key: cord-0033160-i2lei4ne
authors: nan
title: 21st ESICM Annual Congress
date: 2008-08-08
journal: Intensive Care Med
DOI: 10.1007/s00134-008-1241-2
sha: 6da20dd476cf9f0b0f6105decc3e44d95d902e09
doc_id: 33160
cord_uid: i2lei4ne

nan

To analyze the effects on brain tissue oxygen pressure (PbtO2) of mannitol and hypertonic saline (HTS) in patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension.

METHODS. Twelve consecutive patients with severe TBI (GCS B8), admitted to our Neuro-ICU, monitored with continuous PbtO2, and treated with mannitol (25%, 0.75 g/kg) and HTS (7.5%, 250 ml) for recurrent episodes of elevated intracranial pressure (ICP [ 20 mm Hg), were retrospectively identified from a prospective observational database. PbtO2, ICP, mean arterial pressure (MAP), cerebral perfusion pressure (CPP), central venous pressure (CVP) and cardiac output, were recorded every 30 minutes for 120 minutes after osmotherapy.

A total of 42 episodes of intracranial hypertension, treated with mannitol (n = 28 boluses) and HTS (n = 14 boluses), were analyzed. Baseline PbtO2, ICP, CVP, cardiac output, MAP, and CPP were comparable. Mean CPP and MAP did not differ significantly at each time-point analyzed. HTS treatment was associated with a significant improvement of cerebral oxygenation in patients with severe TBI (Table 1) . HTS was also associated with better ICP control and improved systemic hemodynamics. 

Off hour admission to the ICU has been associated with increased as well as with decreased mortality. We evaluated whether ICU admission during off hours affects hospital mortality.

METHODS. All 3 ICUs are mixed surgical/medical intensivist led units in non-academic teaching hospitals. Intensivists are available 24/7 and intensivists on duty have no obligations outside the ICU. During daytime the intensivist is available at the bedside in the ICU and rounds are made at least twice daily. During off hours the intensivist is generally not present in the hospital, but is available within 15 minutes. Off hours were defined as the period between 10 PM and 8 AM during weekdays and between 6 PM and 9 AM in the weekend. All patients fulfilling APACHE II criteria (age[15, no burns, no cardiac surgery, LOS[8 hrs) admitted in [2004] [2005] [2006] [2007] were included. A standardised dataset for calculation of APACHE II and SAPS II scores including standardised mortality ratios (SMR) was prospectively collected.

A total of 6725 patients were admitted in the study period. Table 1 shows that off hours patients are sicker than daytime patients. Hospital mortality is higher in off hour patients, but SMR is not significantly different ( Table 2 ). In logistic regression analysis off hour admission is not an independent risk factor for increased mortality ( Table 2) . *including age and APACHE II expected mortality in the model CONCLUSION. Off hour admission to the ICU is associated with increased mortality. This is seems to be explained though by higher illness severity in patients who were admitted off hours. In the United Kingdom there is evidence of insufficient critical care facilities (1) which leads to delays in intensive care unit admission (2) and inter-hospital transfers. Critically ill patients are at increased risk of morbidity and mortality during transport (3) and therefore, wherever possible, in our institution we use theatre recovery as a critical care overflow facility until an internal bed becomes available. An audit in our institution in 2007 showed an increased mortality for patients cared for in recovery compared with those admitted directly to critical care (4) . However, this did not take into account illness severity.

Patients admitted indirectly to critical care via theatre recovery over a two year period from April 2006 -March 2008 were identified. Their APACHE II score, hospital outcome and predicted mortality were compared with those patients admitted directly to ICU.

RESULTS. CONCLUSION. Patients admitted to critical care via the recovery overflow facility have a higher mortality than those admitted directly. They also have a higher mortality than those patients transferred between UK ICUs (hospital mortality 26%/mean APACHE II 16.3/predicted mortality 31.5%) (5) . This cannot be explained by illness severity. More ICU beds should be made available and care levels increased in recovery. Early patient transfers should be considered in the absence of an immediately available critical care bed. INTRODUCTION. It is well recognised that ward based early warning score systems can be used to predict outcome (1) . In 2007 the UK's National Institute for Health and Clinical Excellence (NICE) recommended (2) that physiological scoring systems should include the following variables: heart rate (HR), systolic blood pressure (BP), respiratory rate (RR), temperature (T), assessment of consciousness level (Alert, Verbal response, Pain response, Unresponsive -AVPU) and oxygen saturation (SpO2). The aim was to assess several published scoring systems against our existing Modified Early Warning Score (MEWS) which includes HR, BP, T, RR, AVPU and urine output (UO).

METHODS. For a period of 3 months from January to April 2008 physiological data were collected for all unplanned ICU (uICU) admissions and cardiac arrest (CA) calls in our institution. Up to 24 hours of physiological parameters prior to the event and the documented MEWS were taken from ward observation charts and collated on a database. The maximum pre-event value for each patient was then compared to corrected MEWS (recalculated from documented physiology), PMEWS (HR, BP, RR, T, AVPU, SpO2), NMEWS (HR, BP, RR, T, AVPU, SpO2, FiO2) and SEWS (HR, BP, RR, T, AVPU, SpO2, UO).

Hospital discharge data were available on 86 patients (overall mortality 45.3%) with 44 CA calls (mortality 54.5%) and 42 uICU admissions (mortality 38.5%). Results are reported as median (IQR) and P values from Mann Whitney test. Receiver Operating Characteristic (ROC) curve areas were different among the scoring systems with the best prediction being those containing a SpO2 score. Second MET call patients were more likely to be surgical and dysrhythmias were a more common trigger. They also had a 50% longer LOS and a 30% increase in mortality. *For continuous variables mean (median) ± Standard Deviation are given CONCLUSION. Patients requiring a 2nd MET call have a higher in-hospital mortality and longer LOS compared to those receiving only a single activation Delayed institution of NFR orders could be one of the possible reasons for this difference.

INTRODUCTION. Acute lung injury (ALI) and the more severe acute respiratory distress syndrome (ARDS) are life threatening conditions characterized by inflammation of lung parenchyma and vascular leakage leading to impaired gas exchange and hypoxemia. The triggering mechanisms for ARDS/ALI are not completely understood, and current treatments provide supportive care rather than target specific mechanisms that have a definitive effect upon outcome. A recent study revealed a protective effect of dexmedetomidine in a rat model of sepsis, demonstrating a decrease in mortality and inflammatory response (1) . With this in mind, we investigated the effect of dexmedetomidine on lung edema formation and albumin permeability in an airway endotoxin model of ALI.

METHODS. Mice were divided into four groups: no lung injury/no treatment (control), lung injury/no treatment (LPS/saline), no lung injury/ dexmedetomidine treatment (saline/Dex), and lung injury/dexmedetomidine treatment (LPS/Dex). Under general anesthesia, the subclavian vein was cannulated after which the mouse was allowed to recover for approximately 60 minutes. The mice were subsequently placed in a closed chamber and exposed to nebulized normal saline (no injury) or 10 mg of LPS in saline solution for 60 minutes to induce an inflammatory response. After an additional 60 minutes, mice were given an IV bolus injection of saline or Dex (10 ug/kg) followed by a constant infsuion (10 ug/kg/hr) for 2 hrs. Mice were also injected with 125I-labeled albumin 60 min prior to euthanasia under general anesthesia at which time blood and lung tissue were collected for determination of extravascular lung water (ELW) content, lung edema formation (wet/dry weight ratio), and albumin permeability.

RESULTS. Exposure of mice to nebulized LPS increased ELW from 15.5 ± 4.0 ul to 40.5 ± 5.5 ul (P.05) following LPS exposure, whereas ELW in mice treated with Dex was significantly reduced (26.9 ± 4.5 ul) and not different from control or Dex treatment alone (17.8 ± 3.1 ul). In addition, LPS-induced increase in the lung W/D ratio (16% increase over control; P.05) was prevented by Dex treatment. Lastly, exposure of mice to nebulized LPS increased vascular albumin permeability from 5.2 ± 0.6 to 6.6 ± 0.8%, whereas treatment with Dex 2 hrs after the onset of LPS exposure tended to block the permeability increase (5.5 ± 0.8% in lungs exposed to Dex alone vs. 5.7 ± 0.7% in LPS/Dex group) though this effect did not reach statistical significance.

CONCLUSION. In conclusion, treatment with dexmedetomidine after induction of lung injury by LPS significantly decreased extravascular water accumulation in the lung, thereby attenuating edema formation. 125I-albumin permeability may also be reduced. These data suggest that dexmedetomidine can block LPS-induced acute lung injury in mice and thus may be the sedative of choice for patients with ALI or ARDS in the critical care setting. RESULTS. 583 early and 626 late energy supply receiving patients aged 60.0±17.2 vs. 61.2±17.7 yr (mean±SD, p=0.25), 367M/215F vs. 393/231 (p=0.98), SOFA 9.1±4.2 vs. 9.1±3.9 (p=0.96) were evaluated. With the exception of a reduced occurrence of acute kidney failure, there was no positive effect of early energy supply during the first 3 days on ICU and hospital mortality and sepsis incidence. Provision of [1500 kcal, apart from separate parenteral glucose, was associated with reduced sepsis incidence (p=0.56), acute kidney failure (p=0.04), ICU (13.4 vs. 18.6%, p=0.026) and hospital mortality (18.7 vs. 24.2%, p=0.035). Increasing energy from 800 to 1300 kcal (Table) was correlated (R=0.99, p=0.0001) with the Odds Ratio for ICU mortality, which suggests a positive effect of early energy supply corresponding to an increasing reduction in mortality from 2 to 6%, respectively. 

During acute illness (day 4) patients without TBI tend to secrete more GH than those with TBI (median AUC 74 vs. 130 mIU/l, p=.46), because GH pulses tend to have higher amplitude (p=.13), but there is no difference in No of pulses (p=.52). During acute-toprotracted transition (i.e. from day 4 to 17), we did not observe any significant change in GH secretion pattern (see Table) , but the overall amount of GH secreted tend to decrease in patients without TBI (p=.098). INTRODUCTION. Early microbiological documentation is a key point for adapted antibiotherapy in patients sustaining a septic shock. This is not consistently possible to achieve using conventional bacteriological methods which require a substantial delay to obtain final results and have a fairly high rate of false negative results. Molecular biology using nucleic acid based techniques may provide an earlier and better identification of the pathogen. We conducted a prospective study to compare the results of conventional microbiology with those obtained from molecular biology at the early stage of septic shock.

Patients admitted to our medical-surgical intensive care unit with a high clinical suspicion of septic shock during daytime were studied. Blood sample and oriented biological sample(s) ( ]) in normally biological sterile fluids and in serum were performed using real-time PCR (SmartCyclerÒ, Cepheid). A universal bacterial DNA sequence identification was also performed followed by DNA sequencer analysis for species identification.

RESULTS. Two patients with positive candidemia were excluded from this feasibility study and 28 patients were studied (age [mean ± SD]: 57±18 years, APACHE II score: 23±7). Septic shock was of pulmonary (n=12), abdominal (n=5), urinary (n=8), cutaneous (n=2) or meningeal (n=1) origin. A bacteremia was documented in 7 patients. Of them, molecular serum analysis was in agreement with conventional bacteriology in 3 patients. At least one pathogen was identified using conventional microbiological assessment in other biological samples in 13 patients (Table) . Of them, 11 had concordant molecular analysis. In addition, PCR analysis allowed the identification of at least one pathogen in the biological samples obtained from 2 patients with undocumented sepsis using the conventional microbiological approach. PCR analysis (n)* 2 1 2 4 9

*: 1 biological sample may be positive for several pathogens CONCLUSION. In this pilot study, we showed that bacterial DNA identification in biological samples other than blood is feasible at the early phase of septic shock. The molecular approach promises to provide early identification of the causative pathogen in either blood or biological normally sterile fluids. Further studies are needed to define the field of use of this promising technique on clinical grounds.

INTRODUCTION. Acute renal failure (ARF) is associated with a poor outcome in patients with severe sepsis or septic shock (1) . We looked for the predictive factors of acute renal failure requiring renal replacement therapy (RRT) in a data base of 445 patients with severe sepsis or septic shock.

METHODS. All patients with chronic renal failure needing dialysis were excluded from the study from the database of 445 patients who had participated in an observational study on severe sepsis in 15 ICUs during 2006. We studied the morphological parameters, organ dysfunction at admission, the plasma creatinine level at admission, and the quantity of fluid resuscitation and the type of fluid during the first 24 hours. These parameters were entered into a univariate and multivariate analysis with logistic regression analysis. The results are presented in real value, percentage or median value (5th and 95th percentile), depending on the studied parameter. P \ 0.05 is significant.

RESULTS. 423 patients were screened for the study, 113 (27%) of them needed RRT. The comparison of the patients with and without RRT is shown in the CONCLUSION. Initial oliguria, the baseline plasma creatinine level and the sex are associated with ARF requiring RRT in patients with severe sepsis. However, the type of fluid infused doesn't seem to influence the occurrence of ARF. GRANT ACKNOWLEDGEMENT. The study was supported by CHU Nîmes.

21st ESICM Annual Congress -Lisbon, Portugal -21-24 September 2008 S99

INTRODUCTION. The development of intensive care has brought the ability to increase patients survival and quality of life but the prolongation of treatment in terminally ill patients without chance to improve outcome has been considered as a futile (1) . The aim of study was obtaining information concerning ICU physician's attitudes in the Czech Republic toward end-of-life decision (EOLD) and real implementation into the clinical practice.

A structured questionnaire was sent to each member of Czech Society of Anaesthesiology and Intensive Care. The opinion of physicians on ways of EOLD including euthanasia was explored. The answers were compared with respect to physicians religion, social and demographic characteristics, length of practice and type of hospital.

A total 870 questionnaires were sent, response rate was 213 (26%). Ninghty percentage of all physicians considered limiting therapy in terminally ill patients as a acceptable, however the implementation to the clinical practice was much less frequent (Table  1 ). In incompetent patients 96% responders considered physicians as a key person for decision making. Only 57 (28,9%) resp. 87 (43%) physicians include family resp. nursing staff in decision-making process. Physicians from small hospitals and with shorter clinical practice include relatives and nurses to EOLD significantly fewer. The majority of responders agree with maintenance of analgosedation and infusion therapy, 76% keep ventilatory support, 43% nutrition, 49% oxygen and 14% antibiotics. Euthanasia is acceptable in 39 (19,1%) physicians, from those most of them were unbelievers. Lack of privacy and absence of family being present was considered as a key barriers for providing death dignity. INTRODUCTION. The majority of deaths in Brazil happen in hospitals and more specifically in ICU. In this country there is few studies about the dying process and there is not clear legal definitions about withhold or withdraw support (WWS). It is important to know about the reality of the dying process to provide the best treatment for dying patients.The objectives of this study are: To analyze the deaths occurred in the HU/UFSC; To compare the profile of the patients who died in the ICU to those who died in the wards; To identify if the decisions of WWS, comfort care plans, patients' identification as dying and/or do-not-resuscitate orders prior to the death were recorded.

Retrospective cohort study, approved by Ethical Committee. Deaths occurred in patients, admitted to the HU/UFSC from July 2004 to June 2007, were analyzed. Demographic characteristics, clinical features and the treatment performed for the patients who died were evaluated. It was considered if WWS preceded the death. Data was allocated in two groups: G1 to the patients who died in the ICU and G2 to the patients who died in the Wards. Data were analyzed using t Student and v2 tests (p-value ,05).

The analyzed hospital has 165 beds (158 in wards and 7 in ICU). During the study period 14330 patients were admitted at hospital. The hospital mortality rates was 4,95%. This index in ICU was 23,77% and in Wards was 3,39%. The data of 710 patients had been analyzed. Two hundred and sixty one died in ICU (G1) and 449 in the wards (G2). The most of patients were men in both groups (56,9% in G1, 53% in G2) and the patients mean age was 57,4±18,1 years (G1) and 69,7±15,8 years (G2) (p\ 0.001). WWS preceded 37,5% of the deaths in G1 and 9,6% in G2 (p \ 0,001). Vasopressor drugs were the most frequently WWS in G1, while intensive care admission was the most WWS in G2. Do-not-resuscitate orders was documented in 0,76% of patient's records (G1) and in 2,44% (G2). Comfort care plans were present in 0,38% in cases (G1) and in 11,13% (G2). Patients were identificate as dying in 2,68% (G1) and 29,84% (G2). Cardiopulmonary resuscitation (CPR) prior to death was present in 27,20% of the cases (G1) and in 20,26% (G2).

CONCLUSION. In G1 the patients were younger and the death was more frequently preceded by WWS. In G2 the patients were older, more commonly considered ''dying'' and the death was more frequently preceded by comfort care plans. A CPR maneuver was more common in G1. Do not resuscitate orders were unusually documented.

GRANT ACKNOWLEDGEMENT. Federal University of Santa Catarina. S100 21st ESICM Annual Congress -Lisbon, Portugal -21-24 September 2008

INTRODUCTION. The Neurosciences ICU (NICU) sees over 650 adult patients per year. 2/ 3 are emergency admissions following traumatic brain injury, spinal injuries, subarachnoid haemorrhage or intracerebral haemorrhage. Legal issues regarding power of attorney, compensation claims, dealing with the police etc are not taught at medical school yet are often immediate concerns for both patients and their families.

A legal firm specialising in medicolegal issues, particularly brain and spinal injuries, was approached about providing pro-bono advice to patients on NICU. After approval by the Hospital Trust a 12 month pilot project was established with lawyers spending one day per week on the NICU. Formal consent/assent was sought from the patient or their relatives by the ICU consultant.

RESULTS. 31 cases were reviewed. Demographics were similar to the overall patient mix on NICU. 10 cases were road traffic accidents (passenger or pedestrian), 6 RTA (driver), 7 medical cases (SAH or ICH), 2 industrial accidents, 1 sport related injury, 3 alleged assaults and 2 falls. Breach of care and the possibility of compensation was identified in 22 cases. Non-compensation issues were identified for all cases and a total of 123 hours spent on noncompensation issues. The legal firm involved were instructed to pursue compensation claims in 7/22 cases. Feedback from families has been universally positive. The service has been extended to all patients in the Neurological Centre.

CONCLUSION. Many ICU patients have immediate legal concerns. The use of a legal team in ICU has significant benefits in terms of access to legal aid and the time taken for completion of legal issues. Overall wellbeing of patients and their family is improved by relief of anxieties regarding legal matters. Identification of compensation claims will potentially allow earlier access to funding for ongoing care. INTRODUCTION. Rapid response systems (RRS) are developed as a tool to decrease the assistential gap between the acute critical patients in the wards and the advanced care avaliable just on critical care areas. Indeed, the RRS calls are usually made for all instable patients in the wards, independently of their resuscitation status. So, some calls are made for patients with do-not-attemp-reanimation (DNAR) orders, and others, have a DNAR order registred after the evaluation of the instability. We quantify here the utilization of resourses of RRS to attend DNAR patients in 6 months.

We describe the proportion of calls made for DNAR patients, the call criteria and the management of this group of patients.

RESULTS. In 6 months, the RRS received 536 calls, 33 was for patients with a previous DNAR order and 31 for patients that received a DNAR order during the RRS attending. This sums a total of 12% of calls for DNAR patients. The median age was 80 ± 11 years. The more frequent calling criteria for DNAR patients was respiratory distress (30%, 19 calls), low oxigen saturation (28%, 18 calls), death constatation (27%, 17 calls) and hypotension (13%, 8 calls). The RRS prescribed medications for 34 (53%) DNAR patients and solicited adictional exams for 12 (19%) . Eleven (17%) DNAR patients were submited to Non-Invasive Ventilation (NIV) and one (2%) was intubated. From the 64 DNAR patients, 1 (2%) was transferred to ICU and 3 (5%) to High Dependency Unit (HDU).

CONCLUSION. These data show that in our experience, a significative proportion of RRS work is dedicated to assist DNAR patients. This group of DNAR patients is old, demand medical attention for respiratory disfunction and has a low rate of investigatory exams performed, low ICU transferences, but high rates of HDU transferences and NIV utilization rates. We suggest that better evaluating the characteristics and needs of this group of patients may provide tools to better organization of care.

INTRODUCTION. The amplitude integrated EEG (aEEG) pattern has shown good correlation to outcome in neonates exposed to asphyxia. Studies evaluating its value in adult cardiac arrest patients are scarce. We have studied the aEEG-patterns and evolution of aEEGpatterns in 101 adult hypothermia treated cardiac arrest patients and correlated the major patterns to outcome.

From feb 2004 to feb 2008, 101 consecutive hypothermia treated cardiac arrest patients were monitored using the NervusÒ-monitor. The monitor was applied on arrival in the ICU, and data was linked to the department of neurophysiology, where assessment was made without knowledge of patient outcome. Patients were sedated using propofol and fentanyl during hypothermia treatment. The evolution of aEEG-patterns at normothermia was correlated to patient outcome (regaining consciousness). Six months evaluation is ongoing.

RESULTS. 101 patients were monitored, 6 died from circulatory failure before normothermia was resumed, and in one case registration was lost, leaving 94 registrations for evaluation. The patients had a mean age of 61 years, 80% were male, the majority of the cardiac arrests were witnessed (83%) and out-of-hospital (84%). The initial rhythm was ventricular fibrillation in 58% of cases. Normothermia was resumed at a mean of 36 h after cardiac arrest. The aEEG-pattern at start of registration did not correlate to patient outcome. At normothermia, 28 patients had a flat or suppression-burst aEEG, two of whom regained consciousness. Fifty-two of 56 patients with a continuos aEEG without electrographic status epilepticus regained consciousness. Twenty-six patients developed electrographic status epilepticus, 10 from a continuous background pattern, and 16 from a discontinuous pattern. Only one regained consciousness.

CONCLUSION. Electrographic status epilepticus is common among hypothermia treated cardiac arrest patients and the outcome is poor. aEEG-monitoring should be performed routinely and treatment initiated as early as possible. A continuous pattern at normothermia is strongly correlated to recovering consciousness.

GRANT ACKNOWLEDGEMENT. This study was supported by Skane county council's research and development foundation and by the governmental funding of clinical research within the National Health Service. INTRODUCTION. Changes in microcirculation and mitochondrial dysfunction appear to be key mechanisms in sepsis, since they can lead to regional mismatch of oxygen supply and demand. Lipopolysaccharide (LPS, endotoxin) can be used to induce endotoxemia as a model of inflammation in humans, but the effects on microcirculatory perfusion have not been tested before. We were particularly interested in microcirculatory changes during repeated administrations of LPS when endotoxin tolerance developed. The aim of our study was to compare 3 methods to investigate microcirculation and vascular reactivity during endotoxemia and endotoxin tolerance.

Endotoxin tolerance was induced in 9 volunteers by intravenous injection of 2ng/kg/day lipopolysaccharide on 5 consecutive days. Microcirculation and vascular reactivity was monitored before (t=0) and after (t=2 and 4 hrs) LPS administrations on day 1 and 5. Near Infrared Spectroscopy (NIRS) measured thenar muscle tissue saturation before, during and after arterial occlusion (ischemia) was induced by inflating a cuff above the elbow to 50mmHg above systolic blood pressure for 90 seconds. Orthogonal Polarization Spectral imaging (OPS) measured microvascular perfusion sublingually using side stream darkfield imaging in small, medium and large sized microvessels. Forearm blood flow (FBF) was measured by strain-gauge plethysmography during local intra-arterially infusion of endothelial-dependent vasodilatory acetylcholine.

RESULTS. Endotoxin tolerance developed during 5 consecutive days of LPS administration as demonstrated by the attenuated release of pro-inflammatory cytokines and absence of symptoms and fever on the fifth day. Both NIRS and OPS did not demonstrate changes in microcirculation during endotoxemia or endotoxin tolerance in vivo. FBF measurements showed an acetylcholine dose-dependent attenuation (from 5.7±2.6 to 2.6±2.0) after the first administration of LPS (p=0.01), but not after acetylcholine stimulation when tolerance was present (from 6.1±2.1 to 5.8±3.7) on day 5(p=0.25).

CONCLUSION. In this human endotoxin tolerance model, no significant effect of repeated LPS administrations on microcirculatory perfusion could be observed using NIRS (thenar muscle) and OPS (sublingual). The forearm blood flow however, was attenuated after the first administration of LPS, indicating an endothelial dysfunction in endotoxemia in vivo. This attenuated response to acetylcholine was not present after the fifth administration of LPS, which may indicate that tolerance is also present at the levels of the endothelium. INTRODUCTION. Several authors have reported that there is no relation between systemic hemodynamics and microcirculation 1, 2 . These reports have focused on microvascular flow but not density. In contrast, a recent study by Trzeciak 3 showed that microvascular density was inversely related to mixed venous oxygen saturation (SmvO2). The goal of this study was to determine if SmvO2 and cardiac output are related to sublingual microcirculation in SS patients.

METHODS. By using side dark field videomicroscopy (Microscan Ò, Microvision medical) we evaluated sublingual microcirculation in 10 SS patients who had already been fluid resuscitated, within the first 24 hours after admission to ICU. Each patient 0 s microcirculation was evaluated looking at 3 to 6 different sublingual areas (10-20 seconds/image). Simultaneously, we assessed systemic hemodynamic parameters (MAP, mean arterial pressure; NA, Noradrenaline dose; CI, cardiac index and SmvO2). Images were analyzed by semiquantitative scores of flow (MFI, Mean flow index and PPV, proportion of perfused vessels) and density (TVD, total vascular density; PVD, perfused vascular density) of small vessels (\20lm). Correlations between parameters were determined by Pearson coefficient and considered significant if p \ 0.05.

We found that SmvO2 and CI are inversely correlated to microvascular density, but not to scores of microvascular flow. MAP and NA were not correlated to density and flow scores.

CONCLUSION. Sublingual microvascular density is strongly correlated to oxygen extraction and cardiac output and may be a critical determinant of systemic hemodynamics. 

We conducted a prospective study to assess sequential sublingual microcirculatory changes associated with passive leg raising (PLR) and volume expansion (VE) in preload-dependent septic patients.

After IRB approval, 25 ventilated septic patients with suspected fluid-responsiveness (respiratory variation in pulse pressure (DeltaPP[13%)) underwent a 5 steps trial. At Baseline, systemic hemodynamics and sublingual microcirculatory parameters (MicroScanÒ, MicroVisionMedical, The Netherlands) including the proportion of perfused vessels (PPV) were acquired. Measurements were repeated after PLR, when returning to baseline position (Post-PLR), when VE induced the same DeltaPP value than PLR (Idem PLR) and at the end of VE (Figure) . Values were analyzed with Friedman, Wilcoxon and Spearman tests.

RESULTS. Twenty septic shock and 5 severe sepsis patients (57±17 years, APACHE II : 23±7, SOFA : 11±4) were included within the first day following sepsis onset. Both PLR and VE improved sublingual microcirculation (increased PVP) but microcirculatory parameters did not correlate with systemic hemodynamics.

CONCLUSION. In preload-dependent septic patients, PLR and VE induced equal sublingual microcirculatory improvement. This result suggests that VE-induced microcirculatory changes were rather due to hemodynamic effects (systemic or local) than rheologic ones. INTRODUCTION. Impaired microcirculation in septic shock (SS) is frequent and has been related to outcome. Fluid challenge (FC) is a hallmark of resuscitation and shifts hypodynamic to hyperdynamic shock at the macrocirculation level. Since microcirculation may behave independently from macrocirculation, little is known about the relation between macro-and micro-circulation after fluid challenge. In this study, we used SDF (1, MicroScan, MicroVision Medical Amsterdam, NL) imaging to assess the sublingual microcirculation in patients with SS. We hypothesized that microcirculatory blood flow may change after fluid challenge relatively independently from macrohemodynamic response.

METHODS. Fourteen patients (mean age 64±17 yrs) with SS of less than 48 hrs, mechanically ventilated and receiving norepinephrine, underwent a fluid challenge (500ml saline over 15 min). SAPS II and SOFA score were collected. SDF imaging of the sublingual microcirculation were performed in each patient, at 3 different spots, before and after FC. Heart rate (HR), invasive mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO) were registered at the same time.

Movie clips of the microcirculation were analysed by 2 independent researchers in a blind manner. Microcirculatory flow Index (MFI) was calculated on a semi-quantitative basis according to the Boerma score (2) . Small vessels (diameter\20lm) changes were considered for statistical analysis using Student's t-test. p \ 0.05 was considered significant. Results are shown as mean±SD.

RESULTS. SAPS II score was 56 ± 18 and SOFA score was 11 ± 4. MFI was constantly impaired at baseline. HR, MAP, CO and CVP did not change significantly before and after the fluid challenge (100 vs 99 bpm, p= 0.68; 75 vs 79 mmHg, p=0.27; 6.9 vs 7.5 l/min, p=0.31 and 10 vs 14 mmHg, p=0.12, respectively). Small vessels MFI score improved significantly after fluid resuscitation (2.1 vs 2.5, p= 0.004).

CONCLUSION. In this cohort, fluid challenge improved microcirculatory flow despite no significant effect on systemic hemodynamic variables. This suggests that microcirculatory parameters are more sensitive in assessing responsiveness to fluid than macro-parameters. Further research should be performed to better clarify the kinetic and the threshold for microand macro-hemodynamic modifications in SS and to evaluate such a functional test for outcome prediction. INTRODUCTION. In sepsis the link between the systemic inflammatory response and the development of MOF is represented by Microcirculatory and Mitochondrial Distress Syndrome (MMDS) that causes an important cellular impairment of aerobic methabolism not corrigible exclusively with a restoration of a normal hemodynamics and oxygen delivery. We observed the changes caused by MMDS in the tissue oxygenation and in the microcirculation with NIRS and microcirculatory analysis in patient with severe sepsis or septic shock, before, during and after Activated Protein C (APC) infusion. We evaluated if APC influences tissue saturation (an index of O2ER) and if alterations of hemodynamics are linked to these changes.

METHODS. Prospective observational study. We evaluated ten septic patients treated with APC from December 2005 to September 2007. Microcirculation images were registered and analyzed by the SDF technic and MAS software that calculate the MFI (Microvascular Flow Index), mean velocity and FCD (Functional Capillary Density) parameters. We carried out evaluation with NIRS of the StO2 with the spectrometer InSpectra (Hutchinson Technology Inc., Minn) putting a probe of 15mm in the brachioradialis muscle of the patients. The measurements were made in 5 steps: pre-APC, at 24h, 48h, 72h and 24h after the end of the infusion (post-APC).

Each measurement (of the basic StO2 and of the slope during and after the ischemia) was registered and transformed from the software InSpectra Analysis. The parameters analyzed with the non-parametric test of Wilcoxon for repeated measurement (P.05).

RESULTS. MICROCIRCULATION: There was a significant increase of MFI and of FCD started after 72 h from the beginning of infusion for small and medium vessels (P.001) and an increase of mean velocity at 72h for small vessels and in post-APC for small and medium vessels (P.05) NIRS: The increase of the basal StO2 during and after APC treatment and its decrease during the arterial occlusion are statistically significant (P.05). The increase of the StO2 slope after arterial occlusion is statistically significant starting from the second day of infusion of APC (P.05).

CONCLUSION. Microcirculation analysis throw SDF technic let visualize the significant modifications which begin in septic syndrome (low capillary density, reduced flow velocity, heterogeneity of the microcirculation) and also the improvements of the microcirculatory state during the APC infusion.

There is an improvement of all the NIRS parameters after the APC infusion, which means an increase of tissutal O2ER. We have to verify if that increase is linked either with a reduced shunt effect in the microcirculation or with the end of metabolic down-regulation that involves the mitochondrial system. APC seams improve microcirculatory state in septic patients acting most of all on small vessels vases. NIRS and the microcirculation monitoring are useful tools to evaluate therapy and the outcome of severe sepsis and septic shock. The Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, 2 The Department of Cardiothoracic and Vascular Surgery, 3 The Department of Anesthesiology, Deutsches herzzentrum berlin, Berlin, Germany

INTRODUCTION. BACKGROUND: The sequential organ failure assessment score SOFA has been shown to predict mortality and morbidity in heterogeneous cardiac surgical patients but not after heart transplantation (HTx) (1, 2, 3) . As patients after HTx need early postoperative catecholamines we evaluated the application of SOFA in prediction of 30-day mortality and morbidity following HTx.

We retrospectively studied 126 consecutive heart transplant recipients (age: median 47, 12-70 years). The SOFA was calculated postoperatively and daily until intensive care unit (ICU) discharge or for a maximum of 7 days. C-reactive protein (CRP) values and white blood cell (WBC) count were reviewed. Lengths of ICU stay and 30-day mortality were assessed.

RESULTS. From the 1st until the 7th postoperative day (POD) only SOFA values, not CRP or WBC counts, were significantly higher in non-survivors (12.5%) than in survivors (Mann-Whitney test: p .001). For SOFA area under the receiver operating characteristic curve (ROC-AUC) for risk of 30-day mortality at ICU admission was 0.90 (95% CI 0.83 to 098). The highest value (0.94, 95% CI 0.88 to 0.99) was reached on the 4th POD. A SOFA value of [ 12 points as a predictor for 30-day mortality had a specificity of 79% and sensitivity of 88%. In survivors the maximum of SOFA, but not of CRP or WBC counts, correlated significantly with the length of ICU stay (p \ 0.001).

CONCLUSION. Although patients after HTx need catecholamines in the early postoperative period, SOFA can be used to grade the severity of morbidity and to identify the risk of 30-day mortality without specific modifications. As an independent score, SOFA is therefore helpful in early therapeutic decision making and resource planning in heart transplant recipients. INTRODUCTION. Nosocomial pneumonia (NP) and tracheobronchitis (TBX) after cardiac surgery are associated with worse outcomes. The aim of this study was to identify risk factors associated with NP and TBX after cardiac surgery and to determine their impact on mortality and morbidity.

METHODS. Retrospective observational cohort study of 1600 adult patients operated under extracorporeal circulation and who stayed in the ICU for more than 24 hours. NP was diagnosed in accordance with the American Thoracic Society guidelines. All NP and TBX episodes were confirmed by a quantitative culture of endotracheal aspirate. Univariate and logistic regression analysis were done.

RESULTS. The frequency of NP in our population was 1.2% (15.6 episodes per 1,000 days of mechanical ventilation) and that of TBX was 1.6% (21 episodes per 1,000 days of mechanical ventilation). The duration of mechanical ventilation with NP was longer (median 21.8 days, IQR 8.9 -35) than without respiratory tract infections (median 5.5 hours, IQR 4.1 -10). Significant independent risk factors for respiratory tract infections are summarized in Table 1 . The median length of stay in the ICU and hospital were significantly longer in patients with NP (30 and 42 days respectively) and TBX (10 and 28 days) than in patients without any respiratory tract infection (3 and 11 days, p \ 0.0001). Mortality in patients without respiratory tract infection was 0.9% (14 of 1555), in patients with NP was 42% (8 of 19) and 12% (3 of 25) in TBX, differences that were statistically significant (p \ 0.0001). INTRODUCTION. Despite a widespread use of fast-track protocols, patients undergoing cardiopulmonary by pass (CPB) may need prolonged mechanical ventilation, based with high tidal volume (10-15 ml/kg) and low positive end expiratory pressure (PEEP). Experimental and clinical data showed that this kind of ventilation might increase pulmonary and systemic inflammation in patients with acute lung injury (ALI), and this has been recently suggested in patients undergoing CPB.

Our hypothesis was that mechanical ventilation with large tidal volumes during the post operative period was a risk factor that may contribute to the development of acute lung injury.

A prospective observational study was conducted on patients undergoing CPB. Exclusion criteria were age\18 years old, off pump surgery, heart and lung transplantations. (Table) . 

A total of 204 measurements were performed. TDCOs ranged from 2.3 to 11.2 and those determined by LiDCO TM from 2.8 and 10.6 L/min. The correlation coefficient r2 between these two methods was 0.59 (P \ 0.05). Mean bias as well as lower and upper limits of agreement (i.e. mean bias ± 2 SD) were 0.32, -2.22 and 2.86, respectively. 96% of the differences between the two methods lied between the limits of agreement.

CONCLUSION. These preliminary results suggest that LiDCO TM seems to correlate fairly well with TDCO even in patients with a reduced pump function after cardiac surgery. In spite of the wide range between the limits of agreement LiDCO TM may thus be an alternative to TDCO in cases were insertion of a pulmonary artery catheter is either contra-indicated or not considered opportune. 

The systemic inflammatory response syndrome (SIRS) refers to the general activation of the immune system by non-infectious stimuli, which may cause cardiovascular failure and subsequent multiple organ dysfunction (1) . Comparable to the clinical presentation of septic shock, hemodynamic instability associated with SIRS is characterized by hypovolemia and peripheral vasodilatation with or without myocardial dysfunction (2) . Further information on the endogenous arginine vasopressin (AVP) response in patients with the postoperative systemic inflammatory response syndrome (SIRS) and vasodilatory shock would give more insight into the pathophysiology of SIRS-associated cardiovascular failure and help to indicate AVP therapy.

Patients after uncomplicated abdominal surgery without SIRS (n=10), critically ill patients after non-cardiac surgery with SIRS (n=9) and patients with SIRS plus vasodilatory shock (n=22) were included into this prospective trial. Plasma AVP (radioimmunoassay) (3) and copeptin (immunoluminometric assay) (4) concentrations together with clinical parameters were documented daily during the first seven postoperative days.

RESULTS. The AVP response significantly differed between the three groups. Patients without SIRS had lower AVP concentrations than SIRS patients with (p=0.001) or without shock (p=0.003). Patients with SIRS and shock had higher AVP levels than patients with SIRS alone (p .001). Without a group difference, AVP decreased over time (p=0.007). Non-survivors had higher AVP levels than survivors at day 28 (p.001). In SIRS patients without shock, serum osmo-larity was indirectly associated with AVP levels, while mean arterial blood pressure and se-rum osmolarity were associated with AVP in SIRS patients with shock. AVP and copeptin correlated significantly with each other (p.001; r=0.76). In patients without hemofiltration, copeptin levels could predict 28 day mortality with a high sensitivity and specifity.

CONCLUSION. The postoperative AVP response in non-cardiac surgery patients seems well preserved. A contributory role of AVP to the failure to restore the vascular tone in patients with vasodilatory shock cannot be excluded but seems less important than in septic or postcardiotomy shock. METHODS. The glucose concentrations obtained from automated laboratory equipment, ward based blood gas analyser(BGA) and bedside glucometer (MediSense)were compared from critically ill children having routine blood tests, in a 20 bed regional PICU in England.

. 101 routine samples of blood were analysed to determine the glucose concentrations when measured by automated laboratory equipment, by ward based blood gas analyser (BGA) and by bedside glucometer (MediSence),a total of 303 analyses.In the absence of a gold standard, these measurements were compared one with another. Only 53.5% of the glucometer and blood gas analyser (BGA) estimations of glucose (n=101) and 56.4% of glucometer and laboratory measurements (n=101) were within 1.0 mmol/l of each other. 86% of the comparisons between the BGA and the laboratory measurements were within 1.0mmol/ L (n=101).

CONCLUSION. There is considerable disagreement between the glucose concentrations measured using the different methods. This may produce difficulties with attempts to aggressively control glucose. RESULTS. Top 5 groups of drugs identified requiring intervention: Prophylactic Cardiac antibiotics, sedation and analgesia, Potassium chloride, dinoprostone and inotropes, and heparin. Interventions identified as effective: change in written guidelines for cardiac antibiotics, sedation and analgesia, dinoprostone and heparin. We have simplified guidelines (cardiac antibiotics, heparin and sedation/analgesia), and changed unit policy to use of standard concentrations of inotropes/prostin. Each change in guidelines has been backed up with notification and training by our education team. All events involving nursing staff are flagged to our nurse education team so that individual training needs can be met, and any general training issues identified. To increase awareness of adverse incidents we also use simulation training. This has helped improve recognition of events and awareness of methods to minimise effects. Adverse incidents are now discussed at medical, nursing and AHP new staff induction and at annual mandatory training. METHODS. Ten pigs (30-35.6 kg) were anesthetized, intubated and mechanically ventilated with a tidal volume (VT) of 10 ml/kg, PEEP = 5 cmH2O, FIO2 of 1.0 and respiratory rate (RR) between 10-20/min. ALI was then induced by means of surfactant depletion until PaO2B 200 mmHg. The VT was then set at 6 ml/kg and RR increased to keep the PaCO2 lower than 55 mmHg. After stabilization, a recruitment maneuver was performed (50 cmH2O, 40 s). Thereafter, PEEP was set at 24 cmH2O and decreased to zero in steps of 4 cmH2O (10 min/step). At each step, arterial and mixed venous blood samples were obtained and cardiac output (CO) was measured. In six animals (CT-Group), whole lung helical CT-scans (1 mm thickness) were obtained at each step during end-expiratory and end-inspiratory pauses. Airway pressure and flow signals were recorded and elastance of the respiratory system (Ers), resistance (Rrs) and PEEP continuously computed by the least squares method. INTRODUCTION. There are only limited data about the influence of posture on the pulmonary perfusion (Qr) in small animals. Ga-68 radiolabeled human albumin microspheres (Ga-68-DOTA-HSAM) with a diameter of 20 lm are expected to lodge in the pulmonary capillaries. The purpose of this study was to quantify Qr in prone and supine position in terms of their imaging manifestations in healthy rats.

METHODS. The animal research committee of the Regierungspräsidium Dresden approved the animal facilities and the experiments according to institutional guidelines and the German animal welfare regulations. Seven anesthetized, spontaneous breathing Wistar rats (297 ± 53 g), were positioned either in prone (n=3) or supine (n=4) position and Ga-68-DOTA-HSAM were infused. Qr was achieved by imaging the radioactivity distribution in the lungs. The animal PET 3D volume data were reconstructed with 3D OSEM MAP algorithm. After first measurement animals were arranged in opposite position and the PET measurement was repeated. The 3D data were at first manually coregistered and residual differences in the relative positioning of the lungs were corrected user independently (Rover, ABX GmbH, Germany). Masks for defining regions of interest (ROI) were set in the coregistered volume data for all animals. Mean normalized Qr values (Qmean) of the dorsal and ventral parts of the lungs were calculated on the basis of an automatic ROI-setting including threshold analysis.

RESULTS. Vertical gradient of regional perfusion was significantly steeper in the supine, -0.131 ± 0.01 %/cm, than in the prone animals -0.055 ± 0.01 %/cm (P = 0.002), indicating that the vertical distribution of regional perfusion in dependent regions was more accentuated in the supine than in the prone infused animals. Changes in the vertical gradient after rotation in the opposite position resulted in a vertical gradient of -0.093 ± 0.031 %/cm in prone position. Vertical gradient in the supine position of prone infused animals was -0.093 ± 0.015 %/cm. Position changes did not produce significant changes in vertical gradient in supine (P = 0.125) and in prone infused animals (P = 0.25). Qmean was not affected by posture. CONCLUSION. The influence of posture on regional perfusion was demonstrated, for our knowledge, for the first time in rodents. Qr was significantly decreased from dorsal to ventral regions in supine infused animals. Ga-68-DOTA-HSAM (20 lm) can be used for non-invasive pulmonary perfusion studies in rats with small-animal PET. Lung structure distribution changes were minor. Distribution pattern of regional perfusion in prone and supine position in normal rat lungs will be used as reference data set for further studies on injured rat lungs. INTRODUCTION. Potential for alveolar recruitment is individually different in patients with Acute Lung Injury (ALI) and can not be predicted by origin of ALI. Delay of regional ventilation (RVD) measured by Electric Impedance Tomography (EIT) during slow inflation has recently been shown to correlate with alveolar recruitment (1). We hypothesized that tidal recruitment can be reduced by individual PEEP optimizing using EIT.

METHODS. ALI was induced (oleic acid + abdominal hypertension) in 8 anesthetized pigs that received PEEP of 0-25cmH2O in steps of 5 in randomized order. PEEP level derived from ARDSnet protocol table was compared to lowest PEEP resulting in minimal differences of local RVD measured by EIT (see Figure) .

RESULTS. PEEP from ARDSnet protocol (10(8-10), Median(Range)) was lower than PEEP that minimized tidal recruitment estimated by EIT (20(20-25), p \ 0.05). PaO2/FiO2 increased with each step of PEEP up to 25 cmH2O and was lower with ARDSnet PEEP (179(139) vs 362(118), mean(SD), p \ 0.01). PaCO2 was not different (38(6) vs 37 (5)).

CONCLUSION. In this model of ALI EIT was helpful to find lowest PEEP level that minimizes tidal recruitment. ARDSnet PEEP was lower and did not entirely avoid tidal recruitment. INTRODUCTION. Continuous lateral rotation therapy (CLRT) has been shown to be effective for prophylaxis of ventilator associated pneumonia (VAP). However, neither hospital stay nor days on ventilator or mortality could be positively influenced by CLRT.

Most studies, however, lack to report on standards of VAP prophylaxis as well as on duration and practicability of CLRT. We performed a prospective randomized trial of the efficacy of CLRT in mechanically ventilated patients with respect to VAP prophylaxis.

Patients were eligible if not suffering from pneumonia or acute lung injury but in the need for mechanical ventilation. Patients were randomized within 48 hours after intubation to undergo CLRT in a specially designed bed allowing continuous rotation of the upper part of the body through an arc of 90°or to be treated in supine position. Rotation had to be performed for at least 18 hours per day. All patients were in a semirecumbent position of at least 30°. Suctioning and change of ventilator circuits were standardized. Sedation was allowed only if clinically indicated. All patients received enteral nutrition if possible. Endpoints of the study were spontaneous breathing, death, lack of tolerance, or development of pneumonia defined as newly acquired infiltrate in two consecutive chest x-rays plus signs of inflammation plus purulent bronchial secretions. CONCLUSION. CLRT is an effective prophylaxis for VAP. It exerts additive effects to other prophylactic measures like semirecumbent position and standardized ventilation and suctioning protocols. Lower VAP rate seems to result in shorter duration of ventilation and length of hospital stay. CLRT is not well tolerated in non-sedated patients during the weaning process. THE INFLUENCE OF TRACHEOSTOMY TUBE WITH INTERMITTENT SUB-GLOTTIC DRAINAGE COMPARED TO CONVENTIONAL TRACHEOSTOMY  TUBE ON THE INCIDENCE OF VENTILATOR-ASSOCIATED PNEUMONIA E. Nagy*, F. Veroniki, C. Toronidis, C. Tsokantaridis Intensive Care Unit, Kavala General Hospital, Kavala, Greece INTRODUCTION. Subglottic secretion drainage (SSD) via an endotracheal or a tracheostomy tube has recently been introduced in clinical practice for prevention of ventilator associated pneumonia (VAP), since it is cosidered to reduce micro-aspiration of secretions from the area around the cuff. The purpose of this study was to investigate the influence of a tracheostomy tube with SSD versus conventional tracheostomy tube on the incidence of VAP in ICU patients.

A randomized comparative clinical study, which included 126 patients, admitted for both medical and surgical reasons, with a length of stay [7 days in the ICU. Group A included 64 patients ventilated via conventional tracheostomy tube (TT-C) and Group B included 62 patients ventilated via a tracheostomy tube with subglottic secretion drainage (TT-SSD). SSD was performed hourly, applying a suction of -20cmH2O. Clinical pulmonary infection score plus quantitative culture of protected specimen brushing were used for the diagnosis of ventilator-associated pneumonia. The following data were recorded: age, APACHE II, predicted mortality rate (PDR), day on which tracheostomy was performed (T-Day), days of mechanical ventilation (MV-Days), length of stay (LOS), incidence of pneumonia, and outcome (death or discharge). Demographic data were compared by the nonparametric Mann-Whitney test. The incidence of pneumonia between the groups was compared by the x 2 test and outcome was compared by the Fisher test. P,05 was considered statistically significant.

The results of this comparative study are shown on the table below. INTRODUCTION. Elevation of the head of the bed of intubated individuals to C 30 degrees (semi-recumbent position) is recommended as a way to prevent aspiration of gastric content in the airways that may lead to nosocomial pneumonia. However, recent data suggest that horizontal orientation of the endotracheal tube (ETT) decreases bacterial colonization of the lower respiratory tract, in comparison to semi-recumbent position. We designed a study to test the hypothesis that lateral, head down position, to achieve horizontal position of ETT, decreases aspiration of gastric contents in comparison to semi-recumbent position.

We enrolled twenty adult patients intubated from less than 48-hour and without signs of pulmonary infection. The first 10 consecutive patients were ventilated in the semirecumbent position (SR group) and the following 10 patients in the lateral, head down position (LHD group). Patients were studied for 64 hours in the SR group and for 12-24 hours in the LHD group. Tracheal secretions were collected every 8 hours (SR group) or every 4 hours (LHD group) and tested for pepsin presence. Oral and gastric suctions were collected and tested for pepsin at baseline and every 12 hours. Data were analyzed by Chi-square, Fisher's exact test, or T-test, as appropriate.

RESULTS. The two groups were similar at baseline ( INTRODUCTION. Using a combination of a N-Methyl-D-Aspartate antagonist (NMDAa) and remifentanil we attempted to use their synergistic effects in order to avoid hypnotic drug accumulation. We assessed the benefits of this Multimodal Short Sedation Regimen by comparing it to more conventional sedative protocols.

METHODS. Medical (n=396), surgical (n=314) and trauma patients (n=88) who needed more than 48 hours of sedation were prospectively allocated into one of 4 groups :Cat.A (patients in shock)-B1(respiratory failure) -B2 (hemodynamic failure)-C (stable patients)) as defined by different hemodynamic (inotropic support) and respiratory (PaO2/FiO2 ratio) parameters. All patients were sedated using a narcotic (remifentanil(0.04-0.45mcg/kg/min)) and a hypnotic agent (propofol(0-7mg/kg/h)+/-midazolam(0-4.5mcg/kg/min)). Titration of the sedative agents was done hourly in order to achieve a Sedation Agitation Score of 4 (yawning; frown). Patients were randomized into two groups (G:n=399). In G1 we added an NMDAa namely Magnesium(0.08g/kg/d)+/-Ketamine(0-5 mcg/kg/min)+/-Clonidine 0-0.02mcg/kg/min) to the baseline sedative regimen and in G2 we added a placebo. INTRODUCTION. There is little information about propofol therapeutic failure incidence during its employment for critically ill ventilated patients. These phenomena greatly hinder patient management and may lead to employing excessive and toxic doses. The aim of this study is to analyse and describe the factors that could influence its onset.

METHODS. Prospective and descriptive study carried out in an intensive care unit (ICU) of a University hospital. We included 1460 ventilated patients that received propofol (1% or 2%) to achieve proposed sedation aims: 3 to 5 level on the Ramsay scale and ventilator synchrony. We defined therapeutic failure as the need to administer more than 350 mg/h to reach these aims. Propofol was administered, preferably, in patients with haemodynamic stability and foreseen sedative requirements lower than 3 days, and in patients with need of frequent neurological evaluations independently of foreseen sedative time requirements. Most of the patients were also treated with intravenous opiates. We analyzed demographical, clinical, and outcome data. Univariate and multivariate analyses were performed to investigate significant risk factors and logistic regression was used to fit the model. In each variable we calculated the odds ratio (OR) with its corresponding confidence interval (CI), significance assumed for P.05. RESULTS. Compared to CS, RS lowered the mean duration of MV from 5.9 to 4.9 days in the total population and from 3.2 to 2.2 days in the subgroup. Similarly, it reduced the length of ICU stay from 8.4 to 7.4 days or 5.7 to 4.9 days in the total population or in the subgroup, respectively. As a result, RS decreased the ICU costs per patient by € 1128 in the total and € 1003 in the subgroup population. The probability of RS being cost-saving was estimated at 85% for all patients and 91% for the subgroup.

CONCLUSION. From an economic perspective, RS seems to be the preferred regimen compared to CS: It leads to a substantially shorter length of MV and length of ICU stay. The associated cost-savings more than compensated the additional drug costs of RS resulting in net-savings to the hospital.

GRANT ACKNOWLEDGEMENT. This study was funded by GlaxoSmithKline. INTRODUCTION. The objective of this research was to assess the potential for improved resource utilization in a District General Hospital (DGH) Intensive Care Unit (ICU) through alterations to existing sedation protocols. We also examined whether other factors needed to be considered to ensure such changes brought long-term benefits. Between 2003 Between -2006 , the ICU at the Princess Alexandra Hospital (PAH) operated 4-5 Level 3 beds with a mean occupancy of 103%, admitting a mean of 326 patients with an mean LOS of 6.27 days, requiring a mean of 35 non-clinical transfers (NCT).There was a need to maximize capacity by investigating methods of reducing LOS and the need for NCT via efficient use of available resources. One likely method was through modifications to the ICU sedation protocol.

METHODS.. The original PAH sedation protocols utilized morphine and midazolam for long stay ICU patients, with propofol and alfentanil used for short stay patients. In 2006, protocol modifications introduced the use of remifentanil and propofol in Specifically selected patients.

Published evidence suggests a reduction in LOS of a day is possible under similar protocols (1, 2) . A mobile simulation course on the use of remifentanil was arranged. A retrospective audit was carried out, using the controlled drug register, the ICU admission register and ICU database. Data was collected on the total number of patients admitted to the ICU, those who received remifentanil, the total duration of use of remifentanil and the total LOS of those patients receiving remifentanil, and compared to the average LOS in the PAH's ICNARC data (3) .

Our data shows 29%(n=110) of our patients received remifentanil with average duration of 2.2 days. Remifentanil was used in line with the protocol in 84.5% cases and LOS in this group is one day. This shows a reduction in LOS of 1.1 days compared with 2.1 days LOS by cumulative ICNARC CMPD data (3) . We have also noticed a marked reduction in number of nonclinical transfers to 4(from 35), reduction in average occupancy to 97% (from 103%) and average LOS to 5.18 (from 6.27)against an increase ICU admission to 337 (from 326).

CONCLUSION. Our data demonstrated a reduction in LOS of 1.1 days, based on appropriate use of Remifentanil in 84.5% of cases. We have also noticed improvement in efficiency of the unit by indirect measurement i.e. increased number of admissions with decreased occupancy and number of nonclinical transfers. Proposed daily drug costs of £70 resulted in a saving of approximately £1500(4) through the reduction in LOS enabling more efficient use of available resources. These findings have shown that there is not only economic benefit to be gained with introduction of remifentanil but that we have improved overall performance and efficiency of our Intensive Care Unit. Further ongoing audit is required to assess whether further improvements in resource utilization might be possible on satisfying outstanding training requirements. METHODS. All patients admitted to 9 Spanish ICUs (1 medical, 1 trauma, 1 surgical, 6 medical-surgical) during a 30 day period were followed until death or discharge. Demographic data and previous history of alcohol, illegal or prescribed psychotropic use was recorded at admission. Mechanical ventilation as well as analgesia and sedation procedures were recorded. Agitation and the presence of emotional disorders, as well as prescription of psychotropic medication during ICU stay were also recorded. Statistical analysis was performed using SPSS 13.0. Significance level p \ 0.05. 

It is recommended to evaluate the levels of pain and agitation in critically ill patients, but only 43% of the ICU's use an analgeso-sedation scale. Implementation of assessment and management of pain also seems to be difficult.This investigation by questionnaire is performed to see whether it was desired to protocolize our pain and sedation therapy. After that, we introduced an algorithm, based on the Critically Ill Assessment score (CIA-score), and analyzed the compliance.

We investigated attitude versus behaviour towards a new clinical strategy. Attitude was analyzed by the results of the questionnaire, where behaviour was analyzed as compliance of a new analgeso-sedation algorithm. This algorithm implies a regular assessment every 4 hours of the CIA-scale and a treatment algorithm in case of high (CIA[9) (with reassessment within 1 hour) or low scores (CIA\7) (with reassessment within 4 hours).

Attitude : all responders (29 nurses and 7 doctors) feel the need for a good management and assessment of pain. 83% of the responders agreed that medication can be administered indepentdently by nurses, when a good analgeso-sedation algorithm is available. Behaviour : the data of 73 patients were analyzed, in total 2596 CIA-scores. There was an adequate score (CIA 7-9) in 69.7% of the assessments. In 9.5% the CIA-score was \7, according to the algorithm reassessment should be performed within 4 hours and this was done in 64.6%. In 20.8% the CIA-score was [9, and reassessment within 1 hour was done in only 26.1% of the cases. Scores \7 indicate a high probability for oversedation, treatment only occurs when a repeated CIA-score is too low, which resulted in weaning in 14.1% and no intervention in 85.9% of the cases with a score\7. For the high scores(CIA[9) 49.7% did not result in a medical intervention within 1 hour. If an intervention was performed, it was more often increasing the sedative drugs (31.8%) than of the analgesive drugs (10.5%).

CONCLUSION. In almost 70% of the patients on our ICU the analgesosedative strategy is according to department-guidelines. This means that in the remaing 30% the compliance to the analgeso-sedative algorithm is not sufficient. Despite all promotion and analyzing of the attitude towards management and assessment of pain on our ward, the introduction of this new algorithm seems to have a limited effect on changing the behaviour of health care professionals. METHODS. This study is a prospective cohort that was carried out in an Intensive Care Unit of an urban tertiary 300 bed hospital in Brazil. Data were collected prospectively from 200 consecutive patients who were admitted to the combined medical and surgical ICU. The outcomes studied were overall ICU and hospital mortalities. In the initial phase of the statistical analyses, relative risks of death to each independent variable and its respective 95% confidence interval were calculated. In a second phase, the Kaplan-Meier procediment was used. The final phase of the statistical analyses consisted of the Cox multiple regressions.

Overall, 56, 2% of patients used invasive ventilatory support; 56, 7% used noninvasive ventilatory support and 24, 6% didn't use ventilatory support. There was significant difference between mortality of patients who needed ventilatory support and those who didn't need (p \ 0,024). The survival of patients requiring invasive mechanical ventilation was 3 to 4-fold lower (p,006) and the survival of patients requering non-invasive ventilation was 2 to 3-fold lower (p \ 0,030). Additionally, those patients who needed high levels of analgesia (p \ 0,001) and sedation (p \ 0,009) (three or more medications) had higher ICU mortality rate. These variables are also related to hospitalar mortality: invasive mechanical ventilation (p \ 0,006); non-invasive ventilation (p \ 0,005); analgesia (p \ 0,001) and sedation (p \ 0, 0001).

Our study suggests that patients with high levels of sedation and analgesy and who had used mechanical ventilation during ICU stay had higher ICU and hospital mortality. From each patient the following data was collected at ICU admission:Age,Gender, hospitaladmission diagnosis (Any co-morbid conditions),details of prior use of anticoagulant therapy,presence of other risk factors for DVT Exclusion criteria included: Age less than 16 yrs, patients with liver disease,contra-indication for use of Vit K antagonists(eg.Pregnancy)and any anticoagulation. Drug Protocol: After informed consent patients were randomized either to oral anticoagulant therapy (Acitrom) or for low molecular weight heparin (LMWH)group.

In the Acitrom group LMWH was given along with oral anticoagulant for 4-5 days until we achieved the target INR of 2-2.5. Elderly, diabetics and hypertensive patients received 1mg/ day and all other patients received 2mg/day.After achieving the INR LMWH was stopped and the patient was maintained on Acitrom. INR was done every fifth day or whenever any change in dosage of Acitrom was required. In the LMWH group daily prophylaxis was given based on international practice. Any complication related to anticoagulant therapy was taken into account in both the arms. Therapy was continued until the patient became ambulatory or was discharged from ICU. Surveillance Doppler of lower limbs was done every 15 days to rule out asymptomatic deep vein thrombosis and to see the efficacy of the drug therapy.

RESULTS. The demographic profile and category of patients in two groups was identical. No significant drug related complication was observed in both groups. Surveillance Doppler did not show any evidence of occlusive or non occlusive deep vein thrombosis in both groups. There was statistically significant difference in the drug expenditure between the two groups.

In the Acitrom group the average cost per patient was 2-3% of the cost of LMWH cost per patient.

CONCLUSION. Acitrom has been regularly used for prevention of reccurrent thromboembolism but there is paucity of literature regarding its use for DVT prophylaxis in Critically ill patients. We conclude from our limited experience that acitrom can be a safe and highly cost effective alternative to LMWH. However a larger trial is imperative to make any definitive conclusions. 

A prospective and descriptive study was carried out on non-intubated critically ill patients between April 2006 and May 2007.A protocol of sedoanalgesia with Remifentanil (RF) was used in those patients who need pain control, propofol was used in those patients excluded from the previous group and remifentanil after extubation (RF-EX) in patients under mechanical ventilation sedated with remifentanil who are extubated keeping remifentanil at analgesic doses. Sedation for more than six hours, sedation for procedures and need for intubation in less than six hours (unless if it was a direct consequence of sedation) were excluded. Therapeutic failure was defined as: need for intubation for sedation, RASS or VAS out of optimal range (considering optimal sedation range as RASS between +1 and -2 and optimal analgesia as VAS between 0 and 3) or non-optimal doses of drugs (RF[6lgr/kg/h for more than four hours or PF[2,5mg/kg/h for more than 4 hours). The following parameters were analyzed: age, APACHE score, reason for admission, indication for sedation, mean dose of sedatives, time spent under sedation, mean ICU stay, quality of sedoanalgesia, non-optimal doses and secondary effects. CONCLUSION. According to our sedoanalgesia protocol, in non-intubated critically ill patients, doses of 1, 59±0,3mg/kg/h of propofol achieved an optimal level of sedation in 75% of the patients. When using RF according to our protocol, an optimal level of sedation and analgesia is achieved between 80 and 90% using doses of 3, 52±0, 5lgr/kg/h. INTRODUCTION. The aims of this stdy was: a) To know the prevalence of non-C.albicans species (NCA) as cause of Candidemia in non neutropenic critically ill patients (CNNCIP) and its influence on global and related mortality to infection, b) to describe the rate of inadequate empirical treatment (IEAT) in this setting and its consequences on outcome, and finally c) to analyse the impact on mortality of the different empirical antifungal therapies (broad spectrum vs Fluconazole).

A prospective and observational study was developed in a Spanish teaching hospital mixed-ICU (16 beds) during 12 years (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) . All episodes of candidemia were collected. Clinical, microbiological and outcome variables were recorded. Uni and multivariate analysis were performed to assess the influence of inadequate empirical treatment, the antifungal agents used as empirical treatment and the species involved on mortality (SPSS 13.0).

Among 397 bloodstream infections 7,8% (n=31) of the episodes were CNNCIP. The most frequent isolates were: Candida.albicans (51,7%), Candida parapsilosis (22,5%) and Candida glabrata (19,3%).There were no differences in age, sex and APACHE II score between C.albicans y non albicans species. Previous use of fluconazole was not more frequent in NCA candidemia (25%vs 26,6%; p= 0,91). Global and related mortality to candidemia were 67,7% and 29% respectively. The rate of (IEAT) was 70,9%, but it had no impact on mortality rates. The related to candidemia mortality rate was statistically higher in NCA (46,6% vs 12,5%; p= 0,03 METHODS. VRC levels were determined in various tissue samples (kidneys, liver, heart, spleen, lung, brain) of 2 patients, who had been on treatment with VRC. Patient 1 had received a single dose of 200 mg, patient 2 had obtained a total dose of 3,800 mg. The intervals between the last administration and death were 36 and 12 hours, respectively. Both patients had been on vasopressor therapy and mechanical ventilation. Antimycotic therapy had been initiated for suspected or proven invasive fungal infections. VRC tissue levels were assessed by extraction of homogenized tissue samples, purification by solid phase extraction and measurement of VRC by high performance liquid chromatography.

RESULTS. Tissue levels of VRC in patient 2 exceeded those achieved in patient 1 in all samples. Highest VRC concentrations (mean ± standard deviation) in VRC treated patients have been found in the organs of elimination -the liver (patient 1: 2.14 ± 0.40 lg/mL, patient 2: 4.21 ± 0.77 lg/mL) and the kidneys (patient 1: 1.97 ± 0.41 lg/mL, patient 2: 6.89 ± 0.06 lg/mL). Mean VRC lung concentration amounted to 1.30 ± 0.63 lg/ml. In the lung of patient 1, VRC levels reached 0.72 -0.76 lg/ml after a single dose. In patient 2, lung concentrations ranged between 1.47 and 2.04 lg/ml. In different areas of brain tissue VRC was below the limit of detection (\ 0.25 lg/mL) in patient 1 and achieved levels of 3.34 ± 0.18 lg/mL in patient 2. There was no difference in VRC concentrations between different areas of the brain, such as cortex, hippocampus, nucleus caudatus, medulla oblongata and cerebellum. VRC concentrations amounted to 1.31 ± 0.03 lg/mL and 2.95 ± 0.05 lg/mL in samples of the spleen of patient 1 and 2, respectively. In the myocardium samples of patient 1 VRC was undetectable, but reached a mean concentration of 2,44 ± 0,25 lg/mL in patient 2.

CONCLUSION. VRC is detectable in the lung and other tissues already after the firs administration and thus appears to penetrate rapidly into human tissues. VRC accumulates in the liver and the kidneys, which are also the routes of elimination. Its penetration into brain and heart is probably slower.

GRANT ACKNOWLEDGEMENT. We thank Pfizer Austria for financial support. Infectious complications associated with the use of pulmonary artery catheters (PACs) are a significant source of morbidity and mortality. Shielded (''hands-off'') PACs have been found to reduce PAC-related systemic infections. However, there is a risk that mobilization of a PAC within a contaminated sleeve may result in inoculation of organisms into the patient's bloodstream. We conducted a prospective observational trial to address the question whether it is safe to manipulate the PAC within the protective sleeve.

We prospectively enrolled 102 patients with PACs and collected the following data: APACHE II and SOFA scores, patient demographics, type, site, date and time of PAC insertion, type of surgery, antibiotic therapy at PAC insertion and removal. Upon PAC removal, 4 specimens were taken under sterile conditions: Saline reaspirated from the protective sleeve (1, ''sleeve fluid''), the distal 5 cm of the PACs (2, ''tip''), swab specimens from the introducer hub (3, ''hub swab)'' and from the skin at the PAC exit site (4, ''exit swab''). In the microbiology laboratory, sleeve fluid and tips were inoculated onto horse blood agar and incubated. After 48 hours, colony counts were performed. Catheter hub and exit swabs were also inoculated onto horse blood agar and incubated. After 48 hours, growth of organisms was classified as ''Nil'' (no growth), ''Colonization'' (scanty growth) or ''Infective'' (moderate/ abundant growth).

RESULTS. Mean duration of PAC residence was 39.1 (24) hours. 92 PACs were internal jugular, 8 subclavian and 2 femoral. 11 patients had blood cultures (all negative), and there was no episode of catheter-related bloodstream infection. 6 patients had an infective shield fluid (5 coagulase-negative staphylococci (CNS), 1 mixed gram-negative bacilli (GNB)). 4 catheter tips were infective (3 CNS, 10 Escherichia coli), 6 introducer hubs were colonized (4 CNS, 1 GNB, 1 diphtheroid). Patients having PACs with an infective sleeve fluid did not differ significantly from those without an infective sleeve fluid in terms of APACHE/SOFA scores, age, gender or site of insertion. There was a highly significant association between a colonized introducer hub and growth of organisms in the shield fluid, OR 30 (4-213, p \ 0.001). Neither a positive PAC tip nor a positive exit site swab was associated with an infective sleeve fluid culture.

CONCLUSION. In this cohort of 102 patients with a short duration of PAC residence, 6 patients had potentially infective cultures of sleeve fluid. This was significantly associated with a colonized introducer hub. These figures suggest that advancing a PAC within a ''sterile'' protective sleeve may have the potential to inoculate organisms into the patient's bloodstream. METHODS. We carried out a prospective cohort study in a medical and surgical ICU. We determine the rate of CR-BSI per 1000 catheters days during the application of an evidencebased intervention used to decrease the CR-BSI in 2007 (March to December) compared with the rate during the same period in 2006 in which we just applied conventional measures of prevention.

During the intervention period we applied five measures: giving educational sessions about how to insert and maintain central catheters, cleaning the skin with chlorhexidine, filling in a checklist during the insertion of the catheter, using the subclavian vein as the preferred site and avoiding the femoral site if possible, and removing unnecessary catheters. CR-BSI was defined as the recovery of the same organism (same species, same antibiotic susceptibility profile) from the catheter tip and blood cultures.

During the control and intervention period we registered 4289 vs 4174 patientdays and 3572 vs 3296 catheter-days respectively. During the intervention period 8 CR-BSI were diagnosed compared with 24 CR-BSI in the control period. The mean incidence rate of CR-BSI was 6.7/1000 catheter days in the control period and 2.4/1000 catheter days in the intervention period (RR 0.3; 95% CI 0.1 to 0.7; p= 0.03). A nursing intervention during the filling of the checklist was required in 17.7% of the insertions. The ratio of use of catheter was 81.5% during the control period and 80.6% in the intervention period without significant differences between periods.

CONCLUSION. The implementation of a multiple system intervention with evidence-based measures significantly reduces the CR-BSI in our intensive care unit.

M. Lugarinho*, L. J. P. Peixoto, P. P. G. Castro, R. Beranger, P. C. P. Souza Intensive Care Unit, Hospital de Clínicas Mario Lioni, Rio de Janeiro, Brazil

INTRODUCTION. Intravascular catheter-related infections are very critical in ICU environment, with elevated morbi-mortality and great impact on costs. In our unit, according to a quality political, it was established standards on prevention, diagnosis and treatment of nosocomial infections, with a periodic review of ours rates. We will describe one year of follow up results after a task force model chosen when we noticed an increase of the catheter related infections incidence: outcome management.

Prospective study, two-phases model, in a general ICU of 23 beds from December 2006 to January of 2008. First phase: multi-professional work group was created (4 physicians, 6 nurses and 2 respiratory therapists) who performed a meeting with the ''brainstorm'' technique. All the infections data were reviewed. The group identified main risk factors related to the problem using a diagram cause-effect. Then, it was established corrective measures, deadlines and ways for execution. The second phase was the implementation of the measures chosen: team for catheter insertion; full-barrier precautions for insertion of central venous catheters; semi-permeable and transparent dressings; avoiding the jugular and the femoral sites whenever possible; routine replacement of the catheters after ten days insertion; removal of the unnecessary catheters. The target was the return of catheterrelated infection rates of the previously year.

RESULTS. Sixty-one patients were followed during their stay in the ICU. A total of 118 intravascular catheters were used in the following sites: 61,9% subclavian vein (n=73), 19,5% internal jugular vein (n=23) and 18,6% in femoral vein (n=22). The median of catheter indwelling time was 10 days (SD de +/-5,16). Regarding the rates or infection, there was a reduction in average rate from 13,08 to 7,43 per 1000 days of catheters (p \ 0,05), with almost the same density of use (54,25 in 2007 versus 54,67 in 2006). The bacterial related to the infections were: BGN in 58.4% (n = 7), MRSA in 33.3% (n = 4) and staphylococcus coagulase negative 8.3% (n = 1). There was no statistical difference in time or site of the puncture between the infected group with the non-infected.

CONCLUSION. Catheter-related bloodstream infection is the nosocomial infection par excellence: costly, common, and frequently fatal. A program to improve patient safety must focus on simple and inexpensive interventions and prevention measures. Our target was achieved, although we were not able to identify the one factor that brought the biggest impact alone. However, we will keep our efforts to a new primary goal: zero rate of infection related to intravascular catheters. INTRODUCTION. CR-BSI is common, potentially lethal, and can indicate the poor quality and the inexistence of safety culture in an ICU. Some studies have demonstrated interventions to reduce this rate [1, 2] , which appears different when there is a comparison between United States of America (4.0) and developing countries (12.5) [3] . The aim of this study was to evaluate the impact of some simple measures that we used in our ICU to decrease CR-BSI.

After we had analyzed CR-BSI rate in our 10 bed medical-surgical ICU in 2006 using National Nosocomial Infection Surveillance (NNIS) methodology [4] , we studied the problem and implemented simple and not expensive measures. Better control of catheter insertion with development of a central-line checklist, not use of femoral site if possible and the daily rounds discussing the removal of catheters were the main actions adopted. The analysis of 2007 rate was done and compared with 2006.

Results are summarized in table. Until recently there was a tendency to treat them in a more conservative way, but nowadays their admission in the ICU has become normal as well as the strong support they receive-Objective: to know the age-related infection rate (IR) in the critically ill patients.

Prospective multicenter study carried out during 3 months in the year 2007. Patients were allocated in three groups (A;B;C) according to their age: less than 60 (A), between 60 -74 (B) and equal or more than 75 years (C). The characteristics of patients were analysed as well as the use of devices. IR is shown per 100 patients and per 1000 days of device. Ventilator associated pneumonia (VAP), urine infection related to urinary catheter (UTI), and primary and vascular catheter related bacteremia (PB +CRB) were monitored.

RESULTS. The survey included 12.453 patients admitted to the ICUs for more than [24h, with 38,8% in the group A, 35,2% in group B and 25,9% in group C, which represent an increase with regard to the previous years. The incidence rates were: use of device (days with device/days of stay) 0,49%, 0,48% and 0,43% for VAP; 0,82-0,81 y 0,80% for UC; and 1,33-1,33 y 1,21% for PB +CB, including arterial (AC) and venous catheter (CVC). Density and rates of infection are shown in table. 

Epidural analgesia has become widely regarded as the ''gold standard'' for post-operative pain relief after major surgery. Due to a lack of data in septic patients receiving epidurals, we have little knowledge of the true perioperative complication rates. The underlying knowledge of epidural abscess and haematoma rates are therefore unknown, making patient consent in septic individuals a difficult issue. The complications rate for patients (the majority being elective)receiving central nerve blockade is quoted as 0.1-0.001% for abscess formation1. Following the MASTER trial there is now some doubt to whether or not there is any improvement in the postoperative mortality in high risk patients undergoing major surgery2 despite the apparent reduction in respiratory morbidity.

METHODS. Following an initial retrospective (2004) (2005) (2006) , 30 case note, review in 2006 we continued our audit prospectively through 2007 (22 case note) in septic patients receiving epidural having undergone major emergency abdominal surgery and required intensive care unit (ICU) post-operatively. The aims were to assess complications associated with epidural usage in this particular patient group. Post-operatively patients were regularly reviewed by our acute pain team until no further acute pain input was required.

Of all the epidurals 38 were sited in theatre and 14 in the ICU for analgesia and as an aid to weaning from mechanical ventilation. The ratio of male to female was 27:25. The overall perioperative mortality was 42% (22/52). Two or more organ failure was seen in 33 patients. Positive blood cultures were identified in 5 cases. Of the epidurals 18 required two or more level attempts and the mean duration of in-situ catheter days was 4.7 (+/-1.3). At the time of insertion patient temperatures ranged from 35.6 to 38.9oC. Associated complications occurred in 6 cases with one epidural haematoma, one subdural catheter placement, two vascular punctures and two dural punctures despite the epidural insertions being made by senior trainees or consultants in 49/52 cases.

CONCLUSION. Due to the rarity of epidural complications in the general surgical population it is not possible to conclude whether the serious complications are greater in septic patients per se, however, it is a question of risk versus benefit in such a patient group. Unless a large scale, multicentre audit or research project is undertaken it is extremely difficult to evaluate both the true, and evidence-based, benefits and risks of epidural analgesia and anaesthesia in the septic patient population undergoing both major surgery and requiring postoperative ICU management. Patients with aneurysmal subarachnoid hemorrhage (aSAH) also experience myocardial injury at the time of rupture, but the prevalence and manifestations of neurocardiac injury are not well described. We investigated neurocardiac injury prevalence as quantified by elevated cardiac troponin I (cTnI) C0.3ng/ml within the first 5 days after aSAH and its relationship to electrocardiographic (ECG) and echocardiographic abnormalities.

METHODS. Prospective longitudinal study of aSAH patients with Fisher gradeC2 and/or Hunt/Hess gradeC3 admitted to the Neuro ICU. Serum cTnI collected for 5 days following hemorrhage with peak value per patient utilized for cohort dichotomization (cTnIC0.3ng/ml vs cTnI.3ng/ml. We evaluated the relationship between cTnI peak and demographics, bleed severity, admission 12-lead ECG, Holter monitoring days 1-5, and echocardiogram.

Of 280 subjects, 31% had cTnIC0.3ng/ml. Few patients in either group had a past cardiac disease history (10% cTnIC0.3ng/ml vs 7.2% cTnI.3ng/ml, p=.448). A significant relationship existed between elevated cTnI and older age (mean 57yrs±11 cTnIC0.3ng/ml vs 53yrs±11 cTnI.3ng/ml, p=.002), but not race or gender. A significant relationship existed between cTnIC0.3ng/ml and greater bleed severity by Hunt/Hess (p=\.0001) and admission Glasgow Coma Scale (p \ .0001). Patients with higher cTnI were significantly more likely to have initial 12-lead ECG findings of prolonged Qtc (mean 484ms±51 cTnIC0.3ng/ml vs mean 452ms±47 cTnI.3ng/ml, p \ .001), but not PR (p=.688) or QRS (p=.217) duration. On Holter monitoring, patients with elevated troponin were more likely to have ventricular dysrhythmias (21% cTnIC0.3ng/ml vs 9.8% cTnI.3ng/ml, p=.030) but not atrial dysrhythmias (p=.473). Elevated troponin was also associated with lower cardiac ejection fraction (p \ .0001) and wall motion abnormalities (40.6% cTnIC0.3ng/ml vs 5.5% cTnI.3ng/ml, p \ .0001) on echocardiogram, as well as pressor infusion (36.8% cTnIC0.3ng/ml vs 18% cTnI.3ng/ml, p=.006).

CONCLUSION. Neurocardiac injury determined by elevated cTnI occurs commonly in young patients without cardiac history after aSAH, and is related to bleed severity. Elevated cTnI is associated with ECG abnormalities at admission and throughout the first 5 days after hemorrhage, as well with as poorer cardiac function on echocardiogram. Further study is needed to determine the mechanistic cause of neurocardiogenic injury and its contribution to neurologic outcomes.

GRANT ACKNOWLEDGEMENT. National Institutes of Health (NHLBI R01HL074316). INTRODUCTION. Critically ill patients are at high risk of developing brain dysfunction which may present clinically as delirium, coma, and long-term cognitive impairment (1). The mechanisms underlying this brain dysfunction are unknown. In order to evaluate the hypothesis that brain dysfunction is associated with histological markers of brain injury, we evvaluated the prevalence and predictors of histologically defined acute brain injury in patients who died of critical illness.

We conducted a case-control study of patients admitted to 2 medical and 3 surgical ICUs during the period 1996-2006 who died and underwent autopsy. Patients with prior neurological disease were excluded. Brain histology was reviewed for evidence of ischemic, hemorrhagic, or inflammatory injury. Clinical and pathological characteristics were compared between cases (histological injury present) and controls (injury absent) in a univariable and multivariable analysis.

We evaluated histological and clinical data in 214 patients admitted to the ICU for respiratory failure (41% of patients), circulatory failure (25%), postoperatively (12%), and and other (12%). Histological evidence of acute brain injury was detected in 99 patients (46%). Lesions were most common in the cerebral cortex (38% of patients), followed by hippocampus (30%), cerebellum (20%), basal ganglia (15%), and brainstem (12%). Lesions were ischemic in 32% of patients and hemorrhagic in 25%, and inflammtory in 12%. Multivariable predictors of brain injury were female gender (OR 1.9, 95% CI 1.3-3), ARDS (OR 2.1, 95% CI 1.5-4.6), and septic shock (OR 1.4, 95% CI 1.1-4.8).

CONCLUSION. Histological evidence of brain injury was found in nearly half of critically ill patients without neurological antecedents who died in the ICU. An association was noted between brain injury and ARDS and septic shock. These results suggest a relationship between systemic inflammatory conditions and acute brain injury. RESULTS. Preliminary communication with the first 50 patients. Age 56±1,8 years; 66% men; APACHE II at admission 11±1. ICU stay 7,8±1 days and 5,4±1 days of mechanical ventilation (DMV). Mortality 20%. There was significant correlation between mortality and SS, specifically APACHE II (p 0,02), SOFA (p 0,001), Glasgow (p 0,001). Serum levels of MMP-9, BNP and DD were high at admission and significantly raised during evolution; pick level of MMP-9 was reached earlier than BNP and DD. Nevertheless no significant correlation was found between mortality and BIM. INTRODUCTION. Pericontusional tissue represents tissue at risk in traumatic brain injury (TBI), and a target for therapy. Diffusion tensor MR imaging (DTI) maps the apparent diffusion coefficient (ADC) that characterises tissue water. Higher ADC values are associated with vasogenic edema, and lower ADC with cytotoxic oedema. DTI shows regional differences in contusions, with a central core and a surrounding region of vasogenic oedema. Many contusions also demonstrate a region of cytotoxic oedema, peripheral to the vasogenic oedema. We have used oxygen-15 positron emission tomography (15O PET) to characterise physiology in these brain regions in TBI.

Six patients (median GCS 5) who required sedation and mechanical ventilation for ICP control underwent DTI at 3Tesla, and 15O PET imaging studies within 24 hours post injury. Four regions of interest were manually drawn around the contusion in order to quantify cerebral physiology respectively in the core of the lesion (low ADC core) in the surrounding vasogenic oedema (high ADC region), in the adjacent rim of tissue with low ADC (cytotoxic edema) and on a control region (structurally normal appearing tissue). ADC maps were coregistered to PET images of cerebral blood flow (CBF), oxygen extraction fraction (OEF), and cerebral metabolic rate of oxygen (CMRO2) in the four ROIs. CONCLUSION. These distinct patterns of physiology in contusions recapitulate a probable evolution of pathophysiology, with incorporation of the cytotoxic rim into the vasogenic oedema and, eventually into the contusion core. This mechanism may underlie the process of contusion expansion in TBI. The coexistence of low/normal OEF with cytotoxic oedema suggests that pericontusional ischemia may be microvascular in origin. INTRODUCTION. The optimal management of blood pressure in acute stroke remains poorly defined. Some studies note an association of poor outcome with patients with high BP on hospital admission. Others have noted a decreased risk of neurologic deterioration from stroke with higher BP and worse outcomes in patients who have a decrease in BP after admission. Therefore accurate measurement of blood pressure is crucial in the acute phase of stroke. Besides, the institution of suscessfuly treatments of blood pressure reduction or augmentation depends on it. Either non invasive or intraarterial blood pressure monitoring is commonly used in ICU. In different populations have been proved that non invasive method does not achieve right accuracy. In acute stroke population discrepancies between direct intraarterial blood pressure (IABP) and indirect blood pressure measurements (NIBP) can adversely affect therapeutic decisions and may have a negative impact on outcomes. The aim of this observational study was to test the hypotheses that IABP measurements are not accurately reflected by NIBP in a population of acute stroke patients.

A total of 52 first ever stroke patients underwent simultaneous noninvasive automatic oscillometric and intra arterial blood pressure monitoring. Each patient's height, weight, and arm circumferences at the mid-arm level were recorded. Intraarterial and oscillometric blood pressure measurements were obtained at least every 3 mins until 10 measurements from the arm into which the arterial catheter was inserted. Agreement between methods was assessed using Bland Altman analysis.

Overall 520 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 52 patients. The mean age was 57 +/-3 years. The mean NIHSS was 15 +/-6. Thirty-five percent of the acute stroke patients were on intravenous anti hypertensive treatment. No patient was on vasopressor therapy. Mean arterial blood pressure ranged from 52 to 165 mmHg. The overall discrepancy between methods of measurement to mean blood pressure was 7,8 +/-9,6 mmHg (p \ 0,001). The estimation of systolic blood pressure (SBP) using oscillometric recordings underestimated radial artery SBP by 12,7 mmHg (95% confidence interval :7,2 -15, p,001 In contrast an upward bias of 6,7 mmHg (95% confidence interval: 4,5 +/-7,2, p,001) was documented when noninvasive diastolic blood pressure (DBP) recordings were compared with intra arterial recordings. For SBP and DBP, the Pearson correlation coefficients between noninvasive and intraarterial recordings were 0,812 and 0,792 respectively.

CONCLUSION. The noninvasive automatic oscillometric blood pressure measurements underestimated mean arterial blood pressure. The SBP is underestimated and the DBP is overestimated by noninvasive automatic device. Therefore oscillometric blood pressure measurement does not achieve adequate accuracy in our acute stroke population. Physicians must consider it before institution of treatments of blood pressure reduction or augmentation. RESULTS. Organ failure resulted in 49 patients (35%). 10 variables gained a significant level at the univariate analysis. Among these, a high blood lactate concentration (Lac), a high CO2 production index (VCO2i), a low central venous saturation (ScVO2), and a low CI achieved the statistical significance at the multivariate analysis (see Table) . The ROC analysis showed a cut-off value of 2,2 mmol/l for Lac, 68% for ScVO2, 2,0 l/min/m2 for CI, and 113 ml/min/ m2 for VCOi. Sensibility vs specificity was 78% vs 69% for Lac, 75% vs 67% for ScvO2, 82% vs 77% for CI, and 72% vs 67% for VCO2i. The area under the ROC curve (AUC) resulted 0,8 for Lac, 0,78 for ScVO2, 0,79 for CI and 0,76 for VCO2i. The different ICU severity risk scores did not reach the statistical significance. The average of ICU stay was 21 ± 6 and 10,2 ± 3,4 days (complicated vs uncomplicated patients, p \ 0,001). Mortality was higher in patients with complications (25% vs 6%, p \ 0,001). INTRODUCTION. The protein S-100B is a brain-specific protein release from astroglial cells into the circulation after Traumatic Brain Injury. Research indicates that the S-100B serum level could be a useful indicator of Head Trauma severity, but there is not evidence enough about the role of S-100B after nonsevere Head Trauma (NSHT). The hypothesis that S-100B is a useful screening tool for the management of minor head injuries was tested.

METHODS. Forty five patients with NSHT without decrease of conciousness but associated syumptons/signs, like amnesia, headache, dizziness, convulsion and vomits, were prospectively included. We recorded the clinical data on admission and a blood sample before tree hours after NHST, for S-100B inmunoluminiscence analysis. A routine cranial computed tomography scan (CT) was obtained within 24 hours after the injury. The diagnositc properties of S-100B serum levels.105 lg /L, for prediction of intracranial lesions revealed by CT were tested with receiver operating characteristic (ROC) analysis.

RESULTS. S-100B levels were \ 0.105 lg /L, in eight of forty five patients (18%) without intracranial lesions. A Sensitivity of 100%, CI, 61-100%; a specifity of 21,6%, CI, 11,4%-72,2%; a Negative Predictive Value of 100%, CI, 67.6%-100% was calculated for this S-100B value. ROC curve and cross-table analysis showed that above cut-off values of S-100B, improve specifity, without changes on sensitivity. In this study the S-100B levels were [0.105 lg /L, in all the patients with brain damage, six of forty five (12.5%).

CONCLUSION. Determination of serum protein S-100B seems to be a useful biochemical indicator of brain damage, in spite of the low specificity for the detection of intracranial lesions. These results, shows that cut-off value of S-100B .105 lg /L, with high negative predictive value, appear to be of substantial clinical relevance for the management of NSHT. INTRODUCTION. Spontaneous Intracerebral Hemorrhage (SIH) has the greatest mortality among strokes. During the stay in the intensive care unit (ICU) these patients develop some complications that often modify the evolution of the disease. The aim of our study was to determine these complications developed by the patients with SIH during their stay in ICU and its relation with mortality.

METHODS. Prospective cohort study. Sixty six adults admitted to the ICU with SIH were studied during one year. SIH less than 24 hours,traumatic and subarachnoid haemorrhage, hemorrhagic transformation in acute ischemic stroke, coagulopathy and patients with preceding use of antiplatelet or anticoagulants agents were excluded. On admission we recorded: sex, age, high blood pressure (HBP), Apache II, Glasgow (GCS), location, volume (ABC/2). Complications during the stay in ICU were classified as neurologic, hemodynamic, infectious and metabolic. The average stay and mortality were determined. We studied the complications that influence more in mortality.

Forty three patients were men. The mean age was 58±13 (35-79) years. Fifty four percent were hypertense. Mean value of Apache II was 16±6 and GCS 7.4. The most common location were basal ganglia (41%) and lobar (41%). The average hematoma volume on CT was 48±25 (8-140)mL. Fifty three percent exceeded 30 mL. The average stay in ICU was 15.4±15(2-78) days. ICU mortality was 44%. Most patients died within the first week. Encephalic death was the most common cause (90%) followed by infectious complications (10%). The most frequent complications were metabolic (30%), neurologic (27%), hemodynamic (26%) and infectious (17%). In the group of metabolic complications, high glucose levels (44%) was most common complication although only hyponatremia was associated with mortality in the ICU (p=0.01). In the group of neurologic complications, brain herniation (59%)in any of its variants was the most frequent and was statistically related to mortality (p=0.03) followed by edema (45.5%), ventricular hemorrhage (41%), rebleeding (35%), hydrocephalus (29%), ischemic (29%) and seizures (12%). The most frequent hemodynamic complication was HBP (53%). The supraventricular tachycardia and auricular fibrillation were the most common arrhythmias. The most frequent infectious complications were traqueobronchitis (36%), pneumonia (21%), urinary tract infection (18%), catheter-related infection (12%) and ventriculitis (1.2%). Only pneumonia was related to mortality (p \ 0.001).

CONCLUSION. Mortality of patients with SIH in the ICU was high and usually happened during the first week. The main cause of mortality was brain death. Most frequent complications were metabolics. Neurologic complications, such as brain herniation, were related to higher mortality. Pneumonia was the infectious complication more frequently associated with mortality.

M. Martinez* 1 , D. Canovas 2 , A. Carvajal 3 , J. Estela 2 , A. Villagra 1 , J. Perendreu 4 1 critical Care Centre, 2 neurology, Hospital Of Sabadell, 3 neuroradiology, 4 interventional Radiology, Udiat, Sabadell, Spain

INTRODUCTION. IV administration of recombinant tissue plasminogen activator (rt-PA) within 3 hours of symptoms onset is the only approved therapy for patients with acute ischemic stroke. The identification of predictors of neurological improvement may help to improve patient selection. The aim of this study was to analyse prognostic factors of neurological outcome in our acute stroke patients treated with rt-PA.

Observational prospective analysis of all patients with acute ischemic stroke admitted in our ICU and treated with rt-PA (2004) (2005) (2006) (2007) . We analysed epidemiological data, stroke severity, CT scan findings, early clinical improvement, complications and neurological outcome at 3 months using a modified Rankin Scale (mRS). Results are expressed as mean (SD) or percentage, using a p.05 as significance level. We applied SPSS with the t test for continuous variables and Chi-square for categorical ones, and logistic regression tests, calculating odds ratio with their confidence interval for the significant variables.

We have treated 64 patients (64% Male), age 66 yrs. The baseline NIHSS was 14 ± 5. History of diabetes was present in 13 patients (20%). Early signs of infarct on CT were found in 18 p (28%). We observed an early neurological improvement ([ 4 points compared to baseline in NIHSS at 24 hours) in 30 patients (47%). The rate of asymptomatic and symptomatic haemorrhages at 36 hours was 14% and 3.1%. The mRS at 3 months was good (0-2) in 34 p. (53.1%). Independent factors related to neurological outcome in multivariate analysis was an early clinical improvement (OR 151, CI 8-2552), while age and baseline NIHSS were associated with poor outcome.

Variables related with neurological outcome are shown in Table 1 . CONCLUSION. In our series of acute stroke patients treated with rt-PA a good neurological outcome at 3 months was achieved in 53%. We found that age and stroke severity (baseline NIHSS and early signs of infarction on CT) were related with poor outcome, while an early neurological improvement was strongly associated with a good neurological recovery, probably related to an early recanalization.

GRANT ACKNOWLEDGEMENT. CIBER-enfermedades respiratorias. RESULTS. Twenty three cases of CVT (age: mean 43 yrs ± 15, ranging from 16 to 68yrs) were hospitalized in ICU in relation with: coma in 48%, status epilepticus in 22%; 13% in post-op. The median delay from the onset of symptoms to the CVT diagnosis was 5.63 days ± 5 SD days and from the diagnosis to ICU admission was 3.96 days ± 3SD days. Diagnosis of CVT was established by MRI/MR venography in 8 patients (35%), intra-arterial angiography in 3 (13%), CT venography in 12 (52%) Monitoring: intra-arterial catheter (20 patients, 87%), transcranial Doppler (14, 61%), capnography (13, 56%), continuous jugular oxygen saturation (4, 17%). Treatment: all patients received heparin at therapeutic dose; 18 patients (78%) were intubated and mechanically ventilated; 14 (61%) received antiepileptic drugs ventilation. Norepinephrine was used in 10 patients (43.5%) to maintain cerebral perfusion pressure.

Within the first 24 hours in ICU, fluid balance was negative in 9 patients (39%) because of brain edema and in 10 patients at day 5 (43.5%). Intra-cranial hematoma was drained in 1 patient, another had a brain abscess drainage, 3 patients had a decompressive craniectomy (2 died). Outcome : 5 patients (22%) died in ICU, four in relation with refractory intracranial hypertension, and 1 for lethal pulmonary embolism. Comparison between survival and dead patients (non parametric tests and univariate analysis): except for sex (more death on female than in male group (p \ 0.05), no difference were observed for medical context, chronic therapy; blood pressure, central venous pressure, heart rate, trans-cranial Doppler data and biological routine tests, except for platelet level at entry (240.103± 108 in survival vs 160.103±37 in dead patients; p \ 0.0033) and initial glycemia (6.41± 1.4 in survival vs 14.24± 13.36; p \ 0.06). Localisation of thrombosis or intracranial complications did not differ between the 2 groups. The mean modified Rankin score for alive patients was 2,6.

CONCLUSION. Only 22% patients with CVT died in ICU under heparin treatment. Other instrumental therapeutic options did not seem to improve poor outcome, which is associated with low platelet level and higher glycemia. METHODS. The charts were retrospectively reviewed for the patients who were discharged from the Neurocritical ICU between January 1, 2006 and December 31, 2006. In-hospital mortality was assessed and information regarding gender, age, and length of stay was collected. Statistical analyses using chi-square tests and wilcoxon rank sum tests were performed using SPSS 15.0.

There were 168 patients that were treated for ICH during this time period. Patients ranged in age from 22 to 94 years (mean = 65.2 years) and 58% were female. Eighteen patients (10.7%) died during this time period. Patients that died were significantly older than patients that survived (73.9 vs. 64.1, p = 0.02). The range of time to death was 1 to 21 days with an average of 5.3 days. Six of the 18 patients died within 1 day and an additional 7 died within 4 days. 3 patients survived longer than 10 days with one patient surviving 21 days. The cause of death in the later 3 patients was not directly related to the ICH diagnosis.

The mortality prior to starting the Neurocritical care program was 26%.

CONCLUSION. The mortality rate with the addition of a dedicated neurocritical care team in our hospital was lower than the nationally reported range. Also this improvement was noted from our pervious critical care model. Based upon this study, we follow strict protocols for all intracranial hemorrhage patients. METHODS. Prospective observational study, in a mixed medical and (neuro) surgical intensive care of a university hospital. All patients who went for BCT, between May 2007 and January 2008 were included. The physician requesting the BCT filled out a special radiological request form, in which the expectations for the results of this BCT and the consequences given these findings for treatment, were addressed. The BCT was evaluated by a radiologist. An ''expectation'' was radiologically confirmed if the finding was new or increased and negative if unchanged, decreased or not found. Treatment strategy after BCT was registered (unchanged, changed according to plan or otherwise).

. 189 clinical questions in 117 BCT's were evaluated. The most important expected findings were shift, edema, ischemia/infarction, hematoma and hydrocefalus. In 20% these expectations were radiologically confirmed. After the BCT, the physician changed the treatment strategy in 53%. This was based on positive radiological confirmation in only 24%. Strikingly, in 76% the treatment was changed although no radiological confirmation of an expected finding was obtained. The chance of a therapy change after a positive CT scan finding is 1.5 times greater than an unchanged policy after a positive CT scan. However, non of the predefined expected abnormalities showed a significant change to be followed by a change in policy. The confidence limits of the crude overall risk tells us that the chance that the policy will be adjusted due to the CT scan can be as small as 1.04 (almost non) and as large as 2.4 (almost 2.5 times). Intracranial pressure was analysed with intraparenchimal catheter, and was considered like HIP without possibility of treatment when PIC was more than 30 mmH2O for more than 20 minutes during maximal medical therapies. In the two groups ICU mortality, Glasgow Outcome Scale (GOS) and GCS after 28 days and after 1 year was valuated.

RESULTS. Mortality rate at 24 hrs was 12.5% in Group 1 and 20% in Group 2, mortality in ICU was 15% in Group 1 and 40% in Group 2, at 28 days 12.5% in Group 1 and 17.5% in Group 2, at 1 year 2.5% in Group 1 and 5% in Group 2. The GCS mean at 28 days was 12 (range 10-14) in Group 1 and 8 (range 6-10) in Group 2. At 1 year in Group 1 GOS was 5 in 10 patients (41.6%), 4 in 7 (16.6%), 3 in 5 (29.1%) and 2 in 2 patients (8.3%); in Group 2 GOS was 5 in 2 patients (22.2%), 4 in 1 (11,1%), 3 in 2 (22.2%), 2 in 4 (44.4%). INTRODUCTION. Severe traumatic brain injury (TBI) is associated with high mortality and morbidity. Decompressive craniectomy (DC) has recently regained therapeutic interest; however, treatment guidelines consider it a last-tier treatment after failure of conservative therapy.

Retrospective chart review analysis was conducted to determine the timely efficacy of DC for the management of severe TBI. Out of 250 patients with severe TBI admitted to the ICU between the years 2000-2006, 30 underwent DC. The following parameters were recorded: age, Glasgow Coma Scale (GCS, accident site), Injury Severity Score (ISS), CT-Scan findings (Marshall scale), APACHE II and SOFA scores upon admission. Follow-up period was of at least 1 year after ICU discharge, the outcome being evaluated with the Glasgow Outcome Score (GOS). The patients were divided in 2 groups: 1) group A (n=17), when early DC within hours and 2) group B (n=13) when delayed DC (within days) after TBI was performed. The decision for early DC was based on clinical parameters, CT-scan and operative findings. The patients were treated with delayed DC when maximal treatment failed. Mann-Whitney was used for the statistical analysis between the groups. All values are expressed as mean (±SD).

Patients that underwent DC comprised 12% of severe TBI admissions (n=250). Early DC was conducted within 3.6 (±1.9) hrs post TBI and delayed DC within 6.6 (±4. 5 INTRODUCTION. Decreased functional capacity of mitochondrial complex I and compromised cellular energetic status are associated with non-survival in septic patients [1] . Mitochondrial enzyme activity largely reflects the level of expressed protein (balance between biogenesis and degradation), but also persisting modifications e.g. from oxidative/nitrosative damage. In an ongoing study in critically ill patients, we investigated respiratory complex activities and corresponding protein expression in skeletal muscle.

With ethics approval and appropriate consents, critically ill patients were recruited within 24h of ICU admission. Age-matched control patients were undergoing elective hip surgery. Muscle biopsies were taken from vastus lateralis. Mitochondrial enzyme activities were determined as previously [1] . Acid-precipitated protein extracts were neutralised and used for immunoblotting. Blots were semi-quantified by densitometry and normalised to the signal obtained with a standard sample. Data were analysed for significance using one-way ANOVA.

RESULTS. Both mitochondrial respiratory enzyme activity and protein expression were decreased in critically ill patients. Expression of the mitochondrial oxidative stress protein MnSOD was increased. Median (IQ ranges); pB0.05; àpB0.01 vs controls CONCLUSION. The reduction in mitochondrial enzyme activity described in critical illness [1] can be partly explained by decreased levels of expressed protein. Elevated MnSOD expression indicates a response to oxidative stress. Together, the data suggest increased degradation of oxidatively-damaged proteins. We previously demonstrated preserved ATP content and transcript levels for markers of mitochondrial biogenesis in patients who eventually survived, but depressed levels in eventual non-survivors [2] . A decreased ability to replace damaged mitochondrial proteins may contribute to ATP depletion and mortality. INTRODUCTION. Activated neutrophils (PMNs) have been implicated in the pathogenesis of sepsis and ARDS. PMN serine proteases such as elastase are believed to contribute to tissue injury. Since increased PMN inflammatory activity is characteristically associated with prolonged survival through inhibition of constitutive PMN apoptosis, we sought to define the role of PMN serine proteases in PMN survival and inflammatory function.

We incubated PMN from healthy volunteers for 5 hours (2 hours for oxidative burst) with the serine protease inhibitor, diisopropylfluorophosphate (DFP, 2.5 mM). PMN apoptosis was quantified by flow cytometry as the nuclear uptake of propidium iodide by permeabilized cells (n=5). Caspase-3 (n=4), -8 (n=3) & elastase (n=5) activities were measured using specific substrate with a fluorescent (caspase-3 & elastase) or colorimetric (caspase-8) plate reader. Western blot was performed to characterize the processing of caspase-3 and caspase-8 (n=3). Oxidative burst was measured as the conversion of dihydrorhodamine 123 by flow cytometry (n=4).

. DFP almost completely ablated elastase activity. PMN apoptosis, and activity of caspases-3 were significantly inhibited by DFP. Caspase-8 activity was slightly inhibited by DFP (Table) . The 12kDa form of active caspase-3 was reduced, and pro-caspase-8 expression significantly increased in DFP treated samples ( Figure) . DFP also inhibited PMN oxidative burst capacity (Table) . INTRODUCTION. The efferent vagus nerve can limit the inflammatory response via stimulation of the alpha7 nicotinic acetylcholine receptor (alpha7nAChR). Nicotine, a nonselective alpha7nAChR agonist has been shown to inhibit cytokine release in human PBMCs and monocytes as well as in animal models of inflammation. Due to its lack of selectivity however, nicotine has many unwanted side effects. Therefore, selective targeting of the alpha7nAChR may be promising for the treatment of inflammatory conditions. We compared the effect of the selective alpha7nAChR agonist GTS-21 and nicotine on LPS-induced cytokine release in human blood cells. Furthermore, because pattern recognition of the diverse classes of microbial products causing infection involves various TLRs, we investigated whether the immunomodulating effect of alpha7nAChR stimulation is dependent on the TLR stimulated.

METHODS. Isolated monocytes and PBMCs of healthy male volunteers were incubated with the TLR4 agonist LPS in combination with GTS-21 (1 nM -100 uM) and nicotine (100 uM -1 mM). Furthermore, whole blood of healthy male volunteers was incubated with TLR2, TLR3, TLR4 and TLR5 agonists in combination with GTS-21, nicotine and the alpha7nAChR antagonist mecamylamine. TNF-alpha, IL-6, IL-1beta, IFN-gamma and IL-10 production was determined by ELISA and multiplex cytokine assays. All described changes are statistically significant.

RESULTS. Stimulation of the alpha7nAChR by both GTS-21 and nicotine resulted in a dramatic dose-dependent inhibition of LPS-induced pro-inflammatory cytokine release in human monocytes and PBMCs. Likewise, pro-inflammatory cytokine release induced by stimulation of the various Toll-like receptors in human whole blood was dose-dependently inhibited by both GTS-21 and nicotine. Production of the anti-inflammatory cytokine IL-10 was not inhibited but stimulated by GTS-21. GTS-21 inhibited pro-inflammatory cytokine production stronger than nicotine at equimolar concentrations. Finally, inhibition of the alpha7nAChR did not have any effect on cytokine production.

CONCLUSION. Selective stimulation of the alpha7nAChR by GTS-21 has a profound antiinflammatory effect by inhibiting pro-inflammatory and stimulating anti-inflammatory cytokine release. In addition, GTS-21 proved to be more potent than nicotine in inhibiting proinflammatory cytokine release. The anti-inflammatory effect of alpha7nAChR stimulation was not restricted to a specific TLR. Therefore, this pathway appears to modulate the inflammatory response by a general mechanism. The lack of an effect of inhibition of the alpha7nAChR suggests that this receptor is not constitutively activated. Selective targeting of the alpha7nAChR using GTS-21 holds promise for future treatment options to modulate the innate immune response. INTRODUCTION. Aberrant regulation of innate immune responses and uncontrolled cytokine bursts are hallmarks of sepsis and endotoxemia. Activation of the liver X receptor (LXR) have been demonstrated to suppress inflammatory genes. Our group has recently proposed that LXR is a key regulator of cytokine release in LPS-challenged human monocytes, possibly by interfering with posttranscriptional events (Myhre, 2008). LXR forms heterodimers with retinoid X receptor (RXR), which bind to LXR responsive elements in promoter regions of target genes. RXR is also a functional partner of several other nuclear receptors. We wanted to study the influence of RXR activation on endotoxin-induced cytokine release.

Peripheral venous blood was obtained from healthy volunteers, and mononuclear cells were isolated by Polymorphprep centrifugation and selective adherence. Adherent human monocytes were pre-treated with synthetic RXR (9 cis retinoic acid/9cisRA) agonists and subsequently challenged with lipopolysaccharide (E.coli LPS, 1 lg/ml). The amount of cytokines released from the adherent monocyte cultures were measured in the supernatants, and the intracellular phosphoproteins activated were measured in cell lysates by a multiplex antibody bead kit, measuring 30 different cytokines (Biosource) or 5 different phosphoproteins (Bio-Rad), according to the manufacturer's instructions. Differences between the groups were analyzed using one-way analysis of variance (ANOVA) for repeated measures with Newman-Keuls comparison test. PB0.05 was considered significant.

RESULTS. In this experimental model, using adherent human monocytes, activation of RXR by 9cis-RA (0,1 lM; 1lM), 1 hour before LPS stimulation, strongly decreased the LPSinduced levels of TNFalpha after 6 hours. Also, IL-6, IL-10, MIP-1alpha and MIP-1beta were significantly attenuated. The studies on intracellular signaling did not reveal any inhibition of LPS-mediated p38 MAPK, JNK, Akt, IkappaB and ERK phosphorylation after 20 minutes.

CONCLUSION. In this study we demonstrate that the nuclear receptor RXR has a strong anti-inflammatory effect in LPS-stimulated human adherent monocytes. The study indicates that RXR may be a target in the immunomodulation of sepsis.

Myhre AE, Å gren J, Dahle MK, Tamburstuen MV, Lyngstadaas SP, Collins JL, Foster SJ, Thiemermann C, Aasen AO, Wang JE. Liver X receptor is a key regulator of cytokine release in human monocytes, Shock 2007 (In press, Epub ahead of print).

GRANT ACKNOWLEDGEMENT. We would like to thank Rikshospitalet, the University of Oslo and the Health authority of Southern Norway for financial support.

G. Gueret* 1 , L. Huard 1 , E. Guillard 1 , M. Gioux 2 , C. C. Arvieux 1 , J. Pennec 2 1 anesthesiology and critical care medicine, university hospital, 2 UA FNST -Laboratoire de Physiologie, faculté de médecine, brest, France

Loss of excitability of skeletal muscle is a central feature of critical illness myopathy (CIM). Electrophysiologic alterations of the voltage dependant sodium channel (NaV) were reported in animal models of CIM (1). As NaV are inhibited by local anaesthetics as ropivacaine, we wonder if sepsis modifiy the sensitivity of NaV to local anaesthetics. The aim of our study was to assess if the local anaesthetics sensitivity of NaV was modified by a chronic sepsis.

METHODS. NaV properties were studied at different ropivacaine concentrations in control and septic rats. Chronic sepsis was induced by cecal ligation and puncture. At D8, peroneus longus was dissected then dissociated by collagenase treatment, and the sodium current recorded by macropatch patch clamp. RESULTS. Compared to unchallenged controls, MRSA caused a 4-fold immediate nuclear ROS/RNS production that was dependent on NOS and NADPH oxidase activity, and a delayed 7-fold ROS/RNS response that was independent of NOS/NADPH oxidase activities. A significant shift in JC-1 fluorescence from 590nm to 520nm was observed within minutes, suggesting that MRSA causes a rapid depolarization of mitochondrial membranes. MRSA also caused 8-oxoguanine and PAR formation, indicators of oxidative DNA damage, within minutes of MRSA exposure. Furthermore, MRSA caused the translocation of AIF from the mitochondria to the nucleus as well as caspase-3 and PARP cleavage.

CONCLUSION. MRSA causes immediate NOS/NADPH oxidase-dependent nuclear oxidation. Mitochondrial depolarization also occurs within minutes, followed by a delayed mitochondrial oxidative burst and activation of apoptotic pathways involving AIF, caspase-3, and PARP. INTRODUCTION. Vascular K ATP channel hyperactivity has been implicated in the pathogenesis of septic shock. However, glibenclamide, the channel's classic inhibitor, is ineffective in reversing septic shock clinically. In contrast, use of inhibitors acting on the channel's pore-forming subunit, rather than on the SUR regulatory subunit to which glibenclamide binds, can reverse sepsis-induced vascular hyporeactivity in vitro. 1 We thus investigated the effect of pore blockade in an in vivo model, and the effect of sedation, a potential confounder that might alter vascular tone, neural reflexes, and sympathetic activity.

METHODS. Male Wistar rats were subjected to faecal peritonitis and were fluid resuscitated for 6 hours. Changes in BP induced by norepinephrine (NE; 0.05 \mug/kg/min i.v. infusion), +/-the vascular K ATP channel pore blocker PNU-37883A (PNU; 1.5 mg/kg i.v. bolus and 1.0 mg/kg/h i.v. infusion), were compared in awake and sedated animals (with midazolam 0.2 mg/kg i.v. bolus and 0.2 mg/kg/h i.v. infusion). The BP-lowering effect of the specific K ATP channel opener levcromakalim (LEV; 150 \mug/kg i.v.), and the ability of PNU to reverse this, was also compared.

Faecal peritonitis induced vascular hyporeactivity as early as 6 hours, as reflected by a substantially lower rise in BP to NE (Table 1) . This was associated with accentuated responses to LEV, that were completely reversed by PNU. However, PNU did not reverse vascular hyporeactivity to NE, although it was able to cause a significant rise in baseline BP in sedated but not awake septic animals. METHODS. PI3Kg wild-type (WT), knockout (KO) and kinase dead (KD) mice were randomized to undergo either cecal-ligation and perforation (CLP)-induced sepsis or a sham laporatomy. After 18 hours, livers were harvested and levels of fibrinogen (pro-coagulatory), plasminogen activator inhibitor-1 (PAI-1) (anti-fibrinolytic), and tissue plasminogen activator (tPA) (fibrinolytic) were assessed.

RESULTS. Following CLP-induced sepsis, WT mice developed a significant increase in fibrinogen and PAI-1 and a significant decrease in tPA compared to sham control. Both KO and KD mice also showed a significant increase in fibrinogen and PAI-1 and a significant decrease in tPA compared to sham controls, however these alterations were significantly less than observed in WT mice. INTRODUCTION. The innate immune system plays a central role for the pathogenesis of sepsis. It has been shown that anti-bacterial substances can modulate the immune system. However, it is not much known whether antibiotics modulate respectively stimulate the innate immune system. This study investigates whether Moxifloxacin (MXF) regulates the expression of the major innate immune receptors, the toll-like receptors (TLRs), and influences cytokine expression in an in-vitro sepsis model.

1) The monocytic cell line THP-1 was stimulated with Lipopolysacharide (LPS), MXF, and MXF in combination with LPS and phosphate buffered saline (PBS) as control for 24h. The TLR expression and the synthesis of the cytokines Tumour Necrosis Factor a (TNF-a), Interleukin-1 (IL-1) and Interleukin-6 (IL-6) were analysed on mRNAlevel (RT-PCR). Results are presented as mean ± SEM. P-values B 0.05 were considered to be significant. 2) To determine, whether MXF activates TLRs, a HEK293 cell line, which expresses a reporter gene driven by NFB, was cultivated MXF. Consequently, the activation of TLR activation was estimated by luminecence measurement.

1) The mono-stimulation with MXF has no effect on TLR-expression and cytokine production. However, in contrast to the mono-stimulation with LPS, MXF in combination with LPS mediated significantly the up-regulation of TLR3 ( INTRODUCTION. Anti-inflammatory effects of drotrecogin alfa (activated) (DAA) have been identified. However, there is lack of data regarding direct organ-related effects of DAA. Since isolated murine heart cells are able to synthesize and release Macrophage Inflammatory Protein-2 (MIP2) upon stimulation with pro-inflammatory cytokines [1] , we investigated whether DAA provides effects on murine heart in sepsis.

METHODS. Sepsis was induced by cecal ligation and puncture (CLP) in male NMRI-mice (n=20, body weight 30±3g). Animals were randomly assigned to vehicle infusion (control), or CLP sepsis with DAA infusion (DAA; 24lg/kg/hr). A third group received only sham operation and vehicle infusion (Sham). 48 hrs prior to CLP all mice were given a permanent central i.v.-line and an arterial transmitter to measure heart rate (HR) and mean arterial pressure (MAP). CLP was adjusted to survive 24hrs. After 12hrs of sepsis, heart tissue was snap frozen in liquid hydrogen and plasma samples were collected and frozen following manufacturers guidelines until measurement. RNA was extracted of frozen tissue (RNeasy, Qiagen, Germany) and analysed by real-time-PCR with mouse specific primers to CD14 and MIP2 normalized to ß-Actin (all: biomers, Ulm, Germany) using an iCycler (Biorad, Hercules, USA). Determination of Interleukin (IL)-6, IL10, and monocyte chemoattractant protein-1 (MCP-1) was performed using a cytometric bead array (CBA, BD Biosciences, Heidelberg, Germany). Differences between groups were evaluated by 1-way ANOVA and Pair-wise fixed reallocation randomisation testÓ for PCR diagnostic. All data are given as mean±SD. P.05 was considered significant.

RESULTS. There were no significant differences in HR between the groups (Sham 650±38/ min; DAA 547±175/min; Control 530±143/min METHODS. The experiment was made up of two parts:

Part one :Animals (N=72) were randomly divided into 3 groups: NC,E and E+C group, and those latter groups were divided into 4 subgroups respectively according to different time interval (n=8). Rats in E and E+C group were injected LPS intraperitoneally;and the C7 spinal cord of rats in E+C group were disconnected. Samples of blood and lung were collected at different time interval. The plasma levels of NE, IL-10, IL-6 and PaO2 were determined. The changes of histopathology and lung wet/dry weight ratio in every group were observed. Part two: Another 20 animals (N=20) were randomly divided into 2 groups: E and E+C group, each 10 animals. Rats in E and E+C group were injected LPS intraperitoneally;and the C7 spinal cord of rats in E+C group were disconnected.We observed the 48-hour survival rates of rats in E and E+C group.

. Rats in E+C group demonstrated decreased levels of NE and IL-6 with increased production of IL-10. The degree of lung injury was also alleviated, and PaO2 was improved. Moreover, the 48-hour survival rate was increased from 20%(E) to 70%(E+C). METHODS. Prospective randomised, controlled animal study. 23 anaesthetised, ventilated pigs (28.2 ± 1.7 kg) were randomised (5 in each shock group, 3 in control group) to volume replacement therapy with colloids, RAc or a non-septic control group (control) receiving RAc. Animals were bled in the shock groups until reaching half of their baseline mean arterial pressure (MAP) or cardiac output (CO) for 45 minutes. After hemorrhagic shock Volume resuscitation started until baseline MAP was accomplished. As second hit sepsis was induced using an E. Coli bacterial clot into abdominal cavity 6 h after hemorrhagic shock. Infusion rate was titrated to maintain a central venous pressure of 12 mmHg. Systemic haemodynamics and cytokines were obtained before (bl) hemorrhagic and septic shock and every 2 hours after induction of septic shock. Cytokine levels were assessed with commercially available enzyme linked immunosorbent assay kits specific for pigs and used according to manufacturer's guidelines. Statistics were performed using ANOVA. METHODS. Thirty sheep were subjected to incremental doses of endotoxin (started at 5 ng/ kg/min and doubled every hr) until MAP fell below 65 mmHg. Thereafter, fluid resuscitation was initiated to maintain CVP at 8-12 mmHg and PAOP at 12-15 mmHg. In sheep allocated to the colloid groups, HES was infused up to a max. dose of 20 mL/kg. Thereafter, only crystalloids were infused in both HES groups. In the crystalloid group, a balanced, isotonic crystalloid (SterofundinÒ ISO) was infused to achieve goal values. The incidence of DSI ranges from 0,5 to 5% percent, with the incidence in most centres being between 1 and 2%. DSI increases the duration and costs of hospitalization, and has a dramatic impact in the prognosis and outcome. The purpose of this study was to determine its exact magnitude in our patients and the prognosis. CONCLUSION. The incidence of colonization of catheter tip and CR-BSI in the study group is similar to other studies and meta analysis. The heterogeneous characteristics of the group and lack of data related to number of days on mechanical ventilation, incidence of postoperative myocardial infarction, bleeding and re-interventions could decrease the value of results obtained. Further, randomized studies should evaluate use of pulmonary artery catheter and infection in cardiac surgery.

INTRODUCTION. Differentiation between acute bacterial infection from other types of inflammation is often difficult in particular in postoperative period. The aim of this study was to assess the profile of time course of procalcitonin (PCT) in peritonitis patient after surgical and anti-effective therapies in ICU.

Every patient admitted to the ICU consequently to surgical procedure for peritonitis over a 18 months period, from July 2006 to December 2007, was included in our study. PCT, CRP and cytokines (TNF, IL-6, IL-8) were measured at admission (J0), on second day (J2) and on fourth and seventh day (J4, J7). Prognostic indicators of severity were recorded on admission: Apache II, IGS II and SOFA score.

RESULTS. Sixty-one patients were included in the study. A second look operation was performed for 10 patients (group I). Fifty one patients (group II) were not surgically reinvestigated. Second look discovered persistent peritonitis 6, peritoneal abscess 1, necrotic pancreatitis 1, ileal fistula 1 and mesenteric ischemia 1. The day of ICU admission, the concentrations of PCT (53.9 ± 42.6 ng/ml) were not significantly different in the group I than in the group II (46.4 ± 51.4 ng/ml). There is a remarkable and significant decrease in concentrations of procalcitonin on day 2, 4 and 7 in group II whereas the concentrations of procalcitonin increase until day 4 then plateau in group I (p \ 0.03).

Changes in procalcitonin in patients with (group I) and without (group II) second look. METHODS. The study comprised 40 patients CABG with CPB divided into the following 3 groups: G0 (control = 12); GA (aprotinin = 12); and GC (methylprednisolone = 16). Blood samples were collected as follows: T0, 24 hours prior to surgery; and T1 and T2, 3 and 18 hours after, respectively. Were quantified: TNF-alpha; IL-6; PCR; fibrinogen; haptoglobin; leukocytes and neutrophils.

RESULTS. The groups did not differ in regard to their demographic, clinical and surgical characteristics. The IL-6 levels were lower in G0 as compared to those in GA and GC (374.4 ± 341.8; 260.2 ± 373.3; 249.2 ± 311.3 pg/ml, respectively), but not significantly (P = 0.2). The TNF-alpha levels in groups 0, A and C did not differ. The differences in the greatest postoperative serum levels (T1 and T2)for fibrinogen, haptoglobin and PCR were equivalent (P = NS). A difference was observed between the greatest levels in T1 and T2 and the baseline levels of leukocytes in group C as compared to those in groups 0 and A (15.0 ± 5.9; 8.4 ± 4.1 and 9.2 ± 3.4, respectively; P = 0.02 and P = 0.003). The relative levels of neutrophils did not differ (P = 0.3).

CONCLUSION. This study could not show a reduction in several markers of the acute phase of inflammatory response in patients undergoing CABG with CPB and receiving aprotinin and methylprednisolone.

We analyzed all landmarks guided IJVAP that were performed by either the anterior or the posterior approach, using the Seldinger technique in both: operating theatre and intensive care unit, during 1-year period. The side of the puncture site was chosen according to clinical necessities. Age, gender, puncture side, number of cannulation attempts and number of arterial puncture after cannulation were recordered. Correct placement of central venous catheter was confirmed by free venous blood return, free flow of fluid through all ports of catheter and post insertion chest X-ray.

During the study period, we studied 112 IJVAP attempts (74 right-sided and 38 left-sided). The patient s age and gender were not associated with increased risk for arterial puncture. The arterial puncture occurred in nine IJVAP attempts (8.03%). Arterial punctures occurred more often although the difference was not statistically significant in the left-sided IJVAP (left-sided IJVAP=13,1%; right-sided IJVAP=5,4%, p=0.12). The single attempt successful rate was 85, 7%, with low risk of arterial puncture (3,1%). Of 16, more than one cannulation attempt IJVAP, six (37.5%) were accompanied by unintentional carotid route puncture. More than one cannulation attempt frequently occurred during left sided IJVAP (left-sided IJVAP=26, 31%; right-sided IJVAP=8,1%, p \ 0.05), and was associated with a significantly increased arterial puncture rate(p \ 0.001).

CONCLUSION. Our results imply that more than one cannulation attempts frequently occurred during left-sided IJVAP, and it was considerably associated with increased arterial puncture rate. Generally, carotid puncture commonly occurred during left-sided IJVAPs, but this difference was not statistically significant. RESULTS. Infections were the main cause of both complications and postoperative mortality. The 54% of our patients presented serious complications. The mortality of the series was 12.5%. Multiorganic failure secondary to sepsis was the more frequent cause of death.

The postoperative complications showed a significant association with: alcoholism (p.04), hepatic cirrhosis (p \ 0.03), the location of the tumor in middle third of the esophagus (p \ 0.04), and the APACHE II score greater of 10 (p \ 0.003). Mortality was associated significantly (Table 1) with the presence of chronic pulmonary disease (p = 0,03) and with an APACHE II score superior to 10 (p = 0,02). (1).EDS typeIV can present as a surgical emergency with organ or arterial rupture. We present the spontaneous occurrence of diaphragmatic rupture with gastric herniation due to violent vomiting in a patient with EDS typeIV.

METHODS. 35 year old male known case of EDS presented with a 2 day history of non colicky lower abdominal pain; he had a negative laparotomy for suspected appendicitis. Post operative period was complicated by refractory nausea and vomiting and then developed respiratory distress with subcutaneous emphysema. Chest Xray and CT scan revealed a diaphragmatic rupture and gastric herniation. The patient underwent a diaphragmatic hernia repair but required ventilatory support for 24 hours post operatively. The patient was subsequently discharged from intensive care.

We succesfully report the occurence of spontaneous diaphragmatic rupture due to projectile vomiting in a patient with Vascular type Ehlers Danlos syndrome, though transient respiratory support was required, the patient made an uneventful recovery.

CONCLUSION. Ehlers Danlos syndrome is characterised by tissue fragility, these cases can present as surgical emergencies due to bowel, organ or vascular rupture. The success of the management lies in the recognition of the syndrome and its associated complications. [1] . Our study has evaluated the incidence of postextubation laryngeal injuries in ICU and their relationship with postextubation laryngeal dyspnea and extubation failure.

After extubation a laryngeal nasofibroscopy was performed in 136 patients within 3 hours by otolaryngologists and damages (ulceration, granulation, edema and vocal cord mobility) were grading (0,1,2). Patients with audible inspiratory wheeze after extubation were classified as postextubation stridor (PES). PES with laryngeal endoscopic lesions were defined as Laryngeal dyspnea (LD). CONCLUSION. Laryngeal injuries following intubation are frequent and could be associated with a use of large diameter of ETT, a long duration of intubation, and the absence of using curare during intubation. These injuries could have several localization and different patterns, but all of these injuries can potentially result in significant airway obstruction. It not seems possible to recognize each type clinically, only endoscopic examination could determine it and the best treatment to avoid recurrences and extubation failure. INTRODUCTION. Reintubation following extubation may be associated with higher mortality for intensive care patients. Risk factors for reintubation include pneumonia and high rapid shallow breathing index (RSBI) 1 . Weaning, extubation, and the use of continuous positive airways pressure (CPAP) after extubation are not protocolised on our unit. An observational study over six months was performed to establish the rate of reintubation on our unit and to describe the characteristics of the patients who were extubated.

METHODS. Between January and July 2007 100 consecutive patients who were extubated on the intensive care unit were studied using a standardized questionnaire. Only data from the first episode of extubation was collected if patients were extubated more than once. Separate admissions to intensive care were counted as separate episodes. Statistical analysis was performed on contingency tables using two-tailed Chi-squared tests with Yates' correction. All analysis was done using Microsoft Excel spreadsheet software.

Ninety-seven patients were included in the analysis. Three patients were excluded from the analysis due to incomplete data. Mean age (SD) was 57.2 (17.2) years. 47.4% of admissions were medical, and 52.6% of admissions were surgical. The duration of intubation prior to extubation was a median of 3 days (range 4 h to 24 days; IQR 1-5 days). There were 16 reintubations (16.3%) and 14 tracheostomies were performed (14.4%). Mean time to reintubation was 16.9 h (range 10 mins -96 h). The mean (SD) duration of the first intubation period in reintubated patients was 6.4 (5.1) days. Patients who were reintubated were admitted with pneumonia (3 patients, 18.8%); post-cardiac arrest (3 patients, 18.8%) or after aortic aneurysm repair (2 patients, 12.5%). 69 (70.4%) patients were extubated after being weaned onto CPAP (with or without additional pressure support). 28 patients (28.8%) were extubated from biphasic positive airways pressure ventilation. There were 84 (85.7%) planned extubations, of whom 13 patients (15.5%) were reintubated. There were 9 (9.2%) unplanned extubations, of whom 3 (33%) were subsequently reintubated. Unplanned extubation was not significantly associated with reintubation (p=0.37). Prior to extubation, mean (SD) fraction of inspired oxygen was 0.38 (0.08), mean (SD) P-F ratio was 29.8 (13.4) kPa and median respiratory rate was 10.5 breaths per minute. Non-invasive CPAP was used in 26 (26.8%) of patients after extubation. Five (19.2%) of these patients were re-intubated.There were only 7 deaths on the unit among the 97 patients studied, giving a unit mortality rate of 7.2%. Mortality among reintubated patients was 12.5% compared to 6.2% in the non-reintubated group, but this was not statistically significant (p=0.72). 75% of those patients who were reintubated went on to have a tracheostomy.

CONCLUSION. There was no association between reintubation and unit mortality in this population of patients. There was no association between unplanned extubation and reintubation. 75% of patients who were reintubated went on to have a tracheostomy to facilitate weaning. INTRODUCTION. The percutaneous dilatational tracheostomy is a minimally invasive, safe, reliable and widely accepted procedure. PDT using Griggs' dilating forceps over the guidewire is still practiced in many ICUs. Recently, a single stage dilational tracheostomy kit, Ultraperc Ò having a gradually curved dilator and an ergonomic tube introducer has gained popularity. The aim of our study was to compare the two techniques of PDT in terms of procedural time, amount of blood loss and immediate complications.

METHODS. Thirty consecutive patients on mechanical ventilation needing tracheostomy during the course of treatment were randomly divided into two equal groups. PDT was performed in either group under sedation, as per the technique. Procedural time was defined from incision to successful placement of tracheostomy tube. Amount of blood loss was calculated by percentage soakage of a 12inch x 9inch gauze piece. 5ml blood completely soaks such a gauze piece. Immediate complications such as bleeding from the stoma, transient hypoxemia (SpO 2 \ 95%) and hypercarbia ([ 5 mm increase in ETCO 2 from the baseline) were recorded. Bleeding was classified in four grades: I :\5 mL, II : 6-10 mL, III : 11-20 mL and IV : [20 mL. Chest x-ray was done after the procedure to look for pneumothorax, lung collapse and position of tracheostomy tube.

RESULTS. The procedure with Ultraperc Ò single stage dilator technique took slightly longer time but had reduced amount of blood loss as compared to Griggs' dilating forceps technique. The incidence of hypoxemia and hypercarbia was higher with Ultraperc Ò single stage dilator technique attributed to longer procedure time. PDT performed in selected patients by experienced and trained individuals is comparable in safety to that of surgical tracheostomy (ST)1. PDT is easier and quicker to perform with less periprocedural bleeding, is cost effective and is cosmetically more desirable than ST. However, it is associated with a 5-11% risk of complications, including catastrophic haemorrhage2, pneumothorax, surgical emphysema, misplacement, cartilage damage, and death2. Bleeding is the commonest complication associated with PDT. MRI assessment of cervical anatomy suggests considerable variation in the relation of blood vessels to the anterior aspect of the trachea3. Portable ultrasound (P-US) prior to PDT has demonstrated the presence of a vulnerable vessel in up to 27% of patients4. NICE guidelines on the placement of central venous catheters encourage the use of P-US to identify blood vessels and to enhance the safety of the procedure.

The project was submitted to the Local Research and Ethics Committee for approval. P-US was used in 97 serial adult patients who had no history of surgery to the neck, prior to PDT as a planned procedure in the general ICU. US examination of the neck was undertaken using a SonoSite iLook25 with a linear 10MHz probe with the patients' neck prepared in position for a standard PDT(SonoSite, Inc, Bothell, WA, USA). The focussed P-US study examined the ease of identification of the tracheal rings and their relation to the midline, the presence of arteries or veins within a 2cm radius of intended point of entry of seeker needle, and the position of the thyroid isthmus or lobes. Subsequently, P-US was not used to further facilitate the PDT procedure.

RESULTS. Ninety seven patients (M:F,45:52) between the age of 26-74yrs (mean 58yrs) were studied. The tracheal rings and their midline, thyroid lobes and isthmus were identified in all patients. Thirty one patients (32%) had a clinically undetected vessel within a 2cm radius of intended point of entry (6 art:25 veins). Of these 4 and 11 respectively were more than 4mm in diameter. The latter 15 patients did not undergo a PDT, and instead, ST was performed safely and without immediate complications. The remaining 82 patients underwent safe and uneventful PDTs without any immediate complications.

CONCLUSION. P-US is a strong and useful non-invasive tool which may enhance informed patient selection and risk stratification, with resultant improvements in the safety and outcome of PDT. 

We have studied a total of 699 PDTs over 11 years and after routine PDT no evidence of barotrauma or other problem requiring urgent intervention was identified on CXR. On one occasion the post-procedure CXR affected management, treating radiographic atelectasis, however derecruitment of bronchopulmonary segments is common after PDT and can be anticipated [2] . In uncomplicated, bronchoscopically guided PDT a routine postprocedure CXR is unnecessary in the absence of clinical deterioration. We recommend that a chest radiograph is mandatory in the following circumstances -anticipated postoperative complications secondary to technical difficulties, visualised tracheal damage or pre-procedure pneumothorax. Objective: The aim of this study is to present our experience with PCT performed at ICU bedside by critical care staff and residents in the last two years of fellowship training in order to evaluate its efficacy in terms of safety and intraoperative and postoperative complications.

We also aimed to quantificate the learning curve for PCT.

We analysed our experiences of a total of 800 PCT performed in our ICU by a collaborative team (critical care and otolaryngologist physicians). Statistical significance was assessed by the Chi-squared test with significance interpreted as a p value \ 0.05.

Most of the procedures (n = 685, 85.6%) were performed at the bedside by residents in the last two years (fourth and fifth) of fellowship training. We observed complications in 32 patients (4%). Intraprocedural complications occurred in 17 patients (2.1%), early postprocedural in 6 (0.75%), and late postprocedural in 9 (1.1%). No case of death was directly related to PCT. The number of complications was superior in PCT performed by the residents in their initial five attempts than in the rest of attempts (9.2 % vs 2.6%; p \ 0.05).

CONCLUSION. PCT is a simple procedure to be learned and to achieve adequate training. The low incidence of complications indicates that bedside PCT can be performed safely, and can be considered a routine procedure in the management of ICU patients in daily practice. In a previous abstract we demonstrated the role of the 30 degree body position on ventilation and oxygenation parameters in patients who were weaned from the ventilator. In this study we investigated the potential benefit of legs horizontal and legs down position on end tidal CO2 (%), rapid shallow breathing index and oxygen saturation in patients who were on pressure support ventilation.

METHODS. 16 patients on pressure support ventilation were studied. Patients were ventilated with a Servo 300(A)Ò and Servo-i Ò ventilator (Maquet). First, patients were placed in the 30 degree position with the legs horizontal. Half an hour after stabilisation, end tidal CO2, tidal volume, breathing frequency and oxygen saturation were measured. After that legs were lowered as much as possible. Rapid shallow breathing index was calculated as :respiratory rate divided by tidal volume. Values were compared using paired samples T-test. A significance level of \ 0,05 was considered significant.

Oxygen saturation improved with 0,63% +/-0,96 when legs were lowered (p \ 0,05). End tidal CO2 improved with 0,16% +/-0,26 when patients were placed in legs down position (p \ 0,05). Rapid shallow breathing index did not show significant changes.

We demonstrated an improvement in oxygen saturation and a decrease in end tidal CO2 when the legs of patients were lowered during pressure support ventilation. Perhaps relieve of abdominal pressure plays a role in an increased ventilation. In this study patients were examined who were weaned from the ventilator. We think, positional therapy in this group of patients is very important. Further study is necessary to confirm our observations. METHODS. Seventeen patients admitted to I.C.U. (of two Italian Hospital) with acute diseases conditioning long-term mechanical ventilation were undergone consecutively to PDT with ''Blue Dolphin'' (BD) technique. The first part of the procedure was quiet similar to the well known one of previous abovementioned methods. After the use of first 14 Fr. introducer dilation and insertion of the cannula was obtained with a balloon-tipped catheter loading dilator assembly where, over the loading dilator, had at first preassembled the tracheal cannula. The dilative balloon is very like to a balloon for Percutaneous Transluminal Coronary Angioplasty obviously modified and bigger. The balloon was inflated at 11 atmospheres of pressure for 5 or 6 seconds. For every procedure was performed an inside and outside video to check every aspect of the ''modus operandi''. Vital signs of the patients was of course monitoring continuously.

The BD was performed in the group of patients without choosing ''best necks''. The operating doctors were the same of the common approach (''Blue Rhino'' PDT). Sixteen on seventeen procedures were uneventfully completed. Median time of BDs was 2,5 minutes (from the 14 Fr. introducer removal to the insertion of the cannula). Vital signs were unmodified during the procedures. The single case in which BD was not completed was related to the choice of the level of dilation (between cricoid and first tracheal ring) and consequent failing balloon dilation. The PDT was however completed with BR rescue. Neither major nor minor complications occurred all over the study.

CONCLUSION. First operating experiences with BD show that the introduction of a dilation ballon is effective, quick and safe. The assembly of balloon together the cannula loading dilator optimizes the kit reaching just about a one-shot PDT. Further studies need to be done for a more definitive evaluation. All Acute Chest Syndrome (ACS)/Vaso-oclusive crisis (VOC) or pulmonary infections were studied in 157 adult SCD patients admitted to the intensive care unit (ICU). All SCD whose haemoglobin S was more than 30% has received exchange transfusion. The average APA-CHEE II score in chest infection group was 21.3 in ACS/VOC group was 20.7.

Out of 157 SCD admitted to ICU 98 patients were admitted with chest infections and 59 patients were admitted with chest infections, in chest infection group 41%(31) patients required ventilator support as compared to patients admitted with ACS/VOC 12%(7) p-value 0.0003 and 32% patients required blood exchange transfusion and 85%(50) in ACS/VOC group p-value.0001, the intotrpes require in chest infection group was 39% (38) and ACS/ VOC group was 0% (0) the p-value .0001.The mortality in chest infection group was 19% where as in ACS/VOC group 5%, the p-value 0.0258 (Table 1) . INTRODUCTION. The diagnosis of meningitis in neurosurgical patients is difficult, as the standard markers in cerebrospinal fluid (CSF) are not always diagnostic. In order to find a reliable marker for the diagnosis of meningitis in these patients we measured interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) in CSF and we compared them with standard markers (CSF leucocytosis, glucose, proteins).

METHODS. 17 neurosurgical patients (13men) with intracerebral or/and subarrachnoid hemorrhage, aged 52±15 years, septic with clinical suspicion of meningitis were enrolled. All patients had intraventricular catheters for external drainage of CSF. 8 had proven meningitis. Samples of CSF and blood were taken at time of suspected meningitis and in meningitis group at time of clinical improvement also. Leucocytes, glucose and proteins were measured in blood and CSF. The samples were centifigurated and frozed in -4oC and IL-6 and VEGF were measured in CSF and serum (the upper limit measured for IL-6 was 5000 pg/ml).

RESULTS. IL-6 concentrations in CSF were extremely high in all patients (3649±1914pg/ ml). IL-6 levels were higher in CSF from patients with meningitis compared with those from patients without meningitis (5000±0 versus 2449±1971 pg/ml, p=0.002). In all patients CSF levels of IL-6 were higher than plasma levels (p .0001) and in meningitis group were over 100fold higher, (p \ 0.0001). In meningitis group, CSF IL-6 levels decreased significantly as patients improved (p=0.03). In contrast VEGF levels performed high in serum as well as in CSF (842±166pg/ml vs 130±47pg/ml), but did not differ in two groups. Between two groups (meningitis and no meningitis group) there was no difference in CSF pleocytosis (523±318,7 vs 273±137,9) CSF glucose (57,1±14,7 vs 85,2±11,6mg/dl) and CSF proteins (275±49,5 vs 225,7±59,4gr/dl).

CONCLUSION. It seems that CSF pleocytosis and glucose are not efficient markers to establish meningitis in neurosurgical patients. CSF IL-6 increases in meningitis, much more than plasma levels, suggesting local production, predicts meningitis with 100% sensitivity 64% specificity and decreases with clinical improvement. More data may help to consider IL-6 as a sensitive and specific marker for postsurgical meningitis in the difficult neurosurgical patient. INTRODUCTION. Sepsis is a life-threatening disease that results from excessive host responses to microbial infections with a rapidly increasing mortality per hour after infection. Therefore, the causative pathogens and/or antibiotic resistances are to be determined as early as possible. The traditional gold standard blood culture (BC) usually takes at least 2-3 days.

Facing the time-to-result, nucleic acid based technologies (NAT) are increasingly desirable. The aim of this study was to compare the sensitivities and specificities of BC with a novel molecular-biological pathogen detection method. The NAT-system includes a sample preparation technology, which enables the enrichment of bacterial and fungal DNA out of whole DNA-samples. Cell lysis within whole blood and subsequent DNA preparation are followed by multiplex PCR to rapidly identify 99% of clinically relevant sepsis causative pathogens. At the same time, five of the most common antibiotic resistance genes are detected.

METHODS. In a prospective study (6/2006-7/2007), a totality of 35 peripheral blood samples from 25 patients (septic group) were consecutively drawn for the evaluation of possible sepsis by culture (e.g. BC) and molecular diagnosis. 32 whole blood samples were taken from 22 patients (control group) without the clinical indication of sepsis. The DNA preparation was performed according to a standard DNA extraction protocol combined with protein-based affinity chromatography (LOOXSTERÒ, SIRS-Lab). All purified DNA specimens were analyzed by multiplex PCR (VYOOÒ, SIRS-Lab). The blood samples were incubated in an automated blood culture device (BacTAlertÒ, BioMerieux). Positive isolates from BC were determined for identification and antimicrobial susceptibility by standard laboratory procedures.

In the septic group, 20% of the patients were tested BC positive with none of them belonging to the positive 28 day mortality group. In the 58% NAT positive patients, four non-survivors (80%) were included. The NAT method was negative as expected for all samples of the control group patients. In contrast, 23% BC were positive in this group. Concerning the clinical microbiological evaluation, the BC positive controls can be considered as false positive results. The positive results from blood cultures were not available before 72 hours whereas the NAT method delivered results within 6-8 hours.

CONCLUSION. Compared to the gold standard and other culture-based methods, the NAT method was in significantly less time more sensitive and specific. This might be a milestone allowing ''same day diagnosis'' of sepsis and SIRS as well. Further, the results revealed the expanding potential of NAT-based methods for the diagnosis of systemic microbial infections.

GRANT ACKNOWLEDGEMENT. This study was supported by grants from the TMWFK. INTRODUCTION. Interleukin 6 (IL-6) is a cytokine with diverse biological activities. IL-6 has been reported as a possible diagnostic marker for the presence of bacteraemia and serves as a marker of disease severity in sepsis [1] . Indeed recently adverse outcome in communityacquired pneumonia has been reported in the context of elevated IL-6 levels [2] . We investigated IL6 gene transcription in peripheral blood leukocytes in three study groups, 58 patients with severe sepsis, 15 patients with a gram-negative infection but without sepsis and 10 healthy controls.

METHODS. This is a prospective observational study. Blood samples were collected from healthy controls at 1 time point. In bacteraemic patients, blood sampling was carried out within 24 hours of the positive blood culture being reported. In 58 patients presenting with severe sepsis blood sampling was carried on day 1 of intensive care admission and on day 7 in survivors. Mononuclear cells were isolated, and total RNA was extracted. IL-6 mRNA was quantified using the technique of quantitative real-time polymerase chain reaction (qRT-PCR (1) and early (6h) faecal peritonitis (2) . We sought to measure temporal changes in circulatory pathophysiology and tPO 2 in these organs in predicted survivors and non-survivors of faecal peritonitis.

METHODS. Fluid-resuscitated male Wistar rats received an intraperitoneal injection of faecal slurry, modelling faecal peritonitis. At 6h post-insult rats were anaesthetised and echocardiography performed. Rats were divided into predicted survivors (mild sepsis) and non-survivors (severe sepsis) based on a stroke volume greater or less than 0.14 ml, respectively (3). At either 6h or 24h post-sepsis, animals received a tracheostomy and tPO 2 probes placed in muscle, between two liver lobes, within the bladder lumen and left renal cortex. After 30-min stabilisation, recordings were made of tPO 2 , and cardiac output (CO) by echocardiography (Vivid 7, GE Healthcare, UK). Blood gas analysis was performed to determine lactate levels. Comparisons were made against sham-operated animals that underwent instrumentation but received no septic insult.

RESULTS. Data shown as mean (± SE), * p \ 0.05 between sham (n=8) & sepsis (n=8). Statistics: 2-way RM-ANOVA and post-hoc Tukey's test. (5) 16 (1) METHODS. Anesthetized and ventilated pigs (40±3kg) were randomly assigned to fluidresuscitated septic shock by fecal peritonitis (S, n=6) or control (C, n=6). In vivo liver samples were collected at baseline (BL) and 24h for analysis of mRNA expression by Affimetrix microarray (S:n=2, C:n=2). Changes in gene expression (ratio in base 2) between BL and 24h and at 24h were analyzed by GeneMath 3.5. To identify the affected molecular pathways, gene expression data were mapped on a pathway database using MapFinder 2.1. INTRODUCTION. An increment in transcutanoeus tissue oxygen tension (tPO 2 ) of \21 mmHg following 100% O 2 administration was associated with a poor outcome in septic patients (1) . We applied this oxygen challenge test (OCT) in our rat model of faecal peritonitis in peripheral (muscle, bladder) and deep (liver, renal cortex) organ beds.

METHODS. Fluid-resuscitated male Wistar rats received an intraperitoneal injection of faecal slurry, modelling faecal peritonitis. At 6h post-insult rats were anaesthetised and echocardiography performed. Rats were divided into predicted survivors and non-survivors based on a stroke volume greater or less than 0.14 ml, respectively (2) . Animals then received a tracheostomy and had tPO 2 probes placed in muscle, between two liver lobes, within the bladder lumen and left renal cortex to measure the regional oxygen supply/demand balance. After confirmation of normovolaemia, the fraction of inspired oxygen (FiO 2 ) was increased to 0.3, 0.6 and 1.0 at 15 minute intervals. In separate experiments, this was repeated at 24h postinsult. Comparisons were made at both timepoints against sham-operated animals that underwent instrumentation but received no septic insult.

RESULTS. Data shown as mean (± SE), * p \ 0.05 between sham (open circles; n=8), goodprognosis sepsis (light grey triangles; n=8) and poor-prognosis sepsis (black diamonds; n=8). Statistics: 2-way RM-ANOVA + Tukey's test.

CONCLUSION. The OCT revealed a reduced response to hyperoxia in predicted nonsurvivors after 6h of sepsis, suggestive of microcirculatory dysfunction in this early phase of sepsis, Apart from the renal cortex, this had recovered by 24h even though clinical status, organ function and lactataemia had significantly worsened (data not shown). The OCT could provide a simple method to assess microvascular perfusion and its responsiveness. INTRODUCTION. Procalcitonin (PCT) is more a ''follow-up'' prognosis marker than an early diagnostic tool. In early stages of shock, it may differentiate between septic and other causes of shock allowing an early treatment according to it. The objective of our study was to determine PCT usefulness as an early diagnostic marker for septic shock. 

Postoperative pain treatment is often initiated during operation, followed up in the recovery room/ICU, and to be continued in a ward. Information, observation and understanding of pain treatment protocols has become a multidisciplinary matter (1, 2) . In order to secure uniform postoperative pain treatment, we have implemented a system based on extending the ICU protocols to the wards: A) Dedicating a ''pain nurse'' from the ICU to follow up on patients after they left the ICU/recovery room. B) Developing uniform procedures for treatment of postoperative pain. C) Introducing the ''pain nurses'' in a liaison role between doctors and nurses in all wards. D) Implement a uniform pain scoring form in all wards. The objective of this investigation is to evaluate the system we have implemented.

Since epidural pain relief is associated with both technical problems and potentially serious side effects (3, 4) , we used this group of patients in this study.

METHODS. Between 2002 and 2006 2062 patients received an epidural infusion as postoperative pain relief. A standardized mixture for epidural pain relief consisting of Bupivacain, Adrenaline and Fentanyl was given to all patients. All data was entered into the form described above by the nurses responsible for the patient on the wards. In this study we have retrieved the following information: Age, type of operation, level of catheter insertion, duration of treatment, average dose (ml/hour), total dose, reason for unscheduled termination of treatment, side effects and patient satisfaction -whether the overall treatment was perceived as poor, acceptable, good or excellent. INTRODUCTION. Pregnant and postnatal women in ICU require specialist care that may not be readily available within the critical care team, with midwifery increasingly recognised as a separate profession to nursing. The aim of this study was to examine the health services provided to parturient women in ICU to identify if a service gap existed.

A prospective cross-sectional study was conducted in four tertiary-level intensive care units (ICU) in Melbourne, Australia. Only one ICU was in a hospital that provided obstetric services. All pregnant and postnatal women admitted to ICU were eligible for the study. Nurses formed core research teams and assisted with the auto-enrolment of eligible women, time-critical data collection and the obtaining of consent. Additional data were gathered from the medical history following discharge. Data were entered in SPSS (v12) and analysed.

Of the 43 known eligible women, 35 were enrolled, and 33 gave consent; 8 were pregnant. Two of the eight pregnant women were 8 weeks' and 14 weeks' gestation respectively. The gestation of the other six pregnant women ranged from 27 to 36 weeks'. Of the six women with a viable pregnancy, three had a fetal ultrasound when in ICU, five out of six had at least one cardiotocograph and one woman had no fetal assessment in ICU. None of the pregnant women gave birth during the ICU admission. Of the 25 postnatal women, 92% were admitted in the first 24 hours following birth. Four women saw their baby whilst in ICU, with the remaining women needing to wait until they were transferred out of ICU. An obstetric condition was the principle diagnosis for two thirds of women. However, pregnant and postnatal women were seen by 23 different types of medical specialties whilst in ICU. The mean number of specialties seen by individual women was 3.6 (median 4.0). 53% of women were seen by an obstetrician when in ICU: 100% of women with private health insurance (n=11) compared with only 29% of public patients (p \ .05). Having the ICU and obstetric services on the one-site increased the chance of the woman being seen by an obstetrician, but did not guarantee it. Only 30% of the pregnant and postnatal women in ICU were seen by a midwife. Whether the woman was pregnant or postnatal did not affect her chance of being seen by an obstetrician or midwife in ICU. 70% (n=23) of women were transferred by ambulance between hospitals to access the ICU bed.

CONCLUSION. Women received fragmented care from many health professionals and service providers. A service gap existed in the care provided to the pregnant and postnatal women admitted to ICU and articulated processes are required if pregnant and postnatal women are to have access to maternity care in ICU. CONCLUSION. Fever magnitude is a good predictor of high pt acuity in the ICU, and can be used instead of APACHE II for properly allocating nursing manpower among febrile pts. INTRODUCTION. Using nursing time in intensive care units is connected with measuring nursing workload. Its aim is to determine optimal level of staffing in order to ensure high quality of medical services.

The purpose of the paper is to present nursing workload in two patients groups: surgical and non-surgical.

METHODS. The studied group comprised 314 patients treated in 5 intensive care units with different treatment profiles [1] . The study applied prospective analysis of nursing workload among surgical and non-surgical patients. The methodological tool was NAS -Nursing Activities Score [2] . INTRODUCTION. Professional autonomy is generally considered a highly desirable nursing attribute and a major factor of nurse job satisfaction. In the critical care environment a high level of accountability, responsibility and autonomy are required in order to optimize outcomes of critical unstable patients.

A cross-sectional survey was conducted in 16 public hospitals located in Athens, from mid Apr to the end of July 2007. 302 critical care nurses completed questionnaires, yielding a response rate of 70%.

Greek critical care nurses reported acting moderately autonomously with a mean score of 165.4 (SD=24.6) compared with the possible range from 60 to 240. Respondents 0 age, gender, level of appointment, completion of clinical specialty, length of critical care experience, shift and membership of a professional organization were found to be significantly associated with reported autonomy (p \ 0.005). A positive moderate association was found between reported autonomy, job satisfaction and role conflict and role ambiguity (r=0.331, p \ 0.001 r=0.324, p \ 0.001 respectively). No significant association was found between job satisfaction and reported role conflict and role ambiguity (r=0.047,p=0.411).

Greek critical care nurses 0 autonomy appears to allow further support and enhancement if the nurses are to realize their full professional role. INTRODUCTION. Ward patients can experience unexpected physiological deterioration that can lead to critical outcomes and death. This deterioration can be signalled in the patients physiological signs that are monitored by ward nurses as part of routine practice. In many cases these physiological signs have been missed, neglected or poorly managed (1 2). Systems designed to track patients physiological signs and trigger referral to an expert team have been widely implemented. Proving effectiveness of these systems has been problematical, partly due to the reliance on a timely and robust system of observation monitoring, plus compliance by the ward teams in the referral process to response teams. It is vital that we understand these ward processes. A systematic literature review is presented that critically evaluates research describing or appraising the nursing practice of taking and recording observations in the detection and management of the deteriorating ward patient.

Eight data bases were systematically searched from 1990 to 2006, plus citations from key articles and reports. Experts in the field were contacted. All study designs were incorporated. Eligible studies were assessed for quality using an assessment tool for both qualitative and quantitative studies. The findings from the studies were critically evaluated using a narrative technique.

Fifteen studies were eligible from 740 titles. Study quality varied. Findings are presented using the Record, Recognise, Report and Rescue (4R) model that outlines a series of actions that characterises the optimal process of detection, recognition and appropriate management of the deteriorating ward patient. Complex dichotomies exist in each of the 4R model categories that show ward nurses struggling to adequately detect and manage the deteriorating ward patient, hampered by inexperience, lack of skill and excessive workloads. Where support systems are in place, they require skilled and complex collaboration with medical staff and can be inconsistently activated and utilised.

CONCLUSION. Effective detection and mangement of patient deterioration relies on robust patient observation practice and adherence to track and trigger referral triggers. In order to see the benefit of these systems we need to understand the issues that enhance and inhibit the practice of recording, recognising, reporting and rescuing (4Rs) by ward nurses. We can then find ways to better equip wards to deal with these issues and improve patient outcome. INTRODUCTION. Medical Art Therapy (MAT) enables medically ill people to express their feelings of frustration, fear, anxiety and hopes in art. In heart failure (HF) depression and anxiety are common.

Aim: To evaluate the influence of guided group MAT on the quality of life and compliance to therapy of patients with advanced HF.

Methods: Between April and July 2006, 20 advanced HF patients were randomly divided: ten in the intervention group (group A) and ten in the control group (group B). First and last visits were individual during which the Ulman Personality Assessment Procedure (a MAT diagnostic tool), the Minnesota Living with HF and compliance questionnaires were recorded. Both groups met weekly for 6 weeks. A MAT therapist (N.T.) guided group A to express their feelings using art material. Group B met for a routine clinical visit only.

Results: Baseline Ulman, compliance and Minnesota scores were similar amongst the two groups. By the end of the study, Ulman score improved significantly in group A compared to group B (95±10 to 82± 14 p=0.0006 vs. 86±10 to 81±12 p=0.5) as was the compliance score (29±11 to 33±13 p=0.05 vs. 36±5 to 36±6 p=0.9). In group A, Minnesota score improved significantly in 7 patients and did not change in 3 while in group B it improved in 2, did not change in 6 and worsened in 2. METHODS. Prospective evaluation of two scoring systems; one that measured nurse workload, developed by Kaiser Permanente, USA (1) and another that rated objective discharge criteria, developed by the Danish anaesthesia society (2) . Patients were scored upon admission and discharge, and during their stay in the PACU.

RESULTS. Thirty-seven postoperative patients were included in this pilot study. Nurse workload was correlated to length of stay and was primarily determined by the number of drugs and/or doses of drugs administered (p \ 0.01, Rsq = 0.37). Twelve patients (32%) fulfilled criteria for discharge upon admission to the PACU. Pain was the major reason why patients did not fulfil discharge criteria at any time.

CONCLUSION. These scoring systems seem to provide relevant information about nursing workload for postoperative patients. Also, objective discharge criteria may ensure that patients will receive care better adapted to individual needs. This pilot investigation precedes a study in 750 patients, data from which will be available at the ESICM congress. 

A two day seminar was developed to give nursing staff insight, theoritical knowledge and skills to use when dealing with the dying patient and the grieving family.The setting was a nursing school situated in a thousand bed general hospital.The participants were twenty-five trained nurses working in adult intensive care, neurosurgical, internal medical and recovery departments.The facilitators were the nurse tutor intensive care course and two nurses trained in group dynamics and with expertise in End of Life and ethics. Two six hour sessions were held. Use of a group dynamic allowed each nurse to express how they view EOL care in their own personal practice. This opening was followed by a group exercise using collage,an art therapy technique adapted to allow exploration of painful feelings on death and dying.By promoting self awareness into individual attitudes on death the caregiver is strengthened when caring for others.Theoritical knowledge was given next via frontal lectures on ethics, attitudes on EOL and law regarding the rights of the dying. The care of the grieving family was addressed using the Family Needs Inventory(CCFNI). Techniques of breaking bad news were discussed and theories of other disciplines such as Oncology were examined for models of palliative care that could be used in intensive care settings.

A pre-workshop questionaire showed that all nurses felt they had received inadequate training in EOL care.The collage exercise demonstrated that nurses experience considerable distress from the death of patients. Post workshop feedback confirmed that nurses felt they had been given tools to use while dealing with death and dying.

CONCLUSION. Composure has been described to be the ability of the nurse to be present for the patient at the end of life,and demonstrate concern and compassion whilst changing the aim of saving life to the preservation of the dignity of the patient and the stability of the family.This workshop was given by nurses to help nurses achieve composure, that most difficult of skills, and allow them to be there for their patients when doing is no longer possible. METHODS. The study is descriptive and interactive. The first part of the study was to establish the use of diaries through telephone interviews with nurses at all ICUs using patient diaries, and the second part was to construct a National Guideline by consensus among Danish ICU nurses from the five administrative regions of Denmark. The guideline was constructed using the AGREE-instrument and was submitted to the Department of Health for discussion of ethical and legal issues, as Danish law is very restrictive regarding patient protection.

RESULTS. Patient diaries are used in half of the Danish ICUs and only few local guidelines have been written. The use of patient diaries has been an unsystematic bottom-up initiative by ICU nurses with little management support. On an initial workshop on patient diaries it was clear that consensus could not be reached regarding the application of the intervention. Five regional groups were established and consensus was gradually achieved by negotiation among the groups.

CONCLUSION. Patient diaries are emerging as an effective instrument for debriefing and prevention of PTSD in patients discharged from ICU. The practice of writing diaries is not homogeneous and needs more conformity in order to be studied further. More studies are needed to establish the role of the family in patient diaries and of follow-up regimes for this group of patients. INTRODUCTION. Extracorporeal CO2 removal is an effective technique to limit minute ventilation, thus allowing a protective ventilatory strategy even in the most severe ARDS patients. However, since CO2 is driven through the membrane lung only by the partial pressure of the dissolved CO2, which is less than 10% of the total CO2 content, extracorporeal blood flow as high as 2 liters/min are required to remove the total CO2 production of an adult patient. We hypothesized that acidification of the blood entering the ML could convert the CO2 contained in blood as bicarbonate ions to dissolved CO2, hence increasing the partial pressure of CO2 (pCO2). The consequent increase in CO2 transfer though the ML should allow for a reduction of extracorporeal blood flow.

Six pigs (37±2 Kg) were sedated, intubated, mechanically ventilated and connected to a veno-venous extracorporeal circuit comprising a ML (Quadrox D). Minute ventilation was adjusted during the experiment to maintain a constant arterial pCO2. The extracorporeal blood flow was set at 500 ml/min while the gas flow was 10 l/min of oxygen. A continuous infusion of 0.5 N lactic acid was added to the extracorporeal blood flow before the ML at a rate of 1, 2 and 5 mEq/min for 15 minutes each. After each infusion we waited at least 30 minutes to allow the acid to be metabolized. Each infusion was repeated two times. At each step we obtained the amount of CO2 removed, free hemoglobin and gas analysis from different sites of interest.

RESULTS. The pH of the acid loaded blood decreased as expected, while blood pCO2 increased (see Table) . ML CO2 removal (VCO2 ML) increased 11, 23, 70% during acid infusion of respectively 1, 2 and 5 mEq/min. Blood free hemoglobin, a marker of hemolysis, was constantly within normal values. CONCLUSION. Blood acidification at the inlet of a ML, with infusion of 1, 2 and 5 mEq/ min of a lactic acid, can increase up to 70%, the CO2 removal capacity of the ML, allowing to remove the equivalent of 80% (173±23 ml/min) of the total CO2 production of an adult man from as low as 500 ml of blood. INTRODUCTION. ARDS due to trauma is associated with a high mortality rate. The use of pump-driven extracorporeal membrane oxygenation (ECMO) is reported in severe posttraumatic ARDS, but the complication rate (bleeding, shock) is high. We report on the use of a pumpless interventional lung assist (iLA, Novalung, Hechingen, Germany) establishing an arteriovenous shunt, in which a single-use ultracompact gas exchange system is integrated. 0,2 (0,03-0,4) 0,1 (0,04-0,5) tidal volume (ml/kg/IBW) 6,6 (6,1-7, 3) 6,1 (4,7-6,7) * 5,5 (4,6-6,8) ** iLA-flow (l/min) 2,0 (1,6-2,2) 1,9 (1,7-2,2) * = p \ 0.05; ** = p \ 0.01; IBW = ideal body weight CONCLUSION. iLA might find a place in the scenario of trauma management, since it provides a useful technique in posttraumatic ARDS. Due to effective CO2-removal, iLA is an important tool in realising lung protective ventilation. In our patients, the mortality rate was lower than expected from the ISS.

M. Arlt* 1 , A. Philipp 2 , S. Voelkel 1 , M. Hilker 2 , C. Schmid 2 , K. Taeger 1 1 Anesthesiology, 2 Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany

Severe respiratory and cardiac failure resistant to critical care treatment leads to hypoxemia and death of hypoxic organ failure. New treatment options for hypoxemia are necessary, even for patients primary located in outlying medical facilities. We report our experience with a new developed, portable Mini-ECMO (Extracorporeal Membrane Oxygenation) system for emergency treatment of hypoxemia caused by ARDS, cardiogenic shock or septic shock. We describe out-of-centre emergency percutaneous ECMO implementation and additional air-and ground ambulance transfer for referral centre treatment.

April 2008, we treated 15 adult patients located in outlying medical facilities with the new portable Mini-ECMO system and carried out interhospital transfer on the running system. Diagnosis included ARDS (n = 6), cardiogenic shock (n = 6) and septic shock (n = 3). Bedside cannulation was achieved percutaneously. In respiratory failure, we used a femoro-jugular veno-venous vessel access, in cardiocirculatory failure we implementated the Mini-ECMO system using a femoro-femoral veno-arterial vessel access. The new portable Mini-ECMO system consists of a centrifugal pump and a membrane oxygenator. Because of tip-to-tip heparin bonded circuits, we need no full dose heparinization. The system (27kg) is capable for hand-held use and suitable for storing on a standard gurney. With its inbuilt battery pack and oxyen-supply the hole system can act as a stand-alone device (e.g. during patient transfer from ICU to the ambulance).

Bedside cannulation was uneventful, bleeding complications did not occur. After start of the extracorporeal membrane oxygenation the systemic blood-flow and oxygenation were restored. During extracorporeal assistance, including air (n = 12) and ground (n = 3) ambulance transfer, no technical complication arrived. Limb ischemia due to the arterial cannula was observed in two cases. Hospital survival rate was 66%.

CONCLUSION. In 15 patients, thoracothomy indication was to control major chest tube bleeding or massive hemothorax, 4 lobectomies were performed. 6 patients underwent revisions within 48 hrs due to persistent bleeding, in other 3 patients 4 delayed reopening were required due to thoracic cavity tamponade with mediastinal shift. Of these 15 patients, 5 (33%)were successfully deconnected from ECLS, and discharged alive from the hospital, 2 remained on ECLS for more than 2 weeks after the first thoracotomy. In one patient a sternotomy with pericardiectomy, following three episodes of cardiac tamponade, was performed; the patient was deconnected from ECLS after operation and survived. In 4 patients thoracothomy indication was to control the source of septic shock and concomitant bronchopleural fistula, 3 pneumonectomy and 1 lobectomy were performed, none survived. One patient underwent a first thoracotomy for bleeding and subsequentely a pneumonectomy due to lung colliquation, and died. Packed red cell and fresh frozen plasma transfusions during surgical procedures were 2.58 ± 1.53 lt and 2.37 ± 1.56 respectively.

CONCLUSION. surgical control of hemorrhage from the thoracic cavity in ARDS patients anticoagulated for ECLS is a demanding task. Since 1991, the use of heparinized circuits allowed us to perform the surgical procedures with normal or close to normal coagulation status while on bypass. Nevertheless, multiple procedures, as reported in literature, are frequently required to control bleeding. Other thoracotomy indications had an unfavorable outcome in our experience. . Surprisingly little studies assessed the physiological changes induced by IPV. In stable COPD patients, IPV induced a significant unloading of the diaphragm (1). In a bench study, we demonstrated that IPV added to a conventional ventilator, increases positive end expiratory pressure and tidal volume (2) . The aim of this prospective study was to assess the short term physiologic effect of a session of IPV in patients at high risk extubation failure treated by non invasive pressure support ventilation (NPSV).

In 10 patients, 1 hour after extubation, we evaluated gas exchange, respiratory rate and inspiratory effort during a 20 minute-period of NPSV and a 20 minute-period of IPV superimposed on SB (IPV-SB). PSV was gradually increased until expired tidal volume was 6 to 8 ml per kilogram of body weight. Positive end-expiratory pressure was set at 4-5 cm H2O.

The setting for IPV were as follows: frequency of the percussion = 250/min, driving pressure 1.2 bar. The interface was a facial mask. Initial measurements were performed while the patient was in SB(initial) with return to a final SB condition.

Main results are shown in Table 1 CONCLUSION. This physiological study, performed in patients at high risk for extubation failure confirmed that the application of IPV is associated with a reduction of the inspiratory effort, and interestingly, with a marked reduction in respiratory rate. The unloading effect is moderate and less important than with NPSV. After induction of ARDS model (PaO2 400mmHg. After this recruitment procedure, optimal mean airway pressure was selected by decreased in 2mmHg every 5 minuets until PaO2 decreased blow 400mmHg, and ventilation was continued for 4 h. Hemodynamics, respiratory mechanics and gas exchange were measured throughout the experiment, and lung histopathological changes, lung wet/dry weight ratio, lung IL-6 expression (ELISA) were determined.

Heart rate (HR), Mean arterial pressure (MAP), cardiac output (CO), Central venous pressure (CVP) and pulmonary arterial wedge pressure (PAWP) did not differ among the four groups in experiment (p [ 0.05). After lung recruitment, sustained improvements in the oxygenation index were observed in all groups. Histologically, lung injury score was significantly lower in 9Hz HFOV group than other groups (p \ 0.05). Lung wet/dry weight ratio did no differ among the 4 groups (p [ 0.05). The expression of IL-6 in lung tissue significantly reduced in 6Hz and 9Hz HFOV-treated animals (p \ 0.05).

CONCLUSION. Compared with CMV and low frequency in HFOV, the higher frequency in HFOV result in less lung injury. High Frequency Oscillation Ventilation (HFOV) may be an optimal lung-protective strategy.

M. Poriazi, C. Routsi*, E. Angelopoulos, D. Zervakis, C. Roussos, S. Nanas ICU, Evangelismos Hospital, Athens, Greece

High Frequency Percussive Ventilation (HFPV) has been used in the past mainly as a rescue therapy in patients with acute respiratory failure and persistent hypoxemia with promising results. However the role of HFPV has not been completely confirmed yet because of a relatively small number of published data. We tested the efficacy of the HFPV (VDR 4 ventilator) in patients with hypoxemia of various etiologies in comparison with the conventional mechanical ventilation.

METHODS. We studied 8 mechanically ventilated patients (APACHE II score 20 ± 6, SOFA score 10 ± 3, Lung Injury Score 2.4 ± 0.8). Oxygenation, respiratory parameters and hemodynamics were monitored on conventional mechanical ventilation (volume control ventilation, VCV), during a short course of 2 hours on HFPV and finally 30 minutes after reconnection to conventional ventilation.

Values of PO 2 /FiO 2 , PO 2 , PCO 2 , pH on conventional mechanical ventilation, before the onset of HFPV, after 2hours on HFPV and 30min after reconnection to conventional mechanical ventilation were analyzed with repeated-measurements method (Anova) and resulted in an overall significant effect. All p-values were Bonferroni adjusted. PO 2 /FiO 2 before the onset of HFPV and 2 hours after was significantly increased (128 ± 68 vs. 281 ±110, respectively, p=0.02). In contrast, it was decreased 30min after reconnection to VCV (202 ± 81, p=0.04). pH values were increased 2hours after HFPV compared to those before (7.47 ± .09 vs. 7.37 ± .09 respectively, p=0.01) and 30min after reconnection to VCV (7.42 ± .09, p=0.03). Changes in PCO 2 were also significant between VCV and HFPV (44.7 ± 15.3mmHg vs. 32.5 ± 5.7mmHg respectively, p=0.049) and 30min after reconnection to VCV (39.07 ± 6.7mmHg, p=0.01). Changes in PO 2 were also significant before and after HFPV(91.6 ± 25.1mmHg vs. 178.7 ± 66.1mmHg respectively, p=0.01) and 30min after reconnection to VCV (123.5 ± 39.2, p=0.03). There were no statistically significant changes in hemodynamics during the study period.

These results indicate that a short course of HFPV acutely improves oxygenation without affecting hemodynamics. Further study should focus on longitudinal effects of HFPV as an alternative type for ventilation in patients with hypoxemia. INTRODUCTION. Several biological markers of lung injury are predictors of morbidity and mortality in patients with acute lung injury (ALI). The low tidal volume lung-protective ventilation strategy is associated with a significant decrease in plasma biomarker levels compared to the high tidal volume ventilation strategy. The primary objective of this study was to test whether the institution of high frequency percussive ventilation in spontaneously ventilating patients with severe smoke inhalation injury exacerbates pre-existing lung injury by using measurements of biomarkers of lung injury before and after starting HFPV.

A prospective observational cohort study was conducted in the burn intensive care unit. Twelve intubated, mechanically ventilated patients with smoke inhalation injury were enrolled. Physiologic data and serum samples were collected within 6 hours before intubation and at two different time points within the first 24 hours after intubation to measure the concentration of interleukin (IL)-6, IL-8 and TNFalpha. The differences in biomarker levels before and after intubation were analysed using repeated measures analysis of variance and a paired t test with correction for multiple comparisons.

RESULTS. Before endotracheal intubation, all of the biological markers (IL-8, IL-6 and TNFalpha) were elevated in the spontaneously breathing patients after smoke exposition. After intubation and the institution of HFPV monitored with Bicore device (tidal volume 7 to 8 ml/kg per ideal body weight), none of the biological markers was significantly increased at either an early (3 ±-2 hours) or later (20 ± 3,5 hours) time point. However, the levels of IL-8 were significantly decreased at the later time point (20 ± 3,5 hours) after intubation. During the 24-hour period after intubation, the PaO2/FiO2 (partial pressure of arterial oxygen/fraction of the inspired oxygen) ratio significantly increased and the plateau airway pressure significantly decreased.

CONCLUSION. Levels of IL-8, IL-6, and TNF are elevated in spontaneously ventilating patients with ALI following smoke inhalation prior to endotracheal intubation. The institution of HFPV does not further increase the levels of biological markers of lung injury; the results suggest that the institution of HFPV does not worsen the pre-existing lung injury in most patients with smoke inhalation injury. METHODS. 6 Patients were studied in the standard treated group and 6 in the group treated with the VestÒ System. Standard therapy consisted of manual hyperinflation with 100% oxygen 3 times a day with suctioning of the airways and exprimation. Patients received an external vest around the thorax. The external vest contained an air chamber which could be inflated with pulsatile oscillative flow. In this way external compressions were done during 20 minutes. SpO2, breathing frequency, tidal volumes, PeCO2 and dynamic lung compliance were recorded at baseline, direct after and 1 hour after therapy. Differences between the measured values compared to baseline were calculated on the time point :direct after treatment and after 1 hour of therapy. These differences were used to investigate if there was a statistical difference between the standard care group and the group treated with The VestÒ System. SPSS version 15.0 for Windows was used to investigate the statistical difference with nonparametric Mann Whitney U testing. A significance level of.05 was considered significant.

The difference in breathing frequency directly after treatment was significant lower in the group treated with The VestÒ System. Oxygen saturation directly after treatment was significantly higher in the standard treated group. INTRODUCTION. Pumpless arterio-venous interventional lung assist (iLA, Novalung, Hechingen, Germany) is used for extracorporeal gas exchange in severe ARDS. iLA is a single-used ultracompact gas exchange system perfused by the heart after arterial and venous cannulation. We report on a reduced complication and mortality rate using a new indication and implementation algorithm in comparison with a published cohort(1). RESULTS. Using a modified algorithm with prior stabilisation, smaller cannulae and improved technique, the incidence of complications and the mortality rate were significantly reduced, although the severity of disease (SOFA-score) was similar between the cohorts. iLA induced a marked CO2-removal allowing a lung protective ventilation (tidal volume \ 6 ml/ kg). CO2 elimination with TGI is dependent on flow rate as fresh gas flushes higher proportion of proximal dead space. High flow rate causes tubulence at tip and increases distal gas mixing. The aim of present study is to confirm effect of TGI throughout the respiratory cycle on alveolar ventilation at various catheter flows and as an adjunct to protective lung ventilation for various pulmonary diseases. We measured effect of TGI on pH and PCO2 in cases of severe respiratory acidosis. METHODS. 20 patients (13 males and 7 females) with varied etiologies were studied. ALI/ ARDS(n= 9), Pneumonia with / without sepsis and MODS (n = 8), Post LVRS (n = 1), Post lobectomy (n=1), Disseminated CMV with MODS (n=1). All the patients were on protective lung ventilation strategies and had respiratory acidosis. The ventilatory parameters were Tidal volume 4-10 ml/Kg, FiO2: 0.4-1, PEEP : 5-15, RR: 12 -30/ min), Inspiration: Expiration (I:E) : 1:2 -1:4. c-TGI was given with a tool using infant feeding tube through a catheter mount and with a flow rate 4 -10 litres / min. Data collected were arterial blood gas (ABG) at 0, 1, 4 hour and at every 24 hours after establishing TGI. The following parameters in ABG were noted: pH, PaCO2, PaO2, HCO3 and compared. RESULTS. After the use of c-TGI with protective lung ventilation we noted Respiratory acidosis with a baseline pH 7.123 ± 0.11 with improvement in pH at 1 hour (7.225 ± 0.1086 (p=0.000)) and 4 hour (pH 7.261 ± 0.0941 (p= 0.000)). The PaCO2 at baseline was 82.9 ± 23.79 mmHg and there was fall in PaCO2.

PCO2 levels were 64.53 ± 18.79(p = 0.00) at 1 hr and 60.4 ± 17.95 (p= 0.00) at 4 hour which are significant. , where it is associated with a significant mortality. Surgery is frequently not possible because of the poor patient's general conditions and high operative risk. The treatment of BPF using Endobronchial Spigots was recently described. This perendoscopic technique makes use of silicone stoppers to obstruct segmental bronchi in the area of a BPF. We report our experience of therapeutic bronchial obstruction for persistant BPF mechanically ventilated patients.

Indications for endobronchial spigots were association of (1) distal BPF in a mechanically ventilated patient with weaning failure (2) persistent pleural leakage after several days of drainage (3) patient not suitable for surgery. The technique comprises 2 steps: 1. Localization of one or several bronchi related to the fistula, using a Fogarty balloon catheter introduced through the bronchoscope working channel. The leakage is localized by inflating the balloon catheter in the selected bronchi until the bubbling stops in the pleural drainage system. 2. Introduction of the silicone stopper (Novatech Ò ''EWS'' or Endobronchial Watanabe Spigots) previously attached to a biopsy forceps through the bronchial tree, down to the localized segmental bronchi. Complete success of the technique was defined by an absolute control of the air leakage, allowing pleural tube removal. The partial success of the technique was defined by the persistence of a reducted air leakage associated with patient's improvement.

Between January 2003 to November 2007, 9 mechanically ventilated patients with untractable BPF were treated by therapeutic bronchial occlusion using EWS. The cause of BPF was an empyema in 6 patients, traumatic pneumothorax in 2 patients and complication of lung surgery in one. In one case, a spigot migration produced a tracheal tube obstruction which obliged to emergency reintubation. In 2 cases (3,4) the air leakage reoccured due to collateral ventilation leading to a second EWS positioning. Results are detailed in table. METHODS. At the present 129 articles published in Critical Care Medicine in 2006 were manually reviewed for 10 potential limitations in the reporting of MLR. Potential limitations were essentially based upon previous recommendations (1, 2) . Values are expressed in median (25th -75th percentiles) and percentages when appropriate.

Of the 129 articles, 29 (22%) reported the use of MLR and the results were shown and could subsequently be comprehended fully in 25. A median of 3 (2-21) models per article were reported. A total of 79 models could be checked for potential limitations. The selection of variables initially included in the models was clearly specified or could be deduced from the manuscript in 91% of the models. Testing for collinearity was properly reported in only 10%. The type of MLR modelling (stepwise, forward, backward..) was not specified in 6%. Nonconformity to the linear gradient and testing for an interaction term or effect modification were checked in only 20% and 25% of all models respectively, and in only 29% and 32% of models including[500 patients. Units of continuous variables were not provided in 33%. Criteria for overfitting data was violated in 35% and Hosmer-Lemeshow statistics were not provided in 84% of the models. Discrimination statistics by mean of area under ROC curves were provided in 3% and in 2/18 (11%) of models which had the primary intention in predicting outcome respectively. The recommendation regarding the coding of the end-point according to the Cochrane Collaboration was violated in 9%. A median of 4 (3-5) limitations were found per model.

According to these preliminary results only a minority of the reports published in critical care literature include enough information to allow the critical reader to fully comprehend the MLR model and the subsequent conclusion of the study. Critical care journals should pay more attention to the statistical review of manuscripts using MLR. RESULTS. The study population (n = 167) accounted for 11.65% of total ICU admissions (n = 1433). Patient data according to reason for admission and statistical significance are referred to in Table 1 

Retrospective study of critically-ill lung cancer medical patients admitted to a 10-bed respiratory intensive care unit in a tertiary care university hospital in order to identify early predictive factors of long-term mortality and outcome (six months) and to assess whether the ICU survivors received afterward any cancer related treatments. INTRODUCTION. The purpose of the study was to identify independent risk factors for intensive care mortality in patients undergoing cardiac valve re-operations in our institution.

We retrospectively analyzed the data concerning 235 patients admitted in our intensive care unit following valve re-operations during a ten years period (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) . Multivariate stepwise logistic regression was used to analyze preoperative, intra-operative and intensive care variables and determine risk factors for intensive care mortality. Statistical analysis was performed using Stata 8 for UNIX.

RESULTS. The overall hospital mortality was 7.89% (19 patients /238) for a predicted mortality by Euroscore of 10.12%. Intensive care mortality was 6.8% (16/235). Univariate analysis showed that the following variables were associated with higher mortality rates: age, urgent intervention, advanced New-York Heart Association functional class, increase preoperative urea, creatinine and lactic dehydrogenase (LDH) plasma levels, low preoperative hemoglobin level, presence of paravalvular leak, number of re-operation (Redo), length of intervention and extracorporeal circulation, necessity for transfusion and length of administration of inotropes. Multivariate logistic regression identified high preoperative LDH, urea plasma levels and Redo as independent predictors of intensive care mortality (Table I) with a high specificity and sensitivity (Area under the ROC curve = 0.94). A score was computed using these factors and the coefficients to predict mortality. No mortality was observed for a score value\3.5.

For postoperatives factors, the prolonged use of inotropes was independently associated with intensive care mortality. Failure to wean patients from inotropes during the first 48 hours was associated with very significant higher mortality rate (odds ratio = 12). INTRODUCTION. Today, in some developed countries, many aged people stay in aged people residence rather than private home with their families by several reasons. Most aged people residence have some relationship with supporting hospitals or clinics because most aged people have some medical problems, who usually regularly consult a doctor of these hospitals or clinics. However, in emergency condition, particularly in the night or holly day, these inhabitants can not be transferred to these hospitals and are transferred near emergency department in which hospital doctors have no information of the patients' medical condition and their philosophy for living and dying process. We often perform aggressive resuscitation against the patient's mind. The aim of this study is to clarify the circumstances of management of inhabitants of aged people residence in emergency condition.

We reviewed patients with OHCPA who were transferred to our center from aged people residence for past 2 years. In Yokohama, CPA patient is basically transferred to the nearest ED of selected 11 hospitals with adequate ability of proper CPR except special cases in which families can immediately tell the patient's mind and hope to EMS.

RESULTS. 27 patients were transferred to our CCE Center. Although in all 27 patients, ADL were restricted and death could be expected, all patients and their families did not consulted concerning their dying process. We blindly performed agressive resuscitation. 12 patients reached ROSC and only 2 survived, 1 of them could returned to the previous aged people residence with neurologically normal condition and the other transferred to other hospital with vegetative state. Although both were witnessed by nurse in the residence, both showed asystole as a first cardiac rhythm on the scene. Of all 27 patients, 16 were witnessed by staff. Of all patients, 7 were witnessed in the dining room, 1 in the bath room, and 1 found in the labatory without witness. In 18 patients who found in the private room, only 7 witnessed by staff and 1 by emergency life saving technicien (ELST) after the scene. In 7 cases bystander voluntarily performed CPR, in 11 cases bystander performed after telephone CPR advice, and in 8 cases any CPR was performed.

CONCLUSION. Most of patients in aged people residence have some ill condition such as malswallowing, low ability and actibity in daily life. They can be expected to die from these conditions. In some countries including Japan, death is put under taboo and most staffs of these residences do not discuss a death with patient or their families. However, to prepare for emergency condition including CPA and to avoid confusion and unwilling feeling in these conditions, we should consult the patient and his families about his dying process. To evaluate specific analysis of mortality, 204 patients were excluded due to readmission. Demographic data were (gender and age, type of patient, origin on admission, and disease group), occupancy rate, severity score (SAPS II and APACHE II), ventilatory parameters, frequency of transfer to the ICU and analysis of the lenght of stay (LOS) and mortality were included.

In the 1090 admissions 549 were male and 542 were female. The mean age was 66,5 ± 20 years. The mean APACHE II and SAPS II score were 10,2 ± 5,1 and 25,9 ± 11,respectively. The mean occupancy rate was 95%. A total of 222 patients were under ventilatory support (20,36%) on admission. When stratified by disease group 228 patients were gastrointestinal (20,8%) and 155 patients (14,1%) were respiratory. In total of admissions 60,7% were nonoperative and 39,3% were operative reason. In relation to origin of admission 70,6% were from ICU, 10,9% from general ward, 10,8% from emergence department, and 7,7% from operating room. Discharge profile was 733 to general ward (67,2%), 178 to home (16,3%) and a total of 159 patients (14,6%) needed to be transferred to the ICU. Invasive mechanical ventilation was used in 48,4% of patients. The most frequent ventilatory mode was continuous positive pressure (CPAP) in 65,2% of patients. The mean positive end expiratory pressure (PEEP) was 9,17 ± 1,04 cmH2O, the mean time under ventilatory support was 7,7 ± 7,8 days. Nocturnal mechanical ventilation was used in 3,6% of patients. The mean LOS was 5,3 ± 6,3 days. The mortality rate intra ICA was 1,8% and post ICA discharge was 9,1%.

CONCLUSION. When confronted with a growing demand for ICU services, developing intermediate care beds for low-risk patients represent a safe and effective strategy for providing critical care at a reduced cost. A proportion of ICU admissions can be considered low risk for receiving services that are unique to or best provided in an ICU. Despite the widespread notion that larger ICA (above 10 beds) can show low occupancy rates, our data is in contrast and shows that a high occupancy rate is feasible and leads to a better utilization of critical resources. INTRODUCTION. Despite the overall decline in maternal mortality in high-outcome countries, postpartum haemorrhage (PPH) still makes a major contribution to maternal mortality and severe morbidity in Europe. The goal of this study was to identify the predictive factors for invasive procedures (haemostatic surgery and arterial embolisation) in case of postpartum haemorrhage already treated with sulprostone infusion.

METHODS. All PPH patients were admitted in our tertiary centre transferred from other hospitals, over a 3-year period. We have compared the patients characteristics in two groups : 1/ a « Invasive Procedure » (IP) group including patient managed with haemostatic surgery and/or arterial embolisation and 2/ a « Medically Managed » (MM) group including the remaining patients for which no intervention was needed. A multivariate analysis led to identify independent predictors of invasive procedure, performed in the 4 hours following admission.

Patients characteristics confirm the occurrence of severe bleeding in our 407 patients before admission in our centre ( Table 1 ). The five identified predictors are represented on the Table 2 . There is not a statistical important correlation between baseline levels of AT III and the outcome of the patient. Also there is not a statistical important correlation between baseline levels of AT III and APACHE II severity score. There is statistical important correlation between baseline levels of AT III and the SOFA score in the group of patients with multiple trauma. The baseline levels of AT III in patients with brain injury is higher compared with the other groups of patients (p \ 0.05). First, we correlated the above parameters with the length of stay (LOS) in the ICU by using Pearson's correlation test. Secondly, we compared the means between survivors and nonsurvivors after 6 months with independent samples' t-test. We finally performed receiver operating curves (ROC curves) of the above parameters according to mortality.

RESULTS. Mortality in the ICU was 22.73% and six-month mortality 63.63%.

The values of the parameters are showed in Table 1 .

No correlation could be found between the LOS and the aforementioned parameters, neither a difference could be found between survivors and non-survivors with the independent samples' t-test (p[0.05).

ROC curves are shown in Table 2 . In November 2007 our ICU started a post ICU outpatient clinic to evaluate specific problems of patients experienced after discharge to improve their medical and psychological status.

METHODS. Survivors after severe sepsis with than 10 days mechanical ventilation were identified and invited to visit the clinic. A questionnaire was mailed to the participants with questions regarding daily living activity (ADL and Barthel). Medical and psychological aspects were discussed during the visit.

. We evaluated the first 24 patients. Preliminary analysis shows that survivors experience a significant range of especially psychological and medical complaints within the first three months after discharge. Problems frequently encountered were weight loss [ 10% (38%), critical illness polyneuropathy (42%), sleep disturbances (29%), post-traumatic stress disorder (29%), and signs of emotional imbalance (20%). New medical problems were less common and not severe. Only nine patients (38%) were discharged with maximum IADL and Barthel score. Duration of complaints varied between 2 weeks up to one year after discharge.

CONCLUSION. After prolonged critical illness significant morbidity may influence recovery and rehabilitation following discharge from hospital. Quality of life including ADL must be considered when assessing ICU outcome. At present this problem may be underestimated and more studies are warranted to improve post-ICU care.

U. Guenther*, H. Wrigge, T. Muders, C. Putensen Anaesthesiology and ICM, University Hospital, Bonn, Germany

Delirium is associated with longer stay in ICU, higher treatment costs and increased mortality up to six months [1, 2] . Though recommended by guidelines [3] , very few ICUs have implemented a daily monitoring for delirium yet. When introducing a delirium-monitoring tool, objections such as ,,too time-consuming'' and ,,too complicated'' will be encountered, and it is often stated, that clinical judgment alone would prove satisfactory to detect delirium. We tested the German translation of the ,,Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)'' [4] in a 20 bed surgical intensive care unit (ICU) for applicability, time-consumption, and compared clinical judgment of nurses to detect delirium with CAM-ICU assessment.

METHODS. Every patient admitted to our ICU in June 2007 was monitored for delirium with the CAM-ICU on a daily basis. (1) Nurses were interviewed for their delirium criteria, and they assessed their patients for delirium based on their clinical judgment. Patients with severe neurological impairment (stroke or dementia) and inability to understand German language were excluded. (2) To assess applicability of the CAM-ICU, nurses familiar with the CAM-ICU were stop watched when examining patients and interviewed for ease of use of each of the four CAM-ICU features. The reported incidence of delirium in non-comatose intensive care patients ranges from 19% to 80% 1,2 and has been associated with GABA agonist (propofol and benzodiezepine) use 3 . Delirious patients may not be agitated, so signs of delirium must be actively sought. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a validated screening tool 4 . The aim of this study was to use the CAM-ICU in a 13 bed mixed surgical and medical ICU to determine the incidence of delirium and whether there was any correlation with sedative agent use. METHODS. JS and RT (trainee ICU doctors who had had a brief tutorial on CAM-ICU) reviewed each ICU patient daily and performed a CAM-ICU if assessable (Richmond Agitation and Sedation Score more than minus 4 = rousable enough to assess). Sedative agents given in the preceding 24 hours were recorded. Statistical significance was determined with Fisher's exact test. RESULTS. 186 reviews of 45 patients were made over 6 weeks; in 117 of these (63%) the patients were rousable enough to perform a CAM-ICU. On 16 of the 117 CAM-ICU assessments (14%) the patients were delirious, and on 12 of these (75%) the delirium was of the hypoactive type (patient calm or drowsy). 11 of the 45 patients (24%) were delirious at least once. 7 out of 24 assessments (29%) on patients who had received a GABA agonist in the previous 24 hours were positive for delirium, compared to 7 out of 66 assessments (11%) on patients who had received no drug in the previous 24 hours (p=0.047), and 2 out of 27 assessments (7.4%) on patients who had received any sedation that did not include GABA agonists (p=0.066) in the previous 24 hours. RESULTS. 92 members responded, of whom 80% were senior medical staff, 50% of the respondents were Anaesthesiologists and 35% with ICU as their primary speciality. Around 90% of the respondents worked in the ICUs which admitted both medical and surgical patients. Only 50% of the respondents had a written protocol for sedation in their units and assessed sedation level every 4-6 hours. A sedation scoring system was used by 90% of the respondents, with Ramsay scoring being the most frequently used system (60%). 21% of the respondents use Bispectral monitor to assess the sedation level, of which 50% were Neurocritical care units. There were only 13% of the respondents who preferred to use propofol for sedation in children, and the youngest age they would use ranged from 6 months to 16 years in children. Only 50% of the respondents admitted that they would adjust the calorie requirement when patients are on propofol infusion. 22% of the respondents have encountered propofol infusion syndrome in their clinical practice. 53% used rise in lactate and 3% used Acyl or malonyl carnitine levels as a marker, if they suspected propofol infusion syndrome. 96% of the respondents used continuous infusion for sedation, with propofol being the preferred drug used by 83% of them for short term sedation (less than 48 hours). Midazolam was the second common drug used for short term sedation (around 58%) but it was the preferred drug (85%) for long term sedation (more than 48 hours). The respondents felt that haemodynamic status (90% of them) and cost (63% of them) did influence their choice of sedation. Only 60% of the respondents were practising sedation hold regularly and around 30% hardly practised sedation hold. Haloperidol was the preferred drug (70%) for treating agitation in the intensive care unit, with clonidine being the second choice (30%). Atracurium was the neuromuscular blocker preferred by the respondents, with approximately 80% of them used it only intermittently. One third of the respondents were not monitoring neuromuscular blockade and only 50% used peripheral nerve stimulator to monitor the neuromuscular blockade.

CONCLUSION. There is wide variation in sedation and analgesia practice. There is also substantial difference in the way sedation and neuromuscular blockade are being monitored.

Considering the potential benefit in the patient outcome, it might be worthwhile implementing evidence based protocol in the clinical practice. METHODS. 10 Physicians well trained in mechanical ventilation, but without knowledge of the 7 ICU ventilators tested, performed 8 tasks per machine. Time performances were compared between each other and with a reference time established by a trained respiratory therapist (RT). Tasks were to successively: switch on the ventilator, recognize the already adjusted mode, recognize and set alarms, change mode, find the pre-oxygenation command, adjust parameters for pressure support mode, stand-by and find NIV mode. Physicians rated their subjective assessment of task difficulty on a visual analogue scale (0: very easy-10 very difficult).

Results are expressed as medians and interquartile range (IQR: 25th-75th percentile). For each task physicians were slower than the RT: 44 (25-89) s for the most rapid, vs. 14 (5-22) s for the RT. A mean of 9 (7-13) failures was observed by ventilator; on 3 machines more than 10 failures occurred. The most rapid task with the fewest failures was pre-oxygenation (5, 3-17 s). Tasks with the most failures were adjusting pressure support mode and finding NIV mode. The longest task was mode recognition (106, 74-146). The most common errors were: confusion between adjusted and measured parameters, type and level of trigger and plateau pressure assessment. Visual analogue difficulty scores ranged from 3.8 to 7.3.

Physicians without prior experience with specific ICU ventilators perform poorly when confronted with specific tasks. These results suggest a need for standardization between machines and improved interface user-friendliness in the design of ICU ventilators. METHODS. Following ethical approval, 12 patients scheduled for elective cardiac surgery were consented and enrolled into this study. Whilst sedated and ventilated post-operatively a 10French catheter was inserted into the nasopharynx via the nose. Pressure measurements were performed once the participant was awake and extubated. Placement of the catheter was first confirmed using end tidal CO2 monitoring. The Fisher and Paykel Healthcare Optiflow TM system was used to deliver humidified nasal oxygen and measurements were performed with gas flow rates of 30, 40 and 50 lpm. Measurements were performed with patients mouth open and mouth closed. Pressure was recorded over one minute of breathing. The mean nasopharyngeal airway pressure was determined by averaging the pressure over one minute. This allowed the entire pressure profile of each breath to be included within the mean airway pressure calculation.

RESULTS. n = 12. Average age = 64.6years (40 -84); average height = 174.3cms (163 -205); average weight = 86.3kgs (55 -121). 75% (n = 9) male.

At 50 lpm with mouth closed, the Optiflow TM system with nasal interface delivered a mean nasopharyngeal airway pressure of 3.3 cmH20.

Other results were: INTRODUCTION. Vibration response imaging (VRI) maps the lung sound distribution during the respiratory process. VRI measurement has been proved sensitive to changes in PEEP. In the present study, we compared the lung sound distribution at different PEEP levels.

Our hypothesis was that elevation of PEEP is associated with better recruitment of dependent lung areas and should be reflected by increased lung sounds in these areas.

METHODS. Lung sounds distribution was assessed at peak inspiration in three lung regions (apex, central and base). Maps of lung sounds obtained at PEEP 0, 5 and 10 cm H2O were compared in 34 mechanically ventilated patients. Furthermore, maps of two repeated measurements at each PEEP level were also evaluated.

Lung sound distribution in the base areas was significantly increased when increasing PEEP (paired t-tests). Furthermore, lung sound distribution in the apex areas was significantly decreased. Central lung segments did not change with PEEP. Furthermore, maps of repeated measurement at same level of PEEP were not significantly different.

CONCLUSION. Lung sound distribution shifted from apex to base when increasing PEEP probably reflecting increased flow in these areas. INTRODUCTION. Patient satisfaction at emergency departments (EDs) can be improved by reduction in patient waiting times. In this paper, we evaluated the impact of an ED informatisation system, available for all ED (medical and nursing) staff and displaying a visual tracking system of all pts admitted to the ED.

We retrospectively analysed all different waiting times for all patients admitted to the ED in a 3months periods before and after the installation of the visual tracking system. Different waiting times were : wR : wait for registration, wX : wait for initial triage, wC : wait for consulting room, Wi : wait for technical investigation, divided in time of technical investigation and time to result of technical investigation available, wT : wait for diagnosis/ treatment and finally wD : wait for discharge from ED (home or hospital).

A total of 4720 pts were included in the first 3months period (2005), compared to 4910 pts for the second period (2006). We observed a significant decrease in all, except one (wR), waiting times after the installation of the visual tracking system. Analysis of different waiting times revealed that largest reductions were obtained in the wait for initial triage and consult (wX : m28min reduced to m19min and wC : m43min reduced to m27min). We also observed a significant reduction in outliers, i.e. extremely long waiting times, mostly occurring for technical investigations (wI) (as well for the investigations as for the results of the investigations) as for final diagnosis (wT).

CONCLUSION. The implementation of an ED informatisation system, providing continuously real-time updated visual tracking screens displaying the flow of all ED pts, resulted in signicificantly reduced waiting times and increased patients satisfaction at the Emergency Department. METHODS. The 4 European partners of the CRITICAL project aim to deliver a screenbased, digital Virtual Intensive Care Patient (VIP) with a wide range of physiological attributes, capable of being reconfigured to treat the variety of pathological states which result in different patient symptoms and outcomes.

The project uses a software toolset called EduCAT which allows teachers who are not computer specialists the flexibility to create their own interactive educational material. Via the web, these intensive care tutors in hospitals and universities worldwide can provide trainees with a readily available, low cost approach to medical management of different disease states. They will be able to try alternative treatment options and observe patient outcomes faster than in ''real life'' without any danger to patients in the ''real'' clinical environment.

Prominent international leaders of ICM will head the project and develop medical-based scenarios which have been rigorously tested, evaluated and refined throughout the project lifecycle.

RESULTS. By the project end in August 2009, the result will be a developed software simulation of an intensive care patient, available in 4 languages (English, French, German and Spanish) which will be configured by the teacher and used directly for diagnostic exercises set by the teacher.

CONCLUSION. The VIP will be accessed over the internet from a website which will also provide a collaborative forum for interested education groups to further develop the model and share latest research of best practice bringing intensive care teaching into the 21st Century.

GRANT ACKNOWLEDGEMENT. We gratefully acknowledge the assistance of ECOTEC UK (Leonardo da Vinci Programme) who have provided 75% of total funding for this project. 

Atelectasis is a frequent occurring disease in ventilated patients. There is no standard treatment for this disease. The treatments of choice are :suctioning, positional therapy, bronchoscopy and conservative treatment. The patient with atelectasis suffers from impaired ventilation capacity and impaired oxygenation in most cases. Therefore the atelectasis should be cleared. We investigated the role of a new external pneumatic oscillation device, The Vest Ò system compared with suctioning in combination with exprimation and hyperinflation, which is the standard therapy for atelectasis in our intensive care unit.

We performed a single centre randomised open study to investigate the effects of The Vest Ò system in atelectatic ventilated patients who were hospitalised in our ICU in 2007. After approval of our ethical committee, 6 patients were studied with the Vest Ò system. They were treated 3 times a day with the use of an external vest, which contained an air chamber. A pulse generator was connected with the airspace in the VestÒ. In this way pulsatile, oscillative compressions were made around the thorax, during 20 minutes. Standard manual hyperinflation in combination with exprimation and suctioning was done 3 times a day in 6 patients. After maximal 12 treatments, the study was stopped. Complete atelectasis of one lobe was scored as 3 points, major atelectasis of one lobe was 2 points and minor atelectasis of one lobe was scored as one point. Complete atelectasis of the right lung should be scored as 9 points. One independent radiologist reviewed the X rays. Atelectasis score and time to reach the lowest score were compared with Mann Whitney U testing. A significance level of \ 0,05 was considered as significant.

RESULTS. Atelectasis score just prior to treatment minus lowest atelectasis score was 1,3 +/-1,5 in the Vest Ò group and 2,5 +/-2,4 in the conservative treated group. Time to reach the lowest atelectasis score was 77,3 +/-23 hours in the Vest Ò group and in the standard treated group 58,7 +/-31,1. No significant changes in both values were seen in both groups.

In this study no benefit in resolution in atelectasis has been demonstrated when the Vest Ò system was used compared to manual hyperinflation in combination with exprimation and suctioning. The sample size in this study was small. Treatment duration and frequency of chestwall oscillations could also be of influence on our results. 

Microphones were applied to four locations on the chest of six anaesthetised pigs, ventilated in volume-control mode with a PEEP of 5 cmH2O applied. Breath sounds were recorded before and after unilateral oleic acid-induced lung injury. Then PEEP was increased in steps of 5 cmH2O from 0 to 20 cmH2O. Breath sounds as well CT scans were recorded at each PEEP level. Pathological changes detected by Fast-Fourier-Transform (FFT) frequency analysis of the sounds were compared to the quantity of non-aerated and very poorly aerated (+100/-300 HU) lung tissue present in the 9 mm CT images.

The acoustic spectra recorded in healthy condition were mainly within 400-500 Hz for both lungs. After unilateral oleic acid injury, the breath sounds recorded over the injured lung, but not over the non-injured lung, turned highly pathologic in all animals, showing increased spectral frequency content above 500 Hz and -70 dB. During stepwise increase of PEEP, the proportion of pathologic sounds gradually decreased and with a PEEP of 20 cmH2O, the breath sounds recorded over the injured lung were significantly decreased. The gradual decrease in acoustic pathology corresponded to a gradual transition of lung tissue from non-aerated or very poorly aerated to aerated in end-expiratory CT images (Table) . METHODS. In our 12 bed medical ICU, we used CVVHDF in the pre-and postdilution mode (Prismaflex system, HospalÒ) . Circuit lifetimes were prospectively collected during a 12 month period. Unfractionated heparin (UFN) was the first choice. No anticoagulation was used in patients with severe coagulation abnormalities or hepatic failure, while regional citrate anticoagulation (CBA) was used in patients with recurrent circuit clotting or with bleeding predispositions. Regular change of circuits was planned after 72 h. We performed survival analysis. Circuit lifetimes were censored when changed because of interventions outside the ICU, a switch to palliative treatment or a 24 h change due to severe septic shock, but not when changed because of access or technical problems.

RESULTS. 38 consecutive patients and 167 circuits were observed. No bleeding or major metabolic complications were seen. There were no differences concerning vascular access site, the proportion of sepsis and vasopressor dependency between the anticoagulation groups. Consistent with the literature, circuit lifetime was longer and circuit patency rate higher in CBA. Our circuit lifetimes are higher than generally reported.

CONCLUSION. CBA is safe and has superior circuit lifetime and patency, compared to UFH. Beneath monitoring of the complication rate, measuring of circuit lifetime, processed by survival analysis tools is easy and feasible to assess quality of a highly complex procedure in critically ill patients. INTRODUCTION. Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently leads to death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) was first developed in 1994, Japan and has been used for the treatment of septic shock. In particular, we usually start DHP-PMX within three hours at the diagnosis of septic shock. On the other, there is another kinds of hemofiltration column, the continuous venovenous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (CVVHDF using PMMA), we have reported with the effectiveness of clinical treatment for crinically ill patients in both therapies.

We treated 34 septic shock patients with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of over 20 by DHP-PMX. We reviewed the effectiveness of DHP-PMX therapy by comparison of the improvement rates of the APACHE II score, blood pressure. In another examination, the patients were divided into three groups: namely, group-1 in which CVVHDF using PMMA therapy following DHP-PMX (17 cases), group-2 in which CVVHDF using a polyacrylonitrile membrane hemofilter (PAN) therapy following DHP-PMX (6 cases), and, group-3 in which CVVHDF was not performed after DHP-PMX (11 cases). The outcomes and improvement rates of the laboratory parameters (IL-6, protein C, PAI-1, endocannabinoids, HMGB-1 and oxidative stress) in the three groups were compared.

RESULTS. The average of APACHE II score and sepsis-related organ failure assessment (SOFA) score were 30.2 and 12.7, respectively. The overall survival rate was 55.9% (good outcome judging from the APACHE II score). The improvement rates of the blood pressure (increased by more than 30 mmHg) were 58.8% (good effect judging from systematic review (1)). For another examination, only group-1 showed a better outcome (survival rate of 76.5%) compared with the other groups (survival rate of group-2 for 33.3%, group-3 for 36.4%). In addition, only group-1 showed significant improvements of the serum PAI-1 (155.6ng/ml before therapy vs. 90.5ng/ml on day 3; p=0.0041), protein C (34.2% before therapy vs. 40.0% on day 3; p=0.0433), IL-6 (13915.6pg/ml before therapy vs. 1052.1pg/ml on day 3; p=0.0477), N-arachidonoylethanolamine (AEA) levels(553.0pg/ml before therapy vs. 477.6pg/ml on day 3; p=0.0235) and oxidative stress marker (F2-isoprostane) (552.8pg/ml before therapy vs. 370.8pg/ml on day 3; p=0.0368).

Our study suggests that the early introduction of DHP-PMX treatment yielded good outcomes. In addition, therapies aimed at blood purification, CVVHDF and continuous hemofiltration (CVVHF) have been reported to be effective for the removal of inflammatory cytokines and various mediators. Although several types columns have been used for CVVHDF, few reports have shown the influence of the column using CVVHDF on the removal rate of the above-mentioned factors. Our findings suggest that CVVHDF using PMMA following DHP-PMX treatment have removed of various factors, and has improved survival rates in severe septic shock patients. The sample was divided in two groups. One group was constituted of children of parents that stayed continuously with their child while in the other group parents didn 0 t stay. The decision of staying or not with the children was made freely by the parents. Informed written consent was obtained in all the cases. Measurements: Demographic data was collected for all the patients. Distress was assessed by obtaining COMFORT scale scores for each patient in the morning. Blood samples for measurement of total cortisol and glycemic levels were also obtained each morning. The risk of mortality was assessed through PRISM scores. Statistical analysis was performed using Mann-Whitney's test. The chosen level of significance was P \ 0.05.

. Twenty children were enrolled, divided in two groups of 10. The medium age was 6.5 months, with no statistical significant difference between the groups. The average PRISM scores were equivalent for both groups (14 and 13.9). The therapeutical interventions for each group were similar, including the total amount of analgesics and sedatives administered. There was statistical significant difference between the COMFORT scale scores of the children which the parents stayed continuously and the other group (7.6 and 13.4, p= 0.0423).

There was no significant difference between the cortisol of the children that stayed with parents and the children that stayed without parents (25.5 ± 16.2 and 52.2 ± 42.8, p= 0.07).

There was no significant difference between the measured glycemia in the two groups (99.3 ± 20.7 and 111.1 ± 34, p= 0.21). The average length of stay in PICU was significantly different (7 days in the staying parents group vs. 11 days in the other group).

CONCLUSION. The patients of both groups showed signs of distress. Comparison between groups suggests that parents staying continuously with their child in PICU can reduce their level of distress and also could shorter their lenght of stay. INTRODUCTION. High Frequency Oscillatory Ventilation (HFOV) have been widely used in pediatric and neonatal patients with acute hypoxemic respiratory failure (AHRF) to limit lung injury and to improve oxygenation and CO2 epuration. Mortality associated with pediatric AHRF is also dependant on other organ failure rather than lung dysfunction. The objective of this study is to quantitate contribution of the nonpulmonary organ failure to poor outcome of pediatric patients with AHRF managed with HFOV.

METHODS. Forty two consecutive pediatric patients (median age : 4 months, IQR:2-10) with AHRF (pneumonia: 35, sepsis with ARDS: 3, Others: 4), failing conventional ventilation (alveolar-arterial oxygen difference (P(A-a)O2) of 580 torr (453-645), Oxygenation index (OI) of 30 (22,5-37)) were ventilated with HFOV. A prospective and repeated record of oxygenation parameters and ventilator settings was made. Assessment of hemodynamic, renal, hepatic, neurological and haematological organ function was performed at regular times.

RESULTS. Thirty four patients (81%) survived to hospital discharge without any oxygen dependency (group 1). Eight patients died (group 2). Nine patients (21%) had isolated respiratory failure and their mortality was 0%. Percentages of patients with 2, and 3 or more organ failure were 31%, 48% and their mortality was significantly higher, 7,6%, and 35% respectively. Patients with isolated respiratory failure demonstrated a significantly rapid and sustained improvement in oxygenation then patients of group 2. Severe shock requiring epinephrine or norepinephrine was associated to death (RR ratio of 8,5, CI [3, [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] 5] ). Patients with 3 or more organ failure had a higher length of hospital stay than the other patients (13 vs 7 days, p:0,03).

CONCLUSION. Patients managed with HFOV for AHRF and with non pulmonary organ failure were significantly less likely to improve oxygenation on HFOV and had a significantly higher length of stay and mortality than patients with isolated respiratory failure. Children with such conditions must be identified early for other therapeutic considerations.

M. Grzeszczak*, F. E. Barr Pediatric Critical Care, Children's Hospital at Vanderbilt, Nashville, United States

INTRODUCTION. The rate of severe pertussis infections has increased in recent decades. It mostly affects young children with the most severe cases and a highest mortality occurring in infants less than 6 months of age. Severe pertussis infections can cause respiratory and cardiovascular failure with an extremely high mortality rate (above 70%). The primary cause of death in severe pertussis is severe refractory pulmonary hypertension (PHT). PHT can progress very rapidly and in general is not responsive to any treatment modalities including extracorporeal support. The exact mechanism of PHT in pertussis is not completely known but hyperleukocytosis with leukostasis and leukocyte thrombi in pulmonary vasculature are thought to be contributing mechanisms.

After IRB approval, the medical records of all patients admitted to our PICU with diagnosis of pertussis between 1997 and 2007 were reviewed. Patients with severe pertussis requiring intubation and mechanical ventilatory support and with a echocardiographic diagnosis of pulmonary hypertension were analyzed.

RESULTS. Six patients were identified who met the above criteria. We have previously described 4 of these patients who required ECMO support for severe pertussis and who all died from severe refractory pulmonary hypertension (Pediatrics 2003; 112:1274-78). Since 2003, we identified 2 subsequent cases of severe infantile pertussis with good outcome. Both patients were treated with leukopheresis to achieve leukoreduction. The first patient had significant respiratory and cardiovascular instability and was initially placed on ECMO for stabilization and then underwent leukopheresis. We previously reported this case in detail (PCCM 2006; 7:580-582). A second more recent unreported patient is now described in more detail. The patient was a 5 wk old male infant who was admitted to PICU on his 5th hospital day. Two days later he was intubated and placed on mechanical ventilatory support for respiratory failure and a presumed diagnosis (subsequently confirmed) of pertussis was made. 

Severe paediatric septic shock is frequently characterized by depressed myocardial function associated with high systemic vascular resistance. In these circumstances, milrinone may be a valuable tool for cardiovascular support of children with septic shock, owing to its inotropic effect (with low myocardial oxygen consumption) and vasodilator properties.

We reviewed the clinical records of patients with septic shock admitted to our PICU from January 2005 to March 2008 who were treated with milrinone. Demographic, clinical and laboratory data were analysed.

Twelve patients received milrinone during the study period, but one patient was excluded due to infra-therapeutic milrinone dosage. The median age of the 11 patients included was 3 years and 3 months (3 months to 7 years). All patients were volume resuscitated to CVP [ 10 cmH2O. Dopamine was the first inotropic agent used in all patients. Milrinone was the second agent used in 4 patients. The average interval between admission and milrinone administration was 15 hours. Only one patient received a milrinone loading dose (50mcg/Kg). The initial infusion dose varied from 0.25-0.75 mcg/kg/min; the maximum infusion dose was 0.82mcg/kg/min. The median duration of milrinone infusion was 72 hours. Nine patients needed 3 or more inotropic agents (7 received norepinephrine). Cardiac function was evaluated by echocardiography in 8 patients before and after milrinone was started: 5 improved, 2 had no change and 1 worsened cardiac contractility. Blood lactate level increased in 2 patients and decreased in 7 patients (a mean decrease of 20.1 mg/dL) after starting milrinone. Concerning the adverse effects of milrinone: mean arterial pressure decreased in 4 patients (a mean decrease of 10 mmHg); 5 patients needed norepinephrine or an increase of dosage after milrinone infusion started; heart rate increased in 7; none had disrythmia; 2 patients developed secondary thrombocytopenia. Seven patients needed mechanical ventilation, 4 needed renal replacement techniques, none had ARDS and 1 patient had severe ischemic sequelae leading to lower limb amputation. The median PRISM scale value was 23. Mortality rate was 18% (2/11).

CONCLUSION. Milrinone has shown promising results with very few adverse reactions. In our patients, despite insufficient haemodynamic monitoring, the results were encouraging in terms of cardiac function and peripheral perfusion. A randomized controlled trial of milrinone use in paediatric septic shock is needed. 

PDT performed over the past ten years in 21 children, requiring prolonged mechanical ventilation admitted to the single intensive care unit (ICU), were analyzed. Institutional ethic approval was obtained.

RESULTS. Age of the children varied from 08 month to 12 years. Average mechanical ventilation and ICU days, respectively were 26 and 36. Seven children were below 06 years, smallest child was only 08 month old. All procedures were performed by a single operator experienced in adult PDT.

In all the children, modifications were required in the steps of Ciaglia technique namely 1) airway control, 2) identification of trachea, 3) stoma formation, and 4) tracheostomy tube insertion.

All children tolerated the procedure without any mortality or significant morbidity. In three children airway was lost transiently. No other complication was observed.

Average procedure time was 25 minutes and ranged between 15 to 40 minutes. Smaller children (less than 06 years)required more time as compared to older children.

CONCLUSION. Like adults, children requiring long term mechanical ventilation need tracheostomy. However, all ICUs providing care to children may not have surgical support to perform surgical tracheostomy.

No custom made introducer and dilational set or wire guides could satisfy the technical needs of procedure. Assorted items were selected from the broad range of products used for adult percutaneous tracheostomy, vascular access, and radiological interventions.

In the hands of experienced operator supported by an expert controlling airway, PDT can be performed safely in the ICU. INTRODUCTION. Dengue epidemics results in new admission in paediatric critical care units in Rio de Janeiro. Low age is one risk-factor to severity in dengue fever and the occurence of secondary pleural effusions is a common alteration in a group of pediatric critical care patients.

We reviewed the medical records of children admitted to the Pediatric Intensive Care Unit, with serologically confirmed dengue diagnosis, from march to april 2008. A specific protocol was filled out by physical therapists to obtain the following data: age, sex, vital signs, utilization of non-invasive ventilatory support, occurrence of pleural effusions, and Lenght-of-stay (LOS).

Among 15 patients, 7 were boys. Age was between 3m and 10y. All children came from Baixada Fluminense area, in Rio de Janeiro state. Sixty-seven percent of them presented pleural effusion on ICU admission, and 40% were submitted to non-invasive ventilatory support (BiPAP) during ICU. The mean LOS was 5,3 days (+-1.45 days). Two patients were submitted to thoracentesis. The occurrence of secondary complications, necessity of invasive ventilatory support and death in this cohort were equal to zero.

CONCLUSION. Respiratory findings were common in this cohort, but were not associated to a LOS [ 7 days, higher morbidity and mortality rates. There was an apparent trend in more consistent respiratory frequency reduction BiPAP group, in contrast to no-BiPAP. Further investigations are needed to study the effects of BiPAP in dengue respiratory manifestations. 

Families of ICU patients need information, proximity to their loved ones and assurance [1] . This leads them to telephone frequently for news [2] . To date, no published data are available on telephone information provided to parents in Italy's pediatric ICUs (PICUs). We investigated this issue in the course of a national survey on visiting policies in Italian PICUs.

METHODS. An email questionnaire on visiting policies was sent to the heads of all 34 Italian PICUs, including questions about their policy on providing telephone information to parents.

RESULTS. The response rate was 100%. Daily meetings of doctors with parents were held systematically in almost all ICUs (97%). Information was also given by phone (often or always, 70%; sometimes, 23%; never, 6%). Those authorized to give this information were mainly physicians (doctor on duty, 94%; charge nurse, 18%; nurses, 35%). Frequently (often or always, 85%) the family was given the ICU's extension number and 23% of ICUs had a specific time slot for taking relatives' phone calls. Not only reassurance (59%) and logistical information (44%) were given over the phone, but also generic clinical information (79%), e.g. regarding temperature or sleep. However, even detailed clinical data, e.g. on diagnosis, prognosis and treatment, was given in 23% of ICUs. To ensure confidentiality, 41% of ICUs arranged with the family for a single interlocutor to call at set times, 47% provided only generic information, and 6% gave the family an ID code.

CONCLUSION. Our findings suggest that in Italian PICUs the telephone plays a relatively important role in giving parents information, and that it is more widely used than in Italian adult ICUs [3] . Day-to-day information must be based on direct meetings between doctors and families; however, despite possible problems of confidentiality and disruption to the work of the ICU staff [2] , the phone can represent a complementary tool in providing certain information to parents and, above all, in addressing their considerable need for reassurance [1] . INTRODUCTION. Inhaled aerosols with Furosemide were used in many studies regarding mechanical ventilated preterm babies with chronic lung diseases (to reduce lung edema) and even in adults in order to improve dyspnoea. The proposed effects for Furosemide were related to lung mechanics improvement.

The study included 30 children with normal lung function (FEV1 / FVC[80%) aged between 8-12 years; sex ratio 1:1; no previous pulmonary disease; the patients have received during surgery anesthetics agents (Propofol 2.5 mg/kg.body weight, Fentanyl 1-2 lg/kg.body weight, Esmeron 0.6 mg/kg). After surgery, they were mechanical ventilated in BIPAP mode (with PIPmaximum 15 cm H2O, PEEP 3 cm H2O, FiO2 =0.3-0.5, Ti/Te = 1 / 2, Tidal volume= 8-10ml/kg body weight) receiving constantly through a pressure nebuliser aerosols with Furosemide / Natrium chloride (2 mg Furosemide / ml). Dynamic compliance (Cd) and airflow resistance (Raw) were measured every minute for the first 10 minutes (M0 to M10)of ventilation with consequent measurements at minutes 15'(M15) and 20' (M20)respectively. The monitored parameters: SaO2[96%; pCO2=35-38 mmHg; pH= 7.35-7.45. To estimate potential electrolytes,ureea and creatinine imbalances,3 blood samples have been taken for each patient: the reference probe before commencing the ventilation, the second at minute 10' and the third one at minute 30'. The urine output was also measured.

We have noticed a decrease in Raw between 8-10% and an increase in Cd between 43 -72% as compared to the baseline values of the patients for each parameter. The difference for each patient between the medium value of the starting moment (M0) and the medium value for M1 to M20 had a statistical significance (p value \ 0.001). The blood natrium, kalium, creatinine and ureea levels were maintained in normal ranges before and after ventilation with Furosemide aerosols.

CONCLUSION. The results were temporary related to the period of the administration of aerosols. The data are encouraging in the treatment of acute respiratory distress syndrome in order to ameliorate, even temporary, the specific pulmonary mechanics in this disease. Mechanical In-Exufflator (MI-E) can be used to improve clearance of airway secretions and therefore to reduce respiratory morbidity in children with NMD. The aim of the present study was to identify the number of children requiring MI-E in Italy, and to establish their underlying diagnosis, and the reason for MI-E use.

METHODS. Surveys were sent by mail to all centers thought to be involved in pediatric long term mechanical ventilation (LTV). The study included all patients aged less than 18 years on LTV on January 1, 2007.

RESULTS. Detailed informations were obtained on 67 children requiring LTV and MI-E use. Eighty seven % (n=58) of MI-E users were patients with NMD. Thirty six patients had spinal muscular atrophy. The most common indication for MI-E application are listed in Table 1 .

The distribution of the age of MI-E users is shown in Table 2 . MI-E was applied via a facemask (88% of children) or via a tracheotomy (12% of children). In 96% of patients in our study population, MI-E was used at home. RESULTS. This study shows a steep decline of infectious disease mortality in the seventies, followed by a relative stabilisation in the years thereafter. This steep decline was caused by an isolated decline in infectious disease mortality in infants (40 to 10 deaths per 100,000 children) and children between 1 and 5 years of age (7.9 to 2.6 per 100,000). In children over 5 years of age the infectious disease mortality remained stable over the whole study period. Analysis of mortality data of our PICU shows an increasing trend in mortality due to infectious diseases in children with underlying illnesses over the last ten years.

CONCLUSION. Infections in childhood remain a stable burden of mortality during the last decades, despite major improvements in therapeutic and preventive measures. This might be explained by increasing numbers of fatal infections in children with an underlying medical condition, known to increase the risk of severe infections. 

We report the results of a ten years retrospective study for poisoning in children.

Are included 218 children with poisoning exposures admitted at our PICU for the period 1998 -2007. It has been evaluated the frequency the age the type of exposure route of exposure and the circumstances of poisoning iatrogenic intentional or unintentional. Patients are divided in three groups: 0-5 years 6-12 years over 12 years and variables were analyzed for each group. Home ventilatory support is the optimal option to satisfy child's psychological needs and therefore enhance quality of life. The aim of the present study was to identify the number of children requiring long term ventilation in Italy, and to establish their underlying diagnosis, ventilatory needs and hospital discharge rate.

METHODS. Surveys were sent by mail to all centers thought to be involved in pediatric LTV. The study included all patients aged less than 18 years on LTV on January 1, 2007.

Of the 611 initial surveys posted, 189 were returned, identifying 407 children requiring LTV. Detailed informations were obtained on 305 children. LTV users were classified in three disorder categories: neurological (n=229; 75%), thoracic (n=13; 4%), lung/ upper airway (n=63; 21%). The age of institution of LTV according to disorder category is shown in Table 1 . One hundred twenty two (40%) children were ventilated via a tracheotomy with the highest percentage (89%) being neurological patients (Thor 2%, Lung/airway 9%). The majority of non invasively ventilated children used nasal masks (87%). All of the LTV users had positive pressure ventilators. Pressure-limited and volume-limited modes were equally distributed among patients with neurological and thoracic disorders. Patients with lung/upper airway disorder preferred pressure-limited ventilation. Twenty one % of LTV users required mechanical ventilation for more than 20 hours per day, 20% were ventilated 12-20 hours per day, and 59% received ventilation only when asleep. The majority of LTV children requiring mechanical ventilation for more than 20 hours per day were neurological patients. Three hundred (98%) children were cared at home. Only five neurological patients remained in hospital. CONCLUSION. In the Italian pediatric population requiring LTV, identified in this study, neurological patients represented the category that needs more health care resources. Successful discharge home was possible for the majority of LTV children despite the very young age, the severity of disease and the need for technological care.

INTRODUCTION. Percutaneous tracheostomy is a frequently performed procedure on the Intensive Care Unit. It's main indication is when mechanical ventilation is expected to be prolonged. However, optimal timing for tracheostomy insertion is unclear, and whilst it has traditionally been viewed as a minimally invasive procedure, serious complications can occur. The requirements for anaesthesia and necessity to teach trainees to become familiar with this procedure are further potential hazards.

Retrospective data for all tracheostomies inserted in our intensive care unit at the Royal Bournemouth Hospital from 2006 -2007 were analysed. The following data was collected: indication for tracheostomy, period from endotracheal intubation to insertion of a tracheostomy, quality of documentation of the procedure, level of supervision, use of fibreoptic bronchoscope, and early and late complications.

The majority were indicated for respiratory and neuromuscular problems. 45% were inserted within 5 days of endotracheal intubation and 86% by day 10. Complete documentation of the procedure occurred in 91% of cases with bronchoscope guidance and full monitoring in 100%. A consultant (64%) and/or Specialist Registrar was directly involved in the procedure in all cases. If a consultant was not directly involved, they were present at the bedside. We had one early complication of minor bleeding and late complications (at 1 year) in 8% cases (2 stomal infections and 1 symptomatic tracheal stenosis). There was no case of mortality related to tracheostomy insertion.

The results from our audit compare favourably with previous studies. A sound level of supervision was achieved in all cases and our complication rate was low. All procedures were successful, and subsequently during this period there were no surgical tracheostomies performed. The one case of tracheal stenosis did not require any intervention and continues to be followed up with no evidence of progressive sequelae. Our level of documentation was below the gold standard as stipulated by the Royal College of Anaesthetists. Since this audit, we are in the process of addressing this, by producing a selfadhesive tracheostomy label to be inserted into the notes. We hope this will not only encourage a more complete documentation of this procedure, but also make identifying insertion details easier. INTRODUCTION. Tracheostomy is one of the most usual procedures in intensive care units. Percutaneous tracheostomy offers advantages over operative tracheostomy, namely requiring less time to be performed and being less expensive.1 In addition, complications may be more frequent with surgical tracheostomy.2,3,4,5 Our objective was to determine the relative costeffectiveness and outcome of PDT.

Intensive Care Unit of a tertiary University Hospital from 2003 until January 2008. Percu-Twist was performed in all cases who had no contraindication. All the procedures were endoscopically guided and held under general anesthesia. Patients were followed-up at six months after discharge or until death. Time of execution, early and late complications were registered.

Sixteen women and 83 men with a median age of 52 (25th-75th percentile: 35-70) years were included. As far as we know this is one of the biggest cohorts using this technique. The admission diagnosis were: trauma in 55% of these patients, medical in 32%, and emergency post-operative in 13%. Mean ± SD SAPS II score was 45 ± 12. Mean ± SD ICU length of stay was 23,6 ± 19,2 days. The motive of tracheostomy was airway protection in 50% and prolonged ventilation in another 50%. Procedures took 5-10 minutes in 36% of cases, 10-15' in 45%, 15-20' in 13% and 20-25' in 6%. Early complications occurred in 20% of the study population, with tracheal ring fracture being the most frequent (17%), followed by minor bleeding (2%) and loss of airway (1%). Late complications were seen in 3% of the group with one tracheal stenosis and two hoarseness cases. No stomal infection was registered and no mortality was associated with the technique.

CONCLUSION. PercuTwist technique is a quick execution, safe method, with low early and late complications.

T. Schuerholz*, M. Tondt, T. Simon, K. Reinhart, G. Marx Anesthesiology and Intensive Care, Friedrich-Schiller-University, Jena, Germany

Severe Sepsis and septic shock are an important problem in the growing group of the elderly. Although the higher incidence of sepsis in elderly patients was described [1] , there is a lack of data in the intensive care unit. We conducted this study to gain more detailed information on this population.

In a retrospective study, 563 patients of a university intensive care unit were included to analyze data between March 2003 and November 2006. Inclusion criteria were sepsis or severe sepsis as defined by ACCP/SCCM consensus conference. Patients were divided in two groups of age more than and less than 65 years. After verification of skewness, patient data were analyzed using Mann-Whitney-U-test and v2-Test where appropriate. P.05 was considered significant.

Of 563 patients 52.2% were above 65 years. APACHE II score was significantly higher in elderly patients compared to those less than 65 years (28±10 (median±IQR) vs. 25±11; p=0.01). TISS score was similar in both groups (49±12 vs. 47±11). CONCLUSION. Elderly septic patients are more severely ill, but were treated to the same extend as patients of less than 65 years. Sepsis origin may change in the elderly and complicating ARF in the ICU is more common in this population. These factors may contribute to a higher mortality in the ICU and in hospital of patients [ 65 years. INTRODUCTION. The hallmark of septic shock is hypotension refractory to fluid administration. Vasopressors are routinely administered to restore mean arterial pressure. Although it may be intuitive, limited data exists relating the dose of vasopressor to the severity of shock. Consequently, doses of vasopressors have been picked arbitrarily to classify septic shock severity. The present study was conducted to evaluate the prognostic value of the maximal dose of norepinephrine (NE) during the first day of septic shock in comparison to the APACHE II, SAPS II and SOFA scores from the same day.

METHODS. Retrospective analysis of a septic shock database compiled from three large academic hospitals. Patients were included in the study if they received NE as the main, but not the only, vasopressor agent to maintain goal MAP. An empirical receiver operating curve (ROC) of mortality was created for selected outcome predictors. INTRODUCTION. The massive haemorrhage is a vital emergency in which the multidisciplinary treatment presents a recommendation grade 1A (1). Our objective is to analyse the fulfilment grade of the clinical recommendations, just as establishing the improvement points, to be able to establish a suitable protocol for our hospital. Design of the intervention protocol, as well as the formative action which allows the homogeneity of knowledge among the different services.

A collection data was designed in order to evaluate the admitted patients in our hospital with massive haemorrhage resistant to conventional treatment. These patients needed a specific treatment in 2004-2008. Items related to the quantity of transfused products, the specific products used, the hemodynamic parameters, the period of diagnosis and treatment, the monitorization, the coagulopathy, the complications and other analytic parameters were gather for that purpose. After analysing the improvement points, a formative programme was designed, which was based on the latest bibliographical recommendations. It included the designed intrahospitalary protocol, with a calendar which contained the different implicated services.

We identified 14 patients whose demographic data with a medium age of 50,5 years, the mortality per month was 28%. The average quantity of hemoderivated pre and post rFVIIa administration was: Concentrated red blood cells pre 3229 ml, post 1022 ml; Plasma pre 1446 ml and post 591 ml; Platelet pre 414 ml and post 167 ml. In the diagnosis of haemorrhage the 81,8% presented coagulopathy, the 42,8% had a shock, the 71,4% presented a temperature of \ 35,5°C and the 35,7% had a heart rate [ 100. The 71,4% presented belated complications. Factor VII was administered in the 100% of the cases, fibrinogen and vitamin K in the 28,5% of the cases and amchafibrin in the 14,2%. The rewarming up with an electrical blanket was of 35,7%. The 64,2% and the 78,5% required inotropic and vasoactive drugs, respectively. The 50% needed continuous venovenous hemodiafiltration techniques. The average of SOFA in the admission was of 9. The rewarming of fluids, the contribution of ions according to the protocol, the availability of specific products (Factor VII recombinant, fibrinogen, protromplex), the speed up of the analytical results, the monitorization of the shock with lactate levels were considered improvement points. The reduction hemoderivates after the administration of specific products lowers the chances of having soon and belated complications.

CONCLUSION. The establishment of an intrahospitalary protocol of critical haemorrhage is necessary, the same as the analysis of the intervention and the evaluation of the improvement points.

The utilization of specific products to control the massive bleeding as the rFVII seems to diminish the cost of hemoderivates and the complications, from which we consider it should be protocolised. CONCLUSION. Early transfer of SAP patients to ICU and routine monitoring of IAP with timely management of intra-abdominal hypertension were found to be readily modifiable factors to improve outcome of SAP patients in the hospital setting where the study was conducted.

INTRODUCTION. Participation of family members in the care of ICU patients, suggested as a component of family-centred care, has met with reluctance among families (1). Patients' opinions are not known. The aim of this study was to determine opinions of families, staff, and patients.

Single-centre prospective study (March 1 to July 17 2006 and September 1 to December 31 2006) of consecutive patients with ICU stays more than 3 days. We evaluated opinions about 13 items of care: wiping the eyes, cleaning the oral cavity, moistening the oral cavity, hydrating the lips, aspirating secretions, cleaning the nose, preventing pressure sores, helping staff change patient's position, helping with bed baths, shampooing, washing the patient's feet, manicuring, and applying hydrating agents. We collected patient characteristics and ICU mortality. Between days 3 and 5, questionnaires were given to the nurse, physician, nursing assistant, and family. Patients were interviewed by phone after hospital discharge. Satisfaction and symptoms of anxiety/depression in families were measured using the CCFNI and HADS scores. Care items actually performed by families were collected by the nurses throughout the ICU stay.

Of 220 admitted patients, 129 were included, among whom 28 were not analysed (no family, n=3; refusal, n=3; not fluent in French, n=4; died on day 4, n=2, second admission, n=5; questionnaire not given, n=1 CONCLUSION. Families and ICU staff were strongly in favour of participating in care aimed at improving patient comfort. Family satisfaction was high, symptoms of anxiety were less than in many other studies, and actual participation in care by families was low. The willingness of patients to receive care from their families warrants an interventional study aimed at encouraging families to participate in care. INTRODUCTION. In order to improve the well-being of patients in our intensive care unit, we have evaluated the sources of discomfort that were reported within discharge.

METHODS. This prospective study was approved by the local ethics committee. It was performed within a 15 beds intensive care unit of a teaching hospital. On the day of discharge, a questionnaire including 16 items was submitted to patients whose Glasgow score was higher than 13, and who spent more than 48 hours in the unit. For some items, we tried to precise if patients were more bothered at night. Besides, we looked for the main sources of pain and anxiety, and how they were relieved.

RESULTS. 50 patients were interrogated (36 men and 14 women, 53.9 ± 14.5 years old; SAPS II 34.7 ± 21.9; mean length of stay 7.7 ± 4.9 days), corresponding to 25.3% of the 197 survivors, over a time period of 154 days. Among these, 32 (64%) had been intubated, for a period of 5.9 ± 6.1 days and 24 (48%) had been sedated for a period of 4 ± 3.4 days. PHYSICAL DISCOMFORTS: the most frequently reported physical discomfort was thirst, mentioned by 56% of patients. 50% of patients complained about a lack of sleep, 48% about pain, most frequently back pain and throat pain caused by intubation (25%). 44% of intubated patients were bothered by the endotracheal tube, and 40% by the restraint. 40% of patients complained about infusion tubing and cables. The next cited sources of discomfort were cold (38%), noise (36%) and light (26%), mainly at night (61% for noise and 84.6% for light). Alarms were responsible for 72.2% and staff for 22.2% of the noise discomfort. Heat, saturometer sensor and hunger were less frequently reported (20%, 18% and 14%). PSYCHIC DISCOMFORT: The main psychic discomfort was anxiety (38%), which was relieved for 66% of the patient, mainly by the staff presence and support (64.2%), more rarely by families and drugs (14.2%). 28% of the patients suffered from a lack of information, 20% felt isolated from their family and 12% complained from a lack of privacy.

CONCLUSION. 43 patients reported at least 3 sources of discomfort, and 7 report 2. Thirst concerned more than half of the patients, despite the use of water sprays and wet compresses. The pain relief protocol is still insufficient, and analgesia alone does not resolve discomfort caused by decubitus or by the endotracheal tube. Noise and light, which are more bothering at night, participated to a lack of sleep that is often complicated by confusion and agitation. Different measures have to be taken in order to improve the well-being of intensive care patients: early screening of physical and psychological pain, changes in the patients environment and in our habits to preserve their nycthemeral rhythm. Once these measures will be built-up, we will evaluate their effect by further surveys.

Follow-up and quality of life after ICU are not routinely integrated in the process of care. We present the results of the outpatient Post-ICU visit. It was systematically given for mechanically ventilated (MV) patients of more than 48 hours with at least another organ failure in our ICU. RESULTS. All results are summarized in the two following tables. 

Quality of life is one of the most important outcome measures of survivors after critical illness. But physical and psychological sequelae have been described even 12 months after ICU discharge. Rehabilitation is therefore mandated as soon as possible after ICU to restore optimal health status. The Short Form 36 (SF 36) is a robust tool validated for quality of life assessment following critical illness (1). Therefore we studied SF 36 as soon as possible after critical illness and before attending the follow-up clinic.

METHODS. In a 6 beds mixed (predominantly medical) ICU in a community hospital, all adults ([18 years) ICU survivors during a 14 months period and with stay [3 days were included. One month after ICU discharge or soon after hospital discharge they were sent the SF 36 using regular mail. Results were compared with an age material matched control group drawn from Danish normative data. Values are expressed as mean (SD).

Among the 76 eligible patients, 49 (64,5%) answered the SF 36. The mean age was 61 years. Their mean SAPS II score was 38,1 and mean length of ICU stay was 6 days. 39 (79,6%) patients had mechanical ventilation during a mean duration of 7 days. INTRODUCTION. Delirium is a common neurobehavioural syndrome associated with increased morbidity and mortality. Delirium goes unrecognised unless a screening tool is used as the majority of delirium is either motoric mixed or hypoactive. The confusion assessment method for the intensive care unit (CAM-ICU) is a validated delirium screening tool for critically ill intubated patients with sensitivity and specificity over 93%. The aim of this clinical audit was to determine the incidence and outcome of delirium using the CAM-ICU in a UK critical care unit.

METHODS. Routine CAM-ICU monitoring was implemented in our mixed critical care unit in January 2007 following two months educational and promotional campaign. Management of delirium guidelines were introduced but there was no change to sedation guidelines. During September and October 2007 the daily CAM-ICU was recorded by the bedside nurse for 50 consecutive level 2 and level 3 patients admitted to the mixed medical/surgical critical care ward in a district general hospital. This was repeated in January 2008 for 30 consecutive patients. Patient outcome was recorded.

It was not possible to assess for delirium in ten patients due to coma. The overall incidence of delirium was 26% (21 CAM-ICU positive). If elective post-operative patients were excluded the incidence was 37%. The mortality in the CAM-ICU positive group was 38% compared 26% for all patients. Nine of the ten patients who were unable to be assessed for delirium died. CONCLUSION. We have demonstrated that delirium screening is feasible in a UK intensive care population. The high incidence of delirium and the impact on outcomes in this UK cohort of patients is in line with previous reports from other countries studying a similar case mix.

There is an urgent need to develop strategies to treat delirium in the critically ill.

INTRODUCTION. The goal of our study was to find predictors for both ICU and long term outcome in patients admitted to the ICU with a hematological diagnosis. The possible predictors chosen were: ventilator treatment, CRRT, secondary infection during ICU stay, ICU length of stay (LOS), APACHE II score and in-hospital length of stay prior to ICU admission.

Retrospective unicentric analysis of patients with a hematological disease admitted to the multidisciplinary ICU (6 beds) at a tertiary university hospital. The ethical issues involved in the individual ICU stay were also studied. We looked for decisions in the patient journals to withdraw or withhold resuscitation, ventilator, CRRT and inotrope therapies.

RESULTS. In this one-year period 65 patients with a hematological diagnose were admitted to the ICU. The decision to admit was taken by both a hematologist and an ICU-specialist in cooperation. The mean age was 56,9 years (range 16 -84), mean LOS on the ICU were 6.4 days (range 1 -52) and the mean APACHE II-score 26,4 (range 12-39).

In-ICU mortality was 30,7%, in hospital mortality 52,3% and one year mortality 70,7%. A total of 20 patients died in the ICU. We found that secondary infection (10/20 50%), CRRT (11/20 55%), ventilator therapy (15/20 75%), ICU stay C 7 days (11/20 55%) and a active ethical decision about therapy level (15/20 75%) all seem to correlate with a higher ICU mortality compared with a baseline mortality of 30.7%. Only two out of the nineteen patients that had had a secondary infection were alive at 1 year. Twenty-eight patients admitted to the ICU had had a prior stay at the hematological ward of C 7 days. Only 5 of those were alive after 1 yr. Secondary infection on the ICU ward and a long pre-ICU stay in the hematological ward both appear to be predictors for long term survival.

CONCLUSION. Even with a moderate ICU-mortality, the one year mortality of hematologic patients seems very high. We find the referral of critically ill patients with hematological disorders to the ICU an increasingly complex task. Improved possibilities for treating malignancies which previously would have been incurable, now renders the task of an initial triage for the ICU difficult.

We suggest that the long term survival rate (1 yr) of the hematological disease be taken into account when considering ICU admission. A long ICU stay with very poor prognosis is possibly both unethical and costly, if we take long term outcome into consideration. Another suggestion could be a critical evaluation after e.g. 7 days of ICU treatment. This suggestion is based on the high 7+ days ICU stay mortality. INTRODUCTION. Microcirculatory dysfunction is thought to play a role in the development from shock to multiple organ dysfunction syndrome.The response to extreme exercise, such as marathon running, is in many aspects similar to the hemodynamic and inflammatory response seen in critical illness (1) . In this study therefore we hypothesized that microcirculatory alterations would occur following a circulatory insult such as running a marathon.

METHODS. We studied 5 marathonrunners (2M/3F) participating in the marathon of Rotterdam. A microcirculatory assessment was performed before, on the finish-line and the following day after the marathon. Microcirculation was measured by sublingual sidestream dark field (SDF) imaging (2) . Sublingual capillary blood flow was estimated using semi-quantitaive microvascular flow index (MFI) in small (diameter 10-25 \mum), medium (25-50 \mum) and large (50-100 \mum) sized microvessels (0 = no, 1 = sluggish, 2 = intermittent, 3 = continous flow).

RESULTS. MFI decreased in all groups of vessels after completion of the marathon race. These alterations persisted the following day in all subjects (P.05) ( Table 1) . We found a difference in weight (pre-race minus post-race) of -1.28 +/-0.98 kg. METHODS. In 6 anesthetized and mechanically ventilated pigs, bodyweight 32 ± 2 kg (mean±SD), a midline laparotomy was performed. Formation of the gastric tube comprised ligation of all gastric arteries except the right gastro-epiploic artery. A gastric tube was formed by dissection of the lesser curvature and the gastro-esophageal junction. Systemic hemodynamic monitoring was performed with an arterial line and a PA catheter. Microvascular blood flow (MBF) was assessed with laser Doppler flowmetry and microvascular HbO2 saturation (mHbSO2) with spectrophotometry (O2C, Lea Medizintechnik Giessen Germany). Measurements were made in antrum, corpus and fundus at increasing mean arterial blood pressures from 50 to 110 mmHg. For this purpose blood pressure was increased in steps of 10 mmHg with incremental infusion of noradrenaline.

RESULTS. Heart rate, cardiac output and PAOPs did not change significantly throughout the experiment. MBF measurements are shown below (BL-baseline, DV-devascularisation). mHbSO2 was significantly lower only in the fundus, and increased significantly at a higher MAP.

CONCLUSION. We were able to establish a animal model for gastric tube reconstruction. In this model we demonstrated that although gastric perfusion is severely compromised following creation of the gastric tube, tissue perfusion could be improved significantly by increasing perfusion pressure with noradrenaline. On the other hand, this impairment in tissue blood flow was aggravated by hypotension. Whether these results should have consequences for the clinical setting remains to be investigated.

A INTRODUCTION. Improvements in the early management of sepsis may result in improved outcomes. This has led to increased interest in the pathophysiology of the early stages of this disease process. Microvascular derangements are well described in patients with established sepsis but little data is available from patients in the early stages of hospital care.

Following local research ethics committee approval, observational data were collected in patients with sepsis, severe sepsis and septic shock within six hours of presentation. Patients received usual clinical care (not including early goal directed therapy). Microvascular flow index (MFI) was calculated from video images of the sublingual microcirculation (sidestream darkfield imaging) whilst cardiac index (CI) and oxygen delivery (DO 2 I) were measured noninvasively using a supra-sternal Doppler method. Additinal data included mean arterial pressur (MAP) and serum lactate.Data are presented as mean (SD) or median (IQR). Data were tested with the t-test where normally distributed and the Mann-Whitney U test where not normally distributed.

RESULTS. 48 patients were recruited. Data are presented in Tables 1 and 2 . INTRODUCTION. Anemia occurs in more than 70% of intensive care patients, and is an independent risk factor of morbidity and mortality. Intra venous iron supply can be suggested, but iron may induce reactive oxygen species (ROS) production, in particular in inflammatory context. The aim of the study was to assess the effect of iron supply on ROS production with a model of human pulmonary micro circular endothelial cells (HPMEC), and to evaluate a possible potentialization of this oxidative stress first induced by a prior exposition to TNF/alpha.

Confluent HPMEC in monolayer conformation have been placed in a perfusion chamber mounted on an inverted microscope equipped with a digital camera. Cells were perfused with Krebs buffer containing a fluorescent probe (2'7' DCFH), which permitted to assess the ROS production, mainly H2O2. 4 groups have been studied: control, iron (iron hydroxide saccharose), TNF/alpha, TNF/alpha + iron. Oxidative stress level was evaluated with DCFH fluorescence variation compared to level at TNF/alpha introduction, after 40 minutes of stabilization. Statistics analysis was performed with ANOVA for repeated measure.

RESULTS. Exposition of HPMEC to iron does not induce intracellular ROS production. On the other hand, after 20 minutes of stimulation with TNF/alpha, iron supply leads to a significant increase of ROS production (p=0.03), which persists despite iron exposition ending (Fig 1) .

CONCLUSION. Iron exposition of endothelial cells first exposed to TNF/alpha potentializes ROS production induced by this inflammatory mediator. Intravenous iron supply could be deleterious in patients in inflammatory state. . LSI is a new technique which exploits the fact that the random speckle pattern that is generated when tissue is illuminated by laser light changes when blood cells move within a region of interest. The contrast image is processed to a color-coded image that correlates with blood flow in tissue.

We used LSI for evaluation of the microcirculation in the nail fold area. 12 Patients scheduled for dobutamin stress scintigram in order to evaluate cardiac ischemia in the out patients clinic of the cardiology department were included in the study. Patients received increasing dosages of dobutamin (10-20-30 mcg/kg/min) or until target heart rate was reached. Microcirculatory flow was measured during the whole experiment. We determined the change in flow for each step compared to baseline flow (delta flux) in arbitrary units (AU). CONCLUSION. Microcirculatory perfusion and oxygenation, parallel to systemic variables, increased following transfusion of red blood cells. Combining these two methods together gives an integrative and comprehensive monitoring of the functional activity of the microcirculation at the bedside by providing information about microcirculatory oxygen delivery by the RBC and oxygen availability.

INTRODUCTION. During on-pump cardiac surgery patients are subject to a number of hemodynamic changes such as hypotension, hemodilution, hypothermia, shifts from pulsatile to continuous bloodflow and inflammation. These insults have been associated with microcirculatory alterations especially in the gastro-intestinal tract. We tested the hypothesis that cardiac surgery induces microcirculatory alterations in the rectal mucosa, directly observed by Sidestream Darkfield (SDF) imaging.

In a single center observational study in 26 elective on-pump cardiac surgery patients SDF imaging of the rectal mucosa was performed in the first hour after ICU admittance. Fecal contamination of the rectal pouch was a contra indication for enrolment. Semi-quantitative analysis was performed as described in detail elsewhere 1 This maybe related to splanchnic flow preservation which prevents gut wall damage and bacterial translocation. This study utilises microdialysis to measure intra luminal glycerol, which was shown previously to be associated with the degree of cellular damage [1] , to assess the impact of changes in oxygen delivery during major surgery on large bowel.

METHODS. An observational study conducted on patients undergoing major abdominal surgery. Intra operative oxygen delivery is derived from oesophageal Doppler monitoring (Deltex Doppler). A CMA 61 microdialysis catheter is placed in the ascending colon and continuously flushed with 2uL/min. Samples are obtained every 6 to 8 minutes if clinically permitted. RESULTS. Twenty one patients were included. Eight of them had died at D28 (NS: n=8; S: n=13). Hemodynamic parameters (MAP, CI, ScvO2), infusion of vasopressor and lactatemia were similar between S and NS at H0, H24 and H48. There was no significant difference in the oxymetric index between the 2 groups at H0 (DeltaPtcO2/DeltaPaO2: S:57±31% vs NS:36±38%, p=0.17). However, at H24 and H48, patients showed a DeltaPtcO2/DeltaPaO2 index significantly higher in group S compared with NS (S:83±40% vs NS:37±22%, p=0.01 at H24; S:105±54% vs NS :43±34%, p=0.02 at H48).

CONCLUSION. These preliminary results suggest that increase in DeltaPtcO2/DeltaPaO2 seems to predict better outcome in severe septic shock while circulatory and metabolic parameters such as ScvO2 or lactatemia during the first 2 days of resuscitation remain similar.

OCT could help us to early detect patients who will undergo pejorative outcome in septic shock but further analysis is needed. INTRODUCTION. The choice of catecholamines in septic shock patients has been an ongoing debate for several years. Because vasopressors can accentuate mesenteric hypoperfusion secondary to circulatory shock, gut circulation is a major consideration in supporting hemodynamics. The objective of our study was to determine the influence of dopamine, norepinephrine, phenylephrine, epinephrine, and an association between norepinephrine and dobutamine on mesenteric microcirculation in a rat model of endotoxemia.

METHODS. Sixty Wilstar rats (250-350 g) were divided into 6 groups of 10 rats. The animals in groups 2, 3, 4, 5, and 6 received 2 mg/Kg of LPS from Escherichia coli -LPS serotype 055:B5. After a 40% reduction in MAP, the animals were treated by the administration of dopamine, norepinephrine, phenylephrine, epinephrine, or the association of norepinephrine with dobutamine. The functional capillary density (FCD) of the intestinal mucosa was estimated with intravital fluorescence videomicroscopy using an epifluorescent microscope. The FCD was estimated before the administration of LPS, after a 40% decrease in MAP, and after the normalization of the blood pressure with vasoactive amines. To reduce the ventilator induced lung injury (VILI) in acute lung injury (ALI) protective ventilation with low tidal ventilation is used. During this low-tidal-ventilation in critical ill patients hypercapnic acidosis (HA)can accur. Hypercapnia has direct effects on the regulation of the vascular bed, which may change organ perfusion. The influence of hypercapnia and acidosis on the regional perfusion (RP) is not exactly known.

METHODS. 16 anesthetised pigs were intubated, mechanically ventilated and recieved an experimental ALI by acid aspiration. To achieve HA pigs were randomized into two groups: group 1) Hypoventilation leading to HA and 2) acid infusion for metabolic acidosis (MA). RESULTS. Cardiac output (CO) tended to be higher during HA. While the perfusion of the gut and the spleen was increased, the stomach-and renalperfusion remained unchanged. In contrast MA did not affect global or regional perfusion. INTRODUCTION. Sepsis is a common cause of morbidity and mortality in intensive care unit, and delayed diagnosis and therapy is associated with increased mortality. Continuous hemodiafiltration (CHDF) and polymyxin-B immobilized fiber (PMX) have recently been widely performed mainly in critical care. To study effects of newly developed cytokine absorption colmu CTR-001 (Kanaka Co. Osaka, Japan), RCT was performed in patients with sepsis.

A total of 18 patients with early septic shock or septic organ dysfunction was enrolled.. Nine of 18 were randomized to direct hemoperfusion (DHP). All patients received supportive intensive care, and those randomized to DHP received direct hemoperfusion for 4 hours more than two times up to 14 times during 14 days. MEASUREMENTS(1): We measured the plasma concentration of interleukin 6, 8, 1-beta, tumor necrosis factor alpha. APACHE II score was evaluated for each patient 1st, 7th, and 14th day after starting treatment before the treatment in the morning.

RESULTS. The decrease of APACHE II score from the pretreatment level at 7th day was significantly larger in the treatment group than in the control group (p=0.0189; Mann-Whitney test). Adsorption column related serious adverse events were not observed in DHP group. The concentration of interleukin 6 and interleukin 8 in the plasma decreased from the pretreatment level in the DHP group significantly (p=0.0464, 0.0464 respectively; Wilcoxon test).

CONCLUSION. Newly developed direct hemoperfusion column improved the septic shock better than the ordinary supportive intensive care. Although decrease in concentration of endotoxin has been reported, the detailed mechanism of PMX treatment is not known. Therefore, we investigated the effects of PMX on hemodynamics and plasma concentrations of procalcitonin and C-reactive protein in patients with septic shock.

Patients with septic shock (ACCP/SCCM-criteria) were included. Demographic data, routine biochemistry, microbiological data, infection focus, the acute physiology and chronic health evaluation (APACHE) II score, the Sequential Organ Failure Assessment (SOFA) score, and 28-day mortality were recorded. PMX treatment was performed 2 * 27 hr (mean 12 hr) for each application once or twice. Blood concentrations of endotoxin, procalcitonin, and C-reactive protein (CRP) were measured before and after PMX treatment. Blood concentrations of endotoxin were measured using the high-sensitivity endotoxin assay based on the kinetic turbidometric Limulus assay (Toxinometer). Changes in hemodynamic parameters and PaO2/FIO2 ratio were also evaluated.

Sixteen patients (11 men and 5 women, mean age 65 years old) with septic shock were studied. The 28-day mortality rate was 50%. PMX treatment significantly (P.05) increased mean arterial pressure and significantly (P.05) decreased body temperature, and tended to improve PaO2/FIO2 ratio. Blood concentrations of endotoxin, procalcitonin and CRP were markedly high in all patients before PMX treatment. In the survivors, blood concentrations of endotoxin significantly (P.05) decreased, and those of procarcitonin and CRP tended to decrease after PMX treatment.

CONCLUSION. These findings showed that PMX treatment improved hemodynamics and tended to suppress inflammatory response, suggesting that PMX treatment might be a useful strategy in septic shock by reducing systemic inflammatory responses. Xigris R has been shown to improve cardiovascular and respiratory failure in severe sepsis. Sepsis-associated encephalopathy (SAE) is a diffuse cerebral dysfunction induced by the inflammatory response to infection. SAE has an unknown incidence but its occurrence is related to an increased mortality rate. We have previously described high levels of the brain-specific S-100eta protein in 42% of patients with severe sepsis and septic shock(1. Distinct cerebral lesions were found with S-100eta [ 4 lg/L. S-100eta levels between 0.06 and 2 lg/L, however, were typically associated with white matter lesions which are thought to represent the pathological substrate of SAE. We studied whether Xigris R influenced S-100eta in patients with acute septic shock who presented with increased baseline levels of this biomarker. METHODS. Patients with septic shock who required mechanical ventilation were recruited. All received standard and goal-directed resuscitation. Glasgow coma scale (GCS) was calculated before start of sedation. Contrast computed tomography (CCT) of the brain was performed in all patients with a GCS \ 14 to exclude significant pre-existing or acute neurological disease. Xigris R was given as a continuous infusion of 24 lg/kg/h for 96 h. Patients who did not receive Xigris R had a known contra-indication for the drug. S-100eta was measured before sedation and start of Xigris R (d1) and then daily during Xigris R infusion. The lower limit of normal was \ 0.5 lg/L. RESULTS. Sixty-six patients were consecutively enrolled.Twelve patients were excluded from follow-up due to death within 4 days after admission (n=5) baseline S-100eta values[ 4 lg/L (n=2), and a pathological brain CTT (n=5).24 patients had S-100eta levels.5 lg/ L upfront that did not increase thereafter. Of the remaining 30 patients, 16 received Xigris R . In this group, S-100eta values -though higher on d1 than in untreated subjects (1.3 +/-0.8 lg/L vs. 0.9 +/-0.4 lg/L; p = 0.16) -progressively and significantly decreased (1.0 +/-0.8 lg/ L at d2, 0.9 +/-0.6 lg/L at d3, and 0.8 +/-0.7 lg/L at d4; all p \ 0.05 vs. d1). S-100eta tended to increase in the untreated group.In both treatment groups, no correlation was found between GCS and S-100eta at baseline. CONCLUSION. PMX-hemofiltration significantly reduces plasma levels of IL-6, IL-10, and TNF-alfa (Table 1) , especially in patients with a better outcome at 28 days (Table 2 ). These data suggest a possible correlation between the post-treatment IL-6 levels and a more favourable outcome, whereas pre-treatment IL-6 levels do not seem to be predictive. In contrast, high pretreatment levels of IL-10 and TNF-alfa appears to be related with a poor outcome (Table 2) . Finally, significant reduction in cytokine levels seems to be linked with an improvement of hemodynamic and respiratory parameters (Tables 1-2 CONCLUSION. In our institution the mortality rate of this kind of patients was about 65%. An optimal timing about the use of the HP-PMX depends on the pathology. In septic patients, with peritonitis due to perforation and/or anastomotic leakage after abdominal surgery, the presence of Gram-bacteria is actually a common condition. Our findings demonstrated that a single 2hours-cycle of treatment with HP-PMX seemed to reduce the incidence of organ dysfunction and mortality. An earlier surgical toilette of the infected site, combined with a treatment with HP-PMX, may significanlty improve the outcome in these critically ill subjects. ) filter has recently been tested, and a meta analysis has confirmed that this treatment is effective at reducing circulating endotoxin levels, improving organ function and decreasing overall mortality. Particularly, the lung was observed to have improved gas exchange following treatment; however, the cellular mechanism for this improved pulmonary function remains unknown. The aim of this study is to investigate the effect of PMX-B treatment of septic patients on pulmonary epithelial cell viability. We hypothesize that PMX-B hemofiltration of septic patients will reduce the cytotoxicity of their plasma on pulmonary epithelial cells.

METHODS. Five consecutive patients with gram negative sepsis with at least three criteria of SIRS and one organ dysfunction were randomized to either conventional (CONV) treatment or conventional treatment in addition to two extracorporeal PMX-B hemofiltration treatments, the first upon inclusion and the second after 24hrs. Plasma was collected and blood gases were analyzed at time 0 and time 72. Plasma from healthy volunteers was used as a negative control. A 20% dilution of this plasma was then utilized to stimulate A549 pulmonary epithelial cells in culture for 72 hours, following which cell viability was determined using an XTT assay. INTRODUCTION. Sepsis associated delirium is a common complication of sepsis. An increase in permeability of the blood brain barrier has been shown to be a potential mechanism of action. Relating to our previous experimental study showing protective effects of magnesium on blood brain barrier permeability in a sepsis model 1, we designed a randomized controlled trial to evaluate the effects of magnesium on the occurrence of sepsis associated delirium in patients with severe sepsis.

METHODS. 30 adult mechanically ventilated, medical and surgical ICU patients with severe sepsis were randomized to receive magnesium (n=14) (2g bolus IV, continued by 16 g/day infusion, target range -1.02.0 mmol/L) or saline (n=16,). Patients were sedated with remifentanil and midazolam titrated to achieve the desired level of sedation measured by the Richmond Agitation and Sedation Scale (RASS). Patients were monitored daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU). Incidence of delirium and daily remifentanil consumption were compared between groups.

RESULTS. Magnesium was well tolerated and no complication was recorded. The incidence of delirium occurrence was 33.3% in the magnesium group and 42.9% in the control group. Addition of magnesium resulted in less days with delirium compared with control group (1.0 ± 2.6 vs 2.5 ± 5.6). The reduction in the daily remifentanil consumption in the magnesium group was nearly significant (p= 0.105).

CONCLUSION. Incidence of delirium assessed by CAM-ICU was high among our severe septic patients. Addition of magnesium to the sedation protocol of septic patients caused reduction in the daily remifentanil consumption and decreased the incidence of delirium. [1, 2] . The aims of this prospective randomized study were to evaluate the effects of MTH on physiologic parameters, and to assess its feasibility and safety during septic shock.

METHODS. All sedated and ventilated patients with septic shock were eligible for inclusion. Exclusion criteria were bradycardia and severe cardiac rythm disturbance, pregnancy, needs for surgery and/or transport within the next six-hours, decision to withdraw/withhold life support, early predictable death. The study was approved by the regional commitee on human biomedical research, and written informed consent was requested for all patients' next-of-kin. Patients were randomly assigned to control group (no intervention on temperature), or to the MTH group (32-34°C), for the next 36-hours. Sedation towards a Ramsay 4-6 was required prior to continuous paralysis using cisatracurium. MTH was induced using an external water-cooling blanket (Meditherm II, Gamida, Eaubonne RESULTS. 62% of patients receiving xigris in the study were male. The respiratory system was the commonest organ associated with sepsis among patients receiving xigris 51% (21 out of 41).The mortality rate was 33% in the xigris group as compared to 40% in the non-xigris group. The xigris group had a higher mean length of stay in the intensive care unit compared to the non-xigris group (22.2 vs 12.2 days respectively) amongst non-survivors and survivors. Base excess is improved following a 96-hour infusion of xigris. 72.5% (29 out of 40) patients had base excess more positive than -2 post xigris infusion as compared to 10.0%(4 out of 40) patients having a base excess more positive than -2 prior to the infusion (Table 1) ÁCRP response to Xigris was improved where 56.4% (22 out 39) patients had CRP of less than 100 following Xigris as compared to 10.2% (4 out 39). No clear improvement was shown with WBC response.There was a higher proportion of patients post-xigris infusion with PaO2/FiO2 ratios greater than 300 compared to before xigris was infused.14 out of 19 surviving patients started on Norepinephrine were completely weaned off following the xigris infusion. INTRODUCTION. Severe sepsis remains the main cause of mortality in intensive care unit (ICU) (1). During sepsis elevated levels of pro-and anti-inflammatory cytokines circulate in blood (2) . CPFA is a new resin-based blood purification technique in clinical practice (3) . After purification of plasma in a first resin filter, a second blood filter could be used for the removal of excessive fluid and small molecular weight substances. The resin cartridge nonselectively removes circulating inflammatory mediators. This reduction in cytokine load could possibly attenuate their negative effects on organ function and restore leukocytes function (3). CPFA could be therefore used in the treatment of severe sepsis or septic shock to reduce the levels of circulating cytokines and preserve organ function.

METHODS. Description of series of five patients with sepsis/septic shock treated with CPFA. Laboratory data, hemodynamics and vasopressor support were followed at start and 48 hours after CPFA treatment.

RESULTS. There were 4 men, 1 woman with average age 51 yrs. The leading ICU admission diagnoses were pneumonia, meningitis, SIRS and in two patients severe acute pancreatitis. The time between ICU admission to CPFA start was 1 day in 4 patients, 1 patient was treated after 2 days. 4 patients survived, 1 patient had died 24 hours after ICU admission. In surviving patients there was a marked decrease in IL-6 and procalcitonin levels within 48 hrs after CPFA treatment. This was followed by reduction in serum lactate levels and relevant decrease in vasopresor need. CRP levels decreased in two surviving patients ( Table 1 ). All patients were on citrate dialysis. There were no bleeding or thrombotic complications during CPFA treatment. Interestingly, heparin-induced thrombocytopenia was diagnosed in 2 patients. Objective: Set criteria for discharge in postoperative cardiac surgery and assess its impact on the rate of pulmonary complications in patients undergoing cardiac surgery.

Design: Study prospective, randomized and controlled.

The study was conducted with 159 patients were undergoing elective heart surgery. Were included, patients over 18y, who carried out the gait (walking) independently and that had SpO2 92% in ambient air or oxygen with support of up to 2 l / min at the time of discharge the ICU. All patients were evaluated by physical therapists trained at the time of discharge from ICU. After randomization, patients in group I (observation) were discharged from physical therapy at the time of discharge from the medical ICU, the patients in group II (intervention) received treatment after discharge from the ICU in accordance with the routine of Physical Therapy -Method Functional Approach. (1, 2) . Due to the rotational nature of junior physiotherapy posts day to day experience of the management and treatment of respiratory patients is not guaranteed, sometimes for periods of up to 12 months. Although yearly on call training was established in this trust some staff members still felt their skills were not adequate to remain on the on call rota. It was therefore decided to devise a questionnaire to determine gaps in knowledge and any particular areas of concern, plan a new on call training programme and evaluate any changes in perception of confidence and competence.

A questionnaire was sent via email to all physiotherapists participating in the respiratory out of hours rota (n=25). This asked about year of qualification, last respiratory rotation, regualarity of on call commitments, suggestions for appropriate training methods, feelings of competency and confidence regarding evening and weekend working, equipment used and treatment modalities used. Results were collated and a training programme devised consisting of theoretical and practical components in the form of role playing scenarios with hands on experience of equipment commonly used by physiotherapists. This included continuous positive airways pressure (CPAP), intermittent positive pressure breathing (IPPB), non invasive ventilation (NIV) and manual hyperinflation (MHI).The new programme was then evaluated at the end of the session using similar criteria to the original questionnare.

Received 17/25 responses to the questionnaire.

16 attended for training (9 were unable to attend on the given day, a further session was arranged). Mean time since last respiratory rotation 11.9 months (range 1 -48) Areas of concern: setting up equipment (65%), isolation (30%), inexperience (24%) Average score for confidence/competence (out of 5) weekends: before training 3.7 after training 4.7 on calls: before training 3.0 after training 4.2.

CONCLUSION. Evaluation of an established on call training programme for respiratory physiotherapists lead to a change in practice that helped improve staff members confidence and competence in emergency on call situations. The programme used consisted of a combination of theory and practical components allowing the participants the opportunity to work through role playing scenarios and gain valuable hands on experience with common pieces of respiratory equipment. METHODS. Between July and December 2007, the treating physiotherapist completed a comprehensive checklist of rehabilitation interventions and adverse incidents that occurred during physiotherapy sessions. Data was collected at the end of each weekday for all patients who were mechanically ventilated. Patients who were ventilated for less than five days were excluded at the time of data entry. The end point for data collection was when the patient was weaned from mechanical ventilation for more than 24 hours, was transferred to another hospital or died. INTRODUCTION. There are many controversies and the evidence is limited on the efficacy of shares used in physiotherapy in the respiratory intensive care unit and little information with regard to physical therapy in patients undergoing mechanical ventilatory support. More recently, we suggest that the fan is action beyond the ventilation, which means to extend the discussion about the use of the ventilator focusing specifically for the physiotherapist action, developing three possibilities: a) as a tool of evaluation, b) as a tool for the therapy c) in monitoring. In this protocol evaluate the impact of manoeuvres carried out with the mechanical ventilator on the mechanical properties of the respiratory system.

Functional changes were characterized by: (1) increase the resistance -by increased pressure resistance in relation to measure up, (2) reduction of compliance -by the reduction of static compliance regarding the measure taken before the specific ventilator intervention. CONCLUSION. Right ventricular dysfunction is common in severe RSV disease and not related to disease severity. Myocardial and hepatocellular damage occurs in infants ventilated with RSV bronchiolitis with normal right and left ventricular function.

RESULTS. The mean baseline value for NT-proBNP at T1 was 12.6 pg/ml (SD ±6.95), and for BNP was 6.49 pg/ml (SD ±5.17). NT-proBNP plasma levels were significantly higher after the removal of CPAP. BNP levels were also raised after CPAP removal although this did not reach statistical significance. There was a trend toward a decrease in both NT-proBNP and BNP plasma levels with the initiation of CPAP. See CONCLUSION. The results suggest that there are changes in ventricular stress following the introduction and removal of CPAP which are reflected in changes in the levels of brain natriuretic peptides measurable in blood. The raised brain natriuretic peptide levels seen in pathological conditions may also prove susceptible to changes in CPAP and this would be an area for further research. 

Propofol is associated with a certain degree of cardiovascular depression, which is mainly manifested by a reduction in the arterial blood pressure. However, the effects of propofol on myocardial contractility remain debatable. This study aimed to investigate whether under in vivo conditions, propofol at clinically relevant concentrations has negative inotropic effects. It also aimed to investigate whether these negative inotropic effects persisted with continuous propofol infusion.

METHODS. Experiments were conducted with rats instrumented for measurement of left ventricular hemodynamic function. We assessed the hemodynamic effects under the following conditions of propofol administration: 1 mg/kg bolus followed by infusion at a constant rate of 100 ug/kg/min (Propofol 100), 2.5 mg/kg bolus followed by infusion at a constant rate of 200 ug/kg/min (Propofol 200), and 0.3 ml intralipid bolus followed by infusion at a constant rate of 1.5 ml/h.

The peak rates of ventricular pressure rise (+dP/dtmax) (P = 0.001) and intraventricular pressure decline (-dP/dtmin) (P = 0.026) of the Propofol 200 group were significantly decreased compared to those the control group. This decrease in +dP/dtmax and -dP/dtmin improved soon after, and no difference was observed between and within groups. INTRODUCTION. Surgical stress and prolonged anesthesia are related to postoperative organ dysfunction, especially in the gastrointestinal tract. One explanation is inadequate tissue perfusion. In this study, we evaluated the effects of mild vs. moderate surgical stress on ex vivo splanchnic vascular reactivity.

METHODS. 15 anesthetized pigs were allocated to mini-laparatomy (mild stress) with placement of drains (n=8) or full laparatomy (moderate stress) with exposure of the major abdominal vessels, gastrostomy and jejunostomy (n=7). After a total of 14 hours (minilaparatomy) or 36 hours (full laparatomy) of anesthesia, slices of superior mesenteric and hepatic arteries were analyzed with the tissue bath method. Contractility was assessed using norepinephrine (NE) from 0.1 uM to 10 uM (dose response curve), and relaxation using adenosine and sodium nitroprusside (SNP, percent of peak contraction, baseline 100 ± 0%). Results are expressed as mean ± SD. ANOVA for repeated measurements and the unpaired t test were used for statistical analysis.

After surgery, cardiac output decreased from 102 ± 13 ml/kg/min to 86 ±12 ml/ kg/min in animals with mild stress and increased from 90 ± 14 ml/kg/min to 103 ± 24 ml/kg/ min in the group with moderate stress (time-group interaction: p = 0.004). Data on vessel contractility and relaxation are shown in the Table. NE dose-response contraction in the hepatic and superior mesenteric arteries was lower in the moderate stress group (dose-group interaction p .001 in both arteries). SNP and adenosine dose response relaxation was reduced in the moderate stress group in both arteries (dose-group interaction p \ 0.04 in both arteries). 

In the view of adverse consequences of sepsis, myocardial depression is a known phenomenon, left ventricular function and brain natriuretic peptide assessment (BNP) had been used to predict mortality in septic patients. No previous studies reported the changes in atrial function and its relation to mortality in patients with sepsis.The present work addresses the latter issue through studying left atrial function which is expressed as atrial ejection force (AEF) in patients with severe sepsis and septic shock and links it to mortality.

We studied 30 patients with severe sepsis or septic shock. Echocardiographic parameters were measured on admission, they comprised left ventricular ejection fraction (EF), and AEF, with AEF defined as the force that the atrium exerts to propel blood into the LV. All patients were subjected to BNP as well. Multivariate analyses adjusted for APACHE-II score was used.

RESULTS. ICU mortality was 30% overall in the studied group. Recovery from severe sepsis or septic shock occurred in 21 patients (70%) which resulted in significant improvement of atrial function (14.8 ± 3.4 versus 11.4 ± 3.1kdyn, p .01). The other group had more frequent moderate to severe left ventricular dysfunction (35.9% versus 11.1%; P.01) and abnormal BNP levels (38.3% versus 9.3%; P.001).

CONCLUSION. As echo parameters revealed that the atrial function showed changes similar to the ventricular function and BNP changes, atiral function may be used as independent predictor of mortality.

GRANT ACKNOWLEDGEMENT. This work was supported by Tawam METHODS. our work here to assess LA function after ablation using scintigraphic imaging of both LA emptying and left ventricular (LV) filling in 20 patients all had paroxysmal AF that resistant to pharmaceutical therapy.All pts were subjected to radiofrequency (RF) ablation of pulmonary vein potentials, followed by 3 weeks of oral anticoagulant therapy. Fourteen pts had successful ablation, 3 had failed ablation, 2 returned to AF, and one died.

Nuclear multigated radionuclide angiography (MUGA) using in vivo method was performed for all pts before, one month and three months following ablation. Scintigraphic parameters assessed comprised. LV ejection fraction (%EF), LV-peak emptying rate (PER), LV-peak filling rate (PFR), LV-time to peak emptying (TPE) and LV-time to peak filling (TPF). Each pt was later subjected to 2D & M mode echocardiography before,one month and 3 months after ablation to assess the following parameters:-LV ejection fraction EF %, LV end diastolic diameter (EDd mm), LV end systolic diameter (LVESd mm) and LA diameter.

RESULTS. Compared to the baseline readings,readings one month after RF-ablation and three months reading showed. 1-Significantly greater percentage reduction in the mean PER (16%, p \ 0.05) than the one month reading (8%, p. NS), 2-Significantly greater percentage increase in the mean PFR (36%, p \ 0.01 vs 27%, p \ 0.05), 3-Significantly greater percentage reduction in the mean TPE (26%, P\ 0.05) than the one month reading (16%, P: NS) and 4-Significantly greater percentage reduction in the mean TPF (20%, p \ 0.05 vs 13%, p: NS Failed cases with persistent AF showed, less significant increases in global EF% and empting and filling data after 3 months from RF ablation.

CONCLUSION. Our data prove the phenomenon of LA stunning through scintigraphic evidence of delayed changes in various parameters of LA filling and emptying. Despite atrial stunning, the improvements in ejection fraction observed, however might reflect the significant reduction in heart rate with improved atrial filling rather than the improvement in LV contractile function. INTRODUCTION. The systolic velocity of mitral annulus (SM) has been correlated with ''peak positive dP/dt'', and with ejection fraction. Also myocardial acceleration during isovolumic contraction (SIVA) has been experimentally correlated with peak dP/dt, demonstrating independence from the ventricular load. The aim of our study was to verify if SM e SIVA were modified by abrupt increase of ventricular load in patients undergoing coronary bypass grafting.

Twenty-three patients undergoing coronary bypass grafting have been included in this study. Exclusion criteria were: low preoperative ejection fraction, mitral anular calcifications, hemodynamic instability. Tissue Doppler imaging has been measured on the lateral mitral annulus, using transesophageal echography. The first determination has been carried out in basal conditions, the second determination has been executed after rapid administration (in 10 min.) of 7 cc/kg of VoluventÒ.

. SM e di SIVC vary in meaningful way after load, while SIVA does not appear modified after load. basal after load Sivct cm/sec 5,65±1,95 6,75±1,53 0,03 Sm cm/sec 8,7±1,04 9,99±0,88 0,04 SIVA cm/sec 2 203,45±45,69 211,41±71,28 0,81.

CONCLUSION. We know that the most utilized indices of ventricular function are influenced by load conditions of ventricle, for this reason would be important find a load independent index of ventricular contractility. SIVA appears to be a load independent index of cardiac functionality and appears to be an optimal index in the clinical evaluation of these patients. INTRODUCTION. Cardiogenic shock occurs in 7-10% of patients after acute myocardial infarction (AMI). Untreated, it is responsible for an early mortality of approximately 80% and is the leading cause of death among patients hospitalised with AMI. Evidence from studies such as SHOCK (Should we emergently Revascularise Occluded Coronaries for Cardiogenic Shock?) have demonstrated a survival benefit from early revascularisation compared to medical therapy, however this is most beneficial in \75 years old. We audited the management of cardiogenic shock in our district general hospital to see the comparison with recommended practice.

Retrospective review of case notes of 46 patients either presenting with or later developing cardiogenic shock in a district general hospital over a 5 year period from August 2002 to August 2007. Cardiogenic shock was defined by a systolic blood pressure of 90 mm Hg for [ 1 hour, unresponsive to fluid challenge, thought to be secondary to cardiac dysfunction, and associated with signs of hypoperfusion.

Of the 46 patients included in the study, 65% were male and 35% female. The average age was 75 (range 40-90). 20 people were aged \75, and 26 above. There were 28 STEMIs and 18 NSTEMIs. Of the 28 STEMIs, 22 were thrombolysed, those not thrombolysed were due to contraindication or late presentation. In the \75 group, 9 (45%) patients were considered for urgent revascularisation and were discussed with tertiary centre. 3 were transferred acutely (within \ 24 hours), all received intervention and were alive at both 30 days and subsequently at 1 year. The remaining 6 patients were managed aggressively with medical therapy on ITU but were thought to be clinically unstable/unsuitable for acute transfer so were planned for intervention at a later date. 11 patients \75 were not considered for early revascularisation due to co-morbidity, instability and poor pre-morbid function. Total of 3/20 (15%) of patients \75 underwent early revascularisation in target group. In Hospital Mortality (IHM) for\75s was 13/20 (65%). In patients[75, 2/26 (8%) patients were considered for urgent revascularisation, however neither was transferred, meaning there was 0% early revascularisation in [75s. IHM for [75s was 25/26 (96%) resulting in a total IHM of 38/46 = 83%.

CONCLUSION. Cardiogenic shock is a major cause of mortality from acute myocardial infarction, current guidance is for urgent revascularisation in patients \75 with a selective approach adopted in older age groups. This audit highlights poor utilisation of revascularisation as an option in these patients, as is reflective/representative of DGH in the UK. Transfer time makes early revascularisation difficult in a DGH without on-site angiographic facilities. Regional care centres that are experienced in the management of shock should be designated and protocols developed for the rapid transport of critically ill patients.

Arterial blood gases and static compliance of respiratory system (Cst,rs) were measured in 25 patients (17 males) during the first 3 days after ARDS diagnosis before (pre-), immediately (0 min) and 30 min after three different RMs applied in random order; RM-1: pressure control ventilation for 1min with inspiratory pressure of 40 cmH2O, PEEP of 5 cmH2O and inspiration to expiration time 1:1, RM-2: two hyperinflations using CPAP of 45 cmH2O for 20 sec each and in meantime 1 min of lung-protective strategy, RM-3: three consecutive 'sighs' with such tidal volume to reach a plateau pressure of 45cmH2O. Data were analyzed using paired t-test.

RESULTS. Patient's mean age was 59.9±16.5 years and APACHE II on day of study 20±7.4 Causes of ARDS included pneumonia (12), septic shock (9), aspiration (2), TRALI (1) and reperfusion syndrome (1) . None of the patients suffered from barotrauma after the implementation of RM. No statistically significant decrease in the mean arterial pressure was observed. The effect of the three RM is shown in Table 1 . Values are mean ±SD,°: significant compared with pre-RM values CONCLUSION. These preliminary results suggest that all RM improve the oxygenation promptly but the effect of RM-2 has longer duration (30 min). The effect of RM-2 and RM-3 on Cst,rs was only temporal. Among our study population no major complications were observed. METHODS. Fourteen patients with ARDS were enrolled in the study.During volume control ventilation with constant inspiratory flow,the pressure-time curve was fitted to a power equation: P=a x timeb + c, where coefficient b (stress index) describes the shape of the curve: b=1,straight curve;b\1, progressive increase in slope, and b[1, progressive decrease in slope. Positive end-expiratory pressure (PEEP) was set to obtain b value between 0.9 and 1.1 after application of a recruiting maneuver (RM). PEEP was changed to obtain 0.6.8 and 1.1\1.3. Experimental conditions sequence was random. Recruited volume (RV) was measured by static pressure-volume curve method. Hemodynamics,pulmonary mechanics and gas exchange were observed at the same time. 

Recently, an automated nitrogen washout technique has been introduced to measure end expiratory lung volume (EELV) that could be of special interest for the determination of optimal PEEP. Ibanez et al. (1) have shown that EELV decreased with 25% after changing the patient's position from sitting to supine during spontaneous breathing in healthy young volunteers. The objective of this study was to measure EELV in ICU patients with different lung disorders and to compare it with the currently available reference values.

We examined 45 sedated mechanically ventilated patients at a mixed ICU of a university hospital. Patients were divided into three groups: normal pulmonary function (group N), respiratory failure due to primary lung disorders (group P) and respiratory failure due to secondary lung disorders (group S). In all patients EELV measurements were performed at 3 PEEP levels (15-10-5 cm H2O). EELV values were compared with predicted sitting FRC values (2) and with the supine FRC reference values according to the findings of Ibanez et al. (1) RESULTS. In patients without lung disorders, EELV was reduced with 34% compared to predicted sitting FRC values and with 12% compared to the predicted supine FRC values at a PEEP of 5 cm H2O. In patients with primary and secondary lung disorders, EELV was further reduced and did not reach the supine reference values even at a PEEP of 15 cm H2O.

CONCLUSION. If one accepts that ventilation of 'healthy' lung at a PEEP of 5 cm H2O occur at FRC level, then we found a reduction of 35% in group N. This extra reduction of EELV is probably due to loss of muscle tension attributed to the use of sedation in our ICU patients. Whether the increase in EELV due to increase of PEEP is due to recruitment of collapsed alveoli or overdistention of already open lung needs further research. We investigated the relationship between the increase the gas lung volume and the anatomical recruitment at two level of PEEP.

A retrospective analysis of sixty-eight ALI/ARDS patients who underwent a whole lung CT scan at 5 and 15 cmH2O PEEP at end expiration. Lung outlines were manually delineated and gas -tissue volumes were computed with dedicated software. Tissue volumes were classified according to the gas/tissue ratio.

RESULTS. The increase in gas volume from PEEP 5 to PEEP 15 was not related to the decrease in the volume of not inflated tissue (r2 = 0.01, p=0.91). The increase in gas volume was well correlated with the increase of the gas volume associated with the well inflated tissue (Increase in gas volume going from PEEP 5 to PEEP 15 cmH2O = 229 + 0.77*Increase in gas volume associated to the well inflated tissue going from PEEP 5 to PEEP 15 cmH2O (ml), r2 = 0.39, p \ 0.0001). The decrease in the not inflated tissue was related to the increase in the poorly inflated tissue (Increase in poorly inflated tissue (g) going from PEEP 5 to PEEP 15 = -95 + 0.53*Decrease in not inflated tissue (g) going from PEEP 5 to PEEP 15, r2 = 0.42, p\ 0.0001).

CONCLUSION. The CT analysis suggest that near all the increase in gas volume due to the increase in PEEP was distributed to already inflated lung regions. Our data suggest a caution to use the EELV changes to estimate PEEP-induced lung recruitment. INTRODUCTION. To assess if body mass index (BMI) has any impact on the effect of three recruitment maneuvers (RM) on oxygenation in patients with early ARDS.

Prospective clinical study in a multidisciplinary intensive care unit. Twenty-five consecutive patients stratified into two groups according to their BMI: Group A, included patients with BMI\27 kg/m2 (n=11), while Group B, patients with BMI C 27 kg/m2 (n=14). Arterial blood gases were measured before (pre-), immediately (0 min) and 15 min after three different RMs applied in random order; RM-1: pressure control ventilation for 1min with inspiratory pressure of 40 cmH2O, PEEP of 5 cmH2O and inspiration to expiration time 1:1, RM-2: two hyperinflations using CPAP of 45 cmH2O for 20 sec each and in meantime 1 min of lung-protective strategy, RM-3: three consecutive 'sighs' with such tidal volume to reach a plateau pressure of 45cmH2O.

RESULTS. On day of study, oxygenation was similar in the two groups, while a significant difference in intrinsic PEEP was identified (0.9±0.5 vs 3±2.9, p=0.029, in Group A and B, respectively). The effect of the three RMs on both groups is shown in INTRODUCTION. The weight of the lung can be calculated by densitometric analysis of computed tomography (CT) data and may help to clarify the pathophysiology of acute respiratory failure, e.g. to distinguish edema from atelectasis. So far, data from mechanically ventilated (MV) patients have been compared with normal lung weights obtained in spontaneously breathing (SB) subjects. However, lung weights of SB patients with normal lungs may differ from those of MV patients with normal lungs because of factors such as raised intrathoracic pressure or intravenous volume-expansion. Thus, we analyzed the lung weights of MV multiple trauma patients with normal lungs, which offered a unique opportunity to provide normal values for comparison with other MV patients. INTRODUCTION. Electrical impedance tomography (EIT) has the potential to become a promising new tool for bedside monitoring of regional lung ventilation and lung volume changes. EIT calibrated with tidal volume changes at one end expiratory lung volume (EELV) level has been used in different studies to predict dynamic change in EELV during various procedures. The aim of our study was to evaluate the relationship between lung volume changes measured with a multibreath nitrogen washout technique and lung volume changes calculated from end expiratory lung impedance changes.

METHODS. We evaluated 25 mechanically ventilated patients. Lung volume was measured at different PEEP levels with a nitrogen washout/in technique (Engstrom Carestation, GE Healthcare). At all PEEP levels end expiratory lung impedance (EELI) and mean impedance tidal change were measured. EELV change derived from EELI changes, was calculated assuming a linear relation between tidal impedance change divided by tidal volume and zero impedance / volume change. EELI change was divided by the resulting tidal impedance change / tidal volume ratio to calculate the EELV (ml) change. INTRODUCTION. Acute renal failure has an incidence of up to 25% amongst critically ill patients and mortality rates range from 23-80%. The study aim was to analyse the long term outcome and quality of life(QOL) amongst the survivors of our critically ill patients requiring renal replacement therapy(RRT).

A Short Form-36 and an additional questionnaire were sent to survivors after ascertaining their fitness to participate from their GP. The patients were from two teaching hospital ICUs with a total of 11 ICU beds and 1270 acute operational beds. A database of relevant patients over a period of eight years was acquired. CONCLUSION. The responders appear to have a reasonable QOL with better scores than some chronic condition patients. The majority must have found their treatment worthwhile to have consented to undergo the same interventions again. 65.4% have more than 70% of their previous level of QOL which is remarkable. This may guide us in future prognosis in this patient group if they survive to discharge.

INTRODUCTION. Patients requiring PMV currently use a disproportionate amount of expensive ICU resources. These patients can be cared for in a weaning unit, a cost-effective alternative. The UK Department of Health has recommended that Trusts should review the need for such a service on a regional basis. We used a retrospective cohort of ICU admissions in Lothian, a region of Scotland, to characterise the PMV population, report incidence and outcomes, and define predictors of PMV. These data were used to model a weaning unit.

METHODS. The study population comprised ICU admissions to the three adult ICUs in Lothian recorded in the Scottish Intensive Care Society Audit Group (SICSAG) database. The study period was from Jan 2002 to Dec 2006. Exclusions were: transfers to or from other ICUs, readmissions and those aged\16. Patients ventilated for[=21 days were defined as the PMV group and\21 days the non-PMV group. Baseline characteristics were compared between groups. Annual incidence was determined and outcomes compared between groups. Trend in mortality was assessed adjusting for age, sex, APACHE II score, hospital site and operative status. Predictors for PMV were assessed at both day 1 and day 7 of ICU stay using binary logistic regression. Weaning unit models were defined assuming PMV patients would be transferred to the weaning unit following 21 days of ventilation and a period free from vasoactive and renal support.

RESULTS. 7419 patients fulfilled inclusion criteria. In comparison to the non-PMV group (n=7094), PMV patents (n=325) were older (59.6 vs 56.9, p=0.007), had a higher APACHE II score (20.9 vs 18.8, p.001), and were more likely to have a non-operative diagnostic code (79.6% vs 63.7%, p \ 0.001). Incidence of PMV was 4.4 per 100 ICU admissions, or 6.2 per 100 ventilated admissions. This was equivalent to 27.2% of funded ICU bed-days in Lothian. PMV incidence showed a downward trend over the 5 years (chi 2 for trend=10.4, p=0.001) using ICU admissions as the denominator; this was confirmed using ventilated patients as the denominator (p=0.02). Mortality for PMV patients was higher at ICU discharge (28% vs 23%, p=0.046), and at hospital discharge (42.1% vs 33.9%, p=0.003). Mortality remained static in the PMV group over the 5 year study period. Adjusting mortality for confounders, however, showed a downward trend. Significant predictors of PMV on day 1 were: APACHE II score, previous cardiopulmonary resuscitation, admission diagnosis, operative status, PaO 2 :FiO 2 (PF) ratio, ventilated on day 1 and vasoactive support on day 1. On day 7, only diagnosis on admission, PF ratio, ventilated on day 1, and requirement for renal or vasoactive support on days 5 or 6 were significant. The weaning unit models showed a potential saving of 1.6-2.0 ICU bed-days/year, equivalent to an annual cost saving of £300000 (€380000).

We have characterised the PMV population and established PMV incidence in Lothian ICUs. Mortality remains higher amongst PMV patients. Predictors have been identified which may aid early identification of PMV patients. Models for a weaning unit show substantial cost savings. This subgroup of ICU patients remains important due to its resource utilisation, using around one quarter of funded ICU bed-days.

GRANT ACKNOWLEDGEMENT. N I Lone received funding from an MRC studentship and Eli Lilly to attend the ESICM.

Intensive care clinicians rely on published evidence to choose interventions that are appropriate for their patients. This evidence has been incorporated into guidelines and bundles extending from local to international level. Examples being the Surviving Sepsis Campaign [1] and the Saving Lives Campaign [2] . The use of this evidence, with increased use of protocols should ensure that effective interventions are uniformly used for all appropriate patients between different intensive care units, and that clinicians should believe that the therapies they choose are beneficial. We wanted to investigate which interventions clinicians commonly used, and which of these were perceived by the same clinicians to be beneficial.

We surveyed delegates at an international meeting. We asked all participants to complete a questionnaire with 24 commonly used, and much published interventions and we asked whether they believed an intervention was effective in reducing patient mortality and intensive care stay, and whether they used that particular intervention.

Of 214 attendees, we took the 80 responses from intensive care clinicians. There was a huge range in frequency of use of each intervention, from 87% to 12% across all 24 interventions. The most used intervention was low molecular weight heparin for thromboprophylaxis (87%). Another, stress ulcer prophylaxis, where appropriate, was only used by 70%. We also compared clinicians who believed an intervention to be beneficial and those who use it. Of the 24 interventions, 20 were perceived to be ineffective and yet were routinely used. 3 interventions were thought to be effective in reducing mortality, but were not commonly used.

CONCLUSION. These results suggest that not only do a significant number of clinicians use interventions that they perceive to be of little benefit, but also many interventions fall into this category. Conversely there are a small number of interventions that are believed to be helpful, but are infrequently used. It remains unclear why particular interventions are used in intensive care units. It is likely that the clinicians are significantly influenced by factors other than perceived patient benefit such as established local practice, national and international guidelines, care bundles and resource availability. 

Recommendations of ventilation with low tidal volumes has been poorly adopted in clinical practice. We evaluated the compliance of lung protective ventilatory principles in Finnish ICU's.

Prospective, cohort study of acute respiratory failure (ARF) in 25 Finnish ICU's during 8 weeks (April 16-June 10 2007). ARF was defined with the need of either invasive or non-invasive positive pressure airway for over 6 hours. The National database was used for data collection.

RESULTS. 2670 ICU admissions were screened. Ventilatory support was needed in 1319 admissions (49%). 958 patients fulfilled our criteria of ARF. 775 (81%) were ventilated invasively at admission and their hospital mortality was 22.6%. INTRODUCTION. Incidence, predisposing factors and their impact on outcome of acute respiratory failure (ARF) has varied in previous studies. Knowledge of these variables is essential in the process of developing new therapies and planning the future resources of ICM.

METHODS. Prospective, cohort study of acute respiratory failure (ARF) patients treated in ICUs. ARF was defined as a need of any form of positive airway pressure. The National ICU quality database was used for data collection.

RESULTS. During 8 weeks (April 16 -June 10 2007), 2670 admissions were screened in 25 Finnish ICUs for the presence of ARF. Ventilatory support for more than 6 hours was needed in 1033 (39%) of ICU admissions in 958 patients. Population-based incidence for ARF was 120/100 000/year. ICU mortality was 12.3% and hospital mortality 23.8%. (2) found that ventilation with tidal volumes of 6 ml/kg ideal body weight (IBW), compared to 12 ml/kg IBW, reduced mortality. Our aim was to establish current ventilation practice on the Intensive Care Unit (ICU) of a large UK district general hospital and compare it to evidence based standards(2) with particular reference to tidal volume (TV). We also assessed whether patient demographics or diagnosis affected practice.

METHODS. This prospective audit between Oct and Dec 2006, included all patients aged 15 years or older admitted for invasive ventilation, excluding those with significant brain injuries. Data were collected from clinical examination, and review of nursing observations, medical notes and X-rays. IBW was calculated based on height according to the formulae RESULTS. The MV frequency was 46%; the overall and specific mortality rates were 23% and 51%, respectively. The mean age (±SD) was 57±18 years; 52% were male; 69% were clinical patients; the mean APACHE II (±SD) score was 22±8.3; 93% were on invasive ventilation and the mean (±SD) duration of MV was 10±7.9 days. The variables independently associated with increased mortality, classified in two groups, were (1) INTRODUCTION. COPD patients requiring mechanical ventilation are often met with a nihilism regarding their outcome, which can limit their admission to intensive care. We present data of COPD patients who were mechanical ventilated and compare their mortality to a general ITU population. We also analysed the subgroup of patients who needed mechanical ventilation after failed trial of NIV. INTRODUCTION. Surfactant proteins are known to be an important factor influencing lung function and the changes in its activity may have a diagnostic and prognostic value in acute lung injury (ALI/VILI). Surfactant protein D can be found and measured in plasma and its increased plasma level in experimental studies indicates the damage of alveolar epithelial barrier with increased permeability and impaired gas exchange. The goal of the study is to evaluate the changes of surfactant protein D serum levels in ICU mechanically ventilated patients looking for possible correlations with the clinical outcome.

With the approval of the university ethics committee 20 mechanically ventilated patients (12 male and 8 female, mean age 58 [23-76], SD±14,36) were enrolled in the study. Acute respiratory insufficiency was caused in 4 patients by the community acquired pneumonia (CAP), in 6 by severe sepsis and 5 patients were ventilated in postoperative period after transhiatal esophagectomy while 5 needed mechanical ventilation during unconsciousness caused by subarachnoid hemorrhage (SAH). Serum samples were taken on admission, than at 1,3 and 5 day of treatment and PCT (Brahms, Kryptor), CRP, WBC count, were evaluated. Clinical course was monitored using APACHE II score, SOFA score, PaO2/FiO2 ratio, the length of mechanical ventilation and the final result of the treatment.

RESULTS. Seven patients, 2 with SAH (brain death), 2 after esophagectomy and 3 with severe sepsis died. There were no difference in baseline serum surfactant protein D levels between survivors and patients who died. In days 1, 3 and 5 serum SP-D concentrations was lower in survivors compared with those who died. We found correlation between decreased serum SP-D concentration and improved oxygenation (PaO2/FiO2) as well as in clinical outcome.

CONCLUSION. These results demonstrate that remained elevated serum SP-D levels may be associated with worse clinical outcome and risk of death in mechanically ventilated patients. These observations indicate that surfactant protein D may be a valuable marker in prognosis of ALI/VILI but further studies are needed. INTRODUCTION. There is evidence that PaO2/FiO2 ratio is able to predict mortality in patients with Acute Lung Injury/Acute Respiratory Distress Syndrome (ALI/ARDS) undergoing mechanical ventilation (MV). However, this ratio could be changed by positive end expiratory pressure (PEEP) application. In this setting, oxygenation index (OI) could be better than PaO2/FiO2 ratio to predict mortality because it includes mean airway pressure in the formula. Our endpoint was to compare PaO2/FiO2 ratio and OI obtained during the first 24 hours as a mortality predictor.

METHODS. All consecutive patients receiving MV whose PaO2/FiO2 ratio on admission was less than 300 mmHg between September 2006 and September 2007 were included. The worst value of PaO2/FiO2 ratio and OI during the first 24 hours, were obtained. Demographic data and severity of illness were assessed using U Mann-Whitney test. The area under the ROC curves (AUROC) for PaO2/FiO2 ratio and oxygenation index were compared using Hanley-McNeil test. Results are shown as mean ± SD. We considered p.05 as statistically significant.

One hundred twenty one patients were studied. Age, APACHE II and SAPS II were: 64±18; 20±7 and 45±14, respectively.The overall mortality was 11%. The PaO2/FiO2 ratio and oxygenation index during the first 24 hours were different between survivors (n=108) and non-survivors (n=13): 220±78 versus 149±77 and 6.5±3.7 versus 12.8±11.5 (p \ 0.05). Moreover, OI was better than PaO2/FiO2 ratio to predict mortality: AUROC: 0.73 (95% CI: 0.58-0.87) and AUROC: 0.22 (95% CI: 0.081-0.36) (p \ 0.001) respectively.

CONCLUSION. The oxygenation index at 24 hours is more accurate to predict mortality than PaO2/FiO2 ratio in ALI/ARDS patients who underwent MV. The OI could be an early and easy method to predict outcome in this kind of patients.

INTRODUCTION. Angiographic embolization of bleeding pelvic vessels is increasingly used in patients with pelvic injuries. The application of angiography and embolisation isn't possible in every hospital because requires a specific local infrastructure. The aim of the study is to compare the functional outcome of patients with mayor traumatic pelvic fractures (MTPF) treated with embolization in comparison to not embolizated patients.

Between January 2005 and September 2007 we collected 35 patients with mayor trauma with pelvic fractures not requiring embolization (Group 1) and 35 patients in which embolization was performed (Group 2). Exclusion criteria were age \ 18 years, brain injury, patients with proximal femoral or sacro-lombar fractures. The mean age was 45.5 years (range 20-70 years).

We collected the Injury Severity Score (ISS) and SAPS II at admission in ICU. The fractures were assisted according to Burgess's score. In this score fracture patterns have been differentiated in two groups: 1) stable pelvic fractures ( INTRODUCTION. Cerebral damage arising from traumatic brain injury (TBI) can occur primarily at the time of injury or can occur secondarily at a temporally distant time point post insult1. Low haemoglobin concentration (Hb) occurs in 17-58% of head injured patients and may exacerbate secondary brain injury2,3. Anaemia may occur as a result of blood loss from extra-cranial trauma, pre-existing disease or dilution from fluid replacement during resuscitation. Low Hb will lead to reduced oxygen delivery to cerebral tissue and may contribute to ischeamic brain injury4. However, high Hb levels or blood transfusion may increase blood viscosity, reducing cerebral blood flow or result in transfusion related side effects5. We have studied the admission Hb in moderate to severe TBI patients, examining its role as a prognostic indicator in these patients.

All patients admitted to the Queens Medical Centre from 1993 to 2002 with a recorded Glasgow Coma Score of 13 or less within 48 hours of a TBI were included in the Nottingham Head Injury Register. The admission Hb and Glasgow Outcome Score at one year was recorded on the register. We looked at the strength of the association between the admission Hb and the outcome.

RESULTS. Data were available on 487 patients. The mean age was 36 years (range 16-91). 76% of the patients were male. Of the 487 patients 165 died at one year. The Hb was abnormal in 37.57% of patients (decreased in 37.16%, increased in 0.41%). Linear regression and logistic regression after group division into Dead versus Alive and Favourable versus Unfavourable outcome were significant for the whole range of decreased Hb but particularly striking and clinically relevant outcome difference was found where the Hb was less than 8g/l (Chi squared p value .001).

CONCLUSION. Decreased Hb was observed in patients presenting with moderate or severe TBI and was associated with unfavourable outcome. An admission Hb less than 8g/l is a statistically significant indicator of poor prognosis in moderate to severe TBI patients and may be useful prognostic markers in these patients. This may be a valuable addition to prognostic scoring systems.

Levosimendan is a new inodilator drug, which improves the myocardial contractility without increasing oxygen requirements and it seems to be interesting in order to improve the cardiac function following open heart surgery. In our study we measured the short-term hemodynamic effects of levosimendan, in postoperative low cardiac output surgical coronary patients.

At the end of cardiopulmonary bypass, twenty patients with a preoperative ejection fraction less than 50%, underwent coronary artery by-pass grafting operation (alone or combined with mitral valve repair/replacement, aortic valve repalcement, ventricular septal defect repair), with low cardiac output states despite receiving dobutamine (mean dose of 15 microg/kg/min) and adrenaline (mean dose of 0,15 microg/kg/min) under or not aortic counterpulsation, were treated with an infusion of levosimendan for 24 hours (0.2 microg/kg/min), without loading dose. We measured the cardiac index, the pulmonary capillary wedge pressure and the mixed venous saturation before levosimendan, 6 hours and 24 hours after the start of infusion.

RESULTS. Fourteen patients survived, six died and the final results shown in the Table 1 were tested with Wilcoxon Signed Ranks Test. Results show that there is a statistically significant increase of CI from pre-infusion to 6 hours (p= 0.04), a statistically significant increase for SvO2 from pre-infusion to 6 hours (p= 0.002) and 24 hours (p \ 0.001) and a decrease of PCWP from pre-period to 6 (p= 0.002) and 24 hours (p= 0.001). The differences between 6 and 24 hours are not statistically significant. CONCLUSION. In this group, levosimendan was able to improve in a significant manner both the hemodynamic status and balance between the global oxygen delivery and oxygen consumption.

Levosimendan could be useful in order to treat low cardiac output states after coronary surgery in cases in which the maximal conventional doses of classic inotropes (and in some cases even associated with the aortic counterpulsation) failed to do it, but more data are needed.

Recent trends in the epidemiology of invasive myloses cum opin infarct

Candidemia and candidemia in critically ill patients admitted to ICUs in France : Incidence, molecular diversity, management and outcome

REFERENCE(S). 1. Swan HJ.The Pulmonary Artery Catheter in Anesthesia Practice

Hemodynamic monitoring in the intensive care unit

Meta-Analysis: methods for diagnosing intravascular devicerelated bloodstream infection

Guidelines for the Prevention of Intravascular Catheter-Related Infections

0540 REFERENCE(S). 1. Friedman et al: ''Comparison of percutaneous and surgical tracheostomies

Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy: A clinical randomised study

Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis

Percutaneous versus surgical tracheostomy: a randomized controlled study with long term follow-up

PercuTwist: a new single-dilator technique for percutaneous tracheostomy

REFERENCE(S). 1

VISIT: FEASABILITY AND RESULTS IN PATIENTS WITH MULTIPLE ORGAN FAILURE

Ely et al

REFERENCE(S)

Predictors of postoperative pulmonary complications following abdominal surgery. Chest97

Lower respiratory tract infections after abdominal operations:Epidemiology and risk factors

Risk factors for postoperative pneumonia

Chest physiotherapy for the surgical patient

Direct effects of propofol on myocardial contractility in the in situ canine hearts

In vitro effects of propofol on rat myocardium

Pre-treatment with clonidine affords protection against acute cerebral ischaemia-reperfusion injury. We hypothesised that clonidine might also protect against regional myocardial ischaemia-reperfusion (I/R) injury. to I/R injury was analysed for

The pro-apoptotic effects of clonidine were abolished by efaroxan, a mixed a2-adrenoceptor blocker and imidazoline-1-receptor blocker (26 ± 2%, n = 6), but not by the selective a2-adrenoceptor blocker yohimbine (46 ± 3%, n = 6). Pre-treatment with clonidine also abolished the cardioprotection afforded by ischaemic preconditioning (apoptosis, 47 ± 3%

pre-treatment with clonidine significantly increased the degree of I/R injury. This detrimental effect of clonidine appears to be secondary to (1) activation of imidazoline-1-receptors (2) inhibition of mitochondrial KATP channels (3) decreased transcription of cardioprotective genes, and (4) increased transcription of pro-apoptotic genes

Clonidine preconditioning decreases infarct size and improves neurological outcome from transient forebrain ischaemia in the rat

Quantitative assay by flow cytometry of the mitochondrial membrane potential in intact cells

Imidazoline compounds inhibit KATP channels in guinea pig ventricular myocytes

This work was funded by the MR Council (UK)

Evangelismos General Hospital, 3 1st Department of Respiratory Medicine, Sotiria Hospital for Chest Diseases

The diagnosis of acute renal failure in intensive care: mongrel or pedigree?

SF-36 Health Survey Manual and Interpretation Guide. Boston, The Health Institute

SF-36 Physical and Mental Health Summary Scales: A User's Manual. Boston, The Health Institute

AGITATION IN THE ICU: DESCRIPTION OF ITS INCIDENCE AND ASSOCIATED RISK FACTORS

A. Sandiumenge* 1

3 ICM, University Hospital Puerta de Hierro, 4 ICM, University Hospital Fuenlabrada, Madrid, 5 ICM

Outcome of mechanically ventilated patients who require a tracheostomy

Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?

Confidential Enquiry into Maternal and Child Health (2007) Saving mothers' lives: Reviewing maternal deaths to make motherhood safer

Fresh frozen plasma transfusion in critically ill patients

Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection

Acute lung injury after blood transfusion in mechanically ventilated patients

The Evidence-Based Use of FFP and Cryoprecipitate for Abnormalities of Coagulation Tests and Clinical Coagulopathy

Verdeal Intensive Care Unit, Barra Dor Hospital, Rio de Janeiro, Brazil INTRODUCTION. Multiple organ failure is the main reason of mortality in sepsis. Liver dysfunction may be caused by sepsis and contributes for a worse outcome. Our objective was to evaluate the prognostic implications of liver dysfunction assessed by the Sequential Organ Failure Assessment (SOFA)

Liver dysfunction was defined as the presence of hepatic SOFA score C 1 in the first ICU-day. Univariate analysis was used to determine the differences of ICU-mortality rate, acute respiratory distress syndrome (ARDS) incidence, use of mechanical ventilation, hemodialysis, and hemotransfusion in patients with and without liver dysfunction. Multivariate regression analysis was used to determine the impact of each component of SOFA

Liver dysfunction was present in 11.9% in the first ICU-day. Patients with liver dysfunction had greater total SOFA score at admission (8 vs 3, p.001), developed more ARDS (46.4% vs 19.7%, p=0.002), required more hemodialysis (50% vs 20.2%, p=0.001) and hemotransfusion (42.9% vs 19.2%, p=0.005), and had higher ICUmortality rate (39.3% vs 16.8%, p=0.005) than those without liver dysfunction. However, multivariate regression analysis revealed that hepatic

Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement Life support Task Force of the International Liaison committee on Resuscitation

Induced hypothermia is underused after resuscitation from cardiac arrest: a current practice survey. Resuscitation

Mild therapeutic hypothermia after cardiac arrest -a nationwide survey on the implementation of the ILCOR guidelines in German intensive care units. Resuscitation

Amsterdam, 3 Intensive Care, Gelre Hospitals, Apeldoorn, Netherlands INTRODUCTION. ALI and ARDS are suggested to be often misdiagnosed, possibly because of disagreement with the presently used consensus criteria for ALI/ARDS. We determined which factors are considered important by physicians when diagnosing ALI/ ARDS at Intensive Care Units

Analysis of the vignettes was done by conjoint analysis (SPSS 15.0). Preferences of factor levels were analyzed by a logistic linear model. Data are presented as odds ratio (OR) with 95% confidence interval (CI). An OR[1 means the factor is in favor of diagnosing ALI/ARDS. Questionnaires, including ten clinical factors physicians might use to diagnose ALI/ARDS, were measured with a Visual Analogue Scale (VAS)

Hundred-one questionnaires from 30 hospitals were returned (response rate 42%)

Dutch ICU physicians consider PEEP important when considering the diagnosis ALI. Implementation of PEEP in the definition is needed. Clinical risk or negative factors for ALI/ARDS, as presently required in the NAECC criteria, are modestly used for diagnosing

Thirteen participating medical/surgical ICU. Population: adult critically ill patients mechanically ventilated[24 hours were enrolled. Exclusion criteria: patients \ 18 years old and thermally injured patients. Within the first 24 hours of mechanical ventilation were obtained: 1. demographic variables, 2. variables related to the acute process and 3. variables related to the basal status

Acute Coronary Syndrome: 2% (n:11)

Univariate analysis: Total SOFA score was higher in patients ventilated C7 days (p=.001). Co-morbidity and functional activity index show no differences. A logistic regression analysis identified total SOFA score (OR: 1,1, IC 95%: 1,05-1,15 p= .001) and non-invasive mechanical ventilation failure

We cannot draw definite conclusions of this preliminary report. However, an interesting finding is the ability of prediction for those variables related to the acute process without predictive ability of other variables related to the basal status

STUDY OF 288 PATIENTS

REFERENCE(S). 1. Bouchama A, Knochel JP. Heat stroke

A physiological body-cooling unit for treatment of heat stroke

Near-fatal heat stroke during the 1995 heat wave in Chicago

Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: A national multiple-centre risk-factor study

IS IT WORTHWHILE TO OFFER FULL TREATMENT AND ICU ADMISSION TO OCTOGENERIANS WITH ACUTE ABDOMINAL AORTIC ANEURYSM

Our strategy is to treat all patients unless they have a very poor performance score. As such, 95% receives full treatment. With the ageing of the population, an increasing proportion of octogenarians reaches the ICU. In view of the demand for health care resources, advanced age may be a factor to refrain from further treatment and ICU admission

Kaplan Meier survival analysis revealed a significantly better survival for the younger either with a cut off at 75 years (log rank test p \ 0.001) or 80 years (p \ 0.05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 72.1% for patients younger than 80 and 59.5% for those older than 80

Even with a devastating event such as AAAA, a mean survival of more than 3.5 years can be achieved in octogenarians, while hospital length of stay is not prolonged compared to the younger, and natural history of disease would give a survival of virtually zero %. Assuming an integrated system for managing AAA is in place

Passos Intensive Care Unit, Hospital Salvador, Salvador, Brazil INTRODUCTION. A meta-analysis of trials comparing anti-pseudomonal beta-lactam antibiotics to treatment of severe hospitalar infections concluded that cefepime was associated with increased mortality compared with other beta-lactams. It was speculated that neurotoxicity induced by cefepime could be associated to it. The aim of our study was to review all cefepime-induced neurotoxicity cases published in medical literature

We selected the pertinent publications dealing with cefepime induced neurotoxicity. The main search term used was ''cefepime'', combined with one of the following: ''encephalopathy'', ''neurotoxicity'', ''cerebral toxicity'', ''seizure'', ''status epilepticus

Renal failure of varying degree and time of onset was present in almost all cases. Fifty-two percent of them have had ClCr \ 15ml/min and 60% of these patients were in renal replacement therapy. The common neurologic symptoms reported were myoclonus (n= 27), confusion (n= 24), coma (n= 12), agitation (n= 10) and seizure

It can be related with increased mortality. When prescribing this drug, any neurologic change, such as myoclonus, confusion, coma, agitation and seizure, should be promptly considered the diagnosis of drug neurotoxicity. Population of concern are renal failure and elderly patients. 21st ESICM Annual Congress -Lisbon

Head injury in the United Kingdom

Brain Trauma Foundation. The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care

CATATONIA IN THE INTENSIVE CARE UNIT

University of Ioannina, 2 Intensive Care Unit

Peris Department of Emergency

05:1. 0678 PREVALENCE OF ADMISSION ARTERIAL PACO2 IMPAIRMENT IN SEVERE BRAIN INJURY PATIENTS

Ospedale del Delta, Comacchio, 3 U.O.C. Shock e Trauma, Azienda ospedaliera San Camillo-Forlanini, roma, 4 Istituto di epidemiologia, universita' di udine, udine, 5 Servizio di Rianimazione e 118

A Follow_Up Analysis of Factors Associated With Head-injury Mortalità After Paramedic Rapid Sequenze Intubation

The Impact of Prehospital Endotracheal Intubation on Outcome in Moderate to Severe Traumatic Brain Injury

Early ventilation and outcome in patients with moderate to severe traumatic brain injury

Changes in pituitary-thyroid function occur in patients undergoing major surgical procedures. Such changes are referred to as the euthyroid sick syndrome, which decreases in serum Triiodothyronin (T3) and Thyroxine (T4) concentrations. This hypothyroidism has different causes in different patients, and has different effects on different tissues. The literature on hypothyroidism after liver transplantation is limited. The influence of hypothyroidism in liver regeneration is controversial. We have prospectively studied thyroid function and its association with liver

We have also investigated the influencing factors on the thyroid function at POD1, including preoperative factors. We collected postoperative liver function tests, such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), International normalized ratio (INR) of Prothrombin time (PT) and Total bilirubin (T-Bil) taken at postoperative day 1, 2, 4 and 7. Finally, we have investigated the relationship between postoperative thyroid function and liver function. Data were expressed as means with standard deviations

Any patients except for pre-hypothyroidism did not have thyroxine during postoperative course

We also could find the positive correlation between the decrease of free-T3 at POD1 and serum T-Bil at POD 4, 7 (p=0.04, 0.04), although we could not find any significant relationship between free-T3 at POD1 and postoperative liver function, complication

Patients undergoing LDLT exhibit marked decrease in serum thyroid hormones, especially in older and higher MELD score patients. Stress response, anesthesia, and perioperative fasting may be decisive factors eliciting this response. These metabolic derangements do not deteriorate the clinical outcome and subsequently may be an adaptive response for energy preservation in various organs

REFERENCE(S)

Tight glycemic control in diabetic CABG patients improves perioperative outcomes and decreases recurrent ischemic events

Watanable et al; Insulin sensitivity accounts for glucose and lactate after intravenous glucose injection

Matache 1-st Anesthesia and ICU Dept., C.C. Iliescu Cardiovascular Diseases Institute

Scesi Anesthesia and Intensive Care Department, University G. d Annunzio, Chieti, Italy INTRODUCTION. Plasma N-terminal brain natriuretic propeptide (NT-proBNP) is synthesised in the ventricular myocardium and released in response to ventricular wall stress (1). Is a useful prognostic marker in patients with cardiac failure (2) and in ICU NT-proBNP increases with severity of disease and predicts mortality

All elective surgical patients admitted to the ICU over a period of 3 months were included. Blood serum NT-proBNP concentrations were determined at admission to the ICU. Death during hospitalization (mortality), the Acute Physiologic Score Age Chronic Health Evaluation (APACHE) II, Simplified Acute Physiologic Scale (SAPS) II, laboratory data, medical history

Patients were a mean of 73,7 (65 to 80) years old. All patients were underwent electiv surgery: 12 major abdominal surgery, 11 open abdominal aortic aneurysm repair, 4 thoracic surgery

The ICU mortality rate was 3,7% (1 death), the APACHE II score was

In the study population NT-proBNP serum concentration was 1001,3 pg/ml (169 -2143). Four patients had complications during ICU stay, their NT-proBNP serum concentration was 1631 pg/ml (mean)

NT-proBNP concentrations are elevated after major surgery and postoperative NT-proBNP level can be a predictor of short-term adverse events after major surgery. More work is needed to explore the diagnostic role and the prognostic significance of NT-BNP in postoperative patient

REFERENCE(S)

Localization and mechanism of secretion of Btype natriuretic peptide in comparison with those of A-type natriuretic peptide in normal subjects and patients with heart failure

The characteristics and prognostic importance of NT-ProBNP concentrations in critically ill patients

Hanssens 2 , D. Deleu 3 , M. Kettern 1 1 Anesthesia and Intensive Care, 2 Pharmacy, 3 Neurology, Hamad Medical Corporation, Doha, Qatar REFERENCE(S). 1. Fisher MM, Blado BA

Mertes PM and Groupe dEtudes des Ractions Anaphylactodes

REFERENCE(S)

Intensive insulin therapy in critically ill patients

Intensive insulin therapy and pentastarch resuscitation in severe sepsis

REFERENCE(S). 1. Oksanen T, et al. Therapeutic hypothermia after cardiac arrest: implementation and outcome in Finnish intensive care units

From evidence to clinical practice: Effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest

Foedisch* 1 , A. Viehoefer 1 , C. Knuth 1 , B. Inderbitzen 2 , D. Barbut 2 1 Department of Anesthesiology and ICM

Effects of magnesium on polymorphic ventricular tachycardias induced by aconitine

Advanced cardiac life support (ACLS) course represents a challenge experience for medical students. During training they have to demonstrate their ability to managed a simulated cardiac arrest scenario which requests the knowledge of ACLS algorithms, effective communication, promptness and firmness in deciding

each consisting of 3 health-care students were studied in a patient simulator (SimMan Laerdal). A scenario of witnessed cardiac arrest due to ventricular fibrillation or asystole was used. Each scenario lasted not more than 20 minutes. Heart rate, systolic and diastolic blood pression, SpO2 were recorded just before and just after the end of scenario. Then an individual self report of identifying sources of mental stress and perceived difficulties (visual analogic scale, VAS : 0-10) was proposed. Assessment of teams' performance was made using standard European Resuscitation Council testing sheets which includes a list of treatments/and interventions appropriated for the scenario

Perceveid difficulties reporting focused on familiarity with the ACLS algorithm (major 41%, moderate 34%) management of airway (minor 20%, moderate 36%), and promptness of medication's choice (major 41%, moderate 37%) whereas difficulties was rarely reported about diagnosis (87%),deliverance of shock (77%) and individual role in the team (68%). VAS was 6 (1-10). Most of the students thought about simulation some days before (major 50%, moderate 26%), had worries about it just before and a large majority thought to be affected by the test

During the testing scenario, hemodynamic constraints were minor. Perceveid difficulties would be decreased by training and consequently mental stress

3 The role of the Anaesthetist in the Emergency service.AAGBI, London 1991. 4 Secondary insults during intra-hospital transport of head injured patients

INTRODUCTION. Partial CO2 rebreathing measure non-invasively the pulmonary capillary blood flow and estimate the cardiac output. Large pulmonary shunt or reduce tidal ventilation may minimized the accuracy of the technique (1, 2) . The aim of this prospective controlled study was to investigate the agreement between partial CO2 rebreathing and thermodilution for the determination of cardiac output in patients with acute respiratory distress syndrome (ARDS), and to test the effect of shunt on the accuracy of the method.METHODS. Twenty patients meeting the American-European Consensus Conference (AECC)criteria for ARDS and receiving low tidal ventilation (VT = 6 ml.kg-1 predicted body weight) with PEEP [ 7 cmH2O were enrolled. All patients had a pulmonary artery catheter (Edwards Vigilance Monitor, Irvine, USA) and a NICO2 monitor (Novametrix Medical System, Wallingford, CT). Seven measurements were performed every 20 min over a 2-h period of haemodynamic stability. A total of 140 pairs of cardiac output values were available. Pulmonary shunt was determined at FIO2 1 at the end of the protocol. We used Bland-Altman method's to calculate bias, precision, limit and percentage error of agreement in the whole population and according to the shunt fraction (higher or lower than 30%). Data are mean±SD.RESULTS. Overall cardiac output was 6.6±0.9 L.min-1 with thermodilution and 5.8±1.7 L.min-1 with partial CO2 rebreathing (r=0.68). Bias was 0.8±1.5 L.min-1 and limit of agreement -2.1 to 3.7 L.min-1. In the 11 patients with shunt \30%, values were 0.4±1 L.min-1 (r=0.86) and -1.6 to 2.5 L.min-1, respectively. In the nine patients with shunt[30%, values were 1.4±1.7 L.min-1 (r=0.41) and -2.2 to 4.8 L.min-1, respectively. The percentage error of agreement was 48% in the whole population, 32% in the low shunt group and 55% in the high shunt group.CONCLUSION. In ARDS patients receiving lung protective ventilation, determination of cardiac output by the partial CO2 rebreathing technique provides relevant information only in less severely hypoxemic patients. In all other patients, the percentage error of agreement largely exceeds 30%, indicating that partial rebreathing cannot substitute for thermodilution. INTRODUCTION. Left ventricular (LV) function alterations in atrial fibrillation (AF) are due to lack of atrial kick, reduced diastolic filling, irregular cycle lengths, but may also reflect an intrinsic form of tachy cardiomyopathy. Whether impairment of LV systolic function is global or regional is an attractive hypothetical question that needs to be answered and the present study is an attempt to address this issue. We studied 20 patients (13 males, mean age 41± 16 years) all had persistent (preceeded by paroxysmal) AF that was resistant to pharmaceutical therapy. One patient (pt) had rheumatic heart disease, five had dilated cardiomyopathy, two had old myocardial infarction and one had Ebstein anomaly.

Following clinical, ECG, and echocardiographic evaluation, all pts were subjected to radiofrequency (RF) ablation of pulmonary vein potentials, followed by 3 weeks of oral anticoagulant therapy, Fourteen pts had successful ablation, 3 had failed ablation, 2 pts returned to AF, and one pt died. Nuclear multigated radionuclide angiography (MUGA) using in vivo method was performed for all pts before and 3 months following ablation.Besides scintigraphic assessment of global LV ejection fraction (%EF), regional %EF was assessed by 6 segment scoring system of standard MUGA.RESULTS. Comparing the baseline readings (i.e. before RF-ablation) to readings after 3 months: (1) global %EF showed significantly greater percentage increase (37%) than the baseline readings (from 48%±7.2 to 65.9%±5.9, pB.001). (2) Significant increases in regional %EF in the high lateral segment (36%, pB0.01), the lower septal segment (53%, pB0.001) and high septal segment (64%, pB0.001). The mid-lateral, inferolateral and inferoapical segments showed significantly lesser increases in regional %EF (20%, PB0.5), (18% PB0.5) and (15%, PB0.5) respectively. (3) Failed cases with persistent AF showed insignificant increases in both global %EF and regional %EF 3 months after RF-ablation.CONCLUSION. Termination of AF restores global %EF (37%), as well as regional contractile LV function thus restoring synchronization of previously asynchronous LV during AF. Greatest improvements in regional EF (64%, 53% and 36%) were exhibited by the high septal, lower septal and upper lateral segments respectively compared to the inferoapial, mid and lower lateral segments which exhibited less than 30% improvement. Improvement of LV hemdoynamics after restoration of sinus rhythm and increases in both global and regional LV contractile functions could therefore be partly ascribed to the LV resynchronization achieved by AF termination. 4 1 Anaesthesia and ICM, Gartnavel General Hospital, 2 Anaesthesia and ICM, Southern General Hospital, 3 Robertson Centre for Biostatistics, University of Glasgow, 4 Anaesthesia and ICM, Gartnavel General Hospital, Glasgow, United Kingdom INTRODUCTION. B-type natriuretic peptide (BNP) and its precursor NT-proBNP are biochemical markers of ventricular stress. Raised levels of these makers contribute to diagnosis and prognosis in a number of pathological states 1,2 commonly encountered in critical care medicine. However, the effects of introducing or removing positive airway pressure on BNP or NT-pro-BNP levels are largely unknown. We investigated the effects of introducing and removing continuous positive airway pressure (CPAP) on the plasma BNP and NT-proBNP levels of healthy male volunteers.METHODS. Following ethics committee approval 15 healthy male volunteers were recruited. After resting semi-recumbent for 1 hour a blood sample for BNP/NT-proBNP assay was taken (T1). Thereafter CPAP of 15cm H 2 0 (Fi0 2 =0.21) was applied via facemask for 1 hour after which time a futher sample was drawn. (T2). A further hour was spent resting semirecumbent before a final BNP/NT-pro-BNP sample (T3) was taken. ECG, non-invasive blood pressure, heart rate, respiratory rate and pulse oximetry were monitored continuously.INTRODUCTION. The open lung theory states that maximizing alveolar recruitment would minimize tidal alveolar hyperinflation. However, ARDS actelectasis are areas of intense inflammatory reaction. We tested the hypothesis that recruited lung areas have different elastic characteristics than the areas that were already normally aerated at ZEEP.

At constant transpulmonary pressure (PTP), distrettual inflation at CT scan is expression of the distrettual elastance. In 21 lung-damaged pigs (intravenous LPS administration, # 7; Hcl inhalation, #7; alveolar lavage, #7) and in 5 healthy pigs, thoracic CT scan were obtained at zero end expiratory pressure (ZEEP) and during a lung recruiting maneuver aiming at a PTP of 35 cmH2O.RESULTS. Data are mean +/-standard deviation; *) p \ 0.01 healthy versus lung-damged. CONCLUSION. The CT scan attenuation properties and hence the distrettual elastances of the aerated compartment were significantly different than those of healthy lung tissue at the same PTP. Moreover we found a highly significant correlation (R 2 0,8779, p \ 0.001) between normally aerated areas at ZEEP and hyperinflated tissue during the LRM, suggesting that these areas are at high risk of hyperinflation, regardless alveolar recruitment.GRANT ACKNOWLEDGEMENT. University of Bari. INTRODUCTION. Atelectasis related alveolar collapse is a common finding in acute lung injury (ALI), leading to increased shunt and hypoxemia. Current treatment strategies aim to recruit alveoli. Collapsed alveoli opened by a recruitment manoeuver (RM) tend to recollapse without adequate positive end-expiratory pressure (PEEP). RMs followed by inadequate PEEP permits unstable alveoli. The resulting cyclic recruitment/derecruitment during mechanical ventilation may contribute to ventilator associated lung injury (VALI) despite improved oxygenation. Results from a previous animal study suggest that total input reactance (Xrs) measured by the forced oscillation technique (FOT) at 5 Hz can be used to assess at the bedside the development of atelectasis and to monitor the efficacy of RM. The aim of this study was to evaluate whether a strategy of RMs followed by ''optimal'' PEEP titrated according to optimal reactance measured by FOT could reduce VALI compared to a standardized strategy.METHODS. In 14 anesthetized and mechanically ventilated pigs, ALI was induced by saline lavage, and the degree of damage was assessed by whole-lung computed tomography. The animals were then studied for 12 hours by continuous monitoring of lung mechanics, gas exchange, FOT and hemodynamics. The animals were randomized into two groups: group A was treated with RMs and PEEP titrated according to optimal reactance measured by FOT every two hours. Titration of PEEP was performed by continuously monitoring reactance during RMs with stepwise reduction of PEEP from 20 cm H20 by steps of 2 cm H2O. PEEP was considered optimal at the step before which the reactance started to decrease. Group B was treated with RMs every two hours and PEEP was adjusted according to the ARDSnet protocol. Plasma TNF-alfa, IL6 and IL8 were measured at baseline and at the end of the experiment. We looked for a relationship between change in lung volume, oxygenation and compliance during this manoeuvre. We used an automated measurement of end expiratory lung volume (EELV) using nitrogen (N2) washout/washin, available in an ICU ventilator (Engstrom, GE).

METHODS. 35 patients with ARDS (PaO2/FiO2= 151 ±53 mmHg) were ventilated in volume controlled (Vt 6mL/kg PBW and flow=60L/min). We evaluated four 45 min successive epochs varying trunk position (Supine, Semi recumbent: trunk elevated at 30°, Seated: trunk elevated at 45°and legs down at 45°with Hill-RomÒ beds, and back to Supine). Arterial blood gas, EELV, and static compliance were measured at the end of each epoch.

Increases in PaO2/FiO2 ratio (12±28% p=0.03 and 18±44% p=0.01) and EELV (13±29% p=0.01 and 16±28% p=0.006) were observed during semi-recumbent and seated positions but did not remain when patients get back to supine position. Patients increasing their PaO2/FiO2 ratio higher than 10% (median, responders) had significant variations of EELV when seated (p.001) by contrast with non responders. Non responding patients had little or no variations of EELV induced by position. Static compliance significantly decreased during semi-recumbent and seated positioning (p=0.001 and 0.0001) but this decrease was lower for responding patients. Origin of ARDS, duration before inclusion and shock were not associated with variations of lung volume or oxygenation.CONCLUSION. Sitting position (''verticalization'') increases PaO2/FiO2 ratio and EELV in approximately half of patients with ARDS. An association between lung volume and oxygenation increase seemed to explain the difference between responders and non responders. Seated position was more efficient than semi-recumbent.GRANT ACKNOWLEDGEMENT. We thank General Electric and Hill Rom which provided ventilator and beds. [1] . The optimal duration of RM is a risk/benefice ratio between effectiveness and cardiovascular compromise. This prospective study was designed to measure the kinetic of recruitment and the hemodynamic tolerance in order to determine the optimal duration for the RM in ARDS. CONCLUSION. These results suggest that the optimal duration of the RM is between 10 and 15 s to achieve the maximal recruitment and to avoid cardiovascular compromise. 

After induction of saline lavage-injured ARDS (ARDSp, n=8) or oleic acidinjured ARDS (ARDSexp, n=8), PEEP was set at 20cmH2O and RM was performed (40/30maneuver). RM was repeated every 5 mins until reaching sufficient alveolar recruitment (PaO2/FiO2[400mmHg), then tidal volume was set at 10 ml/kg and PEEP was lowered by 2cmH2O in every 10 mins. Optimal PEEP was defined at 2cmH2O above the PEEP where PaO2/FiO2 dropped blow 400 mmHg. Computed tomography (CT) scans were done before and after induction of ARDS and at each pressure level. By the changes in the CT-values, lung was divided into hyperinflated, normally, poorly and nonaerated region. Lung volumes were calculated by Pulmo software.

After RM, total lung volume and air volume were significantly increased than before and after induction ofARDS in tow models (p \ 0.05). At optimal PEEP, poorly and nonaerated lung areas decreased and normally lung areas increased sharply but was accompanied by significant alveolar hyperinflation in two models (p \ 0.05). Compared with ARDSexp models, the changing of hyperinflated lung areas was markedly more in ARDSp models at optimal PEEP (p \ 0.05). And after three-dimensional renderings of computed tomography scan, alveolar hyperinflation occurred mainly in nondependent lung regions, whereas alveolar recruitment occurred in dependent regions.CONCLUSION. Alveolar hyperinflation increase and pulmonary heterogeneity climb during RM and at optimal PEEP. A focal distribution of lung injury in ARDSp may be more susceptibility to alveolar hyperinflation with optimal PEEP. 

A non-invasive tool to identify optimal PEEP and to evaluate the efficacy of recruitment manoeuvres (RM) is still missing. We investigated the sensitivity of an index (Cx5) derived from total respiratory reactance (Xrs) measured by Forced Oscillation Technique at 5 Hz in: 1) identifying lung collapse 2)evaluating the efficacy of RMs.

We studied 5 ventilated pigs after lung lavage. PEEP was increased to 24cmH2O and then reduced to ZEEP. PaO2, Cx5 and CT scans were measured. Cx5 was expected to increase with decreasing PEEP to a maximum (Cx5max) and to decrease as the lungs collapse. PEEPol was defined as the PEEP at Cx5max. The efficacy of RMs was defined as the difference between Cx5 in inflaction and deflection (DCx5).

PEEPol was 12±2SD cmH2O. In the following steps PaO2 decreased by 23.4±16.3SD% confirming that Cx5 identified the beginning of collapse. Cx5 at PEEPol was significantly greater during the decremental compared to the incremental trial (64.3±26.7 and 29.3±10.0 mL/cmH2O, p \ 0.05) with a difference between the two (DCx5) of 63.8±44.6 mL/cmH2O. Mortality has been related to the disease itself and not to the physiologic response of PPV. We hypothesized that the oxygenation response during long term prone position ventilation in pulmonary ARDS can discriminate between survivors and non survivors.

Design: observational study. We studied 41 pulmonary ARDS patients. Patients were followed from day 1 when prone position was implemented until prone position was resumed. Values were recorded before prone position ventilation started and then 1, 12, 24, 48, 96 hours of prone position ventilation. The last value recorded in prone position ventilation was also recorded. Oxygenation response (%) was calculated as the percentage of change of the PaO2/FIO2 ratio in relation with the pre prone position ventilation value ((pre prone position value -each time recorded value/pre prone position value). Values were expressed as means and standard deviations. Normality of distribution was tested with Kolmogorov-Smirnov test. Baseline groups characteristics were compared by independent t test. Oxygenation response was compared between survivors and non survivors with the unpaired t-test for each time interval.RESULTS. There were 18 non survivors and 23 survivors patients. ICU mortality was 44%. Baseline characteristics were not statistically different between non survivors and survivors. Age was 42±16 and 44±16, APACHE II was 19±1 and 16±6, lung injury score was 3±1 and 3±1, multiple organ dysfunction score was 9±3 and 7±3 for non survivors and survivors respectively. Days in mechanical ventilation before PPV were 5±6 and 2±2 days, length of PPV was 100±62 and 82±39 hours in non survivors and survivors respectively (non significant differences). Oxygenation response was higher in survivors versus non survivors:1 hour (76 ± 66 vs 66 ± 76, p= 0.7), 6 hours (89 ± 68 vs 83 ± 75, p= 0.8), at 12 hours (150 ±142 vs 76 ± 67, p= 0.047), 24 hours (151±113 vs 77±69, p= 0.0021), 48 hours (163±161 vs 87±87, p= 0.016),72 hours (161±81 vs 63 ± 60, p=0.005), 96 hours (242±106 vs 51 ± 48, p=0.005), last value (163± 95 vs 92 ± 94,p=0.027),respectively.CONCLUSION. Pulmonary ARDS patient survivors improve oxygenation and were able to sustain this improvement when prone position was implemented. Absence of response and the lack of a sustained response of oxygenation to prone position can be associated with bad prognosis in ARDS.

To describe agitation incidence and the factors associated with its development in ICU.

All patients admitted to 9 Spanish ICUs (1 medical, 1 surgical, 1 trauma and 6 medical-surgical) during a 30 day period were followed until death or discharge. Age, gender, previous history of alcohol and illegal drug abuse were recorded at admission. Admission diagnosis, APACHEII, ICU length of stay (LOS) and mortality as well as ICU procedures (mechanical ventilation (MV) and sedation/analgesia (SA)) were also recorded. Presence of agitation was diagnosed according to the clinical judgment of the intensivist responsible for the patient. Statistical analysis was performed using SPSS 13.0. Significance level p \ 0.05. CONCLUSION. Agitation is a frequent complication in ICU patients. Its development can be related to patient characteristics but also to certain ICU interventions such as the sedation and analgesia practice. Several severity scores and gas exchange parameters have been proposed as predictors of mortality in this kind of patients. The oxygenation index (OI) has been widely used in the pediatric field, but it is not always considered in adult intensive care units (ICU). Our objective was to evaluate the early predictive variables including OI as mortality predictor in ALI/ARDS patients who underwent mechanical ventilation (MV).

All consecutive patients receiving MV whose PaO2/FiO2 ratio on admission was less than 300 mmHg between September 2006 and September 2007 were included. Age, APACHE II, SOFA, gas exchange, mean airway pressure, PEEP level were obtained. PaO2/ FiO2 ratio and OI were calculated. These indicators were determined during the first 48 hours. ICU mortality was recorded. Numeric variables were compared with U Mann-Whitney test. In the univariate analysis the risk of mortality between different variables was determined. The significant variables (p .05) were included in a backward stepwise multiple logisticregression analysis. Results are expressed using odds ratio (OR) with 95% CI. INTRODUCTION. Tracheostomy is commonly performed in critically ill patients. About 10% of critically ill patients who require mechanical ventilation have a tracheostomy. However, there are several questions unanswered concerning this procedure, including in whom and when it is indicated, or what is the outcome of tracheostomized patients. The aim of this study was to describe indications, time of tracheostomy and the outcome of tracheostomized patients in a general ICU.

METHODS. Prospective, observational cohort study. All consecutive patients submitted for tracheostomy in a general adult university ICU were included. For each patient the following informations were collected: demographic data, diagnosis at admission, APACHE II score, time and tracheostomy reason indication. According to the timing of tracheostomy, subjects were classified as early group (\ or = 10 days) or late group ([ 10 days). Variables were expressed in frequencies and means. Student's t test was used to compare means and p.05 was considered significant.

A total of 139 patients (73 men) were included; mean age was 63±16 years and APACHE II score was 20.7±9.5. Patients were classified at admission in clinical (n=98; 70.5%), neurological (n=32; 23%), surgical (n=8; 5.7%) and trauma (n=1; 0.7%). Tracheostomy was mostly indicated due to respiratory (n=74, 53.2%, weaning failure, prolonged mechanical ventilation) and neurological (n=65, 46.7%, ischemic and hemorrhagic stroke) reasons. There were no differences between respiratory and neurological indications for age (63±14 yrs vs. 63±18 yrs), APACHE II score (21±12 vs. 20±6) and hospital mortality rates (41.8% vs. 41.5%). The Glasgow coma scale (GCS) was lower in neurological patients (7.7±3.0 vs. 11.5±3.5; p \ 0.001). There were no significant differences between late (n=112, 81%) and early (n=27, 19%) groups for age (63±15 yrs vs. 65±19 yrs), APACHE II score (21±10 vs. 18±7; p=0.084), GCS (9.9±3.7 vs. 8.8±3.9; p=0.173) or discharge hospital rates (57.5% vs. 61.5%; p=0.878).CONCLUSION. Independently of timing and/or indications, tracheostomy has similar morbi-mortality rates. INTRODUCTION. Literature describes a large number of interhospital transferred patients (TP) admitted to the intensive care unit (ICU) of tertiary care referral centres. This specific cohort of ICU patients is known to be more severely ill as compared to ICU non-transferred patients (non-TP). However, in our university hospital, no data dealing on this topic were available. The current study aimed to assess the characteristics, organ failure and outcomes of TP vs. non-TP.

A prospective observational cohort study was performed at the ICU of a 1062bed tertiary care referral centre in Belgium. All consecutive adult patients admitted to the medical and surgical ICU from Sept 15th 2007 through Dec 15th 2007 were included. Demographics, APACHE II, diagnosis, ICU and hospital length of stay (LOS), and outcomes were gathered per patient. Severity of organ failure was assessed by the SOFA score. Data are represented as numbers (%) or as mean ± standard deviation. Statistical analysis was performed using Mann-Whitney U or Fishers' Exact tests. Significance was accepted when P.05.

During the study period, 500 non-TP and 85 TP were analysed. Main patient characteristics were similar between both non-TP vs. TP (age, 56±17 vs. 57±17 years, P=0.67; female sex 41% vs. 39%, P=0.72; APACHE II 16±8 vs. 17±9, P=0.42; medical/ surgical admission, 48%/52% vs. 49%/51%, P=0.64). In 67% of transfers, the main reason for referral was the need for specific surgical procedures (neurosurgery and interventional radiology) or ICU expertise (24% of referrals). General condition of TP was better than non-TP as demonstrated by blank history, less cancer, and less end-stage renal failure (P.001; P=0.02 and P=0.006). During ICU-stay, TP more frequently needed respiratory support (P.001), vaso-active and sedative medication (P=0.01, and P.001), and had higher mean SOFA score (5±4 vs. 4±4, P=0.03); however, no difference was found in need for dialysis (P=0.47). The latter finding could be probably explained by a higher number of TP on DNR-code while in the ICU (15% vs. 6%, P=0.007). A trend towards higher admission rates during the weekend was observed for TP vs. non-TP (34% vs. 24%, P=0.06), respectively. Among the TP-group, higher ICU re-admissions rates (18% vs. 10%, P=0.03), longer ICU-LOS (9±11 vs. 5±7 days, P.01), and increased ICU-mortality (17% vs. 9%, P=0.03) was observed when compared to the non-TP-group.CONCLUSION. In our ICU, TP were found to be more severely ill, to have worse prognosis and poorer outcomes than non-TP. Nevertheless, TP had similar age and severity of illness upon admission, and had less pre-existing co-morbidities. 1, 2 . This study investigates casemix and outcome data and explores the association between admission characteristics and acute hospital mortality of such admissions in England, Wales and Northern Ireland.

A secondary analysis of the ICNARC Case Mix Programme Database was conducted. Admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007 were included. Admissions were selected for analysis if they had haematological malignancy as a primary or secondary reason for admission or as a reason for admission in their past medical history. An analysis of case mix and outcome was performed on these admissions. Multiple logistic regression analysis was used to analyse the effect of admission variables on acute hospital mortality. Admission variables were selected a priori.RESULTS. There were 7689 eligible admissions. The mean (SD) APACHE II score on admission was 24.4 (7.9). ICU mortality was 43.1% (3312 deaths) and acute hospital mortality was 59.2% (4239 deaths). ICU and acute hospital mortality increased with the number of organ failures on admission. Admission characteristics associated with hospital mortality in patients admitted with a primary or secondary diagnosis of haematological malignancy (2980 patients) were age, previous bone marrow transplant, Hodgkin's lymphoma, length of hospital stay prior to admission, tachycardia, tachypnoea, GCS\13, sedation, P/F ratio\200 mmHg, acidaemia, oliguria, hyponatraemia, and uraemia. Factors associated with acute hospital mortality in patients with a haematological malignancy in their past medical history (4361 patients) were age, severe sepsis, length of hospital stay prior to admission, hypotension, tachycardia, tachypnoea, P/F ratio \ 100 mmHg, low GCS, oliguria, sedation, mechanical ventilation, uraemia, serum creatinine below 0.6 lmol l-1, hypo-or hypernatraemia, acidaemia, alkalaemia and anaemia.CONCLUSION. Acute hospital mortality of admissions to ICUs in England, Wales and Northern Ireland with haematological malignancy is nearly double that of other ICU admissions. Mortality increases with the number of failing organs on admission to ICU, and as the hospital length of stay before ICU admission increases. INTRODUCTION. Acute renal failure (ARF) is a serious complication of pregnancy. It is considered as an independent mortality risk factor in the intensive care unit (ICU) and associated with an increased mortality. The aim of this study was to determine the etiologies and to identify risk factors and outcome of peripartum ARF.METHODS. An open prospective observational cohort study in a multidisciplinary ICU. Demographic and obstetric management (transfusion, cesarean section, hysterectomy, anesthetic complications, etc.) data were collected and analyzed.ARF was defined as serum creatinine C 100 lmol/l and/or oliguria\150 ml/8 hours or\500 ml/day and/or doubling of baseline serum creatinine levels. Generalistic scoring systems (SAPS II, APACHE II, APACHE III) and organ dysfunction scoring systems were calculated at admission and on a daily basis. Data were computed on SPSS 11.5 XP-Windows compatible. Results were expressed as means ± standard deviation. Statistical analysis was based on the chi-squared test and Student t test corrected by the Fisher exact test.RESULTS. Between January 1996 and December 2003, 541 obstetrics patients were admited to our ICU. The mean age was 31.2 ± 5.9 years; mean term was 34.7 ± 4.5 weeks. Preeclampsia, eclampsia and peripartum haemorrage were the leading causes associated with ARF. Univariate analysis found that uterine atonia, transfusion, multiple pregnancy and vaginal delivery were significantly associated with ARF, whereas cesarean section showed an odds ratio (OR) = 0.455. Multiple regression analysis retained only transfusion prior to ICU hospitalization as significantly associated with ARF. Oliguria and the level of renal failure are predicting factors of mortality.Overall mortality was 10.4% (n = 57). ARF was noticed in 68 patients, with a mortality of 33.8% (n = 23). The relative risk (RR) of mortality when patients developed ARF was 4.7 with an OR of 6.6. Mean scores for patients with and without ARF were respectively: 41.1 ± 20.9 and 21.6 ± 13.7 for SAPS II; 16 ± 8 and 7.5 ± 6 for APACHE II and 63.3 ± 31.6 and 24.4 ± 23.8 for APACHE III (P \ 0.01 for all scores). Renal failure was usually associated with at least another organ dysfunction as demonstrated by mean SOFA at day 1 (9.3 ± 4.5) whereas without ARF it was 3.7 ± 3 (P \ 0.001).CONCLUSION. ARF is associated with high mortality ([ 30%). Aggressive treatment and prevention of renal failure is necessary to improve prognosis. 

We conducted a retrospective case-note study of obstetric patients admitted to the Intensive Care Unit from January 1994 to December 2005.RESULTS. There were 47952 deliveries over the 12-year period of study. There were 175 obstetric admissions to the Intensive Care Unit. (0.36% of deliveries). Seventy percent of admissions were following operative delivery. Unlike our previous case-note study there was an increased proportion of admissions due to haemorrhage and a decreased rate of admissions associated with pre-eclampsia or hypertensive disease of pregnancy. There was one ICU admission as a consequence of pulmonary thromboembolism.There was one maternal death in this 12-year period compared to 3 maternal deaths in our earlier report. This maternal death was associated with life-threatening coagulopathy.CONCLUSION. The national triennial Confidential Enquiries into Maternal and Child Health (CEMACH) identify thrombosis and thromboembolism, pre-eclampsia and eclampsia, amniotic fluid embolism or haemorrhage as the commonest causes of direct maternal death in the United Kingdom. These do not represent the commonest causes for obstetric admission to our Intensive Care Unit. Despite comprehensive guidelines as many as half of all transfusions in the critically ill may be inappropriate (1) . FFP transfusion in critcal care is associated with significant morbidity, including an increased risk of infection (2) and Transfusion Related Acute Lung Injury (3). Conventional coagulation assays including International Normalized Ratio (INR) are often used to guide FFP transfusion, however a moderately deranged INR (\1.9) is not an accurate predictor of bleeding. Furthermore the use of FFP prophylaxis prior to invasive procedures in critically ill patients has been called into question (4).METHODS. This was a retrospective audit of all FFP transfusions administered to patients in a UK District General Hospital ICU over a period of one year. Indications for transfusion and the volume of FFP administered in each transfusion were documented. In order to gauge thresholds for transfusion INR pre-transfusion was recorded.RESULTS. Approximately 10% of all ICU admissions received a FFP transfusion. A total of 337 units were administered in 104 separate transfusions. Indications were varied, including correction of coagulopathy in actively bleeding patients, prophylaxis for invasive procedures (including epidurals and central venous catheters) and to correct coagulopathy in patients without any apparent bleeding. In 39% of transfusions the pre-transfusion INR was less than 1.9. At least 23% of transfusions were sub-therapeutic, using 2 units (approximately 400ml) or less.CONCLUSION. A significant proportion of FFP administration is inappropriate. Administration to patients with mildly deranged coagulation assays is common. Transfusion is unlikely to be beneficial in these patients in the absence of active bleeding. In addition a large number of FFP transfusions use sub-therapeutic doses -prominent guidelines suggest volumes of 12-15 ml/kg (4). It is important to carefully assess the indications for FFP administration as transfusion is associated with significant adverse effects. Further education is needed.CONCLUSION. Liver dysfunction at ICU admission in septic patients was associated with a higher mortality rate and more organ failures according univariate analysis. Nonetheless, liver dysfunction evaluated by SOFA score was not independently associated with ICU mortality by multivariate regression analysis.GRANT ACKNOWLEDGEMENT. This study was supported by institutional funds. INTRODUCTION. The use of mild therapeutic hypothermia (MTH) has been shown to improve survival and neurological outcome of comatose survivors who recovered spontaneous circulation after cardiac arrest. Although the evidence supporting the method is strong and it has entered the guidelines for resuscitation, implementation of this method is still low: according to recently published data, 87% of physicians and 76% of German ICUs did not use the method. In this survey we investigated current implementation of MTH in Croatia.

A questionnaire was created and served as basis for a structured interview. A list of all Croatian hospitals was obtained from the Croatian health ministry. All hospitals were contacted by phone or personal visits and interviews were lead in December 2007.RESULTS. There are 24 general hospitals and 8 university hospitals in an we conducted the interview in all but two. In those 30 hospitals, there are 33 ICUs admitting patients after cardiac arrest: 15 mixed surgical/medical, 11 coronary care units and 7 general medical ICUs. Only 9% ICUs used MTH as standard method, all in university hospitals. Ice cold infusions and ice packs in combination are methods of cooling in all three. Of those that do not use the method 10% are planning to start using it soon, 7% are not aware of the method, 20% claim it is technically too difficult, 7% claim it is too costly and 7% need more proof of efficiency. Most ICUs (48%) gave no reason for not using the method.CONCLUSION. Even with the ICUs planning to start using MTH after cardiac arrest, it's implementation in is unacceptably low. The reasons given for not using it suggest lack of knowledge and a nationwide program promoting the method and its benefits could be the best way for improving the implementation in near future.INTRODUCTION. The complication rate of intubation under elective conditions is low. On the other hand airway management of the critically ill patient often requires emergent intubation (EI) in the setting of hemodynamic failure.We study the incidence of hemodynamic, airway complications and mortality associated with EI.METHODS. Prosprective clinical trial over a period of 12 months. Patients in cardiopulmonary arrest were excluded. We assesed: indication, hemodynamic and gasometric changes, complications, difficulty and mortality. Definitions: difficult EI when a intensive care last year resident or a staff intensivist couldn 0 t intubate at the first attempt. Intubation associated mortality: as death that ocurred during or within 30 minutes of the procedure. Chi-square was used for statistical analysis.RESULTS. n= 288 patients. Gender (m = 190, f=98), mean age = 56 (15-87). Location of intubation: emergency room: 28%, Intensive Care Unit 60%, other units 12%. Indications for EI: work of breathing 45%, low level of conciousness 39%, bad management of secretions 12,2%, self-extubation 2,1%, airway obstrucion 1,7%. Medications administered: Benzodiazepines and Opioids 75%; propofol 8%; Muscle relaxants: 70%. Attempts: First attempt 81%; Second 8,4%; third or successive 9%; 3 patients (1%) underwent emergency cricothyrotomy. Difficult intubation = 31 (10,88%). 220 patients were normotensive before EI (TAS[=90 mmHg)and 68 patients hypotensive. In the first group 73 patients developed hypotension and two died (0,9%). In the hypotensive group one patient died (1,4%). No significant differences in mortality between both group (p00,5). Hypoxemia postEI: 10% (28); esophageal intubation: 1,7% (5); selective bronchial intubation: 1,3% (4); bronchoaspiration: 1,3% (4): global mortality 1% (3).CONCLUSION. Securing the airway is a vital procedure in the critically ill patient that in many ocassions has to be applied in an emergency situation. Hemodynamic failure arised as the most important cause of death associated to an EI. The previous hemodynamic profile is not a predictor of mortality. 

With global warming and the worldwide increase in heat waves, the threat of heat-related illness is escalating. We describe our experience in the management of heat stroke in a national heat stroke treatment centre.

Retrospective observational study over the past 10 years of patients with heat stroke requiring intensive care, at a 1,600 bed tertiary-care hospital.RESULTS. Between 1998 and 2007, a total of 147 patients were admitted to our institution with heat-related illness. Of these 35 (24%) were transferred to the intensive care unit (ICU). The majority were young, healthy males who had been involved in military training or sporting activities. The mean presenting temperature was 40.5 degrees Celsius, and the mean time to cooling was 60 minutes. Half of these patients were cooled in the body cooling unit (BCU). Organ dysfunction included neurologic impairment (80%), coagulopathy (44%), hypotension (22%) and respiratory failure requiring mechanical ventilation (11%). Most of the patients improved rapidly with cooling and supportive care. The median length of ICU stay was 2 days (range 1 to 12 days) and there was 1 (3%) mortality.CONCLUSION. Exertional heat stroke is associated with multi-organ dysfunction that is generally rapidly reversible with aggressive cooling and supportive care. In our experience, early recognition and treatment in the BCU is associated with a favourable outcome.

HEMODYNAMIC AND RESPIRATORY CHARACTERISTICS AFTER BRAIN TUMOR SURGERY COMPARING EARLY AWAKENING TO SHORT TERM POSTOPERATIVE SEDATION K. Vanstraelen* 1 , C. De Deyne 1 , J. Wuyts 2 , F. Weyns 2 , E. Vandermeersch 3 , R. Heylen 1 1 Anaesthesiology, 2 Neurosurgery, Ziekenhuis Oost-Limburg, Genk, 3 Anaesthesiology, University Hospital Louvain, Louvain, Belgium INTRODUCTION. Intracerebral hematoma and major cerebral edema are the most feared complications after brain tumor surgery. Arterial hypertension is a wellknown risk factor for postoperative intracerebral hemorrhaghe, while hypoxia and arterial hypotension might exacerbate neuronal injury. Therefore, emergence from anesthesia for brain tumor surgery should guarantee stable systemic (cardiovascular as well as respiratory) parameters. This prospective study was performed to compare early postoperative systemic complications after emergence of anesthesia in pts awakened in the operating room at the end of surgery or on the ICU (within a max of 4 hours of ICU admission).METHODS. Over a 2-years period, 142 pts scheduled for elective brain tumor surgery were randomised into early awakening (71pts) or postoperative short-term sedation with propofol (71pts). We analysed and compared the incidence of respiratory events (hypoxia defined as PaO2\90mmHg, hypercapnea defined as PaCO2 [46mmHg) and cardiovascular events (arterial pressure increase above 30% of baseline, systolic arterial pressure.

Patients who were awakened in the operating room revealed a 5.3% incidence of arterial hypoxia, while in 27.3% of them hypercapnea was observed. None of these pts developed respiratory depression necessitating reintubation. In late awakening pts, incidence of arterial hypoxia was 18%, while incidence of hypercapnea was 8.3%.Analysis of cardiovascular complications revealed that no pt in the early awakening group developed postoperative arterial hypotension necessitating administration of vasopressors. In the late awakening group, 4.3% of pt revealed hypotensive values (2.9% necessitating the use of vasopressors). In the early awakening group, incidence of arterial hypertension (necessitating antihypertensive medication) was 14.3%, while for the postoperative short-term sedated pts, incidence of arterial hypertension (with antihypertensive medication) was 21.5%. We observed no difference in duration of postoperative ICU stay between both groups and no difference in incidence of major neurological complications (postoperative hemorrhaghe or cerebral edema).CONCLUSION. Pts allowed to early awakening after brain tumor surgery revealed an increased incidence of hypercapnea, while pts submitted to postoperative short-term sedation with propofol appeared to be more vulnerable to arterial hypoxemia and especially to arterial hypertension. Therefore, both choices of anesthetic regimen require close hemodynamic and respiratory monitoring (and eventual treatment) in the early hours of ICU admission.

A. Stathopoulos 1 , C. I. Routsi* 1 , E. Garini 1 , K. Glynos 1 , C. Psachoulia 2 , S. Nanas 1 , C. Roussos 1 , E. Stamataki 3 1 ICU, 2 Biochemistry, 3 Anesthesiology, Evangelismos Hospital, Athens, Greece INTRODUCTION. Experimental hemorrhagic shock induces increased production of S100B protein, a marker of brain injury, associated with the severity of shock (1) . Whether this increase is exclusively due to cerebral hypoperfusion or other factors also contribute to this increase, remains unclear. Inflammatory response also follows acute hemorrhage (2), and might have a role in the release of S100B. Thus, we investigated the relationship between serum S100B protein and IL-6, and their possible prognostic value in patients with hemorrhagic shock.METHODS. Eighteen (12 men) patients with a mean age of 62±22 yr, undergoing emergency surgery to control hemorrhagic shock of various etiologies were included. None suffered previously from cerebral damage or neurological disease. Blood samples were taken for blood gas, lactate, IL-6, and S100B measurements on admission and over the next three days. Vital signs were recorded and severity of illness was assessed by the APACHE II score.

. Initial values of serum S100B protein were increased (median 0.46 lg/l; interquartile range 0.16 ± 3.5) and were positively correlated with IL-6 (r=0.8, p \ 0.01), lactate (r=0.63, p.01), and hospital outcome (r=0.5, p.05). For all data, there was a significant correlation between S100B levels and IL-6 (r=0.46, p \ 0.01), lactate (r=0.49, p \ 0.01) APACHE II score (r=0.38, p \ 0.01) and outcome (r=0.54, p \ 0.01). Mortality was 44%. Serum S100B and IL-6 concentrations on admission were significantly higher in nonsurvivors compared to survivors (3.7 ± 3.6 vs. 0.7±1.05 lg/l, p \ 0.01 and 505 ± 409 vs. 138 ± 197 pg/ml, p \ 0.01, respectively). By linear regression analysis APACHE II score was an independent predictor of outcome (F=13.9, p \ 0.01).CONCLUSION. Serum S100B protein is increased in patients with hemorrhagic shock and this increase correlates with IL-6, lactate, illness severity and outcome. These findings indicate that, except of a possible cerebral hypoperfusion, the release of S100B may be stimulated by other factors involving the inflammatory response and/or impaired tissue perfusion. INTRODUCTION. The primary aim of this survey was to assess current practice on the use of EVD for monitoring intracranial pressure (ICP) and CSF drainage to treat raised ICP in TBI amongst all neurosciences centres in the United Kingdom.METHODS. Electronic questionnaires were sent to the lead clinicians in 35 adult and paediatric neuro-intensive care and neurosurgical units. A copy of the questionairre was sent by post to all non-responders. The aim was to collect data regarding the type of ICP monitor used, frequency of use of EVD and CSF drainage including indications, contraindications and complications associated with their use.RESULTS. Forty-eight completed questionaires were returned representing 31 neurosurgical and intensive care units. The response rates from the neurosurgeons and neuro-intensivists were 63% and 74% respectively. The number of severe head injuries managed per annum varied between units ranging from 50-150 cases. Sixteen percent of the units used EVD's routinely to monitor ICP, 17% reported never using this technique and the remaining 67% used it occasionally. Of the 16% who used EVD's to monitor ICP routinely only 60% used CSF drainage to treat raised ICP.Eighty percent of the units agreed that CSF drainage had an important role in the management of raised ICP compared to 20% who thought that CSF drainage was of no value. Of those that considered CSF drainage beneficial 47% would consider it to treat raised ICP in the presence of hydrocephalus, accessible or patent ventricles compared to 53% who considered when maximal medical therapy failed to control ICP or if EVD was already in situ. Seventy four percent of the units drained CSF continuously compared to 17% who drained CSF intermittently. There was considerable variability in the use of CSF drainage in relation to second tier therapies such as barbiturate coma, craniectomy and therapeutic hypothermia. Forty-eight percent of the units used it before craniectomy, 41% before barbiturate coma and 11% before therapeutic hypothermia. The reported contraindications to the placement of ventricular drains in patients with head injury inlude:slit ventricles,coagulopathy,infection, midline shift, compound or penetrating injuries and mass lesions. The complications of CSF drainage that were reported include: blockage, infection, misplacement, displacement, bleeding and administration of drugs into EVD.CONCLUSION. Though majority of the units agree that CSF drainage has got an important role in the management of ICP, there was lack of consensus on timing, indication and frequency of CSF drainage in relation to other second tier therapies. INTRODUCTION. External ventricular drainage placement is a common practice in our ICU as a diagnostic and therapeutical technique. Our aim is to know the profile of patients admitted in the ICU requiring EVD, the incidence of observed complications and related risk factors.

Observational study which includes all the patients admitted in a Neurotrauma ICU that required EVD placement due to any cause in a 8-year period (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) . Collected data included demographic characteristics, prognosis scores (APACHE II and APACHE III), cause of admission, EVD placement indication, Glasgow Coma Scale pre and post EVD, complications, length of drainage, cause of withdrawal, incidence of infection and need for ventricular-perithoneal derivation. Cualitative variables are expressed as percentage an cuantitative variables as media ± SD or median and percentiles. Student's t and chi2 were used to compare medias depending on the kind of variable.A p \ 0.05 was considered statistically significant.RESULTS. The studied group includes 168 patients, 56% men, of 57 ± 17 year old in average. The most frequent cause of admission was subarachnoid hemorrhage (48.2%), with an APACHE II 20.69 ± 8.77 and APACHE III 66.48 ± 29.87. The main indication for EVD was hydrocephalia (92%). EVD were placed for 7 [4, 12] days in average. Reasons for withdrawal were cessation of the cause of indication (41%) and exitus (38%). Infection was observed in 11%, being the most frequent complication, followed by hemorrhage. Despite of being infection more frequent in EVD placed in ICU than those placed in the operating room, no significative difference was observed. On the other hand, we could find that there were significative difference in the length of EVD placement between patients without infection and patients with infection (8.13 ± 6.56 vs 17.68 ± 16.88 days, p \ 0.05). Over 50% of patients died during treatment. GCS 12 hours after EVD was 6±4, while survivors showed a GCS 12 hours after EVD of 11±3 (statistically significant). Around 19% required ventricularperithoneal derivation placement, being more frequent in patients with higher cerebrospinal liquid debit (250.56 ± 109.35 vs 153.09 ± 130.92, p \ 0.05).CONCLUSION. In our experience, patients that required EVD showed high severity scores and mortality. The main indication for EVD placement was hydrocephalia. We observed very few complications related with EVD placement.

Catatonia is a syndrome characterized by mutism, posturing, negativism, staring, rigidity, and echophenomena. Catatonia has for long been considered to be associated with psychiatric disorders, but the syndrome is also known to be common in neurologic and general medical conditions. Several studies have estimated the incidence of catatonic syndromes in psychiatric and different medical settings, reporting varying results. Our aim was to estimate the frequency and presentation of the catatonic syndrome in the Intensive Care Unit (ICU) patients.

A prospective observational study was carried out. All patients admitted in the ICU over a six-month period (from August 2007 to January 2008) were examined for signs of catatonia. Diagnosis of catatonia was made according to the criteria proposed by Taylor and Fink. Diagnoses, APACHE scores and previous medical and psychiatric history were recorded.

During the study period a total of 92 patients were admitted in the ICU. The mean age of the patients was 52.2±16.7 years. The mean APACHE score was 20.4±7.1 Four patients (4.3%) met Taylor and Fink's criteria for catatonic disorder. Diagnoses of these patients were multitrauma, respiratory infection (2 patients) and acute respiratory failure ( Table 1 ). In all four patients lorazepam was administrated, which resulted in the resolution of the symptomatology in two cases. 

Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It is characterized by cognitive impairment, disorientation and several psychotic symptoms, such as perceptual disturbances and paranoid ideation. Two motoric subtypes of delirium have been described, the hyperactive and hypoactive type. Our aim was to estimate the frequency and presentation of the hypoactive delirium in Intensive Care Unit (ICU) patients.

All patients admitted in the ICU over a one year period (from January 2007 to January 2008) were examined for signs of delirium. Diagnosis was made according to ICD-10 criteria. The discrimination of clinical subtypes was made with the application of the criteria proposed by Liptzin and Levkoff.RESULTS. Delirium was diagnosed in 74 patients. Hypoactive type was detected in 39 cases (52.7%), hyperactive type in 24 patients (32.4%), whereas the remaining 11 patients (14.9%) were considered to present mixed type of delirium. Differences between the three patient groups regarding age, sex and the underlying medical condition had not been recorded. Length of hospitalization and mortality were not statistically different in patient groups.CONCLUSION. Hypoactive delirium may be the most common type in ICU patients. This may be clinically relevant because this subtype of delirium may go unrecognized and the treatment options are limited. Firm conclusions regarding the length of hospitalization and mortality of hypoactive delirium cannot be drawn at present due to the small study sample and further, larger studies are required. INTRODUCTION. General scores are validated using larges databases composed by heterogeneous patients groups, and it could lose accuracy when applied on some specific patient subgroups. SAPS 3 is a general score and our main purpose is evaluate whether it could be acceptable accurate in traumatic patients in comparison with TRISS.

Prospective study, where were included all patients admitted consecutively in the ICU for eight months, in a total of 128 patients. We evaluated TRISS and SAPS 3 scores in all patients. Then, the database was analyzed using Pearson's correlation and ROC Curves to assess the scores performance.RESULTS. The average ICU length of stay (LOS) on this cohort was 7.35 days (IC95% 6.29-8.41) and the mortality was 31.25%. Both scores had an acceptable performance on the ROC curve (Fig. 1) , without difference between TRISS (AUC = 0.774) and SAPS 3 (AUC = 0.771). It was observed a level of Pearson's correlation of 0.452 between the scores, what was significant (p = 0.01).CONCLUSION. Both scores showed a similar discriminating power to ICU mortality, besides a good correlation between then. CONCLUSION. Age and ISS are significant baseline predictors of ICU LOS in critically ill trauma patients. In our patient sample, a 10-year increase of age and a 10-unit increase of ISS prolonged ICU LOS by 3.6 and 4.4 days, respectively. APACHE II score at admission had no significant association with ICU LOS.

INTRODUCTION. Hypocapnia at hospital admission is correlated with a worse outcome in traumatic brain injury (TBI) patients submitted to prehospital artificial ventilation (1) (2) (3) (4) . Moreover in a recent report (5) a correlation between abnormal PaCO2 level on admission could be demonstrated in the intubated patients, but not in the non intubated.

In order to assess the prevalence of hypocapnia and hypercapnia in patients with TBI ventilated in the prehospital setting, we analized the data of the Italian Trauma Registry (RIT). Among the 753 patients with ISS [ 15, admitted to 3 Italian Level 1 TC over a period of 12 months, we identified a subgroup of TBI patients with a GCS\ 9 at the scene and an arterial blood gas analysis collected just on admission, 144 patients met these criteria. Data of the 115 patients who were intubated on scene and artificially ventilated on admission (IOT group) were compared with the 29 non intubated patients (non IOT).

Patients were non significantly different as for demographics, average GCS (5 vs. 5.5), GCS distribution and average ISS (34 vs. 33). Admission PaCO2 is shown in Table 1 , 41% of the IOT pts had PaCO2\ 35 vs. 17% in the non IOT group; 8% vs. 3% were severely hypocapnic (\ 25). Hypercapnia was less frequent in the IOT group (23% vs. 34%). Only 36% of the IOT patients, compared with 48% of the non IOT, had admission PaCO2 levels within the normal range. However mortality rate was higher in the non IOT group (45%) than in the IOT group (30%), with the highest mortality among non IOT patients who were hypocapnic on admission (80%). Both hypocapnia (40%) and hypercapnia (40%) were associated with a higher mortality than normocapnia (22%). CONCLUSION. Our data confirm the association between prehospital intubation and PaCO2 impairment. Although in our series non IOT patients had a lesser incidence of hypocapnia, they were more often hypercapnic and mortality rate was higher in the non IOT group. INTRODUCTION. Hyperglycemia associated with pancreatogenic diabetes after pancreatic resection often causes dysregulation of liver metabolism and immune function resulting in impaired postoperative recovery. This study evaluated a closed-loop system providing continuous monitoring and strict control of perioperative blood glucose following pancreatic resection.METHODS. Thirty patients who underwent pancreatic resection for pancreatic neoplasm were prospectively randomized. Perioperative blood glucose levels were continuously monitored using an artificial endocrine pancreas (STG-22). Glucose levels were controlled using either the sliding scale method (sliding scale group, n = 13) or the artificial pancreas (artificial pancreas group, n = 17).

In the sliding scale group, postoperative blood glucose levels rose initially before reaching a plateau of approximately 200 mg/dl between 4 and 6 hours after pancreatectomy. The levels remained high for 18 hours postoperatively. In the artificial pancreas group, blood glucose levels reduced steadily, reaching the target zone (80 -110 mg/dl) by 6 hours postsurgery. Total insulin administered per patient during the first postoperative 18 hours was significantly higher in the artificial pancreas group (107 ± 109 IU) compared to the sliding scale group (8 ± 6 IU; P \ 0.01). Neither group showed hypoglycemia.CONCLUSION. Perioperative use of an artificial endocrine pancreas to control pancreatogenic diabetes after pancreatic resection is an easy and effective way to maintain near-normal blood glucose levels. The artificial pancreas promises to revolutionize insulin treatment for patients with pancreatogenic diabetes after pancreatic resection. METHODS. Fifty-two patients undergoing operation of abdomen were allocated, after randomization, to two groups to receive isonitrogenous and isoenergetic TPN over 5 days. Controls received 1.5 g of amino acids kg-1day-1, and the test group received 1.2 g of amino acids and 0.3 g of L-alanyl-L-glutamine (Ala-Gln) kg-1day-1. Venous heparinized blood samples were obtained on days 1, 3, and 6 after surgery for routine clinical chemistry and for the measurement of plasma free amino acids. IgG, IgM, IgA, CD3, CD4 and CD4/CD8 were counted and the generation of cysteinyl-leukotrienes from polymorphonuclear neutrophil granulocytes was analyzed on days 1, 3 and 6 after surgery. Nitrogen balances were calculated postoperatively on days 2, 3, 4,and 5.

No side effects were noted. Patients receiving Gln dipeptide revealed improved nitrogen balances, improved IgG, IgA, CD3, CD4 and CD4/CD8 on day 6 and improved generation of cysteinyl-leukotrienes from polymorphonuclear neutrophil granulocytes (p \ 0.05). Postoperative hospital stay was shorter in the dipeptide-supplemented group. INTRODUCTION. Evidence shows that perioperative tight glycaemic control (TGC) improves patients' outcome 1. However there are suggestions that insulin infusions can enhance glucose conversion to lactate via stimulation of glycolytic enzyme activities 2. At our institution 50% dextrose 50ml + 50u insulin (DI) and 50ml N. saline+50 u insulin sliding scale (ISS) are used to maintain intra-operative TGC during cardiac operations, depending on anaesthetist preference. Higher blood lactate levels were observed among patients who needed treatment for TGC than in patients who did not need treatment (No treatment). Aim of this audit is to identify the effects of our current management of blood sugar control on hyperlactatemia.METHODS. We audited demographic data, co-morbid conditions, type of operation, type of treatment were recorded in 246 unselected consecutive patients who underwent on pump and off pump cardiac operations (intra-op procedure) during 3 months period. Arterial blood gas (ABG) samples were retrieved from the ABG machine database to analyse the lactate levels and blood sugar control.RESULTS. 246 patients (male 80.9% & female 19.1%, mean age 67.47yrs, SD ±9.785yrs) underwent cardiac operations out of which 12 patients were excluded due to no regular ABG results. Intra-operative procedures, blood sugar & lactate levels are presented in Table 1 .Average blood sugar and lactate levels of each patient during 1st 3 hours considered as the outcome variable for assessing the statistical significance. Intra operative procedure has no significant effect on the intra operative blood sugar levels. Significant blood sugar differences were seen between no treatment vs DI (P=0.003), ISS vs DI (P=0.001). Both intra-operative procedure and treatment is significantly associated with intra-operative lactate levels (P=0.001, P=0.002). There were no significant differences in the mean lactate levels of ISS and DI groups. However the ''No treatment group'' has shown the least average intra-operative lactate levels and it was significantly different form the other 2 methods of treatment. METHODS. Case report -A 40-year-old construction worker was trapped under a collapsed building for seven hours. On admission, he was fully awake, but dehydrated and complaining of severe pain in both lower limbs and buttocks.

He was tachycardic but with stable BP. The CT scan of the whole spine, pelvis and abdomen was normal. The laboratory parameters indicated acidosis, hyperkalemia, hypocalcaemia and prolonged coagulation profile. He was diagnosed with crush injury syndrome and admitted to trauma ICU for correction of metabolic abnormalities and intensive monitoring. Twenty four hours later bilateral swelling of the upper legs was observed and the patient gradually started complaining of weakness in both lower limbs with impaired sensation below the right knee. Nerve conduction studies and electromyography confirmed bilateral sciatic nerve injury. Three weeks after admission, he developed sepsis treated with IV ciprofloxacin. Cultures from the gluteal discharge confirmed the presence of Pseudomonas and Bacteroides fragilis, requiring adjustment of the antibiotic therapy to meropenem. Despite this he remained febrile; both buttocks were very tense and edematous up to the lateral aspect of both thighs and associated with severe pain. An MRI of the gluteal region/lower limbs showed bilateral multiple gluteal compartment syndrome, intramuscular hematoma and swelling of both thighs with edema of both sciatic nerves. Urgent fasciotomy of the gluteal and right thigh was performed with drainage of the collection followed by three more sessions of debridement of necrotic tissue and muscle. The patient improved gradually and the fasciotomy was closed on day 62. Strength in the left lower limb recovered, but he had a right foot drop as sequel.CONCLUSION. High index of suspicion and knowledge about gluteal compartment are essential to diagnose and manage these patients as prompt and optimal as possible.

A. Badr* 1 , A. Murray 2 , J. Irving 3 , O. Ostrovsky 3 1 Anesthesiology and Critical Care, Texas Tech University Health Science Center, El Paso, 2 Neurosurgery, 3 Anesthesiology and Critical Care, University of Mississippi, Jackson, United States

Aspiration pneumonitis remains a feared complication with potential for mortality and significant morbidity. Aspiration of acidic gastric contents causes a chemical pneumonitis that is initially manifested by bronchospasm, hypoxemia, and atelectasis. Morbidity has been correlated with low gastric pH (\2.5) and high gastric volume ([0.4 mL/kg.) In severe cases epithelial degeneration, interstitial and alveolar edema, and hemorrhage into the air spaces progresses to ARDS.METHODS. Inclusion criteria: Ages 18 and older,capable of informed consent,NPO for at least 8 hours.Exclusion criteria: Allergy to Famotidine (Pepcid) or Pantoprazole (Protonix). Significant liver,renal,or coronary disease. History of PUD, GERD or any other conditions requiring H-2 blockers or PPI for a period of time prior to surgery. Patients undergoing esophageal or gastric surgery or any other surgical procedure that may alter gastric acidity and pH. Any medical condition or surgical procedure that my preclude passage of an orogastric or nasogastric tube.RESULTS. Seventy-eight participants were enrolled with a total of 50 who completed the study. Men encompassed 49.4% (38), women denoted 50.6% (39) and 1 had missing data. African Americans represented 31.2% (24), Caucasians comprised 68.8% (53), and 1 had missing data. The average age was found to be 46.5 +/-1.7 and ranged from 19 to 79. Twentysix participants received pepcid and 24 participants received protonix. The mean difference for the group who received pepcid was 1.33 +/-.26; whereas, the mean difference for the protonix group was 1.24 +/-.29. The independent t-test yielded a p-value of .829. Therefore the difference in gastric pH between pepcid and protonix was not found to be statistically significant for this subset of patients.CONCLUSION. Pantoprazole at the dose of 40 mg intravenously and famotidine at the dose of 20 mg intravenously given preoperatively had similar efficacy in reducing gastric pH in our patient population. We suggest further studies with larger sample size and prolonged sampling up to 20 hours. Colloids are widely used as vascular volume replacement solutions during the peri-operative period. They are responsible for 27 54% of anaphylactic reactions in anaesthesia (1, 2) . Gelatins have the highest frequency (93%), and they are associated with some risk factors (2) . We report a case of allergy due to gellatin in a patient with a previous history of multiple drug allergies.

We present the case of a woman 56-yr-old ASA II, with a history of allergy to metabisulphites, beta-lactamins, metals, thiomersal and nickel sulphate. She had received the diagnosis of ovarian torsion and she was scheduled for surgery. Surgery was uneventful and she was relocated into our ICU.In the ICU we infused 300 ml of gellafundin, and the patient referred pruritus, rash, and displayed facial, upper-body and tongue oedema immediately, with an important dysarthria. We decided to stop gelafundin infusion, and treat those clinical signs and symptoms with hydrocorthisone 100 mg, ranitidine 50 mg, and dexchlorpheniramine 5 mg, and all the symptomatology partially disappeared. After 24 h. the patient was discharged from ICU without any complications. Prick test was performed after 4 weeks with positive result.RESULTS. The incidence of anaphylactic reactions with colloids varies between 0033% -0219% (2). In most cases (90%) clinical reactions are at least grade II and mortality is 3 6%. There are some risk factors associated with allergic reactions to colloids: male sex, previous drug allergy, and gelatine or dextrane infusion. It has even been recommended that gelatins be avoided in patients with a known history of drug allergy (2) . In those cases the safest alternative would be hydroxyethyl starch with a slower frequency of allergic reactions (0058% -00085%). This patient had drug allergy as a unique risk factor to colloids allergy. Clinical signs and symptoms following so closely after gelatine infusion, strongly indicates an anaphylactic reaction. Cause-effect relation was confirmed after 4 weeks with a positive result for skin tests.CONCLUSION. Although the incidence of severe reaction to colloids is low, it must not be ignored, because colloids infusions are an extremely frequent practice in medicine. Gelatin and dextrane infusion must be avoided in patients with a previous history of drug allergy. METHODS. Tertiary referral centre. We reviewed all patients diagnosed with brain death in 2007 who donated organs. HRT comprises T4 bolus followed by infusion, vasopressin bolus followed by infusion and methylprednisolone 15mg/kg 24hourly.

. 16 patients donated organs, 11 males, 4 females. 1 chart lost. Average age 41years. 5 patients received HRT, 10 standard therapy. Figure demonstrates vasopressor requirement and mean arterial pressure(MAP). On average 2.4 organs per patient were successfully transplanted from HRT group, compared to 2 per patient in standard group.CONCLUSION. HRT conveys haemodynamic stability to organ donors following diagnosis of braindeath as manifested by lower vasopressor requirement and higher MAP. There was a higher successful organ donation from patients treated with HRT. HRT should be considered to stabilise potential organ donors. METHODS. 140 adult patients operated by the single neurosurgical team because cervical,thoracic and lumbar instability and hernia spine had moderate or severe pain before operation (with a pain score[5 using a 0-10 Numeric Rating Scale) in spite of non steroidal anti-inflammatory drugs (NSAIDs)administration including COX-2 selective NSAIDs. In all cases premedication before 30 min of the operation starting included midazolam 0,08 mg/kg and chlorphenamine 10 mg intramuscularly. The anaesthesia induction was performed with Before the incision all patients without allergic NSAIDs history received ketoprophen 100 mg i.m.General anaesthesia was carried out with propofol 2,0 mg/kg/h, fentanyl 2,5 mcg/kg/h and clonidine 0,45 mcg/kg/h intravenously with artificial lung ventilation and total myorelaxation with rocuronium. Before 30 min of the operation ending paracetamol infusion 1000 mg intravenously was administrated. Evaluation of postoperative pain (POP)was carried out several times with Visual Analogue Scale (VAS:from 0 to 100 mm,0=no pain at all,100=the worst possible pain), Nunerical Rating Scale (NRS:from 0 to 10,0=no pain,10=the worst possible pain),Verbal Rating Scale (VRS:4-point scale,0=no pain,1=mild pain,2=moderate pain,3=severe pain).

After exubation in the operating room nobody had POP.The choice of the pain scale during 1st and 2nd postoperative day depended on the patient's age and ability to communicate.Also adverse events considered to be related to analgesics and requiring symptomatic treatment (nausea,vomiting).During 2 postoperative days all patients received paracetamol 3000 mg/day intravenously.10% of patients felt POP at rest (pain was assessed \2 using a 4-point VRS).7% of patients felt POP on movement on the 2nd postoperative day (pain was assessed \ 2 using a 4-point VRS). Nothing cases of nausea and vomiting connected with NSAIDs and paracetamol were observed.There were no cases with hematologic disorders and clinical importance of increased levels of transaminases.CONCLUSION. Multimodal analgesia based on the combined opioids,alpha2-adrenoagonists use during induction of anaesthesia,NSAIDs before incision and paracetamol intraoperatively use and prolonged paracetamol intravenously treatment during 2 postoperative days gives possibility for comfortable patient's condition after spinal neurosurgery and early patient's activity. (1) published a study that radically modified the conventional approach of tolerating high blood glucose levels in the critically ill patient. New trials (2,3) were interrupted prematurely. The reasons were that no difference were seen in mortality and there was a significantly higher incidence of hypoglycemia in the group that received intensive insulin therapy.

The objective of this study was to evaluate the safety and efficacy of a carbohydrate restrictive strategy as compared to intensive insulin therapy for glycemic control in critically ill patients, assessing primarily the occurrence of hypoglycemia, and secondarily the mortality, incidence of infectious complications and organ dysfunctions.

A total of 337 adult patients that presented two blood glucose levels higher than 150 mg/dl in the first 12 hours after admission to a 20-bed multidisciplinary ICU of a general hospital and an 11-bed trauma center ICU. were randomly assigned to a carbohydrate restrictive strategy (group 1) or to strict normalization of blood glucose levels with the use of continuous insulin infusion (group 2). Hypoglycemia occurred in 6 (3.5%) patients in group 1 and 27 (16%) in group 2 (p \ 0.001), and was identified as an independent risk factor for neurological dysfunction and mortality.

Our study analyzes an alternative approach for glycemic control in patients admitted to the ICU, with a strategy of restricting carbohydrate intake and has shown that it is possible to maintain the blood glucose levels within acceptable limits, with lower incidence of hypoglycemia, identified as a risk factor for mortality and neurological dysfunction. Results regarding mortality, infectious complications and organ dysfunctions were comparable between the two groups. This much simpler strategy for glycemic control may even be extended to the hospital ward. INTRODUCTION. Survival after cardiac arrest has increased dramatically over the past years: 67% of good outcome of in-hospital cardiac arrest (IHCA) [1] and 56% of good outcome in out-of-hospital cardiac arrest (OHCA) patients [2] after ICU treatment have been reported. This improvement is at least in part due to the introduction of mild hypothermia (MH). In the present analyses we determined outcome after OHCA and IHCA in 3 Dutch ICU's.

Retrospective multicenter observational study of consecutive patients with all presenting rhythms (VF, PEA, asystole) admitted after cardiac arrest to 3 intensive care units (ICU's) in the Netherlands. We compared outcome after IHCA and OHCA between two separate periods of 12 months, the first before the introduction of MH in 2002 and the second in 2006/7. Hospital survival and final neurological outcome were scored using the Glasgow Outcome Score, 4/5 being good, 2/3 being unfavourable and 1 being dead. Patients with unfavourable outcome (7 in period 1 and 12 in period 2) were presently left out of this analysis. Data were analysed using Pearson's Chi-square test.RESULTS. 252 patients were admitted after cardiac arrest, of whom 203 could at this time be evaluated. Hospital survival with concomitant good outcome after cardiac arrest had improved in period 2 (p=0.04). This was caused by a strong significant increase in survival with good neurological outcome after IHCA (p=0.01). We found however no improvement of good outcome after OHCA. There were no important baseline differences between the two year-groups, except for an (expected) increase in frequency of acute coronary interventions. INTRODUCTION. Septic shock is the main cause of mortality in our ICU units. In these type of patiens multiorgan dysfunction and ARF are common and worsens prognosis. Continuous renal replacement therapies (CRRT) have become an important cornerstone in septic support measures. Renal dose above 35 ml/kg/h has been stablished as the goal standard in critically ill patients with ARF. Sepsis dose has not been still defined as many studies propose higher doses in septic shock patients. Our objective was to compare the efficacy of two different strategies of CRRT (HVHF vs HVVC) in septic shock patients with ARF.

Our study was a randomized and prospective trial. Patients who achieved CRRT inclusion criteria (ARF and septic shock) were randomized, and either HVHF or CVVH was started. We studied 62 patients, 29 treated with CVVH and 33 with HVHF. [1] . Presentation of this data allows evaluation of the incidences and outcomes from cardiac arrest. In an age of early warning systems, Outreach and Medical Emergency teams there is ever increasing interest around inhospital cardiac arrests. It is well recognised that many cardiac arrests, particularly those presenting with pulseless electrical activity (PEA) or asystole are predictable and potentially preventable consequences of suboptimal medical care. Southend hospital is a large district hospital serving an aged population of approximately 300,000. The aim of this audit was to establish the incidence, type and outcome from cardiac arrest occurring amongst in patients on the acute wards at our hospital. The secondary aims were to highlight some of the strengths and weaknesses of our acute care services, and to guide future developments.METHODS. Data collected daily by the Resuscitation Officer was retrospectively analysed for all ward cardiac arrests occurring between 1 June 2005 and 31 May 2007. The hospital PAS system was used to determine long term outcome for patients surviving to and beyond hospital discharge. Cardiac arrest was defined as loss of spontaneous circulation. Data from the Accident Centre, Critical Care Unit, Theatres and out patient areas was excluded. RESULTS. 17 patients did not survive whereas 14 patients survived to hospital discharge. Of the surviving patients four were classified GOS 2, one GOS 3, two GOS 4 and seven GOS 5. PCT obtained within 24 hours of admission was significantly different between survivors and non-survivors. A statistically significant difference between those two groups could not be established for NSE, CRP or lactate. In addition we found a highly significant correlation between GOS at hospital discharge and PCT-levels during the first 24 hours after ICUadmission (Pearson r=-0.56, p=0.0018). CONCLUSION. PCT can be significantly elevated in non-infectious acute states like CPR. Moreover PCT obtained within 24h after ICU admission appears to predict not only survival but also neurological outcome after CPR.

INTRODUCTION. Induced therapeutic hypothermia improves neurological outcome after cardiac arrest, but there is strong evidence in animal models that delays in introduction of cooling negates its beneficial effects. The effectiveness of a new device in rapid induction of cooling using nasopharyngeal approach was shown in this preliminary investigation of post resuscitation cardiac arrest patients.METHODS. Seven patients after succesful resuscitation from cardiac arrest were included into the study. Following standard diagnostic and therapeutic procedures, therapeutic hypothermia (TH) was induced by evaporisation of aerosolized perfluorchemical (PFC) into the nasopharyngeal cavity using a nasal tubing set (RhinoChill device, BeneChill Inc. San Diego, USA) to achieve cerebral and systemic hypothermia. Temperature measurements were continously taken throughout induction and maintanance of hypothermia via tympanic (Ttymp) and arterial catheter (Tcore). After achieving a target temperature (Ttarget) of 33°C in one of the measurement sites, the cooling method was switched to standard sytemic cooling and maintained for 24 hrs. The therapeutic range was defined as 32-34°C with a Ttarget of 33°C.RESULTS. The mean age of the patients was 78 years, the mean time from cardiac arrest to succesful ROSC was 22 min. Core temperature on admission was 35,8°C (mean). Application time of the RhinoChill device was 80,3 min (mean) from start of the nasal cooling; the therapeutic range (34°C) could be reached in 42 min (mean-Ttymp) and in 84 min (mean-Tcore). Ttarget was achieved within 67 min (mean-Ttymp) and 115 min (mean-Tcore) representing a cooling rate of 2,52°C/hr (Ttymp) and 1,6°C/hr (Tcore). Good recovery was achieved in 2 patients, 1 was neurologically impaired, 4 patients died.CONCLUSION. Evaporative nasopharyngeal cooling using a PFC rapidly decreases Ttymp and Tcore and provides rapid establishment of therapeutic hypothermia immediately after admission in the ICU. The added benefit of rapid early cooling on outcome remains to be demonstrated. 1. A breathing frequency of less than 5 or more than 36/minute.

A heart frequency of less than 40 or more than 140 bpm or a systolic blood pressure of less than 90 mmHg.

A decrease in the Glasgow Coma Scale of more than 2 points.

Since 1995 the number of times that the resuscitation team has been called, has decreased from 45 times a year to 29 times (Table 1 ). This number reflects the actual calls for the resuscitation team in which CPR was performed. These calls were coming from all departments in the hospital, except the emergency department, the CCU, the Operating Theatre and the ICU.We corrected the number of calls for the number of admissions through the years. We describe a case of severe deliberate aconite intoxication. This is the first report of a patient successfully treated with MgSO4 in this instance.

A 77-year-old man was admitted to ICU for severe muscarinic syndrome associating hypotension, bradycardia, wheezing, sweating, nausea and vomiting, only 20 minutes after the intentional ingestion of 5 grams of crushed roots from Aconitum napellus. The patient complained numbness, dizziness and ascending paresthesia. Important features of ECG consisted of ventricular bigeminism, then severe bradycardia (20 bpm), long QTc (524 msec) and polymorphic ventricular extrasystoles. Activated charcoal was administered but no gastric lavage was performed seeing severe arrhythmias and hemodynamic compromise. Saline infusion, atropine (3 mg loading dose, and 0.5 mg/6 hours during 48 hours) and magnesium sulfate (6 g loading dose, and 3 g/24 hours for 48 hours) were administered to treat hypotension, muscarinic signs and arrhythmias, respectively. Plasma magnesium levels remained below 4 mmol/L. Symptoms rapidly disappeared and return to regular sinus rhythm (86 bpm) was observed. Further evolution was uneventful.RESULTS. Aconitine is the main toxic alkaloid in monkshood. LD50 is about 5 mg which represents 2 to 4 grams of crushed roots. Cardiac and neurological toxicities, as well as increased vagal tone, are due to activation of voltage-dependent sodium channels. Cardiotoxicity consists in early and delayed afterdepolarisation. Indeed, during late repolarisation (phase 4 of the action potential) of the Purkinje cells, aconitine-attached Na channels open, allowing sodium influx and depolarization (''delayed afterdepolarization''). This results in increased automaticity (premature ventricular beats). During late phase 2 or early phase 3 (repolarisation), aconitine-induced Na accumulation induces depolarization (''early afterdepolarisation''). This results in long QT interval with a risk of torsades de pointes. Antiarrhythmic agents have inconstant results in aconite intoxication. Especially amiodarone could promote torsades de pointes. The effects of magnesium sulfate on aconitine-induced ventricular arrhythmias have been studied in animal models (1) . In contrast to other antiarrhythmic agents, it abolishes early afterdepolarisation and shortens the prolonged duration of the Purkinje cell action potential.CONCLUSION. To our knowledge, this is the first clinical report of aconitine-induced polymorphic ventricular arrhythmias successfully treated with magnesium sulfate. It enables a good cohort of emergency medicine trainees to be eligible for dual certification in ICM.The aim of this study is to compare the training between anaesthesia and emergency medicine for dual certification in ICM.

Comparison of Acute common care stem curriculum between Anaesthesia and Emergency medicine. The curriculums were downloaded from websites of Royal College of anaesthesia and College of Emergency medicine.

6 months each in Intensive care,Emergency medicine,Acute medicine and anaesthetics. It also completes the basic competencies required for ICM.Skills: Rapid sequence Induction, Central and arterial line insertion.

Extra 1 yr training in anaesthesia for anaesthetic trainees. Extra training in paediatrics and surgical specialities for emergency medicine trainees.CONCLUSION. Emergency medicine trainees have wide exposure in managing acute medical and surgical emergencies. Furthermore, as shown in the curricula the basic training for both anaesthetic and emergency medicicne are the same. This give emergency medicine trainees a good platform for further training in ICM. Emergency medicine trainees lack the experience of managing patients on ventilators in comparison to anaesthetic trainees. However, the increase use of non-invasive ventilators in emergency medicine department helps them in understanding the principles of ventilators and respiratory physiology. Emergency medicine is a rapidly changing speciality in United Kingdom with more onus on emergency physicians to diagnose and stabilise patients in emergency department prior to transfer. Therefore emergency medicine trainees should be encouraged and treated equally with their anaesthetic colleagues in the pursuit of a career in ICM. INTRODUCTION. Emergencies in cardiology are among the key demands of therapy in emergency and critically ill patients. Medical simulation used in combination with traditional training methods can provide a comprehensive learning opportunity that allows the clinician to safely learn, practice, and repeat the procedures until proficiency is achieved. Our objective was to address the use of medical simulation as a way for medical learners to acquire and maintain skills needed to manage emergencies in cardiology; to evaluate the students satisfaction with the course.

The study was performed at Berkeley Training Center -Brazil, between March 2002 and December 2006, with a total number of 497 trainees. Trainees received a baseline evaluation (n=283) followed by an 8 hour-training sessions that involved an introdutory lecture, skills management with mannequin simulator, clinical scenarios for training ACLS algorithm, and instructor-facilitated debriefings. After finishing the course, the trainees were retested and completed a numerical scale survey (n=497) of their perceptions about the course (1= poor, 2= fair, 3= good, and 4 =excellent).RESULTS. The study was performed at Berkeley Training Center -Brazil, between March 2002 and December 2006, with a total number of 497 trainees. Trainees received a baseline evaluation (n=283) followed by an 8 hour-training sessions that involved an introdutory lecture, skills management with mannequin simulator, clinical scenarios for training ACLS algorithm, and instructor-facilitated debriefings. After finishing the course, the trainees were retested and completed a numerical scale survey (n=497) of their perceptions about the course (1= poor, 2= fair, 3= good, and 4 =excellent).CONCLUSION. The extremely positive response to simulation-based training on emergencies in cardiology found in this study suggests that this training modality may be valuable in the training of medical students and physicians. Most students considered the course excellent. Simulation-based training is expected to become routine in many health care settings in the coming decade. (1) . Skilled assistance must be available to assist the anaesthetist as Gwinnutt suggests an increased incidence of failed intubations in A&E (2) . The AAGBI state that standards of anaesthesia must be the same as those in theatre(3). Transfer of critically ill patients poses a significant risk. Transporting within hospital is often poorly managed & Andrews et al (5) state that patients deteriorate significantly during such transfers. Our objective was to identify & aim to minimise risks when undertaking anaesthesia in the non-theatre environment.

METHODS. The audit was undertaken in 2006 and reaudited in 2008. Trainees in a department covering 2 large district general hospitals, each with separate A&E, radiology and critical care facilities, received a questionnaire. The questions concentrated on training & orientation of A&E, radiology and equipment. Anaesthesia standards for intra-hospital patient transfer & anaesthesia in A&E were audited according to the RCoA (6).

The results demonstrated deficits in training & knowledge of the equipment & assistance. 71.4% of trainees responded & only 5% had received training in anaesthesia in non-theatre environments within the last year; 13% had received a orientation session. During transfers 65% patients had minimal monitoring, 28% patients had no physiological parameters recorded despite transfer up to 135 min. 67% trainees believed their assistant was suitably trained for induction of anaesthesia & 14.7% described poor assistance with RSI; 21% found minimal monitoring unavailable.CONCLUSION. Changes implemented included the creation of transfer training for trainees. A 24 hr outreach service has now been created in one hospital & a vital part of the role is to support anaesthetists; this data was a major part of the business case to justify its establishment. Reaudit of trainees demonstrated a substantial improvement, but training in emergency situations has now been set up. We recommend that all ICU review their training for the nontheatre environment. New staff should undergo an orientation that is regularly up-dated. We believe that trainees should undergo specific training & demonstrate proficiency in anaesthesia in the non-theatre environment.