-surgical ICU in 2001. The mean score of APACHE–II was 22, mortality 28,2. Mechanical ventilation was used in 82% of the treatment days (utilization rate) and the ventilator-associated pneumonia rate was 19,6. RESULTS. 109 patients (17,8%) developed nosocomial pneumonia (NP). Early-onset NP was observed in 38 patients (34,8%), whereas 71 patients (65,2%) developed late-onset NP. The most common pathogens associated with NP, initial AB, efficacy and ICU mortality are given in the following table: Early-onset NP – 38 patients, pathogens: Stahylococcus aureus 38%, Escherichia coli 26%, Streptococcus pneumoniae 13%; initial AB: Ampicillin/sulbactam 50%, Oxacillin 14%, Ceftazidime 13%. Efficacy of initial AB treatment of early-onset NP was 32% and ICU mortality 13,2%. Late-onset NP – 71 patients, pathogens: Pseudomonas aeroginosa 21%, Acinetobacter sp. 20%, Klebsiella pneumoniae 19%; Initial AB: Ceftazidime 32%, Ciprofloxacin 21%, Ampicillin/sulbactam 15%. Efficacy of initial AB treatment of late-onset NP was 58% and ICU mortality 18,3 %. CONCLUSION. The adequacy of the initial treatment of early-onset NP was substantially lower than the adequacy of the late-onset NP treatment. Rapid and accurate diagnostic methods are needed to initiate the appropriate antibiotic treatment as soon as pneumonia is suspected (2). It is necessary to monitor the adequacy of the initial empirical treatment continuously and to modify it regularly if needed. REFERENCES. 1. Martin H. Kollef, Glenda Sherman, Suzanne Ward, Victoria J. Fraser: Inadequate Antimicrobial Treatment of Infections. A Risk Factor for Hospital Mortality Among Critically Ill Patients. CHEST 1999; 115:462-474. 2. F Alvarez-Lerma ICU_acquired Pneumonia Study Group: Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med (1996) 22: 387-394.

209 MICROBIOLOGICAL CHARACTERISTICS OF INITIAL AND CONSECUTIVE

EPISODES OF VAP

Palomar M.1, Alvarez-Lerma F.2, Diaz E.3, Sa M.3, Spanish Study Group V.4 1ICU, H Vall D´Hebron, Barcelona, Spain, 2ICU, H Del Mar, Barcelona, 3ICU, H Joan XXIII, Tarragona, 4ICU, H Vall D´Hebron, Barcelona

INTRODUCTION. Patients under prolongued mechanical ventilation can develop several episodes of VAP. AIM of the study: To assess microbiological differences between firts and consecutive episodes of VAP METHODS. DESING: Prospective multicentre cohort study. SETTING: 17 ICUs.PATIENTS: All consecutive mechanically ventilated patients >12 hours who developed VAP.INTERVENTIONS: Patients surveillance and data collection. RESULTS. A total of 353 out of 1704 patients developed 403 episodes of VAP (23,65 VAPs x 100 patients) TABLE 1 shows characteristics of the different episodes of VAP No differences were observed in the incidence of polymicrobial VAP in the groups, but in the later VAPs, the number of episodes without ethiology was lower(p=0.036) Diagnostic methods were: non cuntitative bronchoaspirates in 35% of the cases, cuantitative bronchoaspirate in 33,5%, BAL+ PSB in 17,6%, hemoculture in 6,2% and none in 5,7%, without diffences in the groups. TABLE 2 shows ethiology SARM incidence was 43,3% in initial and 71% and 50% in later VAPs

ALL VAPs Firts VAP Second VAP >3 VAP Episodes (n) 403 359 42 8 Day of VAP 19.6 SD 12.1 8.4 SD 9.9 23.7 SD 13.7 37 SD 17.7 MO (n) 431 378 44 9 Polymicrobial episodes n(%)

71 (17.6) 67 (18.9) 3 (7.1) 1 (12.5)

Non MO isolation n(%)

55 (13.6) 54 (15.3) 1 (2.3) 0 (0)

First VAP Second VAP >3 VAP S aureus 21.35 21.92 15.91 22.2 P aeruginosa 21.30 19.0 31.82 66.67 A baumannii 11.11 8.73 31.82 11.11 H influenzae 8.35 9.52 0 0 S pneumoniae 6.26 7.14 0 0 E coli 4.87 5.29 2.27 0 S maltophilia 2.78 2.38 6.62 0

CONCLUSION. The incidence of VAPs with non ethiological diagnosis was hiher in the inicial episodes.S aureus, P aeruginosa and A baumannii were the most frequent isolated MO in all the groups, but with different proportion.Diagnostic methods were similar in all the VAPs Grant. BMS

210 PROSPECTIVE STUDY OF VENTILATOR-ASSOCIATED PNEUMONIA IN A

POSTOPERATIVE INTENSIVE CARE UNIT

Toomtong P.1, Pitimana-aree S.1, Vorakitpokatorn P.1, Lilitdharma S.2, Yamchuti W.2 1Department of Anesthesiology, 2Department of Surgical Nursing, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand INTRODUCTION. Ventilator-associated pneumonia (VAP) refers to pneumonia developing in patients who required intermittent positive pressure ventilation (IPPV) more than 48 hours. The indicence of VAP varies from 10% to 65% with high mortality rate. The purpose of this prospective study conducted in a closed postoperative intensive care unit (ICU) over a six-month period was to learn the incidence, risk factors, and pathogens of VAP in surgical patients requiring ventilator support in ICU. METHODS. A prospective study was conducted to determine the incidence, characteristics, risk factors and pathogens of VAP in a 14-bed postoperative ICU from 1st October, 2001 to 31st March, 2002. During the study period, there were 502 admissions to the ICU and 32 patients, who were at risk of VAP development and required IPPV more than 4 days, were automatically enrolled in this study. VAP was defined as lower respiratory infection develping within 48 hours after ICU admission with the clinical presentation, microscopic study (white cells > 25/LP, epithelium < 25/LP) and bacteriological diagnosis of by quantitative culture of non-bronchoscopic tracheal aspirate samples. RESULTS. VAP occurred in 17 patients (53.13%). Risk factors associated with VAP were duration of IPPV > 20 days (odds ratio [OR] 19.32, 95% confidence interval [CI] 1.42-174.25, p < 0.01), length of ICU stay > 10 days (OR infinity), and the presence of bacteremia (OR 14.23, 95% CI 1.32-117.37, p < 0.01), however, types of ICU admission and admission APACHE II score were not risk factors for the development of VAP infection. The pathogens isolates from culture of sputum samples (endotracheal aspirates) were predominately gram negative bacteria (76.5%), with a high proportion of Pseudomonas aeruginosa infections (58.8%). The mortality rate was not increased in patients who developed VAP. CONCLUSION. Although the overall incidence of VAP in patients admitted in our surgical ICU appears to be low, however, the importance of infection control cannot be neglected, because the common pathogens in this group of patients are very resistant bacteria. REFERENCES. D.C. Sofianou, et al. Analysis of risk factors for ventilator-vssociated pneumonia in a multidisciplinary intensive care unit. Eur J Clin Micro iol Infect Dis (2000) 19: 460–463


213 MULTIPLE ORGAN FAILURE IN TRAUMA OR POSTOPERATIVE PATIENTS WITH

OR WITHOUT VENTILATOR-ASSOCIATED PNEUMONIA Tasiou A.1, Tselioti P.1, Ressos C.1, Burikis G.1, Maltezos D.1, Prekates A.1 1Intensive Care Medicine, Tzanio Hospital, Athens, Greece INTRODUCTION. Multiple organ failure (MOF) frequently occurs in patients with sepsis due to ventilator-associated pneumonia (VAP). The aim of our study is to investigate the MOF incidence in patients with and without VAP. METHODS. We studied prospectively 255 multiple trauma or postoperative patients. All patients set on mechanical ventilation. MOF was defined as failure of >2 organs according to Knauss criteria. VAP was defined when patent had the clinical criteria of pneumonia (>2) and in the bronchoalveolar lavage specimen (BAL) one or more microorganisms in concentrations >105

cfu/ml were isolated RESULTS. There was statistically significant difference between VAP and non-VAP patients in age 46±21 vs 52±20 (p<0.05). There was no difference between the two groups in APACHE II score 21±8 vs 19±7, duration of mechanical ventilation 27±15 vs 20±18 days, and Glasgow Coma Scale (GCS) 10±3 vs 11±3, respectively. MOF developed in 61 out of 85 (72%) of VAP patients, and in 55/170 (32%) of patients without VAP (p<0.05). Thirty-three out of 85 (39%) of VAP patients and 55/170 (32%) of non-VAP patients died. CONCLUSION. Our results suggest that multiple trauma or postoperative patients, who developed VAP may have greater possibility to develop MOF.

214 CONTROLLED AND RANDOMIZED STUDY FOR EVALUATION OF THE EFFECT OF ORAL LAVAGE WITH POLYHEXANIDIUM Christoph S. M.1, Nagel R.2, Muhl E.2, Bruch H. P.2 1Dept of Surgery, Staedtisches Krankenhaus Solingen, Solingen, 2Dept of Surgery, Medizinische Universitaet Luebeck, Luebeck, Germany INTRODUCTION. Nosocomial Pneumonia by 35-40% the most likely complication on longtime ventilated patients. Further to topic noxes there is bacterial contamination from pharynx a discussed source. A couple of studies showed that reduction of pharyngeal bacterias decreases the incidence of pneumonia. Use of bacteriocides may cause selection and resistance in oral flora. METHODS. In an randomized and single-blinded study 200 patients were treated by oral lavage with polyhexanidium versus standard lavage with tea. We monitored the incidence of nosocomial pneumonias, development of MOV and bacterial spectrum. RESULTS. Both groups were similar concerning age (ave: 58,36), sex and kind of illness. All patients were treated by surgical intervention. Outcome and onset was screened by APACHE II, TISS-39. The development of pneumonia within ten days of ventilation was significantly less in the treated group. There was an decrease of bacterial contamination shown in the micobiological investigation. After 10th day of ventilation there is an increase of candida in oral flora with an siginficant increase of apparent candidosis. It was shown that development of nosocomial was 3.46 days later in the treated group. CONCLUSION. Polyhexanidium in a potent drug for reduction of total bacterial count in the supraglottic pharynx. This effect may cause a later onset of nosocomial pneumonia. If treatment is longer than 10 days there is a risc for fungal superinfection which is contraproductive for outcome. Polyhexanidium may is a possible drug to lower the risk of nosocomial pneumonia on patients with ventilation less than 10 days.

211 DIAGNOSIS OF VENTILATOR-ASSOCIATED PNEUMONIA (VAP): A ROLE FOR BLINDED PLUGGED TELESCOPING CATHETERS? Mojoli F. L.1, Capra Marzani F.1, Fumagalli P.1, Negri E.1, Bonato V.1, Rodi G.1, Emmi V.1, Braschi A.2 1Servizio di Anestesia e Rianimazione I, IRCCS Policlinico S.Matteo, 2Cattedra di Anestesiologia e Rianimazione, Università degli Studi, Pavia, Italy INTRODUCTION. We evaluated prospectively the accuracy in VAP’s diagnosis of 3 different techniques allowing protected pulmonary specimens: fiberoptic Protected Specimen Brush (fPSB),fiberoptic Plugged Telescoping Catheter (fPTC) and blinded PTC (bPTC). METHODS. 29 patients with clinical suspicion of VAP underwent 3 consecutive different bronchial samplings obtained by bPTC,fPTC and fPSB respectively. The guided samplings were performed with regard to chest radiographs,and always in the same peripheral bronchial forking. Minimum requirement of VAP’s diagnosis was at least one positive sampling,defined as a significant quantitative culture (>10^3 cfu/ml) or,in presence of antibiotic therapy and confirmed antibiotic sensitivity of the germ,also a non significant one. Our VAP’s diagnostic criteria avoided occurrence of false-positive results. VAP’s high frequency and mortality in ICU justify "extended" diagnosis criteria. Moreover a direct consequence of an imposed 100% Specificity is all the burden of a technique’s accuracy weighting on its Sensitivity: is there a better test for techniques conceived to be as far as possible specific? RESULTS. Microbial investigations isolated 28 VAP’s responsible germs in 23 patients. 4 VAPs were polymicrobial: isolation of all co-responsible germs was considered essential only in one case (isolation of P.Mirabilis and S.Aureus) and occurrence of two distinguished VAP’s episodes was regarded. In the other 3 cases of polymicrobial VAP,we considered that isolation of at least one of co-responsible germs allowed the technique to detect VAP’s episode. Strict agreement was found between fPTC and fPSB,with regard both to germ-response (C=71%) and to VAP-response (C=77%); concordance was never found lower than 67% in all other cases. Sensitivity for VAP’s responsible germs isolation was 61% with bPTC, 79% with fPTC and 71% with fPSB. The most sensitive technique for VAP’s detection was fPTC (positive results in 21 of 24 VAPs episodes;Se=88%); fPSB (Se=75%) and bPTC (Se=62%) detected 18 and 15 of 24 VAP’s episodes respectively. No significant difference was found between fPSB and bPTC sensitivity (p>0.05),while a significant one appeared between fiberoptic and blinded PTC (p<<0.01). CONCLUSION. Our study confirms fPTC’s accuracy for VAP’s detection as well as a real ability to substitute fPSB in the ICUs. VAP is usually consequent to aspiration into the lower airways of contaminated oropharyngeal secretions,which tend to accumulate in dependent areas of the lung,where a catheter passed blindly through the endotracheal tube can easily be directed: reasonable accuracy for VAP’s diagnosis of blinded PTC was not unexpected. A suitable role for this technique could be that of a first microbial approach to mechanically ventilated patients, possibly followed by a guided sample if required.

212 USEFULNESS OF BRONCHOALVEOLAR LAVAGE FOR THE EVALUATION OF

SEVERITY OF ASTHMA

Miyata K.1, Ito T.1, Yanagita K.1, Tachihara H.1, Shiraishi S.1, Ito H.1, Yamaguchi T.1, Hoshino S.1

1Anesthesiology and critical care, Tokyo medical university kasumigaura, inashikigun, Japan INTRODUCTION. In general, severe asthmatic patients are used to be performed by the mechanical ventilation management. In our ICU, we performed the mechanical ventilation management with an inhalation anesthesia for the severe asthmatic attack. However, it must be necessary to reduce the time and the concentration of inhalation in order to prevent the complications induced by inhalation anesthesia. Therefore, in ICU, the development of the proper evaluation for the asthmatic conditions might be useful for the prevention of complitcaions, the adaptation of trachectomy. In addition, at the early stage of entering ICU, it must be important to estimate the diagnosis of infection because of the proper administraion of antibiotics. In the severe asthmatic attack case, we examined the usefulness of the bacterium culture taken by bronchoalveolar lavage (BAL) of asthmatic patients entered in ICU at the early stage in order to diagnose the severity of asthma. METHODS. Since 1995, twenty severe asthmatic attack patients, performed by the mechanical ventilation with intubation, have been enrolled. We took BAL of these patients within two hours after intubation. A 20 ml of sterile 0.9% saline solution was added to BAL and irrigated the left upper lobe(B4 or B5). Lavage fluied was examined for the bacterial inspection and then we divided into two groups as following; One is the I group in which any bacteria was not detected and another is the N group in which bacteria was detected. RESULTS. P. aeruginosa was identified in five cases, and each Entrebacter species, Streptococcus species, H. Influenza and E. Coli was detected in one case. There was no significant difference between two groups in the age, WBC, CRP, PaO2/FiO2, BE, SBP and HR at entering ICU. However APACHE II score is more I group than N group at entering ICU significantly. The time of artificial respiration in I group was longer than that in N group (94.7°80.4 hour), significantly. And the duration of intensive care in I group (15.7°5.7 day) was longer than that in N group( 6.6°6.3 day), significantly. The duration of inhalation anesthesia was not seen any significant changes between two groups. CONCLUSION. Our data indicate that the bacterium culture taken by BAL is useful for the evaluation of the severity of the severe asthmatic attack.


215 EVALUATION OF A NEW TRACHEOSTOMY TUBE McNarry A. F.1, Buoy H. C.1, Goldhill D. R.1 1 Anaesthetics Unit, The Royal London Hospital, London, United Kingdom INTRODUCTION. Portex Blueline Ultra Suctionaid is a novel tracheostomy tube allowing subglottic suction through an additional port terminating above the cuff. Removal of these secretions delays1 or reduces2,3 the onset of ventilator associated pneumonia. METHODS. Intensive care patients requiring a tracheostomy were identified and a size 8.0 Suctionaid was inserted percutaneously or surgically, as clinically indicated. Continuous (15-20 cm H2O) or intermittent suction (4 hourly via a 5 ml syringe) was applied and aspirate volume recorded. Aspirates were sent for microbiological analysis. Normal saline flush was used to clear side port obstruction. Trial tubes were exchanged on unit discharge. RESULTS. Twenty-six tubes were inserted, 27% surgically, 69% in males. A suctionaid was not used in 2 other cases because of patient size, 8.0 being the only production tube at the time. Early removal occurred once for surgical reasons and once for persistent cuff leak despite tube change. Operators graded insertion as easy or very easy in 91% of cases. The average duration of insertion (of Suctionaid) was 7.5 days, median 6 days, range 2-27 days. Five tubes were put on continuous suction, although this method was unpopular with nurses who thought it noisy and cumbersome. Average daily aspirate was 15.1 ml (14.5 ml in the continuous group; median 4 ml, inter quartile range 0-18 ml and in the intermittent group 15.3 ml average; median 7 ml, inter quartile range 0-26 ml). The highest daily volumes (130 ml) were in the continuous group but these were obtained using additional higher pressure suction. No subglottic fluid was aspirated on 30% of the total days. In 2 cases, flush leaked from the stoma immediately following insertion and no aspirate was obtained for the duration of insertion. Flush leak from the stoma was seen at some time with seven other tubes, 77.8% of leaks occurring in male patients. There were no airway problems with any patient. Pseudomonas aeruginosa and Acinetobacter baumannii were amongst a variety of organisms grown from the aspirates. CONCLUSION. The Suctionaid tube allows removal of subglottic secretions in the majority of tracheostomised patients, the proportion likely to increase with the availability of larger tube sizes. It may be a useful non pharmacological adjunct at preventing later onset ventilator associated pneumonia which may be responsible for increasing length of intensive care unit stay and mortality4. REFERENCES. 1 Kollef MH et al, Chest, 1999; 116(5):1139-46. 2 Valles J et al, Ann Intern Med, 1995; 122:179-86 3 Kees Smulders MA et al, Chest, 2002; 121:3 858-62 4 Iregui M et al, Chest, 2002; 121:3 679-81 Grant. Suctionaid Tracheostomy Tubes Portex Limited, Hythe, UK. Ali

Poster Sessions Paediatrics (I) – 216-226 216 PULMONARY CHANGES IN CHILDREN WITH INHALATION INJURY TREATED

WITH HIGH FREQUENCY VENTILATION

Mlcak R. P.1, Hawkins H. K.2, Cortiella J.3, Herndon D. N.4 1Respiratory Care, 2Pathology, 3Anesthesiology, 4Surgery, Shriners Hospital for Children, Galveston Burn Hospital, Galveston, United States INTRODUCTION. Despite improvements in the management of burn injury, pediatric patients with inhalation injury often develop respiratory failure and require mechanical ventilation. Over the last decade the use of positive pressure ventilation has undergone a fundamental change. Protective ventilator strategies are now being used to prevent over-distention and stretching of normal lung units. High Frequency Percussive Ventilation (HFPV) is a form of protective ventilator strategy that has been shown to be effective in the treatment of adults and children with inhalation injury. Cioffi, et al have shown decreased pulmonary damage in primates with inhalation injury treated with HFPV. The purpose of this study was to determine if HFPV would result in less severe pulmonary damage in pediatric patients with inhalation when compared to conventional mechnaical ventilation. METHODS. Sixteen severely burned children that died with inhalation injury who were ventilated by HFPV (n=6) or conventional ventilation (n=10) were evaluated at autopsy. Pulmonary pathologic changes were scored and compared by a "masked" pathologist. Study variables included: airway necrosis, hemorrhage and diffuse alveolar damage. Pathology scores are presented in percent. RESULTS. A total of 16 thermally injured patients with inhalation injury who died were studies. Demographic data showed no significant differences between the two groups in regards to age, % TBSA burn, length of ventilation or peak inspiratory pressure. 10% of the patients in the conventional ventilation group showed severe airway necrosis and hemorrhage. 20% of the patients in the conventional ventilation group showed severe diffuse alveolar damage. No severe airway necrosis, hemorrhage or diffuse alveolar damage was found in the HFPV group. However both groups did show some degree of pulmonary changes. CONCLUSION. Results indicate that the use of a protective ventilator strategy such as HFPV may play a role in decreasing the severe pulmonary pathology changes seen in pediatric patients with inhalation when compared to conventional mechanical ventilation. REFERENCES. Cioffi WG, DeLemos RA, Coalson JJ, Gerstmann DA, Pruitt BA. Decreased pulmonary damage in primates with inhalation injury treated with high frequency ventilation. Annuals of Surgery 1993, 218, # 3, 328-338.

217 ENTERAL ANTIBIOTICS TO CONTROL RESISTANCE

Taylor N.1, Baines P. B.2, Reilly N.3, Thorburn K.2, Kerr S.2, Sarginson R. E.2, Van Saene H. K. F.1 1Medical Microbiology, University of Liverpool, 2Paediatric Intensive Care, 3Pharmacy, Alder Hey Hospital, Liverpool, United Kingdom INTRODUCTION. Enteral non-absorbable antimicrobials polymyxin E combined with tobamycin clear gut carriage of [multi-resistant] aerobic Gram-negative bacilli. In this study, we assessed whether the addition of enteral antibiotics to parenteral antimicrobials controlled the emergence of resistance in terms of both super-carriage and -infections. METHODS. We conducted a prospective study in a 20 bedded paediatric intensive care unit. Children requiring four or more days of ventilation were enrolled. When patients were found to be carriers of abnormal flora including [potentially] resistant aerobic Gram-negative bacilli polymyxin E/tobramycin were given as a paste in the throat and as a suspension into the gut four times daily. Defined primary endpoints were the incidence of children who carried and developed infections with resistant bacteria, and the unit’s pattern of antimicrobial use. RESULTS. A total of 948 patients were admitted 1103 times over 14,110 days during the three year study. Enteral antibiotics were administered during 551 of the 1103 episodes [50%]. Thirty-five children [3.7%] developed 62 infections due to resistant micro-organisms. About 90% of patients were free from carriage of resistant micro-organisms following the administration of enteral non-absorbable antibiotics to only half the study population. Mortality was 10% [94 patients died] the median paediatric index of mortality was 0.076 [IQR 0.03-0.15]. CONCLUSION. Combining enteral non-absorbable antimicrobials with parenteral antimicrobials was associated with a supercarriage and infection rate of 10% and 3.7%, respectively in children requiring mechanical ventilation for 4 or more days. As resistance is not emerging, the original systemic antibiotics remain active and the continuing search for newer agents is less necessary. REFERENCES. Baines PB, Meyer J, de la Cal MA. Antimicrobial resistance in the intensive care unit: the use of oral non-absorbable antimicrobials may prolong the antibiotic era. Curr Anaesth Crit Care 2001; 12: 41-47. Grant. Chris Stoutenbeek Foundation

218 CHARACTERISTICS AND DISTRIBUTION OF ANTIBIOTICS IN PICU

Briassoulis G.1, Natsi L.1, Filippou O.1, Mavrikiou M.1, Kalabalikis P.1, Hatzis T.1 1PICU, Aghia Sophia Children's Hospital, Athens, Greece

INTRODUCTION. To determine the range of antibiotic coverage of critically ill children and to evaluate the relationship between antimicrobial treatment and predisposing factors influencing the use of antibiotics in a PICU. Antibiotic prescription was imposed by definite clinical indications, guided by microbial studies. METHODS. All administered antibiotics to the PICU patients were recorded during a six-month period. The cumulative and the maximum numbers of administered antibiotics, and the duration of administration were related to the number of antibiotics which the patients were already receiving upon admission, the PRISM and TISS, the primary disease and its complications during the course of hospitalization, the development of nosocomial infections with positive cultures, the presence of chronic disease or immunodeficiency, various interventional techniques (mechanical ventilation, central catheters), and other clinical and demographic factors. RESULTS. During the 6-month period, 174 patients of mean age 5±.4 (.6-19) years were admitted to the PICU, with length of stay 8.8±1.6 days, mechanical ventilation 6.1±1.4 days, PRISM 11±.7, TISS 24.6±1.0 and hospital mortality rate 9.8%. The patients received antibiotics for a total of 950 days (62.3% of the length of stay days). While in PICU, 34 patients did not receive antimicrobial treatment (19.5%), 69 received one antibiotic (39.7%), 42 two (24.1%), 17 three (9.8%), and 12 more than three (6.9%), including agents against fungi and viruses. The cumulative summary of antibiotics, which the patients had received during their stay in PICU, was significantly related to the positive cultures (p<.0001) and represented 79.3% of the patients, compared to the 67.2% of the same patients who were receiving antibiotics on the day before admission (p<.0001). Multiple regression analysis demonstrated that independent determinants of the cumulative number of antibiotics were: prior administration of antibiotics (p<.0001), the presence of a bloodstream infection (p<.0001), positive bronchial cultures (p<.0001), a negative outcome (p<.0001), development of MOSF (p=.002), immunodeficiency (p<.001), the PRISM (p<.03) and the number of central catheters (p<.03). The maximum daily number of antibiotics was also associated with the TISS (p=.007), while the duration of antibiotic coverage was additionally related to the length of stay (p<.0001). CONCLUSION. Prior antimicrobial therapy should be recognized as an important risk factor for extended antimicrobial therapy among critically ill children. Additionally, clinical efforts aimed at reducing antimicrobial treatment in critically ill patients, are restricted by the significant proportion of immunocompromised or cancer patients, patients with prolonged length of stay, the increased degree of interventions and development of nosocomial infections. The antibiotic usage in PICU, however, may be restricted and remain at entry levels by imposing definite clinical indications, guided by microbial studies.


221 NOSOCOMIAL FUNGAL INFECTIONS IN PEDIATRIC INTENSIVE CARE UNIT

Volakli E., Sdouga M., Kotsiou M, Stefanidis C, Tamiolaki. M. E. A.1 1Pediatric Intensive Care Unit, Ippokration General Hospital, Thessaloniki, Greece INTRODUCTION. The incidence of systemic fungal infections in patients requiring intensive care unit has increased in recent years with fungi being the fifth most predominant nosocomial pathogen (1,2). Infections may evolve from endogenous colonization of the gastrointestinal tract as well as from nosocomial exogenous transmission. The aim of our study was to investigate the incidence,location and outcome of nosocomial fungal infections (NFI) in our PICU and their relation to risk factors. METHODS. We prospectively examined 94 consecutive PICU patients (pts), 59M/35F with LOS>72h. Screening cultures obtained from fharynx, gastric fluid, stool, blood, urine, tracheobronchial aspirates (in case of intubation)on admission and every 4 days thereafter until discharge. Data collected:age(mo), illness severity score (PRISM III 24h), risk factors(gastrointestinal tract colonization, broad spectrum antibiotic usage, immunosupression, prior hospital admission), MV(days), LOS(days),outcome. RESULTS. 19 (20.2%) pts developed NFI. 4 pts had candidaemia, 3 pts had pulmonary infections with asrergillus (1pt among them had also CNS infection with aspergillus), 12 pts had urinary tract infections with candida spp (table 1).All pts with candidaemia respond well to antifungus therapy. 7/19 pts with NFI died (3 from systemic mycosis, 4 from main disease) compared to 8/75 pts without NFI (p:0.005, x square test).18/19 pts with NFI had prior hospital admissions compared to 35/75 without NFI (p:0.0001, x square test).11/19 pts with NFI had colonization of the gastrointestinal tract compared to 7/75 without NFI (p:0.0001, x square test).Table 1(*statistical significant t test for independent samples, **statistical significant x square test).

Table 1 N Age PRISM III

24h MV LOS Risk

Factors NFI 19 51.3°54.1 15.9°9.1 33°56 43°65 16/19 No NFI 75 54.9°51.9 9.1°7.3 6.5°7.1 8.8°9.06 35/75 Total 94 p:0.7 p:0.001* p:0.001* p:0.0001* p:0.0001**

CONCLUSION. Patients with NFI had higher illness severity score, spend more days on MV and stayed in PICU longer. They showed statistical significance for risk factors, prior hospital admission, gastrointestinal tract colonization and had worse outcome. Certain high risk pts may benefit for prophylaxis, early preemptive or empirical therapy. REFERENCES. 1.The Management of Fungal Infection in the ICU. Jean – Louis Vincent, 1999, The Liposome Company LTD. 2.M.Sigfrigo Rangel – Frausto et al. National Epidemiology of Mycoses Survey (NEMIS). Clinical Infectious Diseases 1999;29:253 – 8.

222 MORTALITY AND THE NATURE OF ACIDOSIS IN CHILDREN WITH SHOCK

Hatherill M.1, Waggie Z.2, Purves L.3, Reynolds L.2, Argent A.2 1PICU, Red Cross Children's Hospital, Cape Town, South_Africa, 2PICU, 3Chemical Pathology, Red Cross Children's Hospital, Cape Town, INTRODUCTION. Mortality in children with shock may be more closely related to the nature, rather than the magnitude (base deficit/excess), of a metabolic acidosis. We proposed to examine the relationship between base excess (BE), hyperlactataemia, hyperchloraemia, 'unmeasured' strong anions, and mortality. METHODS. Prospective observational study set in a multi-disciplinary Paediatric Intensive Care Unit (PICU). Forty-six children admitted to PICU with shock, median age 6 months (1.5 – 14.4), median weight 5 kg (3.2 – 8.8), were enrolled. Predicted mortality was calculated from the paediatric index of mortality (PIM) score. The pH, base excess, serum lactate, corrected chloride (Clcorr), and 'unmeasured' strong anions (Strong Ion Gap) were measured or calculated at admission and 24 hours. Comparative data are reported as median (interquartile range) for survivors and nonsurvivors, and analysed using the Mann-Whitney test and receiver operating characteristic (ROC) curve. RESULTS. Observed mortality (n=16) was 35%, with a standardised mortality ratio (SMR) of 1.03 (95% CI 0.71 to 1.35). There was no significant difference in admission pH [7.25 (7.06 – 7.39) vs. 7.19 (6.99 – 7.23); p = 0.11] or BE [ -14 (-19 to -8) vs. -16 (-21 to -11) mmol/L; p=0.32] between survivors and nonsurvivors. Although there was a trend towards hyperchloraemia in survivors [Clcorr 114 (110 – 120) vs. 111 (105 – 113) mmol/L; p=0.08], there was no association between elevation of 'unmeasured' anions and outcome [5.3 (2.7 – 8.1) vs. 4.9 (3.1 – 8.2) mmol/L; p=0.78], Admission lactate was lower in survivors [3.3 (5.6 – 15.4) vs. 11.6 (2.4 – 6.6) mmol/L; p=0.0003). Area under the mortality ROC curve for lactate was 0.83 (955 CI 0.71 – 0.95), compared to 0.71 (95% CI 0.53 – 0.88) for the PIM score. Admission lactate level >5 mmol/l had maximum diagnostic efficiency for mortality, with a likelihood ratio of 2.0. CONCLUSION. There is no association between the magnitude of metabolic acidosis, quantified by the base excess, and mortality in children with shock. Hyperlactataemia, but not elevation of 'unmeasured' anions, is predictive of a poor outcome. Grant. Institute of Child Health, UCT

219 BOVINE SURFACTANT THERAPY IN CHILDREN WITH ACUTE RESPIRATORY DISTRESS SYNDROME Hug M. I.1, Arenas-López S.2, Schindler M.3 1Departments of Intensive Care and Neonatology, 2Pharmacy Department, 3Intensive Care Units, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom INTRODUCTION. The mortality of acute respiratory distress syndrome (ARDS) in children remains high although various new treatment strategies have been developed and introduced in the past years. In a retrospective case control study we aimed to examine the effect of exogenous bovine surfactant therapy on outcome of ARDS in children and to determine possible factors associated with a response to surfactant treatment. METHODS. 86 children (age 3 months to 14 years) with ARDS, subsequently admitted to a paediatric intensive care unit of a tertiary medical centre, were enrolled into the study. 49 patients who had been treated with bovine surfactant intratracheally were compared against a control group of 37 patients. The administration of surfactant was determined to induce a positive response when the oxygenation index improved by more than 25% at 4 hours after the application. RESULTS. Of the 49 surfactant patients 23 (47%) showed a positive response to the first dose of surfactant. A second dose, given in 45% of the patients, was effective in 23%. The second dose was significantly less effective than the first dose (p=0.03). Responders to surfactant were younger (median 6, range 3-36 months) than non-responders (median 9, range 3-168 months) (p=0.05). Responders showed a significant decrease in peak inspiratory pressure, oxygenation index, A-aD02 and FiO2 and an increase of the PaO2/FiO2 ratio and PO2 following surfactant. 87 % of the responders received a concurrent steroid therapy, this additional therapeutic intervention was associated with a positive response to surfactant (p=0.01). Steroid treatment was the independent predictor of surfactant response (p=0.026). Extracorporeal membrane oxygenation (ECMO) was significantly less frequently required in the surfactant group (p less than 0.001). Children with sepsis were less likely to respond to surfactant (p=0.02), patients with pneumocystis carinii or cytomegalovirus pneumonitis were more likely to respond (p=0.03). Early treatment (less than 24 hours after intubation) was not followed by a better response to surfactant. Mortality at 28 days was not different in the two groups. The overall mortality was 28%. The total duration of ventilation, the intensive care stay and the incidence of new chronic lung disease were similar in both groups. CONCLUSION. The intratracheal administration of bovine surfactant did improve oxygenation and ventilation parameters in the responders. It did not enhance the overall prognosis for ARDS in children, but could decrease the necessity for ECMO. Younger patient age and concurrent steroid therapy are factors predicting a positive response to surfactant.

220 NEUROTROPHINS IN CEREBROSPINAL FLUID AND PLASMA OF CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY Caresta E.1, Langer A.1, Pulitanò S.1, Piastra M.1, Viola L.1, Chiaretti A.1, Genovese O.1, Tortorolo L.1, Polidori G.1 1Pediatric Intensive Care Unit, Catholic University, Rome, Italy INTRODUCTION. Traumatic brain injury (TBI) is the most common cause of death and acquired disability among children and young adults in developed countries, and even when adequate treatment is provided, TBI commonly causes neuronal loss. The objective of the present study was to evaluate the expression of neurotrophins [Nerve Growth Factor (NGF), Brain Derived Neurotrophic Factor (BDNF)and Glial Derived Neurotrophic Factor (GDNF) and their association with the severity and outcome of severe TBI in children. METHODS. 12 children with severe TBI (patients); 11 children with obstructive hydrocephalus (controls) were enrolled in the study. Cerebrospinal fluid (CSF) and plasma samples were collected 1 hour (T1) and 24 hours (T2) after admission. Neurotrophins levels were measured using a two-site immunoenzymatic assay. RESULTS. The neurotrophins levels differed between TBI children and controls. In the CSF of TBI children, the mean NGF level in the first 24 hours following TBI was lower (33.87 ± 18.32 pg/mL versus 110.66±26.02 pg/ml) (p<0.05), and the BDNF level was higher (242.85 ± 53.43 pg/mL versus 180.16 ±20.88 pg/mL) (p=0.327); the GDNF level remained stable. In the plasma of TBI children, the NGF level was higher (22.62 ± 4.25 pg/mL versus 16.00 ± 2.20 pg/mL) (p=0.185); levels were lower for both BDNF (22245.57 ± 2713.37 pg/mL versus 33866.66 ± 4009.54 pg/mL) (p<0.05) and GDNF (3338.25 ± 223.46 pg/mL versus 5069.16 ± 220.46 pg/mL) (p<0.001). In the CSF of TBI children, the NGF level increased from 3.55 ± 0.44 pg/mL at T1 to 48.222 ± 11.70 pg/mL at T2 (p<0.001); BDNF decreased from 4854.00 ± 1303.73 pg/mL to 593.00 ± 114.76 pg/mL (p<0.001); in plasma, no changes over time were observed. Regarding severity and outcome of injury, the only significant associatiopn was that between the diffrence in the CSF NGF level (T1 versus T2) and a good outcome versus a poor outcome (p=0.007) CONCLUSION. The observed changes in plasma and CSF neurotrophins may reflect an endogenous attempt at neuroprotection against biochemical and molecular changes after TBI. Although our results are encouraging, further studies are needed for better understanding neurotrophins-pattern modulation (mostly by exogenously intraventrICUlar administration), with the ultimate goal of reducing the morbidity and mortality related to this common condition. REFERENCES. 1. Ikeda T, Xia XY, Xia YX, Ikenoue T, Han B, Choi BH. Glial cell line-derived neurotrophic factor protects against ischemia-hypoxia-induced brain injury in neonatal rat. Acta Neuropathol (Berl) 2000; 100: 161-167 2. Abe K. Therapeutic potential of neurotrophic factors and neural stem cells against ischemic brain injury. J Cereb Blood Flow Met 2000; 20: 1393-1408


223 LOW DOSE SILDENAFIL ENHANCES THE EFFECT OF INHALED NITRIC OXIDE

Vlasselaers D.1, Vanhoof M.1, Van Den Berghe G.1 1Intensive Care Medicine, University Hospital Gasthuisberg, Leuven, Belgium INTRODUCTION. Inhaled nitric oxide (iNO) has been shown to offer beneficial effects on pulmonary vascular resistance in the immediate postoperative period after congenital heart surgery (CHS) in children with reactive pulmonary hypertension (PHT). Sildenafil (S) is a selective phosphodiesterase type 5-inhibitor (PDE5-I) that increases the availability of cyclic guanosine monophophate (cGMP), an intracellular messenger of NO. We evaluated the additional effect of a low dose PDE5-I to iNO in a single patient after CHS. METHODS. Hemodynamic parameters (systolic and mean arterial blood pressure [sABP, mABP], systolic and mean right ventrICUlar pressure [sRVP, mRVP] via indwelling catheters), percutaneous oxygen saturation (SpO2) and cGMP levels (pmol/ml) in serum were analysed in two postoperative conditions at baseline, 30 minutes after initiation of iNO and 60 minutes after enteral association of 0,2 mg/kg sildenafil to iNO. During the measurements no changes were made in FiO2, ventilation and intravenous fluids and vasoactive medication. RESULTS. Systolic RVP dropped by 33% after initiating 5ppm iNO and further decreased by 30% after associating 1mg sildenafil, without affecting oxygenation and arterial blood pressure. cGMP levels increased by 65,7% and 94,4% respectively. The effects of sildenafil were less pronounced when superimposed on 8ppm iNO.

cGMP pmol/ml

sRVP mmHg

mRVP mmHg

sABP mmHg

mABP mmHg

SpO2 %

iNO 0ppm 15,2 78 31 75 51 65 iNO 5ppm 25,2 52 23 86 58 81 iNO 5ppm + 1mg S

49 36 15 75 51 83

iNO 0ppm 18,3 61 25 70 48 73 iNO 8ppm 47,1 43 18 78 55 83 iNO 8ppm + 1mg S

68,8 39 17 75 54 83

CONCLUSION. Combining a small dose of sildenafil to low concentration iNO creates additional vasodilatation in the pulmonary circulation without affecting systemic perfusion and oxygenation. This might allow to reduce the concentration of iNO, prolong the effect of iNO and can compensate for eventual rebound-PHT after withdrawal of iNO.

224 DOES A PAEDIATRIC RETRIEVAL SERVICE DE-SKILL REFERRING HOSPITAL

STAFF IN MANAGING SICK CHILDREN?

Ramnarayan P.1, Thomas D.2, Britto J.2, Tanna A.2, Alexander S.2, Habibi P.2 1Paediatric Intensive Care Unit, St Mary's Hospital, 2Paediatric Intensive Care Unit, St Mary's Hospital, London, United Kingdom INTRODUCTION. In recent years, centralisation of paediatric intensive care and inter-hospital transport have been prompted by evidence as well as expert consensus. Has the increasing use of specialist mobile intensive care teams (MICT) to transport sick children to intensive care units resulted in referring hospital (RH) staff being de-skilled in initial airway and vascular access procedures? METHODS. The aims of this study were to compare the proportion of airway and vascular access procedures performed by referring hospital (RH) staff on critically ill children in two discrete time periods before and after widespread use of a MICT. Retrieval data were collected from all children for whom a paediatric retrieval was mounted by our MICT in the one year periods between Oct 1993-Sep 1994 and Oct 2000-Sep 2001 inclusive. The proportion of children in whom RH staff performed the initial airway and/or vascular access interventions was calculated. Statistical analysis to compare proportions were performed with the Chi-square test (statistical significance defined as p value <0.05). RESULTS. 340 children were transferred by the MICT in 2000/2001; 64 in 1993-1994. 31/51 (61%) and 227/269 (84%) children were intubated by the referring hospital staff in the first and second time periods respectively (p<0.001). The overall intubation rate remained unchanged during this period (83.9% vs. 79.1%, p = 0.69). Referring hospital staff gained central venous access in 11 vs. 18% (p = 0.22) of cases and arterial access in 22% vs. 19% (p = 0.75) of children in the two study periods. This was in spite of a significant reduction in the proportion of children requiring both these procedures (p<0.05).

1993/1994 Needed/Total

RH MICT 2000-2001 Needed/Total

RH MICT

Endotracheal Intubation

52/64 31 (61%)

21 269/340 227 (84%) *

42

Central venous access

45/64 5 (11%)

40 180/338 33 (18%)

142

Arterial access 52/62 11 41 (22%)

238/335 45 (19%)

189

CONCLUSION. Concerns that RH staff would be de-skilled in the management of sick children with the increasing use of a specialist retrieval service are unfounded. On the contrary, a larger proportion of initial procedures to establish a secure airway and vascular access are being performed by referring hospital staff. REFERENCES. 1. Pearson G, Shann F, Barry P, Vyas J, Thomas D, Powell C, et al. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet; 349:1213-1217. 2. Raffles, A. Intensive care provided by local hospitals should be improved. BMJ 312: 120-120.

225 A SIMPLE METHOD OF REDUCING THE RISKS OF PAEDIATRIC NON-BRONCHOSCOPIC BRONCHOALVEOLAR LAVAGE Morrow B. M.1, Argent A. C.2, Futter M. J.3 1Physiotherapy, Red Cross War Memorial Children's Hospital, 2Paediatric Intensive Care Unit, Red Cross War Memorial Children's Hospital, 3Physiotherapy, University of Cape Town, Cape Town, South_Africa INTRODUCTION. Non-bronchoscopic bronchoalveolar lavage (NB – BAL) is an effective diagnostic procedure in determining the aetiology of pulmonary disease. However, it has been shown to have complications, most notably of oxyhaemoglobin desaturation, which is more severe and prolonged in patients with high oxygenation indices (1, 2). METHODS. This study compared the effects of a new NB – BAL technique to an historical collection of data using an old technique. In the historical group, the suction catheter was passed through an open system so that oxygenation, but not airway pressure was maintained (”unsealed” method). For the new technique the catheter was passed through a diaphragm placed in such a way that positive pressure ventilation continued during NB – BAL (”sealed” method). RESULTS. NB – BAL was performed on 35 patients in one Paediatric Intensive Care Unit using the ”unsealed” technique and two years later on 35 patients using the ”sealed” method. There was no statistical difference between the groups with regard to demographic data or oxygenation and ventilatory requirements (p>0,05). The ”sealed” NB – BAL group experienced significantly less decrease in oxyhaemoglobin saturation during the procedure (p<0,05). Patients with oxygenation indices >10 experienced the most severe desaturation events in both groups. Significantly fewer patients with high oxygenation indices in the "sealed" group experienced severe desaturations to <80% as compared with the "unsealed" group (p<0,05).

Sealed Unsealed P value Age (months) 3 (72) 4 (107) 0.63 Oxygenation index 5.76 (26.09) 6.24 (42.63) 0.99 Ventilation index 18.73 (154.86) 21.11 (199.8) 0.33 Change in saturation (%) - 6.0 (50.0) -13.0 (63.0) 0.03 * Results expressed as median (range). * indicates significance at p<0,05 using the Mann – Whitney U Test

CONCLUSION. The NB – BAL method of maintaining positive pressure ventilation reduces the severity of desaturation during the procedure. Patients with high oxygenation indices, however, are still at risk of severe desaturation and precautions should be taken. It is recommended that the new technique be adopted to improve the safety of this procedure. REFERENCES. 1. Morrow B, Argent A. Risks and complications of nonbronchoscopic bronchoalveolar lavage in a pediatric intensive care unit. Pediatric Pulmonology 2001; 32: 378 – 384 2. Burmester M, Mok Q. How safe is non – bronchoscopic bronchoalveolar lavage in critically ill mechanically ventilated children? Intensive Care Medicine 2001; 27: 716 – 721

226 NUTRITIONAL STATUS IN HOSPITALIZED CHILDREN

Simic D. M.1, Kovacevic I. D.2 1ICU, University Children's Hospital, 2ICU, University Children Hospital, Belgrade, Yugoslavia INTRODUCTION. Nutritional status has important effects in recovery from illness. Malnutrition is observed in many of hospitalized children. The aim of our study was to analyze nutritional status in hospitalized children in Paediatric Surgical Hospital. METHODS. We examined 100 children, mean age of 5 years (53% girls). In 50 patients the admission was scheduled, while 50% patients were admitted from emergency room. Nutritional status on admission was determined by calculation/measuring body mass index (BMI), triceps skin fold thickness (TST), and mid-arm circumference (MAC). Children with BMI<20 and TST or MAC <15th centile were considered undernourished. We also applied subjective global assessment (SGA) – mils, moderate and severe malnutrition. Statistic – Student t-test. RESULTS. In the group of scheduled children, we had 43% undernutrition, 41% normality and 16% overweight (BMI, TST, MAC) and 65% malnutrition and 35% normality (SGA). In emergency group, it was 51% undernutrition, 38% normality and 11% overweight (BMI, TST, MAC) and 53% malnutrition and 47% normality (SGA). Undernourished children stayed longer in the hospital either they were accepted for elective or emergency surgery. CONCLUSION. Malnutrition was frequent in children at the time of admission. Undernourished patients stayed longer in the hospital then non-undernourished ones. According to our results, anthropometrics should be used in patients admitted for the emergency surgery, while SGA should be used for scheduled patients.

Poster Sessions – Airway management – 91-104

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